She said she kept telling her doctor something was wrong.

Her doctor told her, “Just wash your underwear in Dreft,” Jones said, referring to a brand of detergent.

Within months of that 2016 appointment, Jones, who lives in a suburb of Jackson, Mississippi, was diagnosed with stage 3 cervical cancer. She underwent a hysterectomy then weeks of radiation therapy.

“I ended up fine,” said Jones, now 43. “But what about all the other women?”

The question is especially pertinent in Jones’ home state, which had the nation’s second-highest age-adjusted cervical cancer mortality rate, women and girls annually from 2016 through 2020, behind only Oklahoma, according to National Cancer Institute data. And, for non-Hispanic Black women such as Jones, the rates in the state are even higher — 3.7 deaths per 100,000 people. This all translates to about 50 avoidable deaths of Mississippi women from cervical cancer each year in this largely rural state.

Health care experts said such a high death rate from a cancer that is preventable, detectable, and successfully treatable when found early is a warning sign about the general state of health care in Mississippi.

“They desperately need help there,” said , a professor of oncology at Johns Hopkins School of Medicine and an expert on health disparities. “Political leadership is incredibly important in turning this around, and in Mississippi, the political leadership don’t give a damn.”

Despite the beauty of Mississippi, from the rolling hills of the to white-sand beaches on the Gulf of Mexico, and the cultural renown of its famous musicians and storytellers, the state’s reputation is marred by its high rates of poverty. People who live there are accustomed to being the butt of jokes, but it hurts.

“Often Mississippi gets represented poorly,” said , an OB-GYN at the University of Mississippi Medical Center in Jackson.

Recently the state has reeled from crisis after crisis. As recently as March, tornadoes and other severe weather and caused extensive damage. Last year, the , the state capital, was undrinkable for months because of treatment plant failures.

On just about any measure of health, Mississippi ranks near or at the bottom. Nationally, an of people under 65 lack health insurance, but in Mississippi it is . Deaths from , , , and many other illnesses are among the highest per capita in the country.

The high rates of poverty contribute to the high cervical cancer mortality, health experts said. About of Mississippians — nearly 1 in 5 — live in poverty, while nationally it is .

“If I had to pinpoint what that’s from, it’s from lack of education,” said Ridgway, referring to a lack of knowledge about regular cervical cancer screening, which the U.S. Preventive Services Task Force for women 21 to 65.

But it likely goes far beyond that, many health experts said. Doctors may be less likely to stress preventive care to less educated women and women of color, .

“There’s a big difference in the quality of care,” said , a professor of public health at the University of Virginia who has extensively studied oncology care in Appalachia and other underserved areas.

In her case, Jones said, she could not get her doctor’s office to return her calls in a timely manner. She was concerned about her symptoms.

“I felt I wasn’t listened to. I called her more than she called me,” Jones said of her doctor. “I was going to my appointments, and I was ignored.”

And getting access to any care — let alone quality, culturally competent care from providers who acknowledge a patient’s heritage, beliefs, and values during treatment — may be difficult.

Most of the state’s 82 counties are rural. The average travel distance to a grocery store is 30 miles, and half the population lives in a county that is considered medically underserved, said Letitia Thompson, a vice president in Mississippi for the .

Low-income rural residents often lack reliable transportation, she said, and even if they own a vehicle, they lack gas money. They often can’t find — or pay for — someone to take care of their children so they can go to the doctor. Women with low-paying jobs often lack the time to drive to a clinic in a distant town, or the ability to take off from work without losing pay.

“Women who work and take care of children often have a huge burden of responsibility,” Ridgway said. “They don’t have time or the money.”

Many also don’t have insurance. While the Affordable Care Act has in Mississippi, an estimated additional could have coverage through Medicaid if the state expanded eligibility for the federal-state insurance program for low-income Americans. But the state is that have not agreed to expand coverage to more adults.

Mississippi Gov. Tate Reeves, a Republican up for reelection this year, is opposed to expansion. His Democratic challenger, Brandon Presley, a second cousin of the music legend Elvis, favors it. Polls show Presley

Without expansion of Medicaid, people who have low incomes are often left to decide between forgoing insurance and purchasing a policy through the Affordable Care Act marketplace if they cannot get insurance through employment. Even if they qualify for subsidized marketplace plans, they may face high deductibles or copayments for visits, health experts said. That often means going to the doctor only when sick. Preventive care becomes a luxury.

“You save your health care dollars for when you are sick or your kids are sick,” said Thompson, of the American Cancer Society.

But regular medical care can make all the difference with cervical cancer. Pap tests have long helped detect abnormal cervical cells that could turn malignant. Brawley said the test is “one of the best” cancer screening tests because of its accuracy.

In 2006, were first approved by the FDA. The vaccines guard against the common sexually transmitted infection called the human papillomavirus, which causes nearly all cervical cancers. The HPV vaccine is most effective when administered before a person has become sexually active; the federal recommendation is to get the shots by age 12.

Only a handful of places in the U.S. — including Hawaii, Rhode Island, Virginia, Puerto Rico, and the District of Columbia — require the vaccines to attend school. California has that initially would have required that middle schoolers get the shots, but the bill has since been watered down to recommend them instead.

Mississippi does not require the vaccine, and the state has had the lowest share of fully vaccinated teens by a large margin for years. Fewer than 39% of teens there were up to date on HPV vaccination as of 2022, , compared with an estimated 63% nationally.

Thompson said she thinks many parents are hesitant to have their children vaccinated because they believe it would encourage sexual activity.

“This is an anti-cancer vaccine,” Thompson said.

