LOUISVILLE, Ky. - In a plain brown health clinic on a busy boulevard here, the growing pains of the Affordable Care Act are already being felt - almost too sharply for the harried staff trying to keep up with the flow of patients.
Tamekia Toure, 40, is typical of the clinic's new patients, a single mother and recent arrival from Alabama with diabetes, high blood pressure, chronic pain and, for much of her adult life, no health insurance. For her, the new law is a godsend, providing Medicaid coverage that she would not have received before.
Then there is Donna Morse, 61, a widowed dental hygienist and yoga buff who is long overdue for a mammogram and blood work. She lost her insurance last year because it did not meet the new law's standards. Now she has a new plan with much higher premiums, and which few doctors and hospitals will accept. So she too, warily, has landed at the clinic, one of seven here called Family Health Centers.
David Elson, 60, who has been coming to Family Health Centers for several years now, is a self-employed businessman with a multitude of health problems and medical bills. Despite chronic ailments, he went without insurance for years before enrolling in a subsidized private plan. He has not paid the first month's premium, and could well fall back into the ranks of the uninsured.
'If you don't have it, you don't have it,' he said of the money he owed his new insurer.
A critical phase for the Affordable Care Act ends on Monday, with the closing of the first enrollment period for new insurance plans offered under the landmark law. The Obama administration, which initially predicted that seven million people would sign up for private plans, said last week that more than six million had done so. Independent analysts estimate that more than four million others have enrolled in Medicaid through the law's expansion of that program.
The law still faces steep challenges in Kentucky and nationwide, not only from energized political opponents who plan to attack it until Election Day, but also from skeptical consumers who think the cost of many new plans is too high, and the choice of doctors, hospitals and prescription drugs too limited. In Kentucky, where sign-ups for Medicaid have far outnumbered those for private coverage, opponents - including Senator Mitch McConnell, the Republican leader and an unwavering critic of the law - are predicting higher costs for the state.
Yet beneath the loud debate, the law is quietly starting to change the health care landscape. In Kentucky alone, more than 350,000 people - about 8 percent of the state's population - have signed up for coverage. Insurers and medical providers are reporting steady demand from the newly covered for health care, ranging from basic checkups to complex surgical procedures.
And in the daily bustle of the seven Family Health Centers clinics scattered around Louisville, a city of 600,000, the law's early effects are starting to show.
Across the country, community health centers serve more than 20 million people a year, providing primary and preventive care in low-income neighborhoods where private doctors are scant. Their patients are disproportionately uninsured - just over half of the 38,000 patients at Family Health Centers last year had no coverage - and unhealthy.
Like many of those clinics, Family Health Centers is counting on the law to deliver thousands of new paying patients that could help erase debt, raise salaries and hire new staff members.
But the changes are also causing fatigue - and flashes of anger - among the organization's employees, who are struggling to adjust to a new electronic records system and worrying about accommodating a steady stream of newly insured patients, many of whom require extra attention.
A day after seeing Ms. Toure for the first time, Maria Catalano, a nurse practitioner, listened uneasily as Bill Wagner, the executive director of Family Health Centers, updated the staff on the early effects of the law. More than 54,000 people in Jefferson County, which includes Louisville, have gotten coverage since enrollment began on Oct. 1, and Family Health Centers alone has helped nearly 5,000 people apply.
Ms. Catalano raised her hand. 'So we don't have a stop point?' she asked as others nodded in agreement. 'We're just going to keep accepting new patients, new patients, new patients?'
Relief, and Then WorryMs. Toure could not believe her luck on the day she arrived for her first appointment. A month earlier, she had moved back to Louisville, her hometown, from rural Alabama, where she had paid dearly for insurance through a minimum-wage job at a gas station. There were additional out-of-pocket costs for drugs and doctor visits, and so she often went without care.
She had been uninsured for long periods of her adult life, suffering through toothaches that hurt 'worse than labor pain,' and relying on her mother, a fellow diabetic, to mail her some of her own medication.
'I would never want anyone to go through the pain and torment that I went through as far as not being able to take medicine,' she said.
When she returned to Louisville with her four children, she went to apply for food stamps and learned she could also apply for health insurance through Kynect, the state's new online marketplace. With no income except her 16-year-old son's disability check, she qualified for Medicaid - which would not have been possible in Alabama, one of 24 states that has not expanded Medicaid.
'The first thing in my mind was just happiness,' Ms. Toure said.
