The practice is legal, but patient advocacy groups call it unethical.

This article was published on Friday, November 15, 2024 in KFF Health News.

By Renuka Rayasam

In April, just 12 weeks into her pregnancy, Kathleen Clark was standing at the receptionist window of her OB-GYN's office when she was asked to pay $960, the total the office estimated she would owe after she delivered.

Clark, 39, was shocked that she was asked to pay that amount during this second prenatal visit. Normally, patients receive the bill after insurance has paid its part, and for pregnant women that's usually only when the pregnancy ends. It would be months before the office filed the claim with her health insurer.

Clark said she felt stuck. The Cleveland, Tennessee, obstetrics practice was affiliated with a birthing center where she wanted to deliver. Plus, she and her husband had been wanting to have a baby for a long time. And Clark was emotional, because just weeks earlier her mother had died.

"You're standing there at the window, and there's people all around, and you're trying to be really nice," recalled Clark, through tears. "So, I paid it."

On online baby message boards and other social media forums, pregnant women say they are being asked by their providers to pay out-of-pocket fees earlier than expected. The practice is legal, but patient advocacy groups call it unethical. Medical providers argue that asking for payment up front ensures they get compensated for their services.

How frequently this happens is hard to track because it is considered a private transaction between the provider and the patient. Therefore, the payments are not recorded in insurance claims data and are not studied by researchers.

Patients, medical billing experts, and patient advocates say the billing practice causes unexpected anxiety at a time of already heightened stress and financial pressure. Estimates can sometimes be higher than what a patient might ultimately owe and force people to fight for refunds if they miscarry or the amount paid was higher than the final bill.

Up-front payments also create hurdles for women who may want to switch providers if they are unhappy with their care. In some cases, they may cause women to forgo prenatal care altogether, especially in places where few other maternity care options exist.

It's "holding their treatment hostage," said Caitlin Donovan, a senior director at the Patient Advocate Foundation.

Medical billing and women's health experts believe OB-GYN offices adopted the practice to manage the high cost of maternity care and the way it is billed for in the U.S.

When a pregnancy ends, OB-GYNs typically file a single insurance claim for routine prenatal care, labor, delivery, and, often, postpartum care. That practice of bundling all maternity care into one billing code began three decades ago, said Lisa Satterfield, senior director of health and payment policy at the American College of Obstetricians and Gynecologists. But such bundled billing has become outdated, she said.

Previously, pregnant patients had been subject to copayments for each prenatal visit, which might lead them to skip crucial appointments to save money. But the Affordable Care Act now requires all commercial insurers to fully cover certain prenatal services. Plus, it's become more common for pregnant women to switch providers, or have different providers handle prenatal care, labor, and delivery — especially in rural areas where patient transfers are common.

Some providers say prepayments allow them to spread out one-time payments over the course of the pregnancy to ensure that they are compensated for the care they do provide, even if they don't ultimately deliver the baby.

"You have people who, unfortunately, are not getting paid for the work that they do," said Pamela Boatner, who works as a midwife in a Georgia hospital.

While she believes women should receive pregnancy care regardless of their ability to pay, she also understands that some providers want to make sure their bill isn't ignored after the baby is delivered. New parents might be overloaded with hospital bills and the costs of caring for a new child, and they may lack income if a parent isn't working, Boatner said.

In the U.S., having a baby can be expensive. People who obtain health insurance through large employers pay an average of nearly $3,000 out-of-pocket for pregnancy, childbirth, and postpartum care, according to the Peterson-KFF Health System Tracker. In addition, many people are opting for high-deductible health insurance plans, leaving them to shoulder a larger share of the costs. Of the 100 million U.S. people with health care debt, 12% attribute at least some of it to maternity care, according to a 2022 KFF poll.

