Black Americans in the South carry the largest share of medical debt. Advocates say Medicaid expansion can help.

• Americans in the South hold an average of $532 in medical debt, according to a recent study.
• Nearly 28% of households with a Black member had medical debt compared to 17.2% of White households.

A new report highlights that Black Americans in the South carry the heftiest medical debt burden in the US.

The Bloomberg analysis shows a myriad of ways medical and healthcare institutions pursue collecting more than $140 billion in US medical debt, which is the leading cause of bankruptcy in the country.

The Journal of the American Medical Association survey showed Americans in the South hold an average of $532 in medical debt - with a Census survey also finding households with at least one Black American holding 28% of medical debt.

Black Americans are also more than twice as likely to be uninsured than their white counterparts, which healthcare professionals say can lead to higher mortality rates. Experts say this is largely due to Republican governors and state legislatures in Southern states who continue to block the passing of Medicaid expansion.

Insider spoke with advocates who say Medicaid expansion alone could mitigate the impact of medical debt on Black Americans.

"The data is so clear on this," Astra Taylor, a spokesperson for Debt Collective, told Insider. The Debt Collective is a debtors' union working to cancel all forms of debt within US households.

"The states that haven't expanded Medicaid have more medical debt for poor and vulnerable populations," Taylor added. "So there is an absolute cause and effect here."

Advocates argue Medicaid expansion would improve health outcomes for Black Americans

The US healthcare system is complex with many entities eligible to report medical debt to collectors. Nonprofit hospitals, insurers, even independent service providers have the ability to report medical debt to bill collectors.

Under the Affordable Care Act, Medicaid expansion – which began in 2014 – provided health coverage for an additional 12 million people across the country. However, there are an estimated 30 million people still uninsured, which advocates say can have long-term consequences.

Uninsured Americans are more likely to postpone urgent treatment and less likely to seek preventive care for major health conditions and chronic diseases because they'd have to pay out of pocket.

Often, when they do see a doctor it is typically too late because the illnesses have progressed.

According to a study by University of Southern California, which looked at data from 2014 to 2018, of the 32 Medicaid expansion states and 17 non-expansion states, found Medicaid expansion was associated with nearly 12 fewer deaths per 100,000 US adults annually.

"The reduction in all-cause mortality was most associated with the number of women and non-Hispanic Black residents in each state," researcher Dr. Brian Lee wrote in the study

Lee added that "states that have chosen not to expand [Medicaid] have higher proportions of poor and Black residents, so they may have the most to gain" from the program's expansion.

Southern states have continued to reject Medicaid expansion

Republican-led, Southern states have continued over the years to delay movement on passing Medicaid expansion, which allows individuals to qualify for medical coverage on their income alone.

Some Republican legislators have argued that medical coverage should be offered to those who are employed. While others say that the expansion could be a financial risk to their state budgets despite Federal pledged dollars toward the program.

Under the expansion, the threshold to qualify for Medicaid is a household income below 133% of the federal poverty level.

This year, Texas, Florida, Mississippi, Alabama, Georgia, North Carolina, South Carolina and Tennessee have rejected moves to expand Medicaid. Louisiana, Arkansas, and Oklahoma have all expanded Medicaid. Wisconsin, Wyoming, Kansas and South Dakota also haven't expanded Medicaid.

While Republican governor's have led this blockade, in North Carolina, a GOP supermajority in the state legislature has stood in the way of Democratic Gov. Roy Cooper's fight.

The Center of Budget and Policy Priorities estimates, Florida's population makes up the highest share of uninsured Black people in the country at more than 17%. This can be tied directly back to Floridia being one of 12 states that hasn't expanded Medicaid.

Still, Florida Gov. Ron DeSantis has repeatedly proclaimed he's not on board with expanding the program and says that's because of fiscal responsibility despite estimates indicating it would deliver healthcare to 800,000 Floridans who are uninsured.

In a Center of Budget and Policy Priorities survey earlier this year, Medicaid expansion states had smaller medical debt gap between Black and white communities than non-expansion states.

Meanwhile, more than 15% of Black Georgians are uninsured.

Georgia Gov. Brian Kemp has continued to push for a mandatory work requirement in order to qualify for Medicaid, which was rejected by the federal government.

"This is not a free handout. Hardworking Georgians who qualify will have skin in the game," the governor said in 2019. "It is a path forward toward higher earnings, better opportunities and a healthier future."

Fair Fight Action paid off more than $210 million in medical debt for more than 108,000 individuals across the South, including 68,000 Georgians last month.

The advocacy group was founded by Georgia gubernatorial candidate Stacey Abrams, who championed the need to expand Medicaid coverage in Georgia since the movement was first launched to combat voter suppression in Southern states.

That work continues now as an economy wrecked by the COVID-19 pandemic has worsened debt and inequity in healthcare.

"Medicaid expansion is critical to relieving families who continue to struggle amid an ongoing pandemic," a Fair Fight representative, Xakota Espinoza, told Insider.

Espinoza added that the expansion is "fundamental to addressing disparities Black Georgians face in accessing quality affordable healthcare, which have been only further exacerbated throughout COVID-19."

Southern-based advocacy groups combating inequity in healthcare, including the Equal Justice Initiative and Dollar For, have worked to obtain medical debt forgiveness for vulnerable communities.

Dollar For, a nonprofit advocacy group, has paid off more than $10 million in medical debt since the organization started in 2012.

"Our core belief is that a medical crisis should not be followed by a financial crisis," Dollar For's mission statement reads. "Unfortunately, with the current healthcare system in the US being what it is, that's the case more often than not.

Advocates stress that Black Americans have to be at the center of fighting for change, Taylor says

In the Build Back Better Act making its way through the US Senate, there is a provision to expand insurance coverage directly to states that have not thus far.

A Kaiser Family Foundation analysis found that Medicaid expansion nationally would bring coverage to more than 2.2 million people, about 60% of those of color.

Taylor, a Representative for Debt Collective, says that's a significant step.

However, she tells Insider an action that would have a larger impact would be if President Joe Biden's administration began to penalize nonprofit hospitals — the most common in the country — for not offering specific charity-free services to people who qualify.

She calls on the federal government to take away the nonprofit status of hospitals refusing to provide that resource. Debt Collective says the solution is to organize for a more robust universal healthcare system within the US.

Black Americans in particular, Taylor says, need to be at the center of this fight because, as the study notes, they are the most impacted by the construction of the current system.

A previous version of this story erroneously stated that Black Americans hold an average of $532 in medical debt. That figure is for all Americans located in the Southern US.