See the Gap: ‘You’ve got to be able to deliver when folks need you to’

Trent Thomas, a stylist, poses for a photo at Orbit Salon in Birmingham.
Trent Thomas is a stylist at Orbit Salon in Birmingham. He receives health insurance through his job, but he spent more than a decade before then living without coverage. Being uninsured meant enduring pain and deferring needed care. (Photo by Whit Sides)

Trent Thomas, 42, has been doing hair for a while now. And the first thing he’ll tell you is how much of a good thing he’s got going. 

“I love it here for a million reasons – some superficial – but it really is such a great place to be,” he said, showing off his boss’s massive plant collection visible from the street outside.

Trent was able to keep his job and his paycheck at Orbit Salon, in Birmingham’s Five Points South neighborhood, even when the world slowed down in 2020.

“This neighborhood’s always been so cool and aspirational,” he said. “I think that’s what a lot of stylists look for when going into the industry and what a lot of clients look for in a salon, too.”

Trent said he is grateful for their support and knows not everyone is so lucky.

“It’s not every day you get full-time benefits,” he said. “It’s not a normal thing to have insurance through a salon, like I do. It’s incredibly expensive, and not every salon or stylist in town can afford it.”

Pre-ACA: Life in the coverage gap

Things weren’t always so good, particularly when it came to health coverage. Trent decided to attend cosmetology school in his 30s and started getting insurance at work shortly before he turned 40.

Before then, Trent spent many years without health insurance. After aging out of his parents’ plan in 2003, he spent the next 15 years without employer-provided benefits.

“I grew up in the Birmingham punk scene, and I learned to find resources as close to the ground and as close at hand as I possibly could,” he said. “You make it work from within.”

Trent Thomas styles a client's hair.
Trent Thomas styles his client Jason’s hair at Orbit Salon in Birmingham. (Photo by Whit Sides)

Trent has worked many jobs, including punk rock show promoter and clerk at an art supply store. His story of making things work through sacrifice is one of many – and one that resonates with many stylists.

After the Affordable Care Act was signed into law, Trent found a plan that worked for him and paid out of pocket for premiums. That came after more than a decade of putting off care or finding help through non-traditional means.

Even with ACA coverage, he still lacked dental or vision coverage.

“Everything was always out of pocket,” Trent said. “I paid out of pocket in full for glasses. I used coupons when I could. I used the UAB School of Dentistry for a few fillings and extractions.”

He said the school is an amazing resource for uninsured patients in Birmingham. But he also said the services still require payment up front.

Trent’s biggest sacrifice healthwise came when he suffered a hernia and needed it repaired. He waited years to get surgery to ease the pain.

Access to care for LGBTQ beauty workers in Alabama

Trent also had to find a way to get his daily medications regularly without prescription coverage. Many workers in the beauty industry identify as LGBTQ, and that includes Trent. He’s a gay man who takes PrEP to help protect against HIV, which disproportionately affects gay men.

Pre-exposure prophylaxis (or PrEP) is highly effective for preventing HIV when taken as prescribed. PrEP reduces the risk of getting HIV from sex by almost 99%, according to the Centers for Disease Control and Prevention (CDC). The medication is much less effective when not taken as prescribed, so interruptions in access could raise risk.

During his time in the coverage gap, Trent signed up for clinical research trials to gain access to the life-saving drug. Fortunately, access to PrEP is much easier these days. A few years ago, the manufacturer, Gilead, began offering the drug at low or no cost for anyone who has a prescription.

Patients in central Alabama also can pick up PrEP at local health clinics that offer LGBTQ-focused care. Trent regularly gets his primary care at a practice called the Magic City Wellness Center. The center’s mission is to meet the needs of and reduce disparities in care for LGBTQ people in central Alabama. It is affiliated with Birmingham AIDS Outreach.

Trent made it through the pandemic relatively unscathed until he finally caught COVID-19 in December. He said being able to get regular care from his primary care physician has been a godsend during his recovery.

“I was lucky enough to find a doctor that treats LGBTQ folks like myself for free or on a sliding scale,” he said.

Having health coverage and regular access to preventive care has allowed Trent to recover from COVID-19 on his own time. It also has reduced his risk of becoming more ill or losing his job.

The COVID-19 pandemic forces reevaluations 

Trent said recovering from COVID-19 both physically and functionally will be a steep learning curve not just for him, but for the beauty industry as a whole.

“Working on commission, you’ve got to be able to deliver when folks need you to,” he said. “COVID, just like any other disabling condition stylists deal with, comes with nuances that make that sometimes impossible.”

Many stylists are reevaluating their schedules, Trent said. Some are cutting down to three or four days a week. Many are spending less time on their feet whenever they have a spare moment. Striking a balance even when healthy is hard, he said.

“It’s not like doing one haircut is all that taxing. It’s when you’re at the end of the day and you’ve done seven or eight of them,” he said. “Your shoulders and back start to scream at you.”

Many stylists are leaving their jobs or quitting the industry altogether because of rough physical conditions, Trent said. He said he is happy to see more salons working to accommodate disabled and older workers in response. He also called it a “timbre of the times” to see some younger workers organizing for better conditions.

How expanding Medicaid could help an expanding industry

Trent Thomas stands outside Orbit Salon in Birmingham.
Trent stands outside Orbit Salon in Birmingham’s Five Points South neighborhood. (Photo by Whit Sides)

It’s not all sacrifice. There’s plenty of success to go around.

Trent said the future is bright for young stylists. But that better tomorrow will require investments in the industry’s most important assets: people and their health. Trent said he believes full-time benefits and health coverage should be the norm and not the exception for stylists.

About 10,000 stylists and other personal care workers across Alabama would benefit from Medicaid expansion. In total, more than 220,000 Alabamians are caught in the coverage gap, unable to afford health insurance. Another 120,000 or more are stretching to pay for private or employer-based insurance.