Families need time to save money for the high costs of pregnancy, childbirth, and child care, especially if they lack paid maternity leave, said Joy Burkhard, CEO of the Policy Center for Maternal Mental Health, a Los Angeles-based policy think tank. Asking them to prepay "is another gut punch," she said. "What if you don't have the money? Do you put it on credit cards and hope your credit card goes through?"

Calculating the final costs of childbirth depends on multiple factors, such as the timing of the pregnancy, plan benefits, and health complications, said Erin Duffy, a health policy researcher at the University of Southern California's Schaeffer Center for Health Policy and Economics. The final bill for the patient is unclear until a health plan decides how much of the claim it will cover, she said.

But sometimes the option to wait for the insurer is taken away.

During Jamie Daw's first pregnancy in 2020, her OB-GYN accepted her refusal to pay in advance because Daw wanted to see the final bill. But in 2023, during her second pregnancy, a private midwifery practice in New York told her that since she had a high-deductible plan, it was mandatory to pay $2,000 spread out with monthly payments.

Daw, a health policy researcher at Columbia University, delivered in September 2023 and got a refund check that November for $640 to cover the difference between the estimate and the final bill.

"I study health insurance," she said. "But, as most of us know, it's so complicated when you're really living it."

While the Affordable Care Act requires insurers to cover some prenatal services, it doesn't prohibit providers from sending their final bill to patients early. It would be a challenge politically and practically for state and federal governments to attempt to regulate the timing of the payment request, said Sabrina Corlette, a co-director of the Center on Health Insurance Reforms at Georgetown University. Medical lobbying groups are powerful and contracts between insurers and medical providers are proprietary.

Because of the legal gray area, Lacy Marshall, an insurance broker at Rapha Health and Life in Texas, advises clients to ask their insurer if they can refuse to prepay their deductible. Some insurance plans prohibit providers in their network from requiring payment up front.

If the insurer says they can refuse to pay up front, Marshall said, she tells clients to get established with a practice before declining to pay, so that the provider can't refuse treatment.

Clark said she met her insurance deductible after paying for genetic testing, extra ultrasounds, and other services out of her health care flexible spending account. Then she called her OB-GYN's office and asked for a refund.

"I got my spine back," said Clark, who had previously worked at a health insurer and a medical office. She got an initial check for about half the $960 she originally paid.

In August, Clark was sent to the hospital after her blood pressure spiked. A high-risk pregnancy specialist — not her original OB-GYN practice — delivered her son, Peter, prematurely via emergency cesarean section at 30 weeks.

It was only after she resolved most of the bills from the delivery that she received the rest of her refund from the other OB-GYN practice.

This final check came in October, just days after Clark brought Peter home from the hospital, and after multiple calls to the office. She said it all added stress to an already stressful period.

"Why am I having to pay the price as a patient?" she said. "I'm just trying to have a baby."

Renuka Rayasam: rrayasam@kff.org, @renurayasam

So far CMS has rejected OIG's push to limit payments for house visits with no medical treatment — a potential red flag that may signal overcharges.

This article was published on Friday, November 8, 2024, in KFF Health News.

A new federal watchdog audit is ratcheting up pressure on government officials to crack down on billions of dollars in overcharges linked to Medicare Advantage home visits.

But so far, the Centers for Medicare & Medicaid Services has rejected a recommendation from the Health and Human Services Inspector General to limit payments stemming from house visits that don't result in any medical treatment — a potential red flag that may signal overcharges.

In late October, the HHS watchdog found that the health plans pocketed $7.5 billion in 2023 from diagnosing health conditions that prompted no medical services — about $4.2 billion of it through health assessments done in patients' homes. And court records show that for a decade or more, CMS officials have failed to act on their concerns that the home visits waste tax dollars and should be limited.

UnitedHealthcare, the largest Medicare Advantage contractor, accounted for about two-thirds of the payments tied to home visits and chart reviews, in which health plans mine patient medical files to add new diagnoses that can bring in additional revenue, according to the audit.

