The reason, according to Mahoney’s research, appears to tie into the decision by many states in the South to not expand Medicaid as allowed under the Affordable Care Act (ACA). By comparison, in states that chose to broaden their public health insurance for low-income individuals, total medical debt fell significantly more, and the rates at which their residents—including those who live in the lowest-income areas—accumulated new debt from one year to the next also declined.

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Paying the Bills: The Financial Realities of Health Care and Rural America