Trent said he sees how other states and even other countries ensure their residents can get health care. And he wishes Alabama would step up, too.

“I feel like if our state really did expand Medicaid, it would mean money in the pockets of salons and stylists all over,” Trent said.

He said he believes state leaders should do everything they can to support working Alabamians, including expanding Medicaid.

Trent said the Alabama mindset is often hampered by a “pull yourself up by the bootstraps” philosophy, but state officials aren’t doing enough to equip people to thrive.

“I think that we live in the richest country in the world, and I wish we funded our health care system properly so we weren’t so reliant on for-profit businesses to take care of us,” Trent said. “If there’s money on the table to expand and we’re just letting it sit there, who does that benefit?”

About Alabama Arise and Cover Alabama

Whit Sides is the Cover Alabama storyteller for Alabama Arise, a statewide, member-led organization advancing public policies to improve the lives of Alabamians who are marginalized by poverty. Arise’s membership includes faith-based, community, nonprofit and civic groups, grassroots leaders and individuals from across Alabama. Email:

Arise is a founding member of the Cover Alabama coalition. Cover Alabama is a nonpartisan alliance of advocacy groups, businesses, community organizations, consumer groups, health care providers and religious congregations advocating for Alabama to provide quality, affordable health coverage to its residents and implement a sustainable health care system.

See the Gap: ‘Someone’s got to do something for working folks’

A picture of Katie Franklin, a nail technician and manager at a salon outside Birmingham.
Katie Franklin is a mother of two who works as a nail technician and front office manager at a salon outside Birmingham. She works full time but cannot afford health insurance. Medicaid expansion could empower her to get medical care when she needs it. (Photo courtesy of Katie Franklin)


When I first met Katie Franklin, she was juggling requests from three guests at the same time.

I’ve been visiting Nail World II, right outside Birmingham, for nearly 20 years, but this visit was different. Someone new was greeting me at the door.

Katie is a presence who is not easily forgotten. I learned she was the new salon manager. Honestly, it felt like she was right at home.

She made greeting 25 to 30 customers an hour look easy. Her maternal aura and gregarious nature shone bright through all the hustle and bustle.

It was Homecoming Week for many high schools in the Over the Mountain suburbs of Birmingham. Her salon’s clients were stacked back to back for several days in preparation for the big games and dances. And this was on top of the steady stream of walk-ins like me.

“I mean, I’m here all day, every day,” she said. “There’s no days off for me.”

Working full time but still uninsured

Katie is a mother of two who lives in Morris, about 20 miles north of Birmingham. She recently earned her license as a nail technician. A natural extrovert, she soon became a supervisor in one of metro Birmingham’s busiest nail salons.

“I needed a new start. I’m good at it and I get to help people, which is what I love,” Katie said with an infectious grin. “It’s my passion. If I can make someone feel better, then it’s all worth it.”

We exchanged numbers, and over the next month, she shared her story with me.

Katie is one of more than 220,000 Alabamians in the state’s health coverage gap. Like all of them, she cannot afford private health insurance but is ineligible for Medicaid coverage.

Katie is a single mom, working to take care of two teenagers as well as her parents. Both of her children are eligible for health care through ALL Kids, the Children’s Health Insurance Program (CHIP) in Alabama. But since she earns about $2,000 a month, she’s left in a lurch.

Even though Katie works full-time hours, she doesn’t receive benefits like health insurance. Caretakers like her only qualify for Alabama Medicaid if their income is less than 18% of the federal poverty line. For a family of three, that amount is just $4,145 a year.

“I don’t know who makes these numbers, but I’m not rich. Suddenly earning $1,000 every two weeks doesn’t mean I can afford hundreds of dollars a month for health insurance,” Katie said about Alabama’s stringent Medicaid income eligibility guidelines.

‘Imagine the difference this would make’

When Katie needs medical care, she puts off doctor’s visits and treats at home. But sometimes, it’s not enough. That’s when she goes where many other uninsured folks around Birmingham end up: UAB’s emergency room.

“I try not to go unless I absolutely have to,” she said.

Katie said she wishes there were more options for patients paying out of pocket.

She has been to urgent care centers before but dreads the bills that arrive weeks later in the mail.

“I actually spent my COVID stimulus check paying off medical debt,” she said. “I hate debt, and I’m not the kind of person who doesn’t pay my bills.”

Katie said Alabama’s leaders have to do more to support those in need of health care and coverage.

“Someone’s got to do something for working folks,” she said. “I feel like the middle class doesn’t get any of the help that these big companies get.”

She said Medicaid isn’t perfect, but just knowing her kids can see a doctor without her having to sacrifice money for bills or groceries is a big relief. Katie said she hopes Gov. Kay Ivey will expand Medicaid sooner rather than later.

“If all it takes is a stroke of a pen, then I’m all for it,” Katie said. “Imagine the difference this would make for small businesses like mine, struggling to make ends meet.”

About Alabama Arise and Cover Alabama

Whit Sides is the Cover Alabama storyteller for Alabama Arise, a statewide, member-led organization advancing public policies to improve the lives of Alabamians who are marginalized by poverty. Arise’s membership includes faith-based, community, nonprofit and civic groups, grassroots leaders and individuals from across Alabama. Email:

Arise is a founding member of the Cover Alabama coalition. Cover Alabama is a nonpartisan alliance of advocacy groups, businesses, community organizations, consumer groups, health care providers and religious congregations advocating for Alabama to provide quality, affordable health coverage to its residents and implement a sustainable health care system.

See the Gap: How Medicaid expansion would improve life for Alabama’s hairstylists and barbers

Throughout our lives, there are many milestones.

We go to school dances. We graduate, and we get married.

But we don’t get to those moments alone.