Assistant Inspector General Erin Bliss said the health plans are making billions without offering any treatment for medical conditions they flag during the visits, such as diabetes and major depression.

"Frankly, it needs to stop," Bliss said.

CMS, which runs the Medicare program, disagrees.

In a statement to KFF Health News by spokesperson Alexx Pons, the agency said it "appreciates the OIG's review in this area" and will continue to study the issue.

However, CMS disagreed with the OIG's call to restrict use of home health assessments in computing how much to pay health plans. People on Medicare "should have access to care that is appropriately provided in the home setting," CMS wrote in a written response included in the audit report.

"One would think that CMS would kick its regulatory oversight up a notch or two," said Richard Lieberman, a Colorado health data analytics expert.

"In contrast, CMS appears to be unconcerned and is telling OIG to stay out of their lane," he said.

UnitedHealthcare spokesperson Heather Soule said in a statement that the OIG had drawn "inaccurate conclusions" in the audit.

The home visits are "among the most comprehensive and thorough assessments of a patient's health and physical environment available in the healthcare system, helping to identify and drive needed follow-on care for the vast majority of the patients with whom we engage," according to the company.

No Care Provided

Government spending on Medicare Advantage, which is dominated by UnitedHealthcare and a handful of other health insurance companies, is expected to hit $462 billion this year.

The industry, whose more than 33 million members make up over half of people eligible for Medicare, argues that most enrollees are satisfied with the care they receive and typically pay less out-of-pocket than those on original Medicare.

Whether Medicare Advantage is a good deal for taxpayers is another matter, largely because many health plans exaggerate how sick patients are to boost their payments, multiple federal audits and other investigations have shown. Medicare pays the health plans higher rates for sicker patients.

For fiscal year 2023, CMS identified $12.7 billion in overpayments linked to diagnoses not supported by patients' medical records.

The OIG audit tied $7.5 billion in payments to health conditions that prompted no treatment, including serious diseases such as diabetes, congestive heart failure, and major depression. That suggests that the medical condition either didn't exist or that the health plan failed to treat it adequately, auditors said.

"These are serious conditions. You would think you would see additional care during that year," said Jacqualine Reid, who led the OIG audit team. "We are asking CMS to step up its oversight."

Homegrown

The in-home visits have sparked controversy for more than a decade. A June 2014 media investigation found that a sharp rise in home visits had inflated Medicare's costs by billions of dollars. The visits, which typically last less than an hour, are often conducted by nurse practitioners, who do not treat the patient, but go over a checklist of possible health conditions.

Sabrina Skeldon, a Texas lawyer who advises physicians on billing issues, said problems arise when health plans fail to order necessary medical tests to confirm a diagnosis made during a home visit — and treat it.

Skeldon noted that The Cigna Group in 2023 paid $172 million to settle a whistleblower lawsuit that alleged its Medicare Advantage plan illegally collected payments for medical diagnoses that were based solely on in-home assessments.

The OIG audit comes as the Justice Department presses a civil fraud case that accuses UnitedHealth Group of cheating Medicare out of more than $2 billion by mining patient records to churn up diagnoses that boosted revenue, while ignoring evidence of overpayments. The company denies the allegations.

Court filings from the case show CMS officials were concerned years ago that home visits and chart reviews could needlessly drive up costs.

In April 2014, CMS backed off a proposal to restrict their use amid complaints from the industry that it would lose billions of dollars as a result. Similarly, CMS officials scrapped a proposal to tighten scrutiny on the chart reviews after what one official called an "uproar" from the industry.

CMS officials also had concerns that unchecked home visits might affect efforts to recover overpayments through billing reviews known as "RADV" audits.

Former CMS official Thomas Hutchinson, who ran the agency's Medicare Plan Payment Group from September 2006 through June 2010, testified in a deposition that officials had "heard about various folks that figured out how they could RADV-proof things by doing in-home visits."

