Counties in the Diabetes Belt often have high rates of medical debt More than half of the counties in the nation's so-called Diabetes Belt also have high rates of medical debt among their residents, an NPR analysis found.

Many people living in the 'Diabetes Belt' are plagued with medical debt

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In some communities, the health challenges of diabetes and the financial strain of medical debt converge. NPR's Robert Benincasa reports from one such place in South Carolina.

ROBERT BENINCASA, BYLINE: We met Delores Lowery in her single family home not far from where she grew up in Bennettsville, S.C.


DELORES LOWERY: How're you all doing?

BENINCASA: How are you?

LOWERY: Come on in.

BENINCASA: Lowery remembers being at work one day in 2016 and feeling strange.

LOWERY: I looked around when I walked in on my job. And I worked at a weaving plant in Cheraw, and I asked - I said, why y'all got it so dark in here? They said, Delores, it's not dark in here. I said, yes, it is. I said, it's so dark in here.

BENINCASA: Lowery was rushed to the hospital and found out that, like 1 in 10 Americans, she has Type 2 diabetes. She lives in Marlboro County, which is among more than 600 mostly Southern counties identified by the U.S. Centers for Disease Control and Prevention as having high rates of diabetes, a so-called Diabetes Belt. Of those 644 counties, NPR found that more than half of them also have high levels of medical debt, and that includes Marlboro County. We found the overlap by comparing the CDC's list with medical debt data from the Urban Institute, a social policy nonprofit. Institute economist Breno Braga says medical debt, like diabetes, is also concentrated in the South, and the two problems go together.

BRENO BRAGA: The single most important predictor of a county's medical debt is the share of the population that has disease such as diabetes, hypertension and other types.

BENINCASA: When we talked to Lowery, she was dealing with the debt and the disease and more. Soon after Lowery was diagnosed, her daughter and granddaughter were murdered. She was left to parent her teenage grandson alone. In addition to the overwhelming emotional toll, there was financial strain.

LOWERY: The cost of living was so extremely high in trying to raise my grandson. I just got behind.

BENINCASA: Her diabetes got worse until 2021, when she was presented with the promise of the increasingly popular drug Ozempic. You've probably heard about Ozempic lately. It's been in the news because people are using it to lose weight. The drug works in part by stimulating the pancreas to release insulin when blood sugar rises. It helped Lowery more than any other medication she took. But not even a year later, she fell short of payments, and her prescription was cut off just as demand for Ozempic was increasing. Then she tried to renew the prescription out of pocket at the local pharmacy, and she got sticker shock.

LOWERY: I went to get it and the woman told me - she said, I don't think you going to be able to afford this. I said, why not? She said, because it's 700 and some dollars.

BENINCASA: Her insurance company has been no help.

LOWERY: Nobody's willing to work with me with Ozempic. I don't know what to do. They won't send me the medicine.

BENINCASA: She and her provider even talked about getting physician samples, but given the drug's popularity, that didn't work. While there is no easy solution for Lowery, who is over 65 and on Medicare, the Urban Institute and others say a simple policy change could prevent people like her from getting to such a difficult stage in their disease - expand Medicaid. Here's the Urban Institute's Braga again.

BRAGA: Seventy-nine out of 100 counties with the highest levels of medical debt are in states that have not expanded Medicaid under the ACA.

BENINCASA: The ACA is the Affordable Care Act, also known as Obamacare, which offered states the option to expand their health insurance programs for the poor. South Carolina is one of 10 states that still hasn't. It goes back to 2013 and a Republican backlash against the Obama administration.


NIKKI HALEY: Not in South Carolina.

BENINCASA: That's then-Governor Nikki Haley, who is now running for the 2024 Republican presidential nomination.


HALEY: As long as I am the governor of South Carolina, we will not expand Medicaid on President Obama's watch.

BENINCASA: Research shows that states that have expanded Medicaid saw decreases not only in medical debt but also in the severity of diabetes. But in Lowery's state...

KAMBRELL GARVIN: I think Republicans here in South Carolina still see it as a liberal federal overreach.

BENINCASA: That's Democratic State Representative Kambrell Garvin, who has tried repeatedly to get the Republican-controlled legislature to take up the expansion.

GARVIN: This is my third time filing a bill for Medicaid expansion. My Democratic colleagues have been doing it for over the past decade, and the bill never sees the light of day.

BENINCASA: Several messages left by NPR with leaders of the South Carolina Republican Party were not returned. As for Lowery, she says she will continue to rely on her doctor and her church to help her cope with her diabetes and her finances. Robert Benincasa, NPR News.

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