Mark Hyde, founder of Forecast Salon in Homewood, performs a color service on a client. (Photo by Whit Sides)

When we look back at the photos to relive our happiest moments, we see the faces of our friends and family smiling back. But there were other folks who aren’t always pictured.

They’re the hairstylists, barbers and nail techs who listened as we unloaded our anxieties. They always took our call when we realized (at the last minute!) we needed to do something a little extra to look and feel our best. And they deserve the security of knowing they can get affordable health care in their own times of need.

More than just a haircut

Hoover hairstylist Madison Tidwell styles a client’s hair and makeup for a wedding. (Photo courtesy of Madison Tidwell)

It was summer 2018. I was on a new medicine that solved my medical issues but had a gnarly side effect: I started losing my hair in chunks. I spent hours crying in the shower. After a few weeks of trying to convince myself I was a hat girl, I took a radical step and shaved my head. I didn’t dare do it myself. I barely had enough energy to pick up the phone and book the appointment. But when I showed up: There was Jamie.

From the minute I sat in her chair, I felt at ease. My nerves were shot, but her calm demeanor convinced me everything would be OK. Jamie turned what was a disaster into a new identity for me.

When Jamie moved out of state shortly after, I was crushed. We’d been through so much. It was like dating: I didn’t want to put myself out there all over again for a completely new person.

A few weeks (and several Instagram searches) later, I found Madison Tidwell.

Madison was a lot like me. She loved houseplants, grew up in a small town and stayed on top of trends.

Whit Sides and her stylist, Madison Tidwell, go from yellow to red in one (very long and patient) session in Hoover. (Photo by Whit Sides)

It’s been two years, and I don’t trust anyone else to touch my hair. We’ve been through growing out a pixie, evening out mullets – even going purple, green and yellow!

My experience is not uncommon. Many folks trust their hairstylists and barbers with their deepest secrets. And when you find someone you trust, you soon depend on them for more than just a haircut.

Living in the gap: How we got here and how we can fix it

Over the past few months, I’ve met with more than 30 beauty professionals in Alabama.

Some work at busy, upscale salons. Others rent booths in hometown shops. Some created their own business model by joining collectives of small, independent suites.

All have something in common: They all are uninsured or paying out of pocket for medical treatment. And along with nearly 10,000 other personal care and support workers, they would benefit from Medicaid expansion.

Because our state has failed to expand Medicaid, more than 220,000 Alabamians are caught in the coverage gap, unable to afford health insurance. Another 120,000 or more are stretching to pay for private or employer-based coverage.

Stylists usually work six or seven days a week, with little fanfare and long hours on their feet. They open early and stay late, especially on weekends when customers need them. However, most beauty professionals have no safety net in case of their own emergency. Most stylists don’t get health insurance through their employers. And even those who are self-employed often don’t earn enough to afford private premiums.

Like so many working Alabamians, these stylists and beauty professionals still don’t have health coverage or access to affordable care. I want to cover their stories in my See the Gap series. Our series will begin next week and continue over the coming months.

It’s important to share the sacrifices those in the service industry often make in their own lives to take care of everyone else. These stories will show what life is like in the coverage gap: from finding health care services and paying out of pocket for medical expenses to providing for a family when you work for yourself.

Working families in the gap are all around us. Their stories matter.

First, we’ll hear from beauty professionals about what works and what doesn’t. Some of them have graciously offered me a deep glimpse into life in one of the most physically demanding and emotionally taxing fields.

We also will discover what having health care coverage would mean for hairstylists, barbers and their families. And we will talk to workers and salon owners about how simple policy changes – like Gov. Kay Ivey expanding Medicaid – could improve these folks’ lives exponentially.

Nearly every stylist I’ve spoken with says they chose their profession so they could change lives. They center their work around people but are often left unsupported by employers and Alabama’s leaders.

Investing in the health of Alabama’s working families should be a priority for all of us. Why don’t our state’s elected officials expand Medicaid? It’s a question that deserves an answer.

Working people in Alabama are paying the price every day for our state’s failure to expand Medicaid. Imagine what investing in those who do so much for our communities could do for all of us. Imagine what would happen if we see the gap and make life better for those living in it.

Please follow @AlabamaArise and @CoverAlabama on social media to make sure you don’t miss our See the Gap series. And sign up for Arise’s action alerts so you can be ready to speak out for Medicaid expansion and other needed policy changes in Alabama.

About Alabama Arise and Cover Alabama

Whit Sides is the Cover Alabama storyteller for Alabama Arise, a statewide, member-led organization advancing public policies to improve the lives of Alabamians who are marginalized by poverty. Arise’s membership includes faith-based, community, nonprofit and civic groups, grassroots leaders and individuals from across Alabama. Email:

Arise is a founding member of the Cover Alabama coalition. Cover Alabama is a nonpartisan alliance of advocacy groups, businesses, community organizations, consumer groups, health care providers and religious congregations advocating for Alabama to provide quality, affordable health coverage to its residents and implement a sustainable health care system.

Postpartum Medicaid extension brings a glimmer of hope for new mothers in Alabama

This story originally appeared on

On Mother’s Day in 2014, I found out I was pregnant. For me, the existential dread set in just as deeply as the morning sickness.

Motherhood and its crushing weight had been drilled into me my entire life. I told myself it was too hard, that I just wasn’t strong enough to handle parenthood and all its pressures. And I feared that my family’s legacy would repeat itself.

Maude Wakefield, pictured with her husband, William (Andy) Ingle of Nauvoo, Ala. Maude is holding one of their 72 grandchildren. (Photo courtesy of Whit Sides)

One summer day in 1932, while pregnant with her 14th child, my great-grandmother Maude Wakefield finally reached her breaking point. She set off behind her home in Winston County and climbed high into a tree on my family’s land. She had been pregnant regularly since 1906 and decided enough was enough.

