Virginia is one of the 20 states that have opted out of the Affordable Care Act’s Medicaid expansion, shrugging off nearly 700 million federal dollars because of Republican opposition in the state’s House of Delegates. That refusal has left some 400,000 Virginians, many of whom have lost their jobs in the area’s ailing coal industry, without access to affordable health insurance, and dependent on free treatment options—few and far between—like the gratis clinics and medical caravans that roam the poor, Appalachian regions of the state. Last weekend, one volunteer corps, Remote Area Medical (RAM), gave care to almost 2,000 uninsured and underinsured Virginians at an event in Wise County, Va. It was the event’s 15th year but it was the first year it was unable to accommodate all the people who showed up, according to Teresa Gardner, the executive director of the local clinic that hosted the RAM volunteers. Gov. Terry McAuliffe also made an appearance, using the opportunity to pressure the state’s Republican lawmakers to embrace Medicaid expansion. Amid the crowds of people who slept in their cars and stood in hours-long lines in the rain to get their teeth checked and their lungs listened to, there may have been no better place to make his point. Health policy expert Harold Pollack has estimated that the refusal to expand Medicaid could result in the death of 6,000 people each year nationwide. But there is also the much less quantifiable problem of the diminished quality of life that comes with not being able to see a doctor. Photographer Lucian Perkins traveled to this crowded RAM event in Wise to give us a snapshot of this suffering—and the human cost of partisan gridlock. Above, Sheila Wallen (left) and Sandy Jenkins (right) from Dickenson County, Va., wait for the rain to slow down before they leave the RAM clinic set up at the Wise County Fairgrounds. They had dental work done and glasses made while there.