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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Temperatures are dropping in the Commonwealth and community action agencies said help is available for those struggling to pay their heating bills.

The federal Home Energy Assistance Program helps households making less than 60% of the state median income, which for a family of four is just under $95,000.

Liz Berube, executive director of the community action agency Citizens for Citizens, serving the Fall River and Taunton area, called the eligibility requirements very generous.

"These are clearly for people who work, or you were working and you're laid off, you're on worker's comp, people who slip through the cracks," Berube outlined. "This could be the program for you."

Berube pointed out the website HeatingHelpMA.org has information on heating and other energy savings programs, as well as a link to an online application portal.

The Department of Public Utilities recently approved natural gas rate hikes for National Grid and Eversource customers. Monthly bills could increase from 11% to 30%.

Sen. Joan Lovely, D-Salem, said she is already hearing from her constituents in the Second Essex District, wondering how they will make it through the winter.

"Every single day, the biggest call to our office is housing insecurity and how am I going to heat my home," Lovely reported. "How am I going to be able to stay in my home?"

Lovely is grateful for the federal, state and local partnerships making the heating aid program possible.

Joe Diamond, executive director of the Massachusetts Association for Community Action, a coalition of more than twenty community action agencies helping families apply for needed services, said keeping people warm is about more than lowering energy bills.

"It is a health program. It's a safety program. It's a housing preservation program," Diamond explained. "It is also a program that allows people to access other programs."

Diamond noted if households qualify for heating help, they automatically qualify for weatherization programs, which can include new insulation, appliances or heating systems. Public safety officials stressed the programs save both money and lives. They emphasized well-maintained heating equipment is much less likely to cause fire or carbon monoxide poisoning.


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The Save the Children Action Network is asking Iowans to support candidates in the upcoming election who invest time and political muscle in solving children's issues.

Paige Chickering, Iowa state manager for the Save the Children Action Network, is reminding voters about the importance of early education, high-quality affordable child care and school meals for kids. She noted a growing percentage of them are hungry and their families rely on some form of government help.

"In Iowa specifically, USDA data show that about 40% of SNAP beneficiaries -- and that's the Supplemental Nutrition Assistance Program -- are children," Chickering explained. "About one in six children, 15.4%, face hunger in Iowa, according to a Feeding America study."

Chickering pointed out the Save the Children Action Network has endorsed a slate of bipartisan candidates in statewide races who have adopted strong positions on children's issues, including taking on hunger in Iowa.

Chickering highlighted a Ready Nation study shows the critical shortage of child care options in Iowa is costing the state at least $1.2 billion in parents' lost wages and productivity every year. She added helping kids should not be up for debate.

"The issue of prioritizing children in Iowa is a really, truly bipartisan issue," Chickering asserted. "It's been really clear from all the people that we've worked with, our volunteers, everyone we've spoken with, that this is something that everyone is prioritizing."

The action network is also calling on Iowa politicians to approve the summer "Sun Bucks" program in 2025, which would make food available to lower-income families when kids are out of school for the summer. Iowa opted out of the program this year.

Advocates in the antipoverty community said lawmakers are not doing enough to help people escape poverty.

They said the inaction is increasing the number of ALICE families in Arkansas and nationwide. ALICE families are Asset Limited, Income Constrained and Employed, which means they are working but do not earn enough money to cover their expenses.

Wade Rathke, founder and chief organizer of the nonprofit ACORN International, said lawmakers need to adjust the federal poverty line to assist more people.

"If the poverty line doesn't reflect reality, then people suffer," Rathke stressed. "Some members of Congress have advanced a bill to more realistically set the poverty level but given the dysfunction and general election year inertia, there hasn't even been a vote."

He added many states, especially in the South, are setting benefits as low as possible.

The current federal poverty line is $31,200 a year for a family of four. According to the United Way, in 2021 about 36 million households met the criteria to be labeled ALICE. The organization has seen a significant increase in calls to its 211 call centers from people seeking help with housing, child care and utilities.

Rathke pointed out more families are suffering as pandemic subsidies are gone.

"Even working families with income over $100,000 are calling because they can't make groceries given all of household costs," Rathke reported. "Two-worker parented families have no savings or ability to handle emergencies."

Advocates said part of the problem is the cost of groceries is used to determine the poverty line but families are spending more on housing, rent and utilities.

This story is based on original reporting by Wade Rathke for The Chief Organizer Blog.


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