So she offered an ultimatum: She would return to her infinite load of daily household duties only if my great-grandfather would promise that this was it – no more babies. Not long after what would become her infamous last stand, she passed away due to a stroke worsened by postpartum hypertension. My grandmother was left to live without her mother at age 12.

Nearly a century later, during a routine blood pressure check, I was deemed high risk for the same life-threatening condition that killed my great-grandmother.

I didn’t want that same lonely future for my daughter.

The life-saving power of health coverage

Fortunately, I had health insurance. My blood pressure continued to rise to dangerous levels as my pregnancy progressed. After reviewing my family history, my doctor decided it was best for both me and the baby to deliver early under supervision to prevent preeclampsia, a condition that can lead to maternal death during or after delivery.

Because I had access to care, I was easily treated, and it ended up saving my life. Now, when I take my blood pressure pill every morning, I can’t help but think how things could have been different for my great-grandmother.

Hope can be hard to come by in Alabama. Stories like mine remind us how far we’ve come. But when you’re left without coverage, it’s never as simple as a pill and a copay.

Medicaid covers about half of all births in Alabama. And for many new moms, health coverage expires shortly after the baby is born.

Medicaid postpartum coverage extension is a step in the right direction

Some good news could be coming as soon as this fall. On April 7, Gov. Kay Ivey signed a new General Fund budget into law. It includes an extension of postpartum Medicaid coverage from 60 days of coverage to 12 months. This life-saving change will provide thousands of families consistency in care during the critical time after childbirth.

Alabama has the nation’s third-worst maternal death rate. Each year, roughly 40 new mothers in the state die within one year after delivery. Nearly 70% of those deaths are preventable, the state Maternal Mortality Review Committee found. And the toll on Black mothers is nearly three times that on white moms.

In Alabama, children living in households with low or middle incomes are widely eligible for coverage through Medicaid or ALL Kids, Alabama’s Children’s Health Insurance Program (CHIP). For adults, it is much harder to qualify for Medicaid. Just 17% of Medicaid participants in Alabama are adults under age 65 who do not have a disability.

Our state has some of the most stringent income limitations for Medicaid. For example, a single parent of two without a disability is ineligible if they make more than $346 a month. These harsh Medicaid eligibility limits mean affordable health insurance is simply not an option for many people in our state.

Medicaid expansion would ensure coverage for more than 340,000 Alabamians, including those left uninsured by these tight limits. These folks do not qualify for Medicaid, but they are unable to afford a marketplace plan or other private coverage. However, the new postpartum coverage extension means there will now be a brief inclusive window during and after pregnancy.

A lifeline in a time of need

Moms like my friend Brittany Kendrick of Blountsville call this coverage a lifeline.

Brittany lost her fiance, Dylan, in a car accident two months before her daughter Khaleesi was born. They had everything planned out, but her health insurance expired after Dylan’s death. Brittany turned to Medicaid to cover the costs.

Blountsville resident Brittany Kendrick holds her daughter Khaleesi. Medicaid was a lifeline for Brittany after her fiance, Dylan, died shortly before Khaleesi’s birth. (Photo courtesy of Brittany Kendrick)

Then, in August 2021, she made the hour-long drive to Children’s Hospital in Birmingham, where she found out her newborn had contracted COVID-19. After getting emergency care, her baby made a recovery. But as soon as they got home, Brittany tested positive and started to feel worse.

Being able to see a doctor and seek treatment quickly was just the blessing they needed during what Brittany calls the hardest year of her life.

“Medicaid paid for all of our hospital and doctor bills,” Brittany said. “It gave me a chance to use the money I had in savings for a safer car and a new apartment for me and the baby.”

Brittany hopes she will be among those eligible for the new postpartum extension. Having consistent care has brought balance to her life in more ways than one. “I can take medicine for anxiety and depression now. I need that, to stay strong for her,” she said.

Khaleesi Rider in April 2022. (Photo courtesy of Brittany Kendrick)

‘Why not offer this to all mothers?’

Extending Medicaid coverage doesn’t just support new or single parents.

Sarita Edwards of Madison is a mother of five and founder of the E.WE Foundation, a health care advocacy organization. She began her foundation after receiving a rare prenatal diagnosis of Edwards’ Syndrome (trisomy 18) for her son Elijah. The high mortality rate associated with her son’s diagnosis meant her family racked up thousands in medical debt before baby Elijah was even born.

Madison residents Kareem and Sarita Edwards hold their son Elijah. Sarita founded the E.WE Foundation after her son received a rare prenatal diagnosis. (Photo courtesy of Sarita Edwards)

Sarita says every day with Elijah has been a juggling act. Elijah’s condition is terminal, and his care can be exhausting and expensive. She now spends her time advocating for more equitable treatment and access in health care. She knows our leaders can do more, because she’s seen it firsthand.

“I know what our state can do when offering care to mothers and children with rare diseases,” Sarita said. “Why not offer this to all mothers?”

Elijah Edwards, age 5. (Photos courtesy of Sarita Edwards)

The new General Fund budget includes more than $8 million to extend Medicaid coverage for 12 months after childbirth. But the funding is guaranteed only for one year – on a trial basis.

This year marked another Mother’s Day when Alabama mothers are still dying from pregnancy and childbirth at twice the national rate. Reliable health coverage – and the access to care that comes with it – can prevent many of those deaths. Sarita sees no reason to hold off on making Medicaid’s postpartum coverage extension permanent.

“Our babies are taken care of, but what about the mothers?” Sarita asked. “I don’t know why it takes Alabama so long to do the right thing sometimes.”

