Marlboro County is at the heart of what the Centers for Disease Control and Prevention calls the “Diabetes Belt” — 644 mostly Southern counties where rates of the disease are high.
And of those counties, NPR found that more than half have high levels of medical debt. That means at least 1 in 5 people have medical debt in collections.
That’s much higher than the national rate, which is 13%, according to the Urban Institute, a social-policy nonprofit. In Marlboro County, 37% of people have medical debt in collections.
NPR measured the overlap of Diabetes Belt counties and high medical debt counties by merging the institute’s medical debt database with the CDC’s list of Diabetes Belt counties.
Institute economist Breno Braga says medical debt, like diabetes, is concentrated in the South.
“The single most important predictor of a county’s medical debt is the prevalence of chronic conditions. So it’s basically the share of the population that has disease, such as diabetes, hypertension and other types,” he says.
More than 1 in 3 residents of the surrounding county have medical debt in collections, and 1 in 3 live in poverty.
It wasn’t always this way, locals tell NPR. The area once hummed with manufacturing companies, restaurants and other amenities. There were plenty of good jobs to go around.
But one by one, employers moved out. Today, downtown Bennettsville is pretty quiet. South Carolina as a whole has nearly 100,000 fewer manufacturing jobs than it did in 2000.
“Bennettsville used to be a more thriving community years ago,” says nurse practitioner Pat Weaver. “With a lot of our plants leaving for, you know, overseas in the last 15-20 years really made a devastating impact. We used to have a hospital here and now we no longer have that. It is very poor.”
Weaver works for CareSouth, a nonprofit health center that has a federal government designation as a safety net provider.
As she walks the halls of the clinic, checking on colleagues and patients, she says that of the 3,300 appointments she takes every year, more than 90% of them have Type 2 diabetes.
She and others point to Bennettsville’s changing economic fortune as a source of health problems in the community. Half the households in the city have an income less than $32,000.
She says lower-income residents often can’t or don’t choose the kinds of healthy meals that would help them control their diabetes.
“The fast foods don’t help at all, and a lot of people just eat it every day, and that’s a problem. It truly is,” Weaver says. “But we have programs to help them. We even have a program where we take patients to the grocery store and we teach them what to buy.”
CareSouth takes other steps, too, to fight the effects of poverty and disease in Bennettsville. The center has a sliding fee scale based on ability to pay and an in-house pharmacy that uses a federal program to keep drug prices down.
Seventy-nine out of the 100 counties with the highest levels of medical debt are in states that have not expanded Medicaid under the ACA.
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 have declined, and where NPR identified more than two dozen counties that fall within the Diabetes Belt and have high rates of medical debt. There’s evidence from other states that people became healthier and owed less money to medical providers after Medicaid expansion.
A Boston University researcher looked at health centers just like CareSouth — more than 900 of them serving nearly 20 million patients.
The centers in states that did expand Medicaid reported better diabetes control than those in states that didn’t expand the program, and the effect was quick — within three years of the expansion.
Those improvements happened consistently among Black and Hispanic patients, who have higher rates of diabetes.
A study in Louisiana found that people who gained Medicaid coverage after an expansion there had reduced medical debt.