They arrived at a fairground in a deep corner of Appalachia before daybreak, hundreds of people with throbbing teeth, failing eyes, wheezing lungs. They took a number, sat in the bleachers and waited in the summer heat for their name to be called so they could receive the medical help they can't get anywhere else.
Among the visitors at the free, once-a-year medical clinic was Lisa Kantsos, whose first stop was the dental tent, a sprawl of tables and chairs where volunteer dentists and students performed cleanings, filled cavities and pulled teeth. After getting a cleaning, she made a stop at a mammography van. Last year, it was free glasses.
"It's a blessing. It really is," said Kantsos, a 52-year-old diabetic, "because I don't have to worry about these things."
Kantsos and many of the estimated 2,000 others who turned out at the Wise County Fairgrounds in late July are the health care debate's forgotten.
Even with the passage of "Obamacare" in 2010, they have no insurance because they exist in a desperate in-between zone, unable to afford coverage but ineligible for Medicaid. And because they haven't benefited from the Affordable Care Act, the debate on Capitol Hill over repealing it has been all but irrelevant to them.
"Whether there was an Affordable Care Act or not, it really hasn't made any difference for these people," said Stan Brock, who founded the free traveling Remote Area Medical Clinic in the 1980s.
The need for better, more affordable care around here is undeniable.
The central Appalachian area that includes eastern Kentucky, southern West Virginia and western Virginia has long been one of the sickest and poorest regions in the country. More recently, it has been ravaged by the decline of coal mining.
"Everything revolved around coal," said Matt Sutherland, a frequent visitor to the clinic from Castlewood, Virginia. "Now there's not a lot of work, not a lot for people to do."
People in central Appalachia are 41 percent more likely to get diabetes and 42 percent more likely to die of heart disease than the rest of the nation, according to a study released in August by the Appalachian Regional Commission and other groups. The study also found that the region's supply of specialty doctors per 100,000 people is 65 percent lower than in the rest of the nation.
And people from southwestern Virginia die on average 10 years sooner than those from wealthier counties close to Washington, said August Wallmeyer, an author who lobbies the Virginia legislature on health issues.
Opioids are also taking their toll in Appalachia. In Virginia in 2014, drug overdoses became the No. 1 cause of accidental death, according to Wallmeyer's 2016 book, "The Extremes of Virginia."
But Virginia was among 19 states that chose not to expand Medicaid as part of the Affordable Care Act. Many states cited the cost, even though Washington pledged to pick up nearly the entire expense. An expansion in Virginia would have covered an additional 400,000 people.
"A lot of people, when the Affordable Care Act was first enacted and went into effect, had the mistaken belief that it was going to help the very poor people, particularly in Appalachia and other parts of Virginia," Wallmeyer said. "And it's just not true."
Wallmeyer said the clinic in Wise County doesn't see as many patients as it once did from Kentucky, a state that expanded Medicaid under the ACA.
Teresa Gardner Tyson, executive director of Virginia's Health Wagon, a free clinic that takes part in the Wise event, lamented that the politicians "forget at the end of the day that they're our servants."
"They can't get away from the partisan politics, but here we're faced with people dying on a daily basis," she said.
Among the patients at the free clinic was Joey Johnson, who shot himself in the head while playing with a gun when he was a teenager and has been in a wheelchair for 25 years.
No longer receiving health benefits from his stepfather's union miner's insurance, he came to the clinic to get a dental filling and have his eyes checked. His Medicaid doesn't pay for dental check-ups, and he gets just $735 a month in federal disability payments and $20 in food stamps.
"If it wasn't for this (clinic), my teeth would rot out of my head and I would be in bad shape," he said before his checkup, sitting shirtless in the heat. Johnson's assessment of lawmakers' work on health care is more succinct than any tweet: "They don't care about us."
Kantsos voted for Donald Trump last fall in the hope that he could shake up Washington. She said the president needs to concentrate more on his job and less on Twitter.
Sutherland supported Trump, too, and said he thinks the president deserves more time. But Sutherland, who comes to the clinic for dental work and medicine, wishes lawmakers understood how hard life can be in Appalachia. Last year, he said, he walked 30 miles (50 kilometers) to the Wise clinic because he had no car; it took more than seven hours. Others have it bad, too.
"I'm not the only one," he said, sitting in a tent where people were getting teeth pulled a few feet away. "I'm really not the only one."
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