About Alabama Arise and Cover Alabama

Whit Sides is the story collection coordinator for Alabama Arise, a statewide, member-led organization advancing public policies to improve the lives of Alabamians who are marginalized by poverty. Arise’s membership includes faith-based, community, nonprofit and civic groups, grassroots leaders and individuals from across Alabama. Email:

Arise is a founding member of the Cover Alabama Coalition. Cover Alabama is a nonpartisan alliance of more than 115 advocacy groups, businesses, community organizations, consumer groups, health care providers and religious congregations advocating for Alabama to provide quality, affordable health coverage to its residents and implement a sustainable health care system.

When Alabama’s coverage gap hit home for my family

This story originally appeared on

Our borders have become irregular as COVID-19 closes in on almost every part of our lives. The pandemic has made all of us realize how the shapes of our families are becoming irreparably different.

This summer, the shape of my own life changed.

Cathy Parker was one of my mom’s lifelong best friends. They grew up together near the border of Blount, Jefferson and Walker counties, in a small community appropriately called Corner.

Cathy Parker (right) and her husband, Chuck. (Photo courtesy of Chuck Parker)

Cathy was small in stature but had a raspy, larger-than-life voice. She also had a kind, wide-open laugh that made you feel special and heard. She was a rescuer: of plants, animals and even children.

After retirement, my parents began to spend more time with Cathy and her husband, Chuck. Early in the pandemic, they were part of a tiny pod of people with whom my parents visited. My younger sister has special needs, and my mother has asthma, so they kept their circle tight to reduce exposure.

When vaccines started to open the world earlier this year, my daughter began to spend more time with my parents again. That meant more time with Cathy, too.

Cathy was like an aunt to me. My daughter called her “Mamaw.” She loved spending weekends at Cathy’s house in Hayden.

The phone call

One morning as spring turned into summer, my mother called me. She was crying. She said in a small, scared voice that Cathy was sick. Cathy had a tumor in her lungs, and it had spread to her brain.

I couldn’t process the news for days. To be honest, I still haven’t.

I didn’t know how I was going to tell my daughter. I didn’t know how I could help my mother.

Unfortunately, I didn’t have much time to think about any of that. Cathy Parker died in late July after a painfully short battle with Stage 4 cancer.

With her gone, everything feels smaller. I can’t imagine how that feels for my parents, after knowing her for almost a lifetime. The shape of the world changed.

The coverage gap

If you ask my mother what the biggest change has been since, she’ll tell you it’s the anger. Cathy’s death reminds us every day that in Alabama, those who need help the most are often the last to get it.

Cathy was one of hundreds of thousands of people in Alabama without health insurance. That includes about 32,000 older adults (50 to 64 years old) who are in the Medicaid coverage gap.

Cathy did not qualify for Medicaid under the state’s stringent income limits. And her husband, Chuck, said her income was too low to qualify for a subsidized plan under the Affordable Care Act. She was three years shy of Medicare eligibility.

Chuck is a former Marine and Vietnam veteran. He receives benefits through the Department of Veterans Affairs for himself. But Chuck said he was turned away whenever he asked about extending them to his wife. The premium for the cheapest marketplace plan available to Cathy was more than $800 a month, Chuck said. That was more than they could afford.

They paid out of pocket to doctors who helped Cathy as much as they could. Even so, the question haunts us: Was Cathy’s time cut short because she was uninsured?

I believe so. Things easily could have been different.

A bad situation gets worse

Lack of coverage meant lack of access to lots of specialists. And it meant traveling more than an hour to find doctors who would take a patient paying out of pocket. Cathy and Chuck’s pockets often came up empty as the medical bills increased.

Compounding the tragedy, COVID-19 made access to life-saving care increasingly difficult. Several times, Cathy and Chuck drove to the hospital in the middle of the night. They waited hours in the emergency department, hoping for a bed that never materialized.

Chuck recalls that one night shortly before she died, Cathy had a seizure as the tumor grew larger in her brain. He immediately called 911.

They rode in an ambulance for more than an hour, only to be turned away by two hospitals diverting all incoming patients. They were overwhelmed by the overload of COVID-19 cases. Cathy eventually found a bed at a third Birmingham hospital. She passed soon afterward.

COVID-19’s burden on Alabama’s health care system has been enormous. In early September, near the delta variant’s peak, anywhere from 10 to 80 people a day in Alabama were waiting for an ICU bed “that is not there,” Dr. David Kimberlin of UAB told NPR. (Those numbers have improved since, with the Alabama Hospital Association reporting 167 ICU beds available statewide in early October.)

Adding to the challenges of pandemic response, our state has lost eight rural hospitals in the last decade. We surely could have used those resources during the pandemic. And we still might have them if Alabama had expanded Medicaid.

The what-ifs that haunt us

My family is one of thousands haunted by what-ifs resulting from Alabama’s failure to expand Medicaid.

What if Medicaid coverage had been available to Cathy?

It’s not hard to imagine a different outcome.

Cathy was born in Illinois, one of 38 states that expanded Medicaid to adults with low incomes. More than 600,000 people in Illinois now have coverage as a result, including many in Cathy’s family.

Chuck and Cathy considered moving to Illinois so she could get insurance through Medicaid expansion. But her illness progressed so quickly that moving was not an option. If Cathy had returned to Illinois before she started feeling sick, she might have qualified for expanded Medicaid. Doctors might have found her cancer more quickly. And that early detection might have saved her life.

But that’s not what happened. Instead, Chuck still opens the mailbox wondering what bill will arrive today. The last one he received was for $22,000, detailing charges for his wife’s end-of-life care.

Cathy did ultimately make it back to Illinois. Her friends and family honored her request to scatter her ashes there after she passed.

Expand Medicaid to prevent suffering

Cancer patients living in states that failed to expand Medicaid are more likely to die than those in states that have expanded, new research shows. In Medicaid expansion states, patients are more likely to get earlier-stage diagnoses and receive earlier interventions.

Medicaid expansion lowers mortality rates. It saves lives.