Krista Guynes, director of the at the Mississippi State Department of Health, said the state has several efforts underway to better inform women about the need for screening. It also has clinics for uninsured women. In partnership with the National Cancer Institute and University of Mississippi Medical Center, she said, the health department is to evaluate risk and look for new biomarkers in women undergoing screening for cervical cancer.

As for Jones, she considers herself lucky to have survived stage 3 cancer.

“I would just like to say to every woman, ‘Get the vaccine.’ The vaccine will make the difference, so they won’t have to be told, ‘I’m sorry, you have cancer.’”

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The reasons for the gap are vexing, experts said, but may provide an important window into unique challenges faced by Black men as they try to gain not only good health but also an equal footing in the U.S.

Generally, higher education means better-paying jobs and health insurance, healthier behaviors and longer lives. This is true across many demographic groups. And studies show life expectancy is higher for educated Black men — those with a college degree or higher — compared with those who have not finished high school.

But the increase is not as big as it is for whites. This comes on top of the many health obstacles Black men already face. They are more likely to die from chronic illnesses like cardiovascular disease, diabetes and cancer than white men, and their life expectancy, on average, is lower. Experts point to a variety of factors that might play a role, but many said the most pervasive is racism.

Researchers note that Black women face many of the same challenges as Black men, but Black women generally have a longer life expectancy than Black men. (They also point out that it is hard to draw conclusions about Hispanic residents because of a lack of studies on the issues.) As a result, many experts said that the health problems stem from a persistent devaluation of Black men in U.S. society.

“At every level of income and education, there is still an effect of race,” said David Williams, a professor of public health at Harvard University who developed a scale nearly 30 years ago .

The precise difference in health gains between educated white men and educated Black men is hard to pinpoint because of differences in study designs. Some studies, for example, look at life expectancy, while others look at disease burden or depression.

Experts said, however, that the evidence is strong and convincing that these gaps have persisted over many years. A published in Health Affairs, for example, found that life expectancy for white men with the most education was 12.9 years longer than for white men with the least education. For Black men, the difference was 9.7 years.

In addition, other research shows how that gap plays out. A — years cut off because of health challenges — between the groups. Educated Black men lost 12.09 years, while educated white men lost 8.34 years, according to the study, published in the Journal of Health and Social Behavior.

Racism affects Black men’s health and it is persistent, experts said.

“No matter how far you go in school, no matter what you accomplish, you’re still a Black man,” said Derek Novacek, who has a doctorate in clinical psychology from Emory University and is researching Black-white health disparities at UCLA.

S. Jay Olshansky, a professor of epidemiology and biostatistics at the University of Illinois in Chicago and lead author of the 2012 study, said possible risk factors for various diseases and environmental issues could also play a role: “I’d be very surprised if this wasn’t part of the equation. The risk of diabetes and obesity is much higher among the Black population, even those that are highly educated.”

Among other possible causes that researchers are probing are stress and depression.

“When you follow other groups, with more education depression declines,” said Dr. Shervin Assari, associate professor of medicine at Charles R. Drew University of Medicine and Science in Los Angeles County, California, who studies race, gender and health. “But when you look at Black men — guess what? .”

Depression is often an indicator of physical well-being as well as a contributing factor to many chronic illnesses, such as hypertension, obesity and diabetes.

Isolated at Home and Work

Researchers who study the health of various racial and ethnic groups, as well as the social factors that influence health outcomes, see cause for concern. The findings suggest that the power of discrimination to harm Black men’s lives may be more persistent than previously understood. And they could mean that improving Black men’s health may be more complicated than previously believed.

“What has surprised me is how powerfully and consistently discrimination predicts poor health,” said Williams.

the issue. As early as last April researchers noticed higher death and hospitalization rates for Black people. The patterns have persisted, with Black patients being to die of the virus and Black men have the of covid deaths.

The covid outcomes, Williams and others suggested, helped point out that the health and well-being of middle-class, educated Black men have been overlooked.

Higher education hasn’t brought about the health equity many experts had expected. While Black men have worse health than other groups if they are not educated, they can’t catch up to their white peers even when they are.

“What society has done to Black men is to corner them,” Assari said.

Black men, even with an education, have less of a financial and social safety net than white men. That brings added stress, the experts said. Also, as Black men climb a corporate, academic or managerial ladder, many feel isolated. And social isolation harms health.

Thomas LaVeist, a sociologist and dean of the school of public health at Tulane University, said that in a white-dominated society Black men are less likely to have family members with high incomes or social and business connections who can open doors for them. And once hired into the workplace, they are less likely to have mentors, LaVeist said, and that lack of connections is associated with stress, depression and other factors that can lead to poorer health.

“There needs to be a designated effort to provide an on-ramp” for Black men, he said.

And they may have experienced more cumulative adversity and continued racism.

“Your high socioeconomic status doesn’t protect you from the impact or from the incidence” of racism, said Dr. Adrian Tyndall, associate vice president for strategic and academic affairs at University of Florida Health.

“That is difficult,” added Tyndall, who is Black. “If I were to walk out of this institution and into the community, where people don’t know me, I could be called the N-word. And yeah, that’s pretty depressing.”

The Need to Prove Yourself

The cumulative effect of discrimination takes a toll psychologically and physiologically — but so does the anticipation of it.

“It’s not just the actual exposure in dealing with these kinds of experiences, but it’s ‘What do you do before leaving home?’ You’re careful about your dress, your behavior, the way you look because of the threat of discrimination, and so you react,” said Williams, the Harvard professor.

