By Tess Vrbin for The Arkansas Advocate.
Broadcast version by Freda Ross for Arkansas News Service reporting for The Arkansas Advocate-Winthrop Rockefeller Foundation-Public News Service Collaboration.

Brandy Sandersfeld had been putting off a minor surgery for her 4-year-old son, Cypress, for months.

Over three weeks this spring, the Sandersfelds made four trips to Arkansas Children’s Hospital in Little Rock from their home in Big Flat. Having enough gas money for multiple five-hour, 240-mile round trips was stressful, and it wouldn’t have been an issue if the family still had the financial support of the federal child tax credit, which ended in December 2022, Sandersfeld said.

What pushed her to go forward with Cypress’ surgery was the fact that the grant funding her job at the University of Arkansas System was about to expire, she said. She and her two sons have now been without health insurance since July 1.

In 2020, Sandersfeld and her husband moved “away from the hustle” of exurban life in Eureka Springs, and they value their rural community, but they’ve taken on the difficulties of being far away from the specific health care resources their children need, she said. Jasper, their 11-year-old son, needs both physical and behavioral therapies.

“To drive three hours three times a week for physical therapy [is] just not financially doable once I lose this job,” she said in May.

The family’s struggles obtaining health care for their children are among the tough realities Arkansans face if they’re asset limited, income constrained and employed (ALICE), especially in rural areas. ALICE signifies households earning enough money to be above the federal poverty line but struggling to afford the cost of living in their area.

“I make enough money to get by, but too much money to find any programs or resources [for low-income people] and not enough money to have any sort of stretch in my budget,” Sandersfeld said.

Data from United for ALICE, a research movement led by United Way of Northern New Jersey, shows North Central Arkansas, where the Sandersfelds live, and the Delta as regions with the state’s highest percentages of ALICE and poor households.

The annual “household survival budget” for ALICE families in Arkansas varies greatly depending on each county’s cost of living and the number and ages of the people in the household, according to United for ALICE. For a single ALICE adult, the necessary annual income to get by ranges from $22,488 ($11.24 per hour) in Monroe County to $31,152 ($15.58 per hour) in Pulaski County.

For a couple with two school-aged children, that threshold rises to $57,732 ($28.87 per hour) at the low end, again in Monroe County, and $72,120 ($36.06 per hour) at the high end in Benton County.

In the Sandersfelds’ home of Searcy County, the threshold is $30.75 per hour and $61,500 per year.

Affording health care can be a struggle even for well-off Arkansas families, according to United for ALICE.

“In November 2022, nearly one in four Arkansans — both above and below the ALICE Threshold — reported that they had an unexpected major medical expense that they had to pay out of pocket for because it was not completely paid for by insurance,” the group’s 2023 ALICE report states.

Unexpected medical expenses can lead to medical debt, which is “more concentrated in the South and among residents of low-income ZIP codes,” the Urban Institute reported in 2022.

Some states provide protections from medical debt for low-income people whose insurance plans require cost-sharing, but Arkansas is not one of those states.

ALICE households struggle to be prepared for both retirement and financial hardship, according to United for ALICE data. In 2022, only 32% of households below the ALICE threshold in Arkansas, Oklahoma, Texas and Louisiana had three months’ worth of savings that could cover a medical or economic emergency, an increase from 30% in 2019. 

Additionally, Arkansans in rural areas face challenges that might not be directly related to health care or insurance but might have an impact on their ability to access both, said Craig Wilson, director of health policy at the Arkansas Center for Health Improvement and a member of United for ALICE’s state research advisory committee.

“You don’t think that something’s going to happen to you in the immediate term,” Wilson said. “When you’re thinking about the hierarchy of needs, you’re thinking about food, transportation, housing and all those other things that are very much immediate needs and not so much [about] insurance.”

Scarcity of services

Sandersfeld has applied for her children to receive insurance from ARKids First, Arkansas’ Medicaid program for children, and she said she is waiting for the state Department of Human Services to process her application. Her husband, Kurtis, is a construction worker and does not have access to employer-provided coverage.

“I’m a little excited about ARKids because my insurance right now doesn’t pay enough for [therapies] to make a difference, but now I have a new issue: I’m going to have availability for these services, but I have nobody to provide these services,” Sandersfeld said.

Searcy County is one of several Arkansas counties that do not have hospitals, according to the Arkansas Department of Health. Many counties also had very few full-time primary care physicians per 10,000 residents in 2020, according to ACHI data.

The cities closest to Big Flat with any health care providers at all are Marshall and Mountain View, each more than 20 miles away on roads that twist through the Ozark Mountains and require more time and gasoline than flatter terrain.

Long-distance travel for health care is not unique to North Arkansas. Many specialized medical services are only available to Arkansans if they travel out of state or to the Little Rock or Northwest Arkansas metropolitan areas.

