Medical debt afflicts 1 in 5 North Carolina residents

VIRGINIA ANNABLE Public Service Journalist Team

Approximately 20% of North Carolina residents have medical debt that is in collections, making it the state with the fourth highest number of unpaid medical debts.

Alicia Pender lived a pretty normal life before contracting COVID-19 in 2020. She was a traveling nurse working in central North Carolina, being active, vacationing, and doing her own home repairs.

Nearly two years later, she faces a long list of health issues and more than $30,000 in medical debt.

COVID-19 left Pender with heart problems, including an irregular heartbeat that required multiple surgeries. She has “Brain Fog” which affects her balance. She suffers from depression and anxiety. However, the mountain of medical bills causes her the most stress, even though she has health insurance. Debt collectors follow them with phone calls.

The bills were piling up because of a high deductible and out-of-pocket expenses with private insurance, she said. About half of the debt is now in collections.

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“Being ill has resulted in me losing almost everything I’ve worked my life for,” Pender said.

Pender lives in Kernersville, Forsyth County, where 21% of the county’s residents have medical debt in collections. The proportion of people in debt more than doubles in some parts of North Carolina. In eastern Lenoir and Greene counties, about 44% of residents have medical debt in collections. The districts hold the first and second highest level of districts in the country, separated by a hair.

The level of medical debt is equal to the poverty line, according to data from the Urban Institute. Many of the counties with the highest medical debt also have some of the counties with the highest poverty rates. Medical debt rates also correspond to the number of insured persons. The US Census Bureau estimates that there are approximately 1.1 million uninsured people in North Carolina. An estimated 2 million residents have medical debt in collections.

Those who rack up medical debt are often those who are uninsured or underinsured, like those who don’t qualify for Medicaid or Medicare and can’t afford workplace insurance, said April Cook, CEO of the North Carolina Association of Free and Charitable Clinics.

66 clinics serve about 82,000 people in North Carolina, Cook said. It’s a drop in the bucket of the number of people who are uninsured in the state.

“They’re the working poor, they have two or three jobs trying to make ends meet,” Cook said. “They are our infrastructure, they are our most important workforce. … They are essential frontline workers.”

Democratic North Carolina Senator Don Davis, representing Greene County, wants Medicaid to be expanded in North Carolina to better serve those in need. The expansion would allow people living below 138% of the federal poverty line to qualify for federally funded health care. The federal government covers 90% of the expansion costs. According to research from the Urban Institute, expanding Medicaid would cover an estimated 650,000 more people in North Carolina.

“We need to expand Medicaid in North Carolina yesterday,” Davis said. “This is a fight we have been involved in for about a decade now. … We didn’t take advantage of the preventative aspect of the Medicaid expansion health-wise. We could have prevented many deaths over time. We could help people live healthier lives in the same amount of time, and that would have brought the state millions of dollars.”

More than eight years after states were allowed to expand Medicaid coverage, North Carolina has begun taking steps in that direction. For years, Republicans opposed expanding Medicaid, but some have changed their minds.

This summer, the Republican-controlled North Carolina Senate almost unanimously passed legislation expanding Medicaid. Republican Sen. Ralph Hise spoke in the Senate before the vote.

“The expansion of Medicaid has progressed to the point where it’s good government fiscal policy,” Hise said. “We’re not going to get a better deal to expand Medicaid than we have right now.”

Shortly thereafter, the Republican-controlled North Carolina House of Representatives passed a bill creating a joint legislative committee to recommend a Medicaid expansion plan by December of that year. In November, after the midterm elections, NC House Speaker Tim Moore said consideration of a Medicaid expansion would be delayed until 2023, the Associated Press reported.

“Until recently, all Republican leaders were totally opposed to the expansion of Medicaid,” said Democratic Representative Robert Reives. “Many are seeing what has been clear for years: Medicaid expansion is good business and right for North Carolina.”

In September, the North Carolina Healthcare Association got involved. The coalition, which represents hospitals across the state, suggested health systems and hospitals would bear much of the state’s expansion costs, about $550 million a year. The association has been committed to expansion for a decade, said NCHA vice president of communications and public relations, Cynthia Charles.

“The primary beneficiaries of the expansion will be rural hospitals and families,” Charles said. “The additional funds flowing into rural communities as Medicaid expands would help retain providers, keep rural hospitals open, and recoup previously uncompensated health care provider costs for caring for uninsured people. In other words, it would strengthen the capacity and stability of our rural health infrastructure.”

Cook, chair of the state Association of Free Clinics, said expanding Medicaid is a good move to give more people access to health care, but she worries a drastic increase in eligible recipients could make finding a provider more difficult.

“We have a shortage of providers in North Carolina. Where will (the patients) go?” said Koch. “Medicaid is not the same as access. It doesn’t. We hope that’s the case, but it doesn’t necessarily mean access.”

Cook said she’d like to see more funding for free and nonprofit clinics to bridge the gap and help people transition to Medicaid if the expansion is approved.

Free clinics see the impact of medical debt on their patients who can’t afford health care, she said.

“These people are scared of debt, so they wait until the last minute for the Grim Reaper’s vision to come around the corner to get treatment,” Cook said. “Because they are afraid of the medical guilt. You know that this burden can completely destroy a family.”

North Carolina Treasurer Dale Folwell is committed to protecting people from this burden. Folwell is urging lawmakers to pass medical debt disarmament legislation, which will likely go back to the House of Representatives next year, he said.

The bill would require hospitals to screen patients for eligibility for charitable care and public support. It would also require prices to be posted online, a graduated rebate scale for people earning less than 400% of the federal poverty line, and would protect family members from medical or nursing home debt incurred by a spouse or parent.

Among other things, the bill would also ban medical bills from being reported to credit bureaus a year after they were billed.

“Citizens generally don’t make ends meet,” Folwell said. “Not because of the murderous invasion of Ukraine. Not because of COVID or force majeure, but because of things related to medical debt.”

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