For example, when Williams, who is Black, first became a professor at Yale University, he wore a coat and tie every day. No one else in his department did that. And yet, he said, he kept up the practice for years.

LaVeist remembers getting onto an elevator at an academic medical center around 1990, shortly after earning his Ph.D., and a passenger wearing a white coat — presumably a doctor — assumed LaVeist worked in housekeeping. The man asked LaVeist, who was dressed in a suit, to clean up a spill on the sixth floor.

“When I told him that I was a professor, he didn’t speak,” said LaVeist. “He simply didn’t speak.”

Greg Pennington, 67, of Atlanta, has a doctorate in clinical psychology from the University of North Carolina and an undergraduate degree from Harvard, owns a professional consulting firm and has worked with hundreds of men individually as well as dozens of Fortune 500 companies. “It’s not so much that [Black men] experience discrimination and depression ‘even after’ they have advanced degrees,” he said. “It’s more descriptive to say ‘throughout the whole process.’”

Despite their academic credentials, Black men said, they often feel they need to prove themselves, which adds another layer of stress.

“It’s almost like I can’t fail; I’m representative of other Black males,” said Woodrow W. Winchester III, director of professional engineering programs at the University of Maryland-Baltimore County. “Your value and your success are around advancing the collective.”

The bottom line, experts agreed, is that discrimination has a lingering effect on health.

Dana Goldman, director of the USC Schaeffer Center for Health Policy and Economics, was co-author of the 2012 Health Affairs study on these chasms. Goldman said he agrees that the underlying cause is racism and added that he thinks one solution is to improve education. He and others suggested that schools, starting in the lower grades, need to provide Black students with more culturally appropriate curricula that bolster their self-image and help build social relationships between white and Black youngsters. Those efforts need to continue as students progress into higher education.

“The policy remedy is not just less racism but to improve the quality of our schools, occupational safety and public health,” Goldman said.

Others agree that the findings suggest a need to reconsider broad policy changes — in education, housing and the justice system — so that Black males feel confident and supported in pursuing better educations and jobs.Ìý

It will be a long-term project, said Williams, the Harvard professor.

“We need a Marshall Plan for all disenfranchised Americans,” he said, but one that especially addresses implicit biases and how American society views and treats Black males.

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Yet 50 years after the civil rights leader was killed, some public health leaders here wonder whether the city is failing to live up to King’s call for justice in health care. They point to substantial disparities, particularly in preventive care.

“We have world-class health care facilities in Atlanta, but the challenge is that we’re still seeing worse outcomes” for African-Americans, said Kathryn Lawler, executive director of the Atlanta Regional Collaborative for Health Improvement. That group includes representatives of more than 100 nonprofit organizations, governments, hospital systems and other health care providers working to improve access and care for minority communities.

“We did certain things here, we went through the civil rights era, and we did things like desegregation, but we just over the years never kept the conversation going,” said Tom Andrews, president of Mercy Care, a health center that serves mainly homeless Atlantans, the vast majority of whom are African American.

Among the problems:

— Atlanta has the widest gap in breast cancer mortality rates between African-American women and white women of any U.S. city, with per 100,000 residents dying compared with 20 per 100,000 white women, according to in the journal Cancer Epidemiology in 2016.

— It is the city with the nation’s highest death rate for black men with prostate cancer, with a rate of 49.7 deaths per 100,000 residents. The mortality rate for white men here is 19.3, the National Cancer Institute reports.

— There’s a among neighborhoods in Fulton County, of which Atlanta is the county seat. Those living in the city’s Bankhead or Northwest neighborhoods, which are predominantly black, fare worse when compared to those who live in affluent, mainly white Buckhead, researchers at Virginia Commonwealth University found.

— Large gaps in mortality exist between African-Americans and whites in such diseases as HIV, stroke and diabetes, according to the .

African-Americans make up just over half of the city’s residents. But a found that 80 percent of black children here live in neighborhoods with high concentrations of poverty, which often have poor access to quality medical care, while 6 percent of white children do. Several of the neighborhoods with predominately minority communities have poverty rates higher than 40 percent.

“I think we should be further along in Atlanta, but I think we should be further along in all cities in this country,” said Dr. David Satcher, a former U.S. surgeon general and now senior adviser at the Satcher Health Leadership Institute at Morehouse School of Medicine here.

The health gaps between African-Americans and whites in Atlanta or in any U.S. city are not due necessarily to shortcomings in the health care system, according to people who have studied the issue. Rather, they are the result of decades of discrimination.

“It’s a constellation of things,” said Thomas LaVeist, chairman of the department of health policy and management at the George Washington University’s school of public health in Washington, D.C. “African-Americans couldn’t own land, wealth couldn’t transfer from one generation to the next. Those were advantages [for whites] that were formed decades ago.”

“The disparities are really national problems,” he added, “and there really is not a city that’s spared.”

The result has been, the experts said, lower incomes, lower levels of education, higher stress, unsafe neighborhoods, lack of insurance and a host of other social factors that combine, over the years, to create differences in quality of health.

It starts with a lack of preventive care, said Dr. Otis Brawley, chief medical officer of the American Cancer Society and a longtime Atlanta resident. In addition to not having insurance or money for care, many African-Americans lack trust in the health care system and see it as another part of American life that has let them down.

Ricardo Farmer, 57, has not been to a doctor for a checkup in almost 30 years, he said. He is uninsured, and his funds are limited. More than anything, however, Farmer said he does not trust the health care system.

“If I don’t have any symptoms, I feel like I don’t need to go,” said the tile craftsman.

Yet he has a back problem that causes him to miss work occasionally, and he has high blood pressure, which he self-treats by reducing his salt intake and giving up meat, and asthma, which sometimes forces him to the emergency room because he has trouble breathing.