The nonprofit Community Health Centers of Arkansas has about 50 sites statewide that provide primary care services with a sliding scale cost system, depending on the patient’s ability to pay. Dr. Lanita White, the nonprofit’s CEO and a University of Arkansas for Medical Sciences professor, said in February that not enough Arkansans are aware of this resource, calling it “a PR issue.”

Phillips County in the Delta has two community health centers, but the number of beds at the local hospital in Helena-West Helena has shrunk to 25 when at one point it was 120, said Donna Dunlap, who has been a nurse in the county for 33 years.

Physicians from more populous areas used to regularly visit Phillips County, but the decline in population in the county and the region has led to fewer available health services, Dunlap said.

“We had surgeons, we had an orthopedic doctor that came to the area, we had cardiologists,” she said. “They may have had to travel in from another town — a lot of times they would come from Little Rock — but at least we had those services available for our patients to go locally instead of having to travel two hours to see someone.”

Barriers to care

While state officials have increased Arkansas’ minimum wage over the past several years, Medicaid income limits have not been adjusted accordingly, which has created coverage gaps, Dunlap said.

“A lot of people [are] kind of falling through the cracks on the kind of health care they can receive,” she said. “Say they’re covered at work, but they can’t afford to cover their spouse or their family.”

Melissa Cleveland of Harrison is also a nurse and said she has had this experience: she is covered by her employer’s insurance, but covering her family would reduce her paycheck by an untenable amount. Her family is already “barely making it” since her husband cannot work due to disabilities, she said, and her three children were covered by ARKids before unexpectedly losing coverage earlier this year.

“You’re paying a high deductible for a cheaper plan, but you’re still losing money and you can’t ever climb out of that,” Cleveland said. “It’s just going to keep you under, and you get denied crucial benefits just because an insurance [company] looks at you on a piece of paper and says, ‘Nope, you don’t need that, we’re not going to pay.’”

Alison Guthrie of Little Rock said she had to turn down a job offer that pays more than her current employer because the medical expenses she would have incurred after losing Medicaid coverage would have led to an overall financial loss.

Guthrie needs a wide range of specialists and medications to treat her Ehlers-Danlos syndrome, which causes chronic pain, gastrointestinal issues and a host of other problems, she said. The job she turned down had a “generous” insurance policy but still would not have covered as many copayments as Medicaid does, she said.

“Being chronically ill is a full-time job,” Guthrie said. “There are times when you can’t function and you have no control over that, and if you’re not salaried and you’re paid by the hour, you’re screwed that way too.”

While Guthrie has the benefit of living in the vicinity of the specialized care she needs, low-income people in poorer, less resourced areas such as Southeast Arkansas might not even seek primary care, said Isierene Brown, who was the nurse at Reed Elementary School in Dumas until she lost her job in the school district’s recent layoffs.

Residents of Desha County often don’t have the means or the time to go to the doctor, so they “opt out not to do it, and they just hope for the best,” Brown said.

Potential remedies

In her 25 years as a school nurse, Brown saw students consistently develop respiratory illnesses such as the flu, strep throat and COVID-19 as a result of a lack of preventative health care, she said. She added that many children in the Dumas School District aren’t vaccinated against these illnesses because their parents are vaccine-resistant due to insufficient education.

“We definitely need more clinics and more doctors, but when you don’t have a lot to offer people — I mean, we don’t even have a Walmart — people don’t want to relocate to our area of the state,” Brown said.

Most physicians practice in the same state where they complete their residencies, and the University of Arkansas for Medical Sciences sponsors roughly 80% of residencies statewide. Medical school graduates have outpaced available residency slots throughout Arkansas the past few years, according to ACHI data.

Republican U.S. Sen. John Boozman, an optometrist from Rogers, has been sponsoring multiple bipartisan bills to create more residency slots nationwide and retain the doctors that train in those positions, particularly in rural areas. One proposal would allow medical and dental school graduates to pause student loan payments during their residencies, and another would give areas where a hospital has recently closed — often in rural communities — a greater chance of receiving new residents.

Meanwhile, President Joe Biden’s federal fiscal year 2025 budget proposal calls on Congress to revive the child tax credit and expand it “from $2,000 per child to $3,000 per child for children six years old and above, and to $3,600 per child for children under six.” The new federal fiscal year begins Oct. 1.

A $78 billion tax package moving through Congress would fulfill the request, but it stalled in the U.S. Senate in March after Republicans compared the child tax credit to welfare programs.

In May, Sanderfeld was one of five mothers from across the country invited to the White House to advocate for the return of federal aid for families with children.

Sandersfeld said she and her husband could afford preventative health care for their children, including the cost of travel, when the child tax credit gave them “a little bit of surplus” financially.

“We didn’t have to worry about unexpected health expenses or these copays at the children’s hospital,” she said. “…When you give people enough money to make good decisions for their family, they will.”


Tess Vrbin wrote this article for The Arkansas Advocate.