In a confidential April 2015 slide presentation, CMS officials observed that health plans were "now conducting health risk assessments in beneficiaries' homes. One purpose of the assessments is to identify conditions and create medical records documentation that substantiates diagnoses."

And an October 2015 CMS memo circulated among senior agency staff cites "limitations around home visits" among the possible ways to "strengthen" the RADV audits.

In its statement to KFF Health News, CMS said it was "committed" to ensuring that diagnoses health plans submitted for payment were accurate. But the agency declined to answer written questions about the impact of home visits on its audit program, which has yet to complete reviews of payments dating back as far as 2011.

UnitedHealthcare had the lowest rates of unconfirmed diagnoses among five large Medicare Advantage organizations audited in 2011, according to court records.

Overall, the company ended up with underpayments of more than $261 million for 15 of its plans audited for 2011-2013, court records show. The audit findings for other Medicare Advantage firms are blacked out in court filings.

CMS audits payments to just 30 out of more than 700 contracts a year. That's not enough to protect tax dollars, said Matthew Fiedler, a health policy researcher at The Brookings Institution.

"They should be auditing 10 times as many contracts," he said. "Where we are now you are not likely to get caught."

Fred Schulte: fschulte@kff.org, @FredSchulte

Vermonters pay the highest prices nationwide for individual health coverage, and state reports show its providers and insurers are in financial trouble.

This article was published on Wednesday, November 6, 2024 in KFF Health News.

By Phil Galewitz

RICHMOND, Vt. — On a warm autumn morning, Roger Brown walked through a grove of towering trees whose sap fuels his maple syrup business. He was checking for damage after recent flooding. But these days, his workers' health worries him more than his trees'.

The cost of Slopeside Syrup's employee health insurance premiums spiked 24% this year. Next year it will rise 14%.

The jumps mean less money to pay workers, and expensive insurance coverage that doesn't ensure employees can get care, Brown said. "Vermont is seen as the most progressive state, so how is healthcare here so screwed up?"

Vermont consistently ranks among the healthiest states, and its unemployment and uninsured rates are among the lowest. Yet Vermonters pay the highest prices nationwide for individual health coverage, and state reports show its providers and insurers are in financial trouble. Nine of the state's 14 hospitals are losing money, and the state's largest insurer is struggling to remain solvent. Long waits for care have become increasingly common, according to state reports and interviews with residents and industry officials.

Rising health costs are a problem across the country, but Vermont's situation surprises health experts because virtually all its residents have insurance and the state regulates care and coverage prices.

For more than 15 years, federal and state policymakers have focused on increasing the number of people insured, which they expected would shore up hospital finances and make care more available and affordable.

"Vermont's struggles are a wake-up call that insurance is only one piece of the puzzle to ensuring access to care," said Keith Mueller, a rural health expert at the University of Iowa.

Regulators and consultants say the state's small, aging population of about 650,000 makes spreading insurance risk difficult. That demographic challenge is compounded by geography, as many Vermonters live in rural areas, where it's difficult to attract more health workers to address shortages.

At least part of the cost spike can be attributed to patients crossing state lines for quicker care in New York and Massachusetts. Those visits can be more expensive for both insurers and patients because of long ambulance rides and charges from out-of-network providers.

Patients who stay, like Lynne Drevik, face long waits. Drevik said her doctor told her in April that she needed knee replacement surgeries — but the earliest appointment would be in January for one knee and the following April for the other.

Drevik, 59, said it hurts to climb the stairs in the 19th-century farmhouse in Montgomery Center she and her husband operate as an inn and a spa. "My life is on hold here, and it's hard to make any plans," she said. "It's terrible."

Health experts say some of the state's health system troubles are self-inflicted.

Unlike most states, Vermont regulates hospital and insurance prices through an independent agency, the Green Mountain Care Board. Until recently, the board typically approved whatever price changes companies wanted, said Julie Wasserman, a health consultant in Vermont.