Alabama’s leaders have the resources and tools to expand Medicaid. But they keep passing the buck, blaming it on money or politics. Each day, struggling Alabamians are the victims.

Gov. Kay Ivey can begin the process of expanding Medicaid today. It would prevent death for so many people living in the coverage gap. And it’s the single most important public health intervention available to uplift Alabama’s hospitals, doctors and patients after the pandemic.

For now, we’re left with the irregular borders closing in on us. Our families are growing smaller, and especially after the year we’ve had, it’d be easy to feel like there’s nothing we can do. But that’s just not true. We can expand Medicaid. And we must.

It’s too late for Cathy. But it’s not too late for the governor to protect other Alabama families from enduring the pain we’ve experienced. All it takes is the stroke of a pen.

About Alabama Arise and Cover Alabama

Whit Sides is the story collection coordinator for Alabama Arise, a statewide, member-led organization advancing public policies to improve the lives of Alabamians who are marginalized by poverty. Arise’s membership includes faith-based, community, nonprofit and civic groups, grassroots leaders and individuals from across Alabama. Email:

Arise is a founding member of the Cover Alabama Coalition. Cover Alabama is a nonpartisan alliance of more than 110 advocacy groups, businesses, community organizations, consumer groups, health care providers and religious congregations advocating for Alabama to provide quality, affordable health coverage to its residents and implement a sustainable health care system.

‘It’s time for someone to stick up for us’: Walker County’s need for Medicaid expansion

Rev. Robin Hinkle stands in front of the sign for St. Mary's Episcopal Church
Rev. Robin Hinkle is the rector at St. Mary’s Episcopal Church in Jasper. Her ministry has greatly scaled up food assistance to the community to help ease financial suffering during the COVID-19 recession. (Photo courtesy of St. Mary’s Episcopal Church)

Walker County has gained notoriety in recent years as one of the epicenters for Alabama’s opioid epidemic. Overprescribing, lack of health care access and extreme poverty seemed to form a cursed trifecta leaving residents of the rural county to rebuild and recover.

Outside the headlines, community organizations and rural health advocates have been earning praise for their efforts to bring as many resources as possible to the northwest Alabama county of 67,000 people.

“If there’s a problem, you don’t have to look far for someone to help,” said Rev. Robin Hinkle of St. Mary’s Episcopal Church in Jasper.

Hinkle’s ministry has scaled up its food assistance to the community exponentially in the last year. The church went from distributing about 250 bags of food a week to more than 1,000 bags a day. Hinkle said the COVID-19 pandemic and its associated recession left more people than ever in need.

“The system is absolutely not working as it is, especially with the state and local governments,” she said.

Hinkle said many people she works with do receive Supplemental Nutrition Assistance Program (SNAP) benefits or other public assistance. But the income restrictions attached often force people to make painful decisions.

“I see it all the time,” Hinkle said. “When you lose your insurance and paycheck, what used to be $5 at the pharmacy is now $40. And the first thing you give up is medicine.”

‘A big, giant problem’

Hinkle said she has been offering more financial assistance than expected to families on the margins of the middle class. Many of these households have been hit hard by the pandemic, too. And resources can be scarce for families who make too much to qualify for public assistance, but still not enough to reliably pay the bills.

These are the families who are in Alabama’s health coverage gap. They make too much money to qualify for Medicaid under the state’s stringent eligibility limits but not enough to get a subsidy to help pay for a private insurance plan on the health care marketplace.

Alabama is one of 12 states that have not expanded Medicaid to cover adults with low incomes. Even before the pandemic, more than 220,000 Alabamians were caught in the coverage gap. And another 120,000 were stretching to pay for coverage they can’t afford.

“This is a big, giant problem,” Hinkle said. “Once you lose a job or are forced to work minimum wage, it’s very hard to be poor because of all the gaps in our system.”

Medicaid expansion would relieve the burden on families and those deciding whether to pay for medicine or buy groceries, Hinkle said.

“If we had better access and treatment options, it’s better all around,” she said. “Every dollar counts. If we could just get the resources, we can work to solve the problem just like we’ve done before.”

Removing barriers and strengthening rural clinics

Over the past decade, community organizations have come together to form networks bringing more money and treatment options into the county. Spearheaded by the Walker County Community Foundation, the Healing Network of Walker County includes 25 organizations providing prevention, intervention, treatment and recovery resources for mental health and substance use disorders.

One of those partners is Capstone, a group of rural health clinics located across Walker and neighboring Winston counties.

“Over half of our patients are uninsured, and the majority of the others receive Medicare or Medicaid,” said Dr. F. David Jones, executive director of Capstone Rural Health in Parrish.

Jones is one of more than 300 medical professionals who signed a joint letter last week urging Gov. Kay Ivey to expand Medicaid.

Photo of Dr. F. David Jones
Dr. F. David Jones is executive director of Capstone Rural Health in Parrish. He said Medicaid expansion would allow clinics like his to grow and serve more people across Walker County. (Photo courtesy of Capstone Rural Health)

Capstone’s clinics often house primary care, dentistry, pharmacy, social work and mental health care under one roof. While this one-stop shop can be invaluable for rural communities, Jones said access barriers are always involved when someone is struggling to make ends meet.

“We do still need to see valid ID, a bill showing your current address, and proof of income, which can be hard to get if you’re unemployed or don’t have a license,” he said.

Jones said the clinic tries to treat everyone who comes in. But even with local help, they can’t do it all.

“Communities can keep casting off the poor by just ignoring all their problems or burdening the church, but they need us more than they realize,” he said.

Medicaid expansion’s life-saving potential in Walker County

An injection of money from Medicaid expansion could be a lifesaver, Jones said. The funding could ease the burden placed on community health centers and UAB to treat areas of Walker County with low access.

“Medicaid expansion is a no-brainer,” he said. “With that kind of money coming in, we would grow. We could bring professionals in, and it could prop up a lot of the other community health centers that do good work.”