An Abundance Of Health Care, For Some

Atlanta is a major health care hub, home to the federal Centers for Disease Control and Prevention, the American Cancer Society, the Arthritis Foundation, two schools of medicine and several universities that offer degrees in public health. And yet health care is still a scarce commodity in many poor neighborhoods.

“Atlanta spends $11 billion on health care in a given year, but much of that is misspent,” said Lawler. Too many patients end up in emergency rooms, for example, because they do not have a primary care doctor or seek treatment after their illnesses are much more advanced, she added.

In addition, after being diagnosed, getting treatment can be difficult for some, said Brawley. African-American women are nearly four times more likely than whites to forgo treatment for breast cancer, which can include a combination of surgery, chemotherapy and radiation, he said.

Adherence to the radiation regimen is particularly challenging, he explained, because a woman typically has to go five days a week for six weeks. That presents problems for those who must rely on public transportation or work in low-wage jobs that don’t offer generous sick leave benefits.

“It takes them 2½ hours to get there every day, and [the treatment] takes 45 seconds,” Brawley said, when describing bus commutes for some residents. “So they figure it’s not worth it.”

Those involved in seeking better care for Atlanta’s poor say the lack of insurance coverage also plays a huge role in the problem. Yet, that, too, is tied to race, since African-Americans than whites are uninsured in Georgia.

“One of the greatest barriers to care in all these states that didn’t expand Medicaid [under the Affordable Care Act] is lack of insurance,” said Brawley. “And it happened in all of the states of the ‘Old Confederacy.’ This is a huge racial insult.”

State Rep. Jason Spencer said Republicans’ opposition to Medicaid expansion “had nothing to do with race.” He said whites living in parts of northern Georgia also have higher mortality rates. “The common denominator is education and finances. The race card is a worn-out, tiresome excuse.”

‘I Didn’t Want To Think About Bad Things’

Austin Gilmore, 60, is emblematic of the patients who don’t have a regular physician and therefore ignore their health needs.

He had a roofing business and lived with his wife in a four-bedroom house with two bathrooms. But he lost his bearings when she died in 2011 from kidney disease. Without insurance and with few economic resources, he didn’t know where to turn for help.

“I didn’t even know I was depressed,” said Gilmore. He started drinking and eventually lost his house and his business.

“I had no livelihood, no job, no place to live. I didn’t want to think about bad things, so I drank,” Gilmore said. He knew he was harming his health.

In September 2016, Gilmore decided he could not ignore his health issues any longer. He went to an emergency room and after several days of treatment was referred to Mercy Care for longer-term care. He has been sober for 19 months.

“I thank God for Mercy Care,” Gilmore said. “I can’t think of where I’d be without them.”

Dr. Kathleen Toomey, district health director for the Fulton County Board of Health, said the county has initiatives to help narrow the gaps. But just as the disparities were not caused by the health care system alone, the problems will not be solved solely by the health care system.

“The ownership is not just on public health, but across all sectors of the community that address social, economic and environmental factors that influence health,” Toomey said.

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But she needed to update the couple’s health insurance and went shopping on the Affordable Care Act’s online marketplace. Trawick, 43, who considers herself nearly as skilled with a computer as she is with a skillet, found the Obamacare website daunting.

“It was not exactly user-friendly,” she said. Trawick needs specific medications to control her hypertension, and the section on drug coverage left her “confused.”

“I could have done it without her, maybe, but it would have taken me forever,” Trawick said.

This fall, it will be different.

Open enrollment for ACA plans, which begins Nov. 1, has been shortened to 45 days. At the same time, funding for navigator programs and other support for consumers has been cut dramatically in Georgia — by 86 percent — and across the country.

The number of navigators for Insure Georgia, the nonprofit agency that has received the bulk of federal funding for enrollment efforts in past years, will drop to 21 from 42 last year, said Fred Ammons, chief executive officer of Community Health Works, the parent organization of Insure Georgia.

There is no advertising budget to even inform consumers that open enrollment begins. Ammons said he is concerned that with all the past year’s rhetoric among Republicans in Washington about repealing and replacing Obamacare, some people may not even understand that the program is still available.

That could be a problem in Georgia, which, after seeing increased enrollment in the first three years of the marketplaces, experienced a 16 percent drop in sign-ups for 2017 coverage. In some rural counties the decline was as much as 36 percent. Georgia ranks third in uninsured residents, behind only Texas and Florida.

‘Isn’t Obamacare Dead?’

ACA supporters are concerned that residents in the rural portions of Georgia — which make up about 17 percent of the population — could be most at risk. In recent decades, those rural areas have fallen behindÌýother parts of the state in income, educational achievement and in access to health care.

With enrollment assistance resources so strapped, it will be hard to reach out to rural consumers.

“We had a booth at the PRIDE festival in Atlanta last Sunday, and someone said, ‘Why are y’all even here? Isn’t Obamacare dead?’” Ammons said. “And if they think that in Atlanta, you can only imagine what they think in south Georgia.”

Health economist William Custer, who teaches at Georgia State University in Atlanta, echoed those fears about increases in the number of uninsured in rural Georgia.

The effects of less insurance will be felt hard in those areas, he explained. Nearly half of the state’s counties, most of them in rural areas, do not have an OB-GYN. Seven hospitals in rural Georgia have closed within the past four years. Several have closed their labor and delivery units. If people in rural Georgia lose insurance rather than gain it, efforts made in recent years by state leaders to stanch financial bleeding at rural hospitals could be jeopardized, Custer said.