The board allowed one health system — the University of Vermont Health Network — to control about two-thirds of the state's hospital market and allowed its main facility, the University of Vermont Medical Center in Burlington, to raise its prices until it ranked among the nation's most expensive, she said, citing data the board presented in September.

Hospital officials contend their prices are no higher than industry averages.

But for 2025, the board required the University of Vermont Medical Center to cut the prices it bills private insurers by 1%.

The nonprofit system says it is navigating its own challenges. Top officials say a severe lack of housing makes it hard to recruit workers, while too few mental health providers, nursing homes, and long-term care services often create delays in discharging patients, adding to costs.

Two-thirds of the system's patients are covered by Medicare or Medicaid, said CEO Sunny Eappen. Both government programs pay providers lower rates than private insurance, which Eappen said makes it difficult to afford rising prices for drugs, medical devices, and labor.

Officials at the University of Vermont Medical Center point to several ways they are trying to adapt. They cited, for example, $9 million the hospital system has contributed to the construction of two large apartment buildings to house new workers, at a subsidized price for lower-income employees.

The hospital also has worked with community partners to open a mental health urgent care center, providing an alternative to the emergency room.

In the ER, curtains separate areas in the hallway where patients can lie on beds or gurneys for hours waiting for a room. The hospital also uses what was a storage closet as an overflow room to provide care.

"It's good to get patients into a hallway, as it's better than a chair," said Mariah McNamara, an ER doctor and associate chief medical officer with the hospital.

For the about 250 days a year when the hospital is full, doctors face pressure to discharge patients without the ideal home or community care setup, she said. "We have to go in the direction of letting you go home without patient services and giving that a try, because otherwise the hospital is going to be full of people, and that includes people that don't need to be here," McNamara said.

Searching for solutions, the Green Mountain Care Board hired a consultant who recommended a number of changes, including converting four rural hospitals into outpatient facilities, in a worst-case scenario, and consolidating specialty services at several others.

The consultant, Bruce Hamory, said in a call with reporters that his report provides a road map for Vermont, where "the healthcare system is no match for demographic, workforce, and housing challenges."

But he cautioned that any fix would require sacrifice from everyone, including patients, employers, and health providers. "There is no simple single policy solution," he said.

One place Hamory recommended converting to an outpatient center only was North Country Hospital in Newport, a village in Vermont's least populated region, known as the Northeast Kingdom.

The 25-bed hospital has lost money for years, partly because of an electronic health record system that has made it difficult to bill patients. But the hospital also has struggled to attract providers and make enough money to pay them.

Officials said they would fight any plans to close the hospital, which recently dropped several specialty services, including pulmonology, neurology, urology, and orthopedics. It doesn't have the cash to upgrade patient rooms to include bathroom doors wide enough for wheelchairs.

On a recent morning, CEO Tom Frank walked the halls of his hospital. The facility was quiet, with just 14 admitted patients and only a couple of people in the ER. "This place used to be bustling," he said of the former pulmonology clinic.

Frank said the hospital breaks even treating Medicare patients, loses money treating Medicaid patients, and makes money from a dwindling number of privately insured patients.

The state's strict regulations have earned it an antihousing, antibusiness reputation, he said. "The cost of healthcare is a symptom of a larger problem."

About 30 miles south of Newport, Andy Kehler often worries about the cost of providing health insurance to the 85 workers at Jasper Hill Farm, the cheesemaking business he co-owns.

"It's an issue every year for us, and it looks like there is no end in sight," he said.

Jasper Hill pays half the cost of its workers' health insurance premiums because that's all it can afford, Kehler said. Employees pay $1,700 a month for a family, with a $5,000 deductible.

"The coverage we provide is inadequate for what you pay," he said.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Racial inequities are especially severe across the Southeast, home to most of the country's Black population.

This article was published on Thursday, October 24, 2024 in KFF Health News.

