About 20% of North Carolina residents have medical debt that is in collections, making it the state with the fourth-highest level of unpaid medical debt.
Alicia Pender lived a fairly normal life before contracting COVID-19 in 2020. She was a travel nurse working in central North Carolina and was active, taking vacations and handling her own home repairs.
Nearly two years later, she’s facing a long list of health issues and more than $30,000 in medical debt.
Alicia Pender has incurred close to $30,000 of medical debt due to long COVID and other illnesses and injuries.
COVID-19 left Pender with heart problems including an irregular heartbeat, which required several procedures. She has “brain fog” that affects her balance. She’s suffering from depression and anxiety. Still, what causes her the most stress is her mountain of medical bills, despite having health insurance. Debt collectors hound her with phone calls.
The bills piled up due to a high deductible and out-of-pocket costs with private insurance, she said. About half of the debt is now in collections.
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"Being sick has caused me to almost lose everything I have worked my life for," Pender said.
Pender lives in Kernersville, in Forsyth County, where 21% of the county’s residents have medical debt in collections. The share of people with debt is more than double in some parts of North Carolina. In Lenoir and Greene counties, in the eastern part of the state, about 44% of residents have medical debt in collections. The counties hold the first and second highest county levels in the country, separated by a hair.
The levels of medical debt correspond to poverty levels, according to Urban Institute data. Many of the counties with the highest levels of medical debt are also among those counties with the highest poverty rates. The rates of medical debt also correspond to the number of people with insurance. About 1.1 million uninsured people in North Carolina, according to 2021 estimates from the U.S. Census Bureau. An estimated 2 million residents have medical debt in collections.
Those who accumulate 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, CEO of the North Carolina Association of Free and Charitable Clinics April Cook said.
Sixty-six clinics cover about 82,000 people in North Carolina, Cook said. It’s a drop in the bucket of the number of people 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're our essential workers. … They’re essential frontline workers.”
North Carolina Democratic Sen. Don Davis, who represents Greene County, would like to see Medicaid expanded in North Carolina to get more care to people in need. The expansion would allow people living under 138% of the federal poverty level to qualify for government-funded health care. The federal government would cover 90% of the cost of expansion. It is estimated expanding Medicaid would cover 650,000 more people in North Carolina, according to research by the Urban Institute.
“We need to expand Medicaid in North Carolina yesterday,” Davis said. “This has been a fight we've been engaged in now for about a decade. … We have failed to benefit from the preventive aspect of Medicaid expansion in terms of health. We could have prevented, over time, a lot of death. We could help people live healthier lives over the same time period and this would have brought in millions of dollars into the state.”
More than eight years after states were allowed to expand Medicaid coverage, North Carolina has started taking steps in that direction. For years, Republicans opposed Medicaid expansion, but some have changed their tune.
This summer, the Republican-controlled North Carolina Senate passed a bill to expand Medicaid in a nearly unanimous vote. Before the vote, Republican Sen. Ralph Hise spoke on the Senate floor.
“Medicaid expansion has evolved to the point that it’s good state fiscal policy,” Hise said. “We will not get a better deal to expand Medicaid than we have right now.”
Shortly after, the Republican-controlled North Carolina House passed a bill to create a joint legislative committee to recommend a Medicaid expansion plan by this December. In November, after mid-term elections, N.C. House Speaker Tim Moore said consideration of Medicaid expansion would be pushed to 2023, the Associated Press reported.
“Until recently, all Republican leaders were entirely opposed to Medicaid expansion,” Democratic Rep. Robert Reives. “Many are seeing what has been clear for years: Medicaid expansion is a good deal and the right thing to do for North Carolina.”
In September, the North Carolina Healthcare Association weighed in. The association, which represents hospitals across the state, proposed health systems and hospitals would pay for a majority of the state’s cost of expansion, about $550 million per year. The association has advocated for expansion for a decade, NCHA Vice President of Communications and Public Relations Cynthia Charles said.
“Expansion will especially benefit rural hospitals and families,” Charles said. “The additional funding that flows into rural communities with Medicaid expansion would help to retain providers, keep rural hospitals open and recoup previously uncompensated costs to health care providers of providing care to uninsured people. In other words, it would strengthen the capacity and stability of our rural health care infrastructure.”
Cook, the leader of the state’s free clinic association, said Medicaid expansion is a good step in getting more people to access to health care, but she worries a drastic increase in eligible recipients could make it difficult to find a provider.
“We have a shortage of providers in North Carolina. Where are (the patients) going to go?” Cook said. “Medicaid does not equate to access. It doesn’t. We hope it does, but it doesn’t necessarily mean access.”
Cook said she would like to see more funding for free and charitable clinics to help cover the gap and help people transition to Medicaid if expansion is approved.
Free clinics see the effects of medical debt on their patients, who cannot afford health care, she said.
“These folks, they’re afraid of debt, so they'll wait until the last minute, until the vision of the grim reaper is around the corner, to get care,” Cook said. “Because they’re afraid of the medical debt. They know it can completely destroy a family, that burden.”
North Carolina Treasurer Dale Folwell is advocating to protect people from that burden. Folwell is pushing for the legislature to pass a Medical Debt De-weaponization Act, which will likely be reintroduced to the House next year, he said.
The bill would require hospitals to screen patients for eligibility for charity care and public assistance. It would also require prices to be posted online, a sliding scale of discounts for people earning under 400% of the federal poverty level, and would shield family members from medical or nursing home debt incurred by a spouse or parent.
The bill would also prohibit medical bills from being reported to credit bureaus before one year after the patient was billed, among other protections.
“Citizens in general can't make ends meet,” Folwell said. “Not because of the murderous invasion of Ukraine. Not because of COVID or an act of God, but because of things associated with medical debt.”
