She works in healthcare and pays $787 a month for insurance. She still can’t afford her daughter’s care.

• Cassenda Nelson, 47, struggles to afford care for her daughter’s complex health conditions.
• Steep insurance premiums and medical debt make it difficult to afford housing, food, and utilities.
• Millions of Americans have medical debt, which can negatively affect household credit scores.

Cassenda Nelson holds her breath when the phone rings.

She knows that it could be a hospital or ambulance service calling about unpaid bills. Nelson said she has dialed 911 several times in recent months for her 16-year-old daughter, Amunet, who has serious health issues. It’s staggeringly expensive, but she doesn’t have other options — and her daughter’s life is at stake.

Nelson is a single mother of four in Camilla, a small town in southwest Georgia. She estimates that her medical debt exceeds $10,000, though she said the total is likely much higher. The ongoing cost of her daughter’s care is a constant source of stress and has affected the family’s ability to afford groceries, rent, and household expenses.

“I pay what I can, what’s most important,” Nelson, 47, told Business Insider. “I don’t have any other help.”

She is one of over 100 million Americans saddled with medical bills they can’t pay. Healthcare debt is among the top causes of personal bankruptcy in the US, and a 2024 analysis of government data by KFF found that millennials and Gen X carry the most debt compared to other generations. Black Americans and people living in rural areas are at the highest risk, and about 14% of these debt holders owe at least $10,000.

Collection agencies can’t legally charge interest on medical bills, but they can report the information to credit bureaus if the balance is over $500 for at least one year. Nelson said her credit score has tumbled because her debt is above this threshold. The cost of care is backbreaking, even with her employer-sponsored insurance plan. Her situation isn’t an outlier: Many Americans with medical debt have health insurance.

“Sometimes I can’t even buy groceries,” Nelson said. “I make a certain amount of money, but I bring home very little because she needs to have the best insurance. When I was on other insurances, I kept getting issues with pre-authorization. I couldn’t even get my baby insulin.”

Health insurance takes up a big chunk of Nelson’s monthly budget

The past five years have been a whirlwind for Nelson and Amunet. The teenager developed type 2 diabetes in 2020, alongside a seizure condition. She requires daily access to insulin and other medications, full-time care, and frequent trips to the emergency room. The family also lives in a rural area, meaning they sometimes travel for hours to see specialists.

Nelson pays $787 a month for her family’s health insurance. She works as a community healthcare worker in Camilla, mostly focused on cancer screening education. She said the role has more stable coverage than her previous employers and past marketplace plan, but insurance premiums are a big part of her monthly spending.

Like many Americans, her job is directly tied to her family’s healthcare access. Missing extra days or hours to support Amunet puts both in jeopardy. “I feel heavy every day getting up,” Nelson said. “I have to literally pray, ‘God, please don’t let Amunet have a seizure. I need to go to work, please.”‘

Years of paying for ambulances, hospital stays, prescriptions, lab tests, and doctor co-pays have bled into other parts of Nelson’s life. Her food budget has shrunk, and she can rarely afford her own healthcare. She has stopped contributing to her son’s college tuition. The lights in her house were recently shut off due to unpaid electricity bills. And, without enough money to hire a caregiver for Amunet, Nelson relies on help from her other children or brings her daughter to work.

The debt weighs on her too: Nelson said she and her family recently moved into a low-income housing unit because she could no longer afford their home. And the hit to her credit score has made it more difficult for her to get approval for a lease or an auto loan, she said. Without a clear path to financial stability, Nelson said her mental health has worsened.

Beyond money, Nelson said that navigating the healthcare system, especially as a Black family, can be exhausting. There are hours of medical paperwork, phone calls with insurance, meetings with doctors, and travel between appointments. She does her best to be her daughter’s advocate.

Sometimes, she lays out her clothes before bed in case her daughter has a seizure in the middle of the night. That way, she can quickly change before the ambulance arrives. “I know that because of me being an African American woman, I cannot walk here without any clothes on my hair combed,” she said. “It shouldn’t matter, but I have to present my best self.”

Nelson isn’t sure how she will pay her next set of bills, or if she will ever be able to pay down her medical debt — but she would do anything for Amunet.

“I don’t give up,” she said. “I get up every morning and I pray.”