Jones said he hopes Alabama can put aside partisan politics and finally take advantage of the taxes we already use to pay for Medicaid expansion in other states.

“I hope the governor will sign on,” he said. “It’s time for someone to stick up for us. We should’ve been at that table a long time ago.”

About Alabama Arise and Cover Alabama

Whit Sides is the story collection coordinator for Alabama Arise. Arise is a nonprofit, nonpartisan coalition of congregations, organizations and individuals promoting public policies to improve the lives of Alabamians with low incomes.

Arise is a founding member of the Cover Alabama Coalition. Cover Alabama is a nonpartisan alliance of more than 100 advocacy groups, businesses, community organizations, consumer groups, health care providers and religious congregations advocating for Alabama to provide quality, affordable health coverage to its residents and implement a sustainable health care system.

‘Everything is fine, until it isn’t’

Elizabeth works at a sewing machine in the family’s home. (Photo courtesy of Geoff)

Part 1: A hard winter ahead

Winter has been a long time coming for Geoff* and his wife, Elizabeth*. He didn’t think he could actually feel more anxious than he had since March, when he and his family began isolating along with the rest of the country.

(*Geoff and Elizabeth agreed to share their story using pseudonyms to protect their privacy.)

Every day since has been essentially the same. Geoff wakes up early to go for a run around his neighborhood in Montgomery. He gets back in time to get the kids ready for their long day of virtual learning.

But this morning, Geoff felt himself dragging.

“I am a young dude, but I get a new creak or squeak every day,” he says jokingly. Running used to be so much easier when he was in his 20s, he said. He’s now in his mid-30s.

His tone begins to shift, and his voice becomes heavy. “I lay down to go to sleep and everything is fine, until it isn’t,” he says.

Back in May, like millions of other Americans, Geoff started to realize his job was becoming less secure. Finally, in September, he was let go. “That’s when I started experiencing panic attacks,” Geoff said. “And like, who wouldn’t in my situation?”

Geoff lost his income, his daily routine and his health insurance on Oct. 1. He has found it hard to sleep ever since.

Alabama’s coverage losses have soared during the pandemic

The COVID-19 pandemic and resulting economic crash have caused the greatest health insurance losses in American history, according to research published by the nonpartisan research organization Families USA in July.

An estimated 5.4 million workers became uninsured because of job losses they experienced from February to May this year. And 69,000 of those are in Alabama.

“Even before COVID-19, Alabama’s failure to expand Medicaid left more than 220,000 adults uninsured,” Alabama Arise campaign director Jane Adams said. Adams directs Cover Alabama, a coalition of nearly 100 organizations pushing for Medicaid expansion in Alabama. Arise is a founding member of the coalition.

“Further coverage losses during the ongoing economic recession will bring health and financial suffering for even more families across our state. More people will go without needed health care. More hospital bills will go unpaid. And more families will fall into poverty.”

‘All the things I had that I suddenly don’t’

For Geoff, this coverage loss means every choice he makes could bring a new risk.

“I just lay there and my brain reminds me of all the things I had that I suddenly don’t, and it changes the way I interact with the world,” he said.

Geoff and his wife both remain physically active, he said. He used to take comfort in the alone time that running provided. But after he lost insurance, every crack in the pavement or acorn on the sidewalk gives him yet another thing to worry about.

“I have nothing,” he said. “If I fall and twist my ankle, that’s it. I won’t be able to provide for my family.”

Part 2: Sacrifice

Geoff and Elizabeth own a small event business in Montgomery. They have relied heavily on working weddings and other public events to pay the bills since losing his salary. Without these gigs, he said, he has no idea how they would make it after losing his salaried job.

Elizabeth also does freelance work that allows their kids to be covered under her private insurance. When Geoff first learned he’d be laid off, he immediately asked his wife if he could join her plan.

“You just take this stuff for granted, right?” Geoff said. “I had great insurance under my parents. Then, I was covered in college, and right after, I was blessed to get a good job,” he said.

But when he saw the monthly premium to get coverage with the rest of his family, he knew it wasn’t an option.

“It was thousands of dollars just to add me!” he said, exasperated. “She doesn’t even make that much altogether!”

Beyond just money, Geoff said he fears most for his children.

A simple hospital visit would cost several thousand dollars thanks to a high deductible, he said. Even a quick trip to the doctor for his children would set them back on groceries for a few weeks.

“I make sacrifices,” he said. “I haven’t bought anything for myself since April, but I still can’t give my kids everything they need, and that is terrifying.”

Geoff and his wife have relied on word of mouth to book business. Their work often means taking jobs that leave the family at higher risk of contracting COVID-19.

“I’m a healthy guy, but every day you see a news story with bodybuilders… guys bigger than me hospitalized and their bodies just ravaged by this virus,” he said.

Parental coverage loss hurts children, too

“COVID-19 is jeopardizing lives and economic security for thousands of Alabama workers just like Geoff,” Adams said.

And now that case numbers are rising exponentially as the United States faces its third wave of COVID-19, many local communities are facing long-term challenges for health care capacity and economic recovery.

Geoff and Elizabeth’s children at the dinner table. (Photo courtesy of Geoff)

But Geoff said he has more to worry about than just the virus. “I’m getting used to the panic attacks because even though I’m undiagnosed, I know it’s a product of the situation I’ve been put in,” he said. “It’s not so easy when I think of my daughter.”

Geoff and Elizabeth’s young daughter was diagnosed with autism spectrum disorder at a young age and was receiving regular care from a specialist. After months of research to find a provider, it would take them even longer to get an appointment.

“And that was with great insurance,” Geoff said.

After losing his job, they could no longer afford the $150 out of pocket per visit. They stopped going to appointments.

“We are left with a child who spends all day at home with two parents who are very clearly not experts for autism. Not even close,” Geoff said.

