Introduction
At CommWell Health, a small rural clinic in North Carolina, Dr. George Gould sees the same cycle play out: patients delay care until a condition becomes severe, despite having insurance. Meanwhile, staff like Ana Maria Deaver, who provides both physical and linguistic care, struggle to afford screenings for themselves.
This essay explores how the socioeconomic and wealth gap continues to shape access to preventive care, with implications for both vulnerable patient populations and the frontline workers who serve them. Section I examines how gaps in insurance quality, geographic access, and healthcare system navigation contribute to delayed care, even among those with coverage. Section II shifts focus to the caregivers themselves, such as Certified Nursing Assistants (CNAs) and similar direct care workers, who often lack sufficient wages, benefits, and institutional support to access the preventive care they need. Their stories highlight a lesser-seen dimension of the healthcare crisis, where caregivers face the same barriers as their patients, ultimately placing strain on the entire system.
By analyzing interviews from the Southern Oral History Program alongside recent scholarship on healthcare access, labor inequity, and rural care delivery, this essay illustrates the broader implications of economic disparity in preventive healthcare. These narratives show that addressing disparities in access must involve supporting both patients and the workforce entrusted with their care.
Section I: Delayed Care, Diminished Outcomes: Coverage Doesn’t Always Mean Care
The expansion of insurance coverage through policies like the Affordable Care Act (ACA), especially via Medicaid, has undoubtedly improved access to preventive healthcare. However, as recent studies show, racial and socioeconomic disparities in the utilization of these services still remain. For example, studies have found that Hispanic, non-Hispanic Black, and Asian populations experience higher rates of under-screening and over-screening for cervical cancer compared to non-Hispanic White populations. These disparities are influenced by factors such as education level and household net worth, with lower-income and less-educated individuals being more likely to experience under-screening. [1] Even when individuals are technically covered, insurance denials for preventive services disproportionately impact Asian, Hispanic, and Black patients, creating additional administrative barriers that reinforce inequitable access. [2]
These disparities are not merely abstract statistics. They manifest daily in clinics across the country. Dr. George Gould, a retired physician who now works part-time at CommWell Health, a rural community clinic in North Carolina, observes this firsthand. Throughout his career, he has seen that a patient’s insurance status, more importantly, the quality of their coverage, can significantly influence health outcomes. He explains that the scope of care is often determined by what insurance providers are willing to cover, which means that even insured patients may lack access to essential preventive services. In his experience, patients from low-income and minority backgrounds often postpone preventive visits due to factors like cost concerns, lack of trust in the system, or poor coverage even when they technically have insurance. Many arrive at the clinic only when their condition has progressed significantly, leaving fewer, more costly options for intervention. [3] This is particularly problematic in rural settings, where the intersection of geographic isolation and poverty further reduces the utilization of preventive care services. Even with expanded coverage under ACA provisions, rural patients must often travel long distances to see their medical providers, take unpaid time off work, or navigate the complex U.S. healthcare system with limited support. These realities reflect findings in recent research showing that even insured individuals may forgo screenings or early treatment because of high deductibles, limited provider availability, or administrative burdens. [4]
Section II: Caring from the Margins: Income, Health, and the Hidden Strain on Those Who Care
The relationship between income and access to preventive healthcare is often framed around patients, yet it is just as important to examine how these factors impact the workers responsible for delivering that care. Low-wage healthcare workers, including Certified Nursing Assistants (CNAs) and home health aides, are the backbone of long-term care and community health clinics. Despite playing a crucial role in patient care, especially for underserved populations, these workers often face barriers to accessing preventive healthcare themselves. This paradox not only places them at risk for preventable illness but also creates a ripple effect: when caregivers are unhealthy, overstretched, or unsupported, the quality of care they deliver can suffer, especially in already-vulnerable communities.
Ana Maria Deaver’s experience portrays this. Originally from Panama, she pursued nursing school in her home country but was unable to complete her degree due to economic instability and the demands of moving frequently as a military spouse. After immigrating to the United States and raising children as a single mother, she pursued certification as a CNA, drawn to the field by a strong desire to care for others. However, repeated life disruptions and the need to prioritize family responsibilities made returning to nursing school difficult, ultimately steering her into a lower-paying role within the healthcare system. [5]
As a CNA working in a rural health clinic, Ana is intimately familiar with the challenges her patients face, but she is also subject to the same socioeconomic structures that make preventive care elusive. Studies show that financial constraints such as high deductibles, copayments, and lack of paid leave often prevent CNAs from affording routine screenings, vaccinations, and health counseling. [6] These barriers are especially pronounced in rural areas, where geographic isolation further restricts access to providers, transportation, and flexible scheduling. [7]
Ana works not only as a CNA but also as a Spanish-language interpreter for many of the clinic’s underserved patients, helping bridge the gap between the complex U.S. healthcare system and communities that have long been marginalized. Her story reveals how emotional labor and cultural competency are often unrecognized, and contributions made by frontline workers uncompensated. However, her role also underscores a troubling truth: caregivers like Ana often go without the care they need.