KINGSTREE, S.C. — One morning in late April, a small brick health clinic along the Thurgood Marshall Highway bustled with patients.

There was Joshua McCray, 69, a public bus driver who, four years after catching COVID-19, still is too weak to drive.

Louvenia McKinney, 77, arrived complaining about shortness of breath.

Ponzella McClary brought her 83-year-old mother-in-law, Lula, who has memory issues and had recently taken a fall.

Morris Brown, the family practice physician who owns the clinic, rotated through Black patients nearly every 20 minutes. Some struggled to walk. Others pulled oxygen tanks. And most carried three pill bottles or more for various chronic ailments.

But Brown called them "lucky," with enough health insurance or money to see a doctor. The clinic serves patients along the infamous "Corridor of Shame," a rural stretch of South Carolina with some of the worst health outcomes in the nation.

"There is a lot of hopelessness here," Brown said. "I was trained to keep people healthy, but like 80% of the people don't come see the doctor, because they can't afford it. They're just dying off."

About 50 miles from the sandy beaches and golf courses along the coastline of this racially divided state, Morris' independent practice serves the predominantly Black town of roughly 3,200 people. The area has stark health care provider shortages and high rates of chronic disease, such as diabetes, high blood pressure, and heart disease.

Such racial inequities are especially severe across the Southeast, home to most of the country's Black population.

But South Carolina remains one of the few states where lawmakers refuse to expand Medicaid, despite research that shows it would provide medical insurance to hundreds of thousands of people and create thousands of health care jobs across the state.

The decision means there will be more preventable deaths in the 17 poverty-stricken counties along Interstate 95 that comprise the Corridor of Shame, Brown said.

"There is a disconnect between policymakers and real people," he said. The African Americans who make up most of the town's population "are not the people in power."

The U.S. health care system, "by its very design, delivers different outcomes for different populations," said a June report from the National Academies of Sciences, Engineering, and Medicine. Those racial and ethnic inequities "also contribute to millions of premature deaths, resulting in loss of years of life and economic productivity."

Over a recent two-decade span, mounting research shows, the United States has made almost no progress in eliminating racial disparities in key health indicators, even as political and public health leaders vowed to do so.

And that's not an accident, according to academic researchers, doctors, politicians, community leaders, and dozens of other people KFF Health News interviewed.

Federal, state, and local governments, they said, have put systems in place that maintain the status quo and leave the well-being of Black people at the mercy of powerful business and political interests.

Legacy of racism

Across the nation, authorities have permitted nearly 80% of all municipal solid waste incinerators — linked to lung cancer, high blood pressure, higher risk of miscarriages and stillbirths, and non-Hodgkin lymphoma — to be built in Black, Latinx, and low-income communities, according to a complaint filed with the federal government against the state of Florida.

Federal lawmakers slowed investing in public housing as people of color moved in, leaving homes with mold, vermin, and other health hazards.

And Louisiana and other states passed laws allowing the carrying of concealed firearms without a permit even though gun violence is now the No. 1 killer of kids and teens. Research shows Black youth ages 1 to 17 are 18 times more likely to suffer a gun homicide than their white counterparts.

"People are literally dying because of policy decisions in the South," said Bakari Sellers, a Democratic former state representative in South Carolina.

KFF Health News undertook a yearlong examination of how government decisions undermine Black health — reviewing court and inspection records and government reports, and interviewing dozens of academic researchers, doctors, politicians, community leaders, grieving moms, and patients.

From the cradle to the grave, Black Americans suffer worse health outcomes than white people. They endure greater exposure to toxic industrial pollution, dangerously dilapidated housing, gun violence, and other social conditions linked to higher incidence of cancer, asthma, chronic stress, maternal and infant mortality, and myriad other health problems. They die at younger ages, and COVID shortened lives even more.