Since receiving coverage, Ms. Toure has seen a dentist to get a painful tooth removed. New Medicaid patients can also see private orthopedists, neurologists and other specialists, addressing problems they may have endured for years. Newly insured patients have flooded Family Health Centers with requests for referrals; its largest clinic, in Louisville's impoverished West End, had a backlog of several hundred requests in mid-March and was hiring temporary workers to help patients arrange appointments.
'People have insurance, and they're getting important care,' said Janet Kleinhelter, a medical receptionist at Family Health Centers who is spending long days working through the backlog of referral requests. 'But we weren't quite prepared for this.'
Ms. Toure had been off her medications for a month when she arrived at Ms. Catalano's clinic, near the famous Churchill Downs racetrack. She got a thorough workup, new prescriptions and referrals to a weight-loss specialist and a hospital for an X-ray of her spine. As a Medicaid patient, she paid nothing. 'I like you guys,' she said, beaming beneath her stylish bob.
But even as she felt the relief of being insured, Ms. Toure faced a new potential problem. After her appointment that day, she went to a job interview at Amazon, which has warehouses in the area, and got hired.
She was elated to find work so quickly - 'In Alabama, it took me years,' she said - but also a little scared. Would her new income make her ineligible for Medicaid, so soon after she had signed up? With the expanded program, this so-called churning in and out of Medicaid, based on changes in income, is expected to be common, and for many, problematic.
'I really expect to lose it,' Ms. Toure said.
Higher Costs Now for Some 
When Ms. Morse, the dental hygienist, came for her first appointment at Family Health Centers that same morning, she had finally given up smoking, five years after her husband died of lung cancer. But she had gained 20 pounds as candy became her substitute vice. In October, she had been shocked to learn that her longtime insurance policy through Humana was getting canceled.
'I'm really not very happy with what my experience has been,' Ms. Morse said.
She is among several million Americans, many of them middle class, who lost insurance last year because those plans did not provide all the benefits required under the law. The wave of cancellations, coupled with the stumbling rollout of the online marketplace, caused a political crisis for President Obama that continues to affect Democrats around the country.
After she lost her old plan, Humana sent her a chocolate bar - dark and 'heart healthy,' the wrapper said - to thank her for her loyalty. She is off candy now, but she saved it as a memento.
She then went to work researching plans through Kynect, and learned that because of her earnings - in addition to her hygienist's salary, she gets some income from her husband's life insurance policy - she did not qualify for a subsidy. So she is paying $448 a month for a new Humana plan, up from the $258 monthly premium she paid before.
Needing to find a new doctor, she called several who would not take her new insurance. So she arrived at Family Health Centers, which she would not have considered before. 'They were not in the best area,' she explained.
At her first appointment, on her lunch break, Ms. Morse was dressed in a royal-blue uniform and clasping her hands as she talked with Ms. Catalano and Tanisha Thompson, a nurse-practitioner student. Her blood pressure was borderline high, and she needed a mammogram and a colonoscopy.
'I'll do whatever y'all say,' Ms. Morse said.
Ms. Morse, who lives with her grown daughter in a bungalow-style home with a porch swing in a quiet neighborhood in Louisville's South End, did not want to go on blood pressure medication just yet, preferring a holistic approach. But her blood work showed her cholesterol was high enough to require medicine immediately.
So she drove to the Walgreens near her house to pick up the prescription, but discovered that the chain did not accept her new Humana policy, a so-called narrow network plan with a limited number of providers.
But despite that problem, and the cost of her new plan - which she called 'a kick in the butt' - she declared herself 'very pleasantly surprised' with her experience at the clinic. And unlike many who have had policies canceled because of the law, she said she could see its benefits.
'I'm really thankful that a lot of people are getting health care that couldn't have it in the past,' she said.
Now, she just hopes that she will qualify for a subsidy after she retires, perhaps later this spring.
'Then maybe I'll be able to be part of health reform,' she said.
Selecting the Right Plan 
Mr. Elson, the self-employed businessman, is just the kind of person who should benefit from the Affordable Care Act. Diabetes has taken a toll on his body and his finances, weakening his heart and kidneys and leaving him with so much debt that bankruptcy is a lurking possibility.
He went to Family Health Centers last fall to see about signing up for coverage and learned he was eligible for a substantial subsidy, $252 a month. But he found the choices so overwhelming that he put off a decision, losing the paperwork amid the clutter of his shotgun home.