“This is really the big worry. The problem in Georgia is that we have very different geographics, very different demographics and very different health care. These changes this year really seem to be pushing us even more to two Georgias,” Custer said.

‘Let Obamacare Fail’

Much of the cutbacks and confusion, health care advocates said, follows President Donald Trump’s disparagement of the law. He campaigned on a promise to “repeal and replace the disaster that is Obamacare” and announced in July that he would “let Obamacare fail.” Even though Congress could not pass a replacement bill, the Trump administration’s changes in timing and funding for enrollment will have an effect, the advocates charge.

“The most damaging has been the rhetoric and confusion,” said Laura Colbert, executive director of Georgians for a Healthy Future, an advocacy group. “Overall, this could be a bellwether for future years.”

The federal marketplace English-language website:

The federal marketplace Spanish-language website:

The federal call center for consumer questions, available 24/7: 1-800-318-2596

Insure Georgia: ; 1-866-988-8246

And while the need for insurance is high in the state, Georgia lawmakers have been resistant to the federal health law. Georgia, like 18 other Republican-leaning states, refused to expand Medicaid, as the law allowed. The Legislature also prohibited the state from employing navigators to help enroll consumers.

Ammons, who is from rural Georgia, said he lies awake at night wondering how to reach people who need health insurance.

“I don’t know what I can do to help these uninsured people,” he said, adding that “for a brief moment, I thought ‘We can’t even do this.’”

That was the night he learned, in an email, that Insure Georgia’s funding had been cut from $2.3 million to $328,000.

Ammons said he realized that he would have to lay off full-time employees. He said he also figured out that he would have to cut back on navigators that Insure Georgia typically hired short term for open enrollment.

Next, he cut every non-personnel line item he could, which meant terminating leases and closing offices. The group found donated space in Vidalia, in central Georgia, and in Brunswick, a port city near Savannah. But that leaves the southwestern portion of the state, an especially poor area of Georgia, without a nearby office.

Ammons said that other nonprofit groups have donated money that will allow Insure Georgia representatives to travel to 500 community enrollment events across the state. While Insure Georgia held more than 1,500 community events last year in all of Georgia’s 159 counties, his goal is more modest this year.

“We want to at least be in every county with a Walmart,” he said.

Jeri Trawick said she is worried for herself and for thousands of other Georgians.

To help with enrollment efforts, the Trawicks on Nov. 6 will be serving something else along with their homemade food at Ms. Stella’s in Eatonton.

“We’re going to have an open enrollment event, with a navigator here, from 10 until 6,” she said. “And I’ll be the first one in line.”

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Brenlee’s birth was touch-and-go after Peebles realized something was wrong. “I couldn’t feel the baby move, and my blood pressure was sky-high,” said Peebles, a nurse.

Dr. Roslyn Banks-Jackson, then an OB-GYN specialist at Emanuel Medical Center in Swainsboro, Ga., diagnosed , a potentially lethal complication of pregnancy, and induced labor to save Peebles and the baby. Brenlee was born on Oct. 28, 2014, completely healthy.

Had Peebles given birth the following year, she might not have been so fortunate, she said. Emanuel shuttered its labor-and-delivery unit the next spring, becoming one of a handful of such units in the state to close from 2010 to 2015, most because of budget problems. Another is expected to close this month, said Daniel Thompson, executive director of the Georgia OBGyn Society.

The nonpartisan Congressional Budget Office released June 29 that the Senate plan would slash 35 percent of expected federal Medicaid funding by 2036.

“Cuts now would cripple rural Georgia,” said Dr. Ben Spitalnick, president of the Georgia chapter of the American Academy of Pediatrics.

He said that is because most primary care visits, which include OB-GYN, pediatric and adult care, in the state’s sparsely populated areas rely heavily on Medicaid reimbursements.

The federal cutbacks would have to be offset by the state. But that means taking money from other programs or raising taxes. As a result, state officials facing those shortfalls would likely scale back an already lean Medicaid coverage.

“If you cut back, [people] still go to the hospital, they’ll still need care. No matter what you do, the buck stops somewhere,” said Renee Unterman, a Republican state senator who chairs the health and human services committee. In the end, she added, the cost for that uncompensated care gets passed to taxpayers and consumers through higher health costs and insurance premiums.

Georgia’s rural hospitals have proved vulnerable. Five closed in the past five years and another two merged. Plus, several have closed their emergency rooms.

That translates to a loss of doctors in affected counties. Of Georgia’s 159 counties, 79 do not have an OB-GYN specialist, and 65 do not have a pediatrician, according to 2015 figures from the Georgia AAP and the Georgia OBGyn Society.

Close to 1.7 million Georgians, or nearly 1 in 5 state residents, live in these areas, according to figures from the Rural Health Information Hub.

Improving Pay For Doctors

For 15 years, Georgia Medicaid reimbursed primary care doctors at only 60 percent of the amount that the federal Medicare program reimbursed similar services, said Ward.

But in 2015, the Legislature implemented three rounds of pay increases to primary care doctors, including pediatricians and OB-GYNs, to bring them in line with the Medicare reimbursement.

Many of these doctors are now concerned those rates would be the first to be lowered. “That’s our big fear,” said Rick Ward, executive director of the Georgia chapter of the AAP. “We just clawed our way back and to deal with it again would just be unbelievable.”

Key among those concerns are prenatal care in rural areas. With a maternal mortality rate that is in the country, OB-GYNs are worried that the cuts would eliminate fragile solutions to doctor shortages that the state has implemented.

