AILSA CHANG, HOST:
Knoxville, Tenn., like many cities, was reshaped in the 1950s and '60s by so-called urban renewal. That took a toll on the city's Black neighborhoods, and it also left a legacy of crushing medical debt. For our investigation into America's debt crisis with partner Kaiser Health News, Noam Levey went to Knoxville to explore that connection.
NOAM LEVEY: I'm standing in what used to be the heart of Black Knoxville. It's a bleak place now. There are acres of empty parking lots. Traffic rumbles by on a noisy freeway. Decades ago, though, there were medical offices here, grocers, funeral homes. The city's first Black millionaire built a YMCA. The Gem Theater hosted performers like Billie Holiday. My guide is Gwen McKenzie. She's a city councilwoman who grew up nearby.
GWEN MCKENZIE: We had doctors. We had lawyers. We had teachers. There were affluent Black people who lived in this area, all this land that you see, that was basically devastated.
LEVEY: Starting in the 1950s, Knoxville systematically bulldozed the area. They wanted to make way for the freeway and a new civic auditorium. Churches, Black businesses and hundreds of homes were leveled in the name of modernization.
RENEE KESLER: It changed the whole landscape. So you'll have generations that won't recover from that.
LEVEY: That's Renee Kesler. She directs a nonprofit that preserves Knoxville's Black history. It's called the Beck Cultural Exchange Center. What urban renewal left behind was a neighborhood that's now the poorest in Knoxville, and one with the city's largest share of Black residents. A tiny fraction of people here are homeowners. Blocks are blighted by boarded-up buildings and overgrown lots. A Dollar General closed recently. It was one of the only stores in the area that sold groceries. Here's Councilwoman McKenzie again.
MCKENZIE: What happened is that we concentrated Black poverty, and from there, it became generational.
LEVEY: That's had a big impact on health. In East Knoxville, residents are sicker. There's more diabetes and other chronic illness. People here are less likely to have health insurance. They also have more medical debt. More than 30% of residents have a past due medical bill on their credit report. That's according to data from the Urban Institute. A few miles to the west in Knoxville's overwhelmingly white suburbs, fewer than 10% are in debt for medical care. Eboni Winford, a clinical psychologist, says what's behind that is a wealth gap.
EBONI WINFORD: Black people are less likely to have generational wealth to pass on, which means we don't have pockets of money that we can just use if medical bills arise.
LEVEY: Winford works at Cherokee Health, a network of clinics that serve low-income patients around Knoxville. Nationally, the typical white family has about $184,000 in assets. This includes home, savings and retirement accounts. The assets of the typical Black family - just $23,000. Lack of wealth feeds a vicious cycle. Black families without means are more hesitant to seek medical care. That means more illness. A trip to the hospital creates bigger bills. Many patients are forced into debt, making it even harder to build wealth. Back at Cherokee Health, Derrick Folsom says something else is going on that discourages people from seeking care - aggressive debt collection.
DERRICK FOLSOM: Somebody knows somebody who's getting sued from medical bills, so they stay away from medical facilities.
LEVEY: Folsom helps people enroll in health insurance. At the courthouse in Knoxville, debt cases brought by local hospitals fill the docket. National studies have shown that debt collectors target Black people more aggressively than whites. Tabace Burns has seen the impact of all this medical debt and poor health too many times to count. She's a nurse in Knoxville. Burns told me about a good friend who'd come to see her recently with a medical concern. Burns was so worried, she felt almost angry.
TABACE BURNS: She lifted up her shirt, and it was evident that she had this chronic something going on in her breast. And after I told her I ought to punch you in your face - that's the first thing I told her because I'm like, how long have you seen this? And I know you knew you needed to take care of this. She didn't have any insurance, so she just thought it would get better.
LEVEY: Turned out, the friend had cancer. Burns helped her find medical care, and the friend has since recovered. There was a cost to waiting so long, though. Because the cancer was so advanced, the woman had to get chemotherapy, and she had to have both breasts removed. It could have been worse.
BURNS: What if she didn't know me? What if she just continued to let her breasts leak?
LEVEY: Burns says, if her friend hadn't been so worried about medical debt, maybe she'd have gone to the doctor sooner.
CHANG: That was Noam Levey with our partner, Kaiser Health News.
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