Months passed. The harsh winter proved terrible for his business installing burglar alarms. Off his diabetes medicines because he could not afford them, Mr. Elson had emergency surgery to stanch bleeding at the back of his eyes - another bill he could not pay - and spent many hours in bed, the warmest place in his house.
'The work just dried up,' Mr. Elson said recently over a dinner of chicken and ribs.
In February, he went to his kidney doctor, who said that his blood pressure was up. He complained of a pain in his chest, and she told him to get an echocardiogram, 'preferably today.' When he went to pay for the doctor visit, he was told that the fee for uninsured patients had risen to $70, more than three times the cost for previous appointments. He left without the echocardiogram and has not returned.
But later that week, Mr. Elson did return to Family Health Centers and, with the help of a counselor, chose a plan, one of the few that all of his doctors would accept. With the subsidy, he would owe $350 a month toward the premium. The midlevel plan, offered by Anthem Blue Cross and Blue Shield, had a deductible of $2,600. But his income, about $22,000 last year, was low enough to qualify for additional help paying out-of-pocket costs for health care and medications up to that amount.
Mr. Elson was satisfied. But his nurse practitioner at Family Health Centers, Susan Elrod, was worried: 'He'll never be able to afford that.'
Nationally, as many as about 20 percent of those who signed up for coverage that took effect in January have failed to pay their premiums on time, according to insurance companies and industry experts. Others may be keeping up with their premium costs but struggling to meet high deductibles, which many of the new plans have.
Mr. Elson is long divorced and lives alone but has an affectionate relationship with his daughter, who lives several states away. He carefully tends his backyard garden, jarring tomatoes and storing them on a shelf in his kitchen. Perhaps partly because of his advanced disease, he can be forgetful and disorganized: His home is strewn with alarm equipment, buckets of empty diet soda cans and unopened mail. In January, he said, he neglected to bill his customers who pay monthly.
'I plum forgot,' he said, shrugging.
His first premium payment was due March 8, for coverage that was to take effect March 1, and he missed the deadline. Several customers owed him money, he said, and after paying his rent, water bill and the fee for a car he had rented after his van broke down, he did not have enough money left for insurance.
He got some free diabetes medicine from Family Health Centers in February, but it was meant to last only a few weeks.
'That's the next bill I'm paying,' he said. 'You can trust me on that.'
Challenges for ProvidersFamily Health Centers has always been one of the few medical providers in Louisville to take all comers, regardless of their ability to pay, and it will not abandon that role in the Affordable Care Act era, said Mr. Wagner. Even last month, as a record percentage of its patients presented insurance cards, almost 30 percent of the medical appointments were still for 'self-pay' customers with no coverage.
But already, the change in its patient mix is striking. The number of visits by Medicaid recipients last month was 30 percent higher than in February 2013. Visits by uninsured patients fell by 52 percent, to 1,760 from 3,697. Visits by patients with private insurance dropped slightly, but Mr. Wagner hopes they will rise as more people like Ms. Morse discover Family Health Centers and like what they find.
For now, the new revenue from Medicaid - which reimburses community health centers at a higher rate than private doctors - should help Family Health Centers erase a $2 million deficit in its $28 million budget, Mr. Wagner said.
With the new revenue, he also hopes to raise salaries and recruit new doctors to replace several who left over the last year. Mr. Wagner is in negotiations with five candidates; if he succeeds in hiring them, it could help ease the pressure on nurse practitioners, who now make up 60 percent of the clinic's medical staff, but who rely on doctors for advice and support.
Ms. Elrod, the nurse practitioner who treats Mr. Elson, was among the staff members who were feeling demoralized as the enrollment period drew to a close, even as they were happy to see more patients getting coverage. She said it has been tough getting used to the electronic record system and a new 'open-access' scheduling system, which is supposed to eliminate long waits for appointments but has kept some patients from seeing their usual doctors or nurse practitioners.
Dr. Michelle Elisburg, a pediatrician at Family Health Centers, sounded equally worn as she spoke of her frustrations with electronic records, which swallow more of her time than paper charts used to. 'Hours at home,' she said, 'signing all the charts, all completely uncompensated.'
Mr. Wagner, a Louisville native in his fourth decade at the clinic, keeps pleading for perseverance.
'It's been the year of the most change of any year since I've been here,' he told the staff not long ago. 'We're reinventing the wheel.'