For example, pregnant, low-income women in 17 counties around Augusta can arrange for a ride in a van, paid for by Medicaid, for their prenatal visits at the medical school at Augusta University. The service has been vital in keeping these women healthy and insuring successful births. Advocates fear it is the type of program that could face problems if Medicaid funding becomes tight.

People With Disabilities Fearful

Advocates for residents with disabilities worry that home health care would be likely to suffer from the cuts.

That’s because while states are required under Medicaid to pay for nursing home stays, care for people living at home has been optional.

About 38,000 people in the state get the services, also called community-based benefits. Qualifying takes years, and benefits are not guaranteed, even for people who are eligible. Almost 10,000 Georgians are on the waiting list, according to Jacobson, because there is not enough money in the Medicaid budget to cover everyone.

One of those who is getting coverage is Joshua Williams, 22, who has severe cerebral palsy and needs constant care at home and school.

“I’m terrified” that funding cuts could end the program, said his mother, Mitzi Proffitt, 53. “I’d have to quit my job” to take care of him. Williams’ stepfather, Jack Proffitt, 65, has advanced cancer and cannot provide much assistance.

Nursing home or institutional care for a year, on average, is $172,280, said Jacobson, while the average home health care is $28,901.

Williams, who is on the dean’s list at East Georgia State College in Swainsboro and loves NASCAR, also admits to being “very scared.” He said if his coverage is discontinued, he would have to drop out of college, ruining his hopes of becoming a sports broadcaster. He is eager to get a part-time job until he graduates.

“I want to work. I don’t want handouts,” he said.

A supporter of President Donald Trump’s, Williams said he is counting on the president to keep disability benefits in place and to ensure that health care is affordable for all.

“He thinks that if Trump knew his story, he’d get on this and fix things,” said Mitzi Proffitt.

“I like him because he’s a businessman, but he said he has heart,” Williams added.

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“They cost a thousand, $1,200 [a month], and they have a deductible of $6,000,” she said. “I don’t know how they think anyone can afford that.”

Bryan, who lives in Hull, Ga., a hamlet of about 200 near Athens, was on her husband Tony’s insurance plan for decades. When Tony died in 2013, she continued his workplace , and she had to pay almost the full price of the insurance — about $800 a month. That was high, but it was “the Cadillac of insurance,” Bryan said, with low copays, prescription drug coverage and a $500 deductible. That option will run out in a few months.

So she is turning to the individual insurance marketplace in what is shaping up to be the most expensive year for the 400,000 or so consumers in Georgia who buy individual policies but don’t purchase them on the health law’s marketplaces. About 10 million Americans buy individual insurance coverage either on or off the marketplaces and get no federal subsidies to help bring down the cost, according to the Congressional Budget Office. About the same number get the financial assistance for the plans they purchase on the exchanges.

“For those receiving subsidies, the subsidy protects them against the increase. If they’re not eligible, they’ll be paying a lot more. And the more premiums go up, the higher the cliff,” said William Custer, a health policy and insurance expert at Georgia State University.

Numbers like those are rattling other states too. BlueCross BlueShield of Tennessee was granted a , while state officials approved a 46 percent increase for Cigna.ÌýFlorida authorities gave plans there an average .ÌýAnd last week, Minnesota officials announced that premiums for the seven insurers on the individual market are rising .

The insurers are now adjusting for some miscalculations, said Graham Thompson, executive director of the Georgia Association of Health Plans. “The prices are up this year, but our hope is that things will settle down after this year,” he said.

While consumers have faced sticker shock, the insurers have faced what might be called “sicker shock,” which has sent their prices spiraling. They are adjusting premiums after finding that the pool of clients buying plans on the individual market were sicker and more costly than expected when the health law was implemented.

Almost two-thirds of Americans get their coverage from plans offered through their workplaces. But those who don’t can buy either on or outside the health law’s marketplaces, also called exchanges. Those with marketplace coverage who earn up to 400 percent of the federal poverty level — $47,520 for an individual — are entitled to a subsidy, and federal officials say most will for insurance.

Policies sold off the marketplaces must still meet health law standards and the same prices as plans offered on the exchange, according to Linda Blumberg, a senior fellow at the Urban Institute.

Federal and Georgia officials note that customers can change plans each year to find a better price, but that also can result in higher deductibles and may force a change in doctors to stay in network.

Bryan, who makes just over the $47,520 limit for a subsidy, finds herself in that market now.

“I’ve worked … all my life,” said Bryan, a maintenance supervisor who has been employed for more than 40 years. “We’re the ones entitled to something, because we’ve worked. They tear me up in taxes and then they say my income is too high for a subsidy?”

She could end up paying as much as $14,000 in premiums for a pared-back policy the likes of which she had never imagined, she said, with no coverage for her asthma and high blood pressure medications. The cheapest policies amount to more than a quarter of her yearly income, or double her mortgage, she noted.

That total package would increase her premiums $4,400 over what she is paying for her COBRA plan and raise her deductibles by $5,800, for a possible increase in costs of $10,200. And that was based on 2016 premium prices.

For a state struggling with how to extend coverage to its nearly 1.4 million uninsured, the added frustration, anger and fear of the rising premiums complicates Georgia’s already complex health care landscape.

Some People Gain, Some People Lose

Elena Hamilton of Dunwoody has seen her premiums nearly double in the first three years under the Affordable Care Act. She does not receive a premium subsidy and is afraid of what she will find when the exchanges open Nov. 1. And she, unlike Bryan, isn’t looking until she has to.

“Under this program with Obama, things just keep going up and up and up. People who own small businesses are hurt, the middle class is hurt,” said Hamilton.