Disparities in American health care mean Black people have less access to quality medical care, researchers say. They are less likely to have health insurance and, when they seek medical attention, they report widespread incidents of discrimination by health care providers, a KFF survey shows. Even tools meant to help detect health problems may systematically fail people of color.

All signs pointed to systems rooted in the nation's painful racist history, which even today affects all facets of American life.

"So much of what we see is the long tail of slavery and Jim Crow," said Andrea Ducas, vice president of health policy at the Center for American Progress, a nonprofit think tank.

Put simply, said Jameta Nicole Barlow, a community health psychologist and professor at George Washington University, government actions send a clear message to Black people: "Who are you to ask for health care?"

The end of slavery gave way to laws that denied Black people in the U.S. basic rights, enforced racial segregation, and subjected them to horrific violence.

"I can take facts from 100 years ago about segregation and lynchings for a county and I can predict the poverty rate and life expectancy with extraordinary precision," said Luke Shaefer, a professor of social justice and public policy at the University of Michigan.

Starting in the 1930s, the federal government sorted neighborhoods in 239 cities and deemed redlined areas — typically home to Black people, Jews, immigrants, and poor white people — unfit for mortgage lending. That process concentrated Black people in neighborhoods prone to discrimination.

Local governments steered power plants, oil refineries, and other industrial facilities to Black neighborhoods, even as research linked them to increased risks of cardiovascular and respiratory diseases, cancer, and preterm births.

An ineffective government response

The federal government did not even begin to track racial disparities in health care until the 1980s, and at that time disparities in heart disease, infant mortality, cancer, and other major categories accounted for about 60,000 excess deaths among Black people each year. Elevated rates of six diseases, including cancer, addiction, and diabetes, accounted for more than 80% of the excess mortality for Black and other minority populations, according to "The Heckler Report," released in 1985. During the past two decades there have been 1.63 million excess deaths among Black Americans relative to white Americans. That represents a loss of more than 80 million years of life, according to a 2023 JAMA study.

Recent efforts to address health disparities have run headlong into racist policies still entrenched in health systems. The design of the U.S. health care system and structural barriers have led to persistent health inequities that cost more than a million lives and billions of dollars, according to the National Academies report.

"When COVID was first hitting, it was just sort of immediately clear who was going to suffer the most," Ducas said, "not just because of differential access to care, but who was in a living environment that's multigenerational or crowded, who is more likely to be in a job where they are an essential worker, who is going to be more reliant on public transportation."

For example, in spring 2020, the North Carolina health department, led by current Centers for Disease Control and Prevention director Mandy Cohen, failed to get COVID testing to vulnerable Black communities where people were getting sick and dying from COVID-related causes at far higher rates than white people.

And Black Americans were far more likely to hold jobs — in areas such as transportation, health care, law enforcement, and food preparation — that the government deemed essential to the economy and functioning of society, making them more susceptible to COVID, according to research.

Until Joshua McCray, the bus driver in Kingstree, S.C., got COVID in his mid-60s, he was strong enough to hold two jobs. He ended up on a feeding tube and a ventilator after he contracted COVID in 2020 while taking other essential workers from this predominantly Black area to jobs in a whiter, wealthier tourist town.

Now he cannot work and at times has difficulty walking.

"I can tell you the truth now: It was only the Good Lord that saved him," said Brown, the rural physician who treated McCray and many patients like him.

Federal and state governments have spent billions of dollars to implement the Affordable Care Act, the Children's Health Insurance Program, and other measures to increase access to health care. Yet, experts said, many of the problems identified in "The Heckler Report" persist.

When Lakeisha Preston in Mississippi was diagnosed with walking pneumonia in 2019, she ended up with a $4,500 medical bill she couldn't pay. Preston works at Maximus, which has a $6.6 billion contract with the federal government to help people sign up for Medicare and Affordable Care Act health plans.

She is convinced that being a Black woman made her challenges more likely.