Part 3: The shock of it all

It’s becoming harder and harder for Geoff to relax. What weighs the most, he said, is the shock of it all – even this long into the pandemic.

“I mean, look, I’ve been blessed my whole life,” he said. “I’m a white guy in Alabama. I have a college degree. My parents set me up for success. But things are falling down all around us.”

Geoff said he would vote for Medicaid expansion if it were on the ballot.

“Growing up in Alabama, you always gotta expect the worst but still try to vote for the best,” he said.

For the first time in his 30 years of living in Alabama, Geoff said he feels like state leaders might finally shore up the safety net that keeps so many Alabamians afloat.

“We have got to give up this long legacy of Scotch-Irish stubbornness passed on from our state’s founders hundreds of years ago,” he said. “It’s 2020. You can no longer pretend that you don’t know who you’re hurting by not offering folks help.”

Geoff’s family enjoying the beach. (Photo courtesy of Geoff)

‘I feel like I did everything right’

Recovering from the COVID-19 recession – as families, as a workforce, as a state – is going to require every tool and resource available. Closing the health coverage gap for tens of thousands of hard-working Alabamians like Geoff is the single biggest step our state can take to protect families from delayed health care and medical debt, strengthen our economy and move Alabama forward.

Geoff said if this year has taught him anything, it’s that being nimble is just as important as planning.

“I feel like I did everything right,” he said. “I did everything right, and still I woke up one day and none of that matters. I need help just like everybody else.”

About Alabama Arise and Cover Alabama

Whit Sides is the story collection coordinator for Alabama Arise. Arise is a nonprofit, nonpartisan coalition of congregations, organizations and individuals promoting public policies to improve the lives of Alabamians with low incomes.

Arise is a founding member of the Cover Alabama Coalition. Cover Alabama is a nonpartisan alliance of nearly 100 advocacy groups, businesses, community organizations, consumer groups, health care providers and religious congregations advocating for Alabama to provide quality, affordable health coverage to its residents and implement a sustainable health care system.

Cover Alabama Conversations: Alabama Arise’s Jim Carnes

Alabama Arise’s Sherrel Wheeler Stewart talks to Arise policy director Jim Carnes about how Medicaid expansion would save lives and reduce suffering for hundreds of thousands of adults with low incomes across Alabama. They also discuss how expansion would help the state combat the COVID-19 pandemic and rebuild in its aftermath.

Listen to the full interview below:

Arise is a proud member of the Cover Alabama Coalition, which is urging Medicaid expansion in our state. Click here to share your health care story with Arise and Cover Alabama today.

Full transcript


Our state, our nation and our world are at a crisis point right now. The global pandemic COVID-19 is claiming thousands of lives, flooding hospitals with patients and wrecking the economy. In Alabama, it’s exposing a serious gap in health care for poor people in our state.

Now a coalition of partners, Cover Alabama, is working together to help bring change, expanded access to Medicaid now and a better quality of life in the years ahead.

I’m Sherrel Wheeler Stewart, story collection coordinator for Alabama Arise. I’m talking by phone with Jim Carnes, the Alabama Arise policy director. He tells us why Medicaid expansion is needed in Alabama right now.


So recently, the vice president said states have been given some flexibility in using their Medicaid dollars to help the uninsured at this time. What does it mean for Alabama? If anything?


If anything, there is that basic question offered by the Affordable Care Act. You know, will you expand Medicaid to cover this population of people who are earn up to 138% of the poverty level?

Alabama is one of 14 states that have not accepted that option. What’s happened with the COVID-19 pandemic is that states have some additional flexibilities. Now, a lot of these are flexibilities that states always have, but emergencies kind of open that door. And there are things Alabama could do through several different mechanisms, through a waiver process or an amendment process. The technical mechanisms differ, but the general idea is that there are a whole host of things that Alabama could do to broaden our coverage and to streamline coverage and services. For example, we could suspend a lot of the administrative processing required for people to get certain kinds of services or to get coverage that they qualify for.


In other words, what you’re saying is, get rid of some of the red tape?


Exactly, exactly. There is an opportunity now to get rid of a lot of the red tape. Alabama has made some moves in that direction. We have passed for and gotten permission to do a few things. But there are many more options available to Alabama that we have not yet sought.

Now, the option to expand Medicaid coverage to those adults, working-age adults, is something that is obviously still available. And Alabama has not chosen to do that. That is not, however, a new flexibility that is prompted by the emergency. There is not really an emergency expansion opportunity. We can roll out services in a new way, and we can make enrolling in coverage easier. But if we want to expand coverage outright, the opportunity still stands. We could do it. The word “expand” is the key there.

There are two things to bear in mind. No. 1 is that the Affordable Care Act 10 years ago gave states the authority to expand their Medicaid programs to cover low-income adults up to 138% of the federal poverty level and to include adults without children. Here in Alabama, which has the second most restrictive Medicaid program – we have the second strictest program after Texas – we allow adults under age 65 who do have a disability, which is sort of one way to distinguish between adults who qualify and adults who don’t. People with disabilities can get Medicaid coverage under certain conditions. But looking at what some people call able-bodied adults – that is, adults who are working-age without a disability. In Alabama, No. 1, you have to have a dependent child. And No. 2, your earnings cannot exceed 18% of the federal poverty level.


In dollars, what are we talking about here?


Yeah, well, for a family of three, that would be, you can’t earn more than $329, I believe. So it’s under $350 a month, if you think of it in big round numbers. If you earn more than $100 a week in Alabama, you can’t get Medicaid.


Well, that doesn’t sound like a whole lot. It sounds like what you get when you pick up lots of cans and just take them down to be recycled.


Yeah, exactly. I mean, you’re talking about not being able to hold a job and get Medicaid in Alabama. It’s extraordinarily restrictive.

We do