Bryan said she feels like she is paying for other people’s subsidies with her high premium.

But the Urban Institute’s Blumberg explained that the subsidies do not work that way.

“It is not the people paying full premiums who are paying for the lower-income person,” she said. Federal dollars are already allocated for that.

Yet Blumberg said she understands why people like Bryan would be upset.

“For a lot of modest income people, this can still feel expensive to them,” Blumberg said. “I actually think we’ve underinvested [in the amount set aside for subsidies]. I sympathize with it enormously.”

The federal Department of Health and Human Services that as many as 95,000 people who buy insurance off the exchange in Georgia and 2.5 million nationally may be eligible for a subsidy and not know it.

, a health policy strategist in Washington, D.C., said the Obama administration and health care advocates need to listen to the complaints of the those who do not receive assistance.

“These people are invisible,” Laszewski said. The ACA “is working very well for lower income people, but the Obamacare supporters missed the fact that if you’re raising a family of four on $100,000, you’re not rich. This is the … guy who remodeled your house, who drives a pickup truck and he’s wearing a Trump hat.”

This needs correcting, he said. Offer a wider range of options, he suggested, so that more middle-class people can afford it.Ìý

Delivering Bad News

Individual brokers said they are calling their clients, bracing them for higher premiums.

Russ Childers sells insurance policies in Americus, near President Jimmy Carter’s hometown of Plains.

“I’ve been talking to a lot of people who are concerned,” said Childers.

Childers said he’s working with a man who makes just above the subsidy limit for a family of four. For a scaled-back, nearly catastrophic plan — with a deductible of $6,450 — the monthly premium would be $1,600. “And he can’t afford that,” Childers added.

Athens broker Jim Carrow said he’s starting to hate his job. He once thought he was helping people. Now, he’s delivering bad news.

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Dr. Shannon Novosad was on a plane to Utah the next day, one of 10 detectives looking for answers about this case to help other professionals deal with this rapidly growing health problem.

Novosad is a critical care pulmonologist by training, but she is also in a two-year fellowship at the Centers for Disease Control and Prevention’sÌý. Her colleagues in the program include about 80 medical and scientific professionals who study disease prevalence, patterns and control. The group includes dentists, doctors, veterinarians and entomologists.

The teams include not only epidemiologists but also scientists with backgrounds in a particular disease itself, such asÌý. Entomologists, vector technicians, communications specialists and public health scientists have been part of the Zika teams.

They rush to areas where the disease is reported and help with local efforts to identify other patients and health care workers who may have been in contact with an infected person. They also provide extra hands in the collection and analysis of blood samples. And, in the Salt Lake City case over the summer, two entomologists who are vector-borne disease specialists helped local authorities trap mosquitoes to see if they were transmitting Zika.Ìý

These medical SWAT teams Ìýhave also deployed to Texas and the Miami area. Nearly 800 people have been diagnosed in Florida with Zika, at least 64 of them having been infected locally. The size of the teams vary.

Novosad said that she hopes people know “that we have these mechanisms in place” to send in experts to deal with these outbreaks. “That’s why public health is there … and we do have a strong public health workforce.”

CDC Plan For Outbreak

Zika, which can be transmitted by mosquito bites, sexual contact or from mother to fetus, typically causes mild symptoms, including a rash, fever, joint pain and bloodshot eyes. It has also in rare cases been associated with Guillan-Barre syndrome, which includes temporary muscle weakness and paralysis.

However, the effect that has brought the greatest concerns involves pregnant women. The infection sometimes causesÌý, a birth defect in which a baby’s head is unusually small. That can result in developmental delays, intellectual disabilities, problems with balance and with swallowing, according to the CDC.

CDC officials developed a detailed,ÌýÌýfor handling Zika outbreaks, which called for epidemiologists to study outbreak patterns; doctors to interview and treat health care workers and other who may have been in contact with people who had the disease; entomologists to trap and study mosquitoes in the outbreak area; and communications officers to coordinate getting information out to the public.

The Zika plan drew from lessons in the Ebola outbreak, in which health care workers who contracted that deadly virus at first were not interviewed about their exposure to Ebola and precautions for their health and those of others not taken. That led to sharp criticism of the CDC. The agency broadened its teams of epidemiologists normally sent to investigate disease outbreaks to include other experts, such as the vector-born specialists sent in response to Zika.

Behind the scenes in Miami, the disease detectives are interviewing people, collecting data and trapping mosquitoes, all the while working not only to contain the disease but also to quell growing concerns about its reach, said Nordlund.

“Our teams have been well-received and helped contribute to the response.ÌýThe states and local health departments have done a lot of work to get prepared for Zika and are putting in tremendous effort in the Zika response,” the CDC’s director, Dr. Thomas Frieden, said in an email.

The much-publicized logjam in Congress overÌýÌýhas not hampered the CDC efforts, Frieden said, but he added that a shortage of funding could impair response efforts going forward.

Frieden said money for the teams has come from $222 million in repurposed funds.ÌýThe administration earlier this year redirected funding for Ebola research and prevention to help pay for its efforts on Zika.

“We’re in peak mosquito season right now and if more states see local transmission, CDC’s resources will be stretched thin as we help respond in multiple areas,” Frieden wrote in the email. Ìý“But it’s not too late, and we are hopeful that Congress will do the right thing, as they have with Ebola, for example.”

An Urgent Call

The call from the Utah Department of Public Health to the CDC came in on July 12. “We were all on a plane July 13,” said Novosad. “We took whatever plane that could get us there fastest.”

Once there, Novosad said the first job was to identify all health care workers who had come into contact with the patient.