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For six decades, the U.S. has been carrying out a coordinated effort to keep poverty levels in check.

Support offices in North Dakota say while needs may change, their multi-faceted approach to improving outcomes remains intact.

Policy analysts say poverty rates in the U.S. are well below where they were when President Lyndon Johnson declared a war on poverty in 1964. But they also note the mission is far from over.

Erv Bren is the executive director of the Community Action Partnership office in North Dakota's Williston region.

He said no matter what the landscape looks like, his staff takes a deep look at each client's situation as they map out a plan toward a better future.

"They look at their budgets, whatever it may be," said Bren, "so that they can be self-sufficient and hopefully land a decent, stable job."

Bren said he feels there are still misconceptions that low-income individuals simply need to find a job and their problems will be solved.

Community Action Agencies, celebrating their 60th anniversary, assist with things such as job training and housing stability to ensure a client can move up in the world without having setbacks.

North Dakota's poverty rate is currently at 11.5%.

Kari Schultz is the client services director for the Williston office. She said she feels a lot of their work still flies under the radar.

"[It's] like, 'Oh, I didn't know that you help with cooling assistance for seniors' or, 'I didn't know that you provided veteran supportive services,'" said Schultz. "It's getting that education piece out instead of just having the sign on the corner of the building."

Bren said putting energy into needs that rise to the top is key in preventing things from spiraling out of control.

A lack of housing is fueling demand right now, and he says after the pandemic upended progress in reducing poverty, his team is focused on renewing stability within the region.

The good news, he said, is that jobs are available. Clients need to realize the opportunity.

"Once you're out of the workforce for a while, you lose touch," said Bren. "You lose the connection and it's just the challenges that come up that are beyond the individual's control."

With chants of "We are the swing vote," poor and low-wage workers gathered in Washington, D.C., recently to rally and strategize ahead of the election.

The Poor People's Campaign describes itself as "a national call for moral revival," and advocates for a so-called "Third Reconstruction" which would address the crisis of poverty. Leaders cited research showing poverty is the fourth-leading cause of death nationwide.

William J. Barber II, co-chair of the Poor People's Campaign, said with more than 140 million poor and low-wage workers in the nation, empowering the group to vote is critical.

"Poor people make up 30% of the electorate now, 40% in every battleground state," Barber pointed out. "Poor people and low-wage workers are the largest swing vote in the country. Every state where the margin of victory was within 3%, poor and low-wage voters make up over 43% of the electorate."

The Campaign estimated low-income Marylanders account for about 21% of the electorate.

The rally included religious leaders, workers, and representatives of organized labor from across the nation. The Campaign believes all workers should have the right to join unions and receive equal pay for equal work. Unfair pay was highlighted by members of the Association of Flight Attendants-CWA.

London Lester, a flight attendant for PSA Airlines and a member of the union, said the big carriers use subsidiaries to avoid paying fair wages.

"Most of you probably don't recognize my airline, PSA, when you fly. We fly the smaller planes under the American Eagle brand, and we're owned by American Airlines," Lester pointed out. "We wear the same uniforms, we do the same work but our corporate bosses have created 'tiers' between regional and mainline, so that they can pay a huge part of the workforce poverty wages."

While Maryland has raised the state minimum wage to $15 an hour, the living wage in the state is estimated to be $24 an hour for one person, and nearly $42 an hour for an adult with one child.

Some Missouri nonprofit groups have teamed up to help those in need in the rural southeastern part of the state.

Many households in these communities struggle to pay their electric bills, as poverty rates are 10% higher than the state average. The local electric utility provider has been criticized for not doing more to help alleviate the financial burden. In response, Renew Missouri is partnering with churches and other nonprofits to help people get signed up for state and federal energy assistance programs.

Jessica Polk Sentell, eastern director for Renew Missouri, works with the Ministerial Alliance at its food banks.

"I have been there with some literature and educational materials," Polk Sentell explained. "To help bring some education and some visibility and some outreach, to these programs that help people pay their energy bills."

She pointed out Renew Missouri's mission is to advance renewable energy and energy efficiency in the state. To be eligible for assistance, you must be a Missouri resident, a U.S. citizen or legal permanent resident. You must have no more than $3,000 in bank or retirement accounts, or investments and meet the income guidelines for your household size.

Brian Abbott, pastor of Trinity United Methodist Church in Piedmont, also serves as president of the local Ministerial Alliance. He said there are many people coming in for help and while they do their best with food banks and food trucks, it is a growing challenge.

"We don't have the resources, coming out of COVID and a lot of other things that have gone on in the last five years or so in the economy," Abbott emphasized. "It's really left a gap there for us, you know. We're telling a lot of people, 'We understand you may have a shut-off notice, but we just don't have the funds to help with that.'"

The Renew Missouri initiative is also bringing relief to under-resourced Community Action Agencies, which often struggle to connect households with resources to help pay their energy bills.


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