"Think about how many centuries the same thing has been happening," said Preston, noting how her mother worked two jobs her entire life without a vacation and suffered from health conditions including diabetes, cataracts, and carpal tunnel syndrome. Today Preston can't afford to put her 8-year-old son on her health plan, so he's covered by Medicaid.

In email exchanges with the Biden administration, spokespeople insisted that it is making progress in closing the racial health gap. They said officials have taken steps to address food insecurity, housing instability, pollution, and other social determinants of health that help fuel disparities.

President Joe Biden issued an executive order on his first full day in office in 2021 that said "the COVID-19 pandemic has exposed and exacerbated severe and pervasive health and social inequities in America." Later that year, the White House issued another executive order focused on improving racial equity and acknowledged that long-standing racial disparities in health care and other areas have been "at times facilitated by the federal government."

"The Biden-Harris Administration is laser focused on addressing the health needs of Black Americans by dismantling persistent structural inequities," said Renata Miller, a spokesperson for the administration.

The CDC, along with some state and local governments, declared racism a serious public health threat.

U.S. Rep. Alma Adams, a North Carolina Democrat, pushed for "Momnibus" legislation to reduce maternal mortality. Yet federal lawmakers left money for Black maternal health out of the historic Inflation Reduction Act in 2022.

"I come to this space as an elected official, knowing what it is like to be poor, knowing what it is like to not have insurance and having to get up at 3, 4 in the morning with my mom to take my sister to the emergency room," Adams said.

In the 1960s in North Carolina, Adams and her family would take her sister Linda, who had sickle cell anemia, to the emergency room because they had no doctor and could not afford health insurance. Linda died at the age of 26 in 1971.

"You have to have some sensitivity for this work," Adams said. "And a lot of folks that I've worked with don't have it."

'Like having two strikes against you'

The website for Kingstree depicts idyllic images of small-town life, with white people sitting on a porch swing, kayaking on a river, eating ice cream, and strolling with their dogs. Two children wearing masks are the only Black people in the video, even though Black people make up 70% of the town's population.

But life in Kingstree and surrounding communities is marked by poverty, a lack of access to health care, and other socioeconomic disadvantages that have given South Carolina poor rankings in key health indicators such as rates of death and obesity among children and teens.

Some 23% of residents in Williamsburg County, which contains Kingstree, live below the poverty line, about twice the national average, according to federal data.

There is one primary care physician for every 5,080 residents in Williamsburg County. That's far less than in more urbanized and wealthier counties in the state such as Richland, Greenville, and Beaufort.

Edward Simmer, the state's interim public health director, said that if "you are African American in a rural zone, it is like having two strikes against you."

Asked if South Carolina should expand Medicaid, Simmer said the challenges South Carolina and other states confront are worsened by health care provider shortages and structural inequities too large and complicated for Medicaid expansion alone to solve.

"It is not a panacea," he said.

But for Brown and others, the reason South Carolina remains one of the few states that have not expanded Medicaid — one step that could help narrow disparities with little cost to the state — is clear.

"Every year we look at the data, we see the health disparities and we don't have a plan to improve," Brown said. "It has become institutionalized. I call it institutional racism."

A July report from George Washington University found that Medicaid expansion would provide insurance to 360,000 people and add 18,000 jobs in the health care sector in South Carolina.

"Racism is the reason we don't have Medicaid expansion. Full stop," said Janice Probst, a former director of the Rural and Minority Health Research Center in South Carolina. "These are not accidents. There is an idea that you can stay in power by using racism."

South Carolina's Republican governor, Henry McMaster, in July vetoed legislation that would have created a committee to consider Medicaid expansion, saying he did not believe it would be "fiscally responsible."

Expanding Medicaid in the state could result in $4 billion in additional economic output from an influx of federal funds in 2026, according to the July report.

Beyond health care coverage and provider shortages, Black people "have never been given the conditions needed to thrive," said Barlow, the George Washington University professor. "And this is because of white supremacy."

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