“We started by contacting the employees, and we administered surveys,” she said. “I think people were just really interested in helping, given the unusual nature of this outbreak.”

The team of epidemiologists talked to family members to see if any others were infected.

A lab team helped make sure all necessary blood samples had been taken and were accounted for. A communications group coordinated information among the teams. Each morning at 6 a.m., the entire crew assembled to talk with experts in Atlanta.

The team Tuesday. It did not name the man or his son. Although they did not determine how the son became ill, the investigators noted that he had close contact with his father, who had a very high virus level. The son had hugged and kissed his father, as well as assisted medical workers in caring for him. The report noted that health care workers and family members “should be aware that blood and body fluids of severely ill patients might be infectious.”

Nordlund said she understands why people become unnerved and impatient when disease outbreaks occur.

People typically do not pay attention to the work of public health agencies when no immediate outbreaks are occurring, she said.

“When public health is doing its job, you don’t see it,” she said. When a crisis occurs, it’s suddenly news, she said.

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But for all of its firsts, the state is worst — or at least among the very worst — in a key measure: its rate of maternal mortality.

Federal officials as the death of a woman from a cause related to her pregnancy during that pregnancy or within a year after its termination. But analysis of the issue is difficult because states keep records differently, and the length of time a woman is considered “postpartum” differs too. As a result not many organizations offer comparative listings, but a report issued by Amnesty International in 2010 ranked the state 50th in maternal mortality. Another group, the National Women’s Law Center, in 2006 of Michigan at the bottom of the pack.

State officials do not quibble about where Georgia ranks and note that the numbers have risen since 2010. And they vow to do something about it.

That is considerably higher than the national rate. In 2012, the most recent year for which figures are available from the Centers for Disease Control, the U.S. had a of 15.9 per 100,000 births. That was a decline from a high in 2009 and 2011 of a rate of 17.8.

“These staggering rates and the underlying racial and ethnic disparities” led to the committee’s formation, according to the introduction to the report. It noted that maternal deaths were four times higher among blacks than whites.

So far, the committee has analyzed and issued a report on only one year, 2012, in which 25 pregnancy-related deaths were identified. It is now reviewing deaths from 2013.

The cases take a long time to review, Lindsay and other members said. The committee is looking at many factors: hospital and clinical medical records; prescription medication history; coroner and autopsy reports; emergency transport records and police reports.

Some trends have emerged, and a few changes have been made, such as providing tool kits for patients with high blood pressure.

Problems Before, During And After Pregnancy

The report identified postpartum hemorrhage as the leading cause of death among those who died from pregnancy-related deaths in 2012. That was followed by hypertension, cardiac problems, embolism and seizure. Suicide and depression were last.

The committee also identified deficiencies in care in treating many of those conditions.

Those included a lack of mental health services for pregnant and postpartum women; women not accessing high-risk care, possibly due to lack of referral or geographic challenges; rural hospitals possibly having limited stores of blood products; lack of diligent follow-up for women at risk for complications; and women with chronic health issues not having access to effective contraception — or even consistent health care.

“One of the real concerns — and the report supports this — women are in poorer health when they get pregnant, and are not getting proper care,” Dr. Brenda Fitzgerald, the state’s public health commissioner and an OB-GYN, wrote in an email. “Chronic health conditions like obesity, hypertension, diabetes and heart disease are more and more common in pregnant women, and those conditions make delivery more dangerous.”

Those point to an over-arching issue, according to a health care advocate in the state.

“It’s about women not having access to care along the continuum,” said Cindy Zeldin, executive director of Georgians for a Healthy Future.

More than 70 of the state’s 159 counties do not have an OB-GYN. Since 1994, 35 labor and delivery units, mainly in rural hospitals, have closed, said Pat Cota, executive director of the Georgia OBGYN Society. The closures have accelerated in recent years, Cota said, with at least three labor and delivery units closing each year.

And yet, Lindsay said that the review indicated that 70 to 80 percent of women who died had received pre-natal care. It’s not clear, however, how regular or extensive that care was. The report also says that only 35 percent began prenatal care in the first trimester.

In addition, Lashea Wattie, an OB-GYN nurse and a member of the review committee, notes this is not just a problem in rural areas. “To blame it all on one area is a little naive, being in denial a little,” said Wattie, who works in a metro Atlanta hospital. Ìý“There’s a statewide issue that needs to be addressed.”

Quality Of Care Is A Problem

The quality and consistency of that care could be a factor, the experts said. For example, a lack of referral for high-risk, hypertensive, diabetic or obese patients to OB-GYNsÌýwith expertise in those areas could play a role. Among the cases in which the weight of the woman was known, more than half — 58 percent — were overweight, obese or morbidly obese.

“Things pile up on top of one another,” said Wattie. “Yes, it’s lack of transportation, but it’s bad food, smoking, a lot of things together.”

While hemorrhage, the leading cause of death, can be hard to predict, the report suggested that more could be done to treat it during labor. Providers may not recognize hemorrhage during childbirth and thus may delay urgent care. Blood supplies may not be sufficient, especially in small or rural hospitals, the report said.

Also, women should be informed that they could still hemorrhage even after they leave the hospital.

“They may think ‘I’ve delivered the baby; I’m fine,’” said Wattie.

Georgia is not alone in its hemorrhage problem, as deaths from hemorrhage are a big problem nationally.

Georgia’s leaders said they are determined to go from worst to, if not first, much better.

“As a doctor and the mother of two, I’ve been in the delivery room and I know how one of the happiest times in life can change in an instant,” said Fitzgerald, the public health commissioner.

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