Low-income healthcare workers are significantly less likely to receive preventive counseling on key risk factors such as diet, smoking, and physical activity, and are less likely to undergo screenings for chronic diseases like hypertension or diabetes. [8] This can result in unmanaged health conditions that compromise not only personal well-being but also job performance and stamina. A 2023 qualitative study published in Health Services Research found that the health status of a caregiver is closely linked to the quality of care they can deliver, particularly in high-demand settings where continuity, attentiveness, and resilience are critical. [9]
Moreover, job insecurity, low wages, and lack of upward mobility can lead to high turnover rates among CNAs and home health aides. These resignations serve as disruptions to patient relationships, institutional knowledge, and continuity of care. As workers leave, the remaining staff are burdened with heavier workloads, leading to an increased risk of errors, burnout, and patient dissatisfaction. [10] In Ana’s clinic, where many patients already face systemic barriers such as lack of insurance, immigration concerns, or mistrust of institutions, the loss of a familiar caregiver can mean going without seeking care altogether.
Ana’s story also touches on the gendered nature of caregiving work, which is predominantly carried out by women, especially women of color and immigrants. Her inability to return to nursing school due to family relocation and economic stress is not uncommon. The care economy is structured in ways that extract labor from women while offering limited financial and institutional support in return. [11] Ultimately, Ana’s experience demonstrates how the socioeconomic and wealth gap affects not only patients but also the healthcare workers who serve them.
Conclusion and Looking Ahead
The socioeconomic and wealth gap in preventive healthcare highlights the complex, layered nature of healthcare access in the United States. While expanded insurance coverage through initiatives like the ACA has helped reduce some barriers, access to preventive care remains limited, particularly among low-income, minority, and rural populations. These disparities are shaped not only by structural issues like cost and geography but also by the lived experiences of those within the healthcare system. As shown through the narratives of both patients and caregivers, economic hardship limits not just when and how people seek care, but also the capacity of healthcare workers to consistently deliver it. Addressing these issues will require a comprehensive approach, one that not only expands access to preventive services but also improves working conditions, wages, and health protections for the U.S. healthcare workforce. A more just and sustainable healthcare system must ensure that both patients and providers have the resources and support needed to fully engage in preventive care. Only then can we move toward a model of care that is truly equitable and inclusive for all.
References
[1] Shin, Michelle, et al. Abstract B007: Racial/Ethnic and Socioeconomic Disparities in over- and under-Screening of Cervical Cancer among a National Sample of Commercially Insured Individuals. Sept. 2024, doi:10.1158/1538-7755.disp24-b007.
[2] Hoagland, Alex, et al. “Social Determinants of Health and Insurance Claim Denials for Preventive Care.” JAMA Network Open, vol. 7, no. 9, Sept. 2024, p. e2433316, doi:10.1001/jamanetworkopen.2024.33316.
[3] “Y-0026 Interview with George Gould.” Southern Oral History Program Interview Database, dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/28256/rec/1. Accessed 19 Apr. 2025.
[4] Huang, Shannon, et al. Bridging Health Disparities: Examination of Healthcare Utilization and Care in the U.S. Hispanic Community. Apr. 2024, doi:10.58417/nlqu7190.; Molla, Azaher A., et al. “The Impact of Health Insurance on Preventive Care Utilization: An Evidence from the Graves County in Kentucky.” Eastern Journal of Healthcare, vol. 2, no. 1, May 2022, pp. 65–68, doi:10.31557/ejhc.2022.2.1.65-68.
[5] “Y-0020 Interview with Ana Maria Deaver.” Southern Oral History Program Interview Database, dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/27882/rec/1. Accessed 19 Apr. 2025.
[6] Neugebauer, Jan. Economic Barriers as a Large Part of the Problem with Access to Healthcare. Aug. 2024, doi:10.52950/4osc-athens.2024.8.004.; Shahu, Andi, et al. Income Disparity and Utilization of Cardiovascular Preventive Care Services among U.S. Adults. Nov. 2021, p. 100286, doi:10.1016/J.AJPC.2021.100286.
[7] Tang, Lian. “The Impact of Inequality in Socioeconomic Status on Healthcare Services Utilization.” Journal of Education, Humanities and Social Sciences, vol. 28, Apr. 2024, pp. 455–58, doi:10.54097/zxymv497.
[8] Shahu, Andi, et al. Income Disparity and Utilization of Cardiovascular Preventive Care Services among U.S. Adults. Nov. 2021, p. 100286, doi:10.1016/J.AJPC.2021.100286.
[9] Cho, Jacklyn, et al. “To Care for Them, We Need to Take Care of Ourselves: A Qualitative Study on the Health of Home Health Aides.” Health Services Research, Feb. 2023, doi:10.1111/1475-6773.14147.; Duffy, Mignon. “Why Improving Low-Wage Health Care Jobs Is Critical for Health Equity.” AMA Journal of Ethics, vol. 24, no. 9, Sept. 2022, pp. E871-875, doi:10.1001/amajethics.2022.871.
[10] Tyler, Denise, and Robyn I. Stone. “Policy Attention Needed to Improve Direct Care Worker Wages and Other Challenges.” Innovation in Aging, vol. 6, no. Supplement_1, Nov. 2022, pp. 248–49, doi:10.1093/geroni/igac059.986.; Ranucci, Rebecca, and Daphne Berry. “Home Sweet Home? How Home Health Aide Compensation, Benefits and Employment Security Influence the Quality of Care Delivered by Home Health Organizations.” Health Care Management Review, vol. 46, no. 1, Jan. 2021, doi:10.1097/HMR.0000000000000289.
[11] McMullen, Tara, and Jasmine L. Travers. “Certified Nursing Assistants: Exploring the Federal Policy Landscape and Discussion of the National Academies Workforce Recommendations.” Journal of the American Geriatrics Society, vol. 71, no. 2, Feb. 2023, pp. 335–41, doi:10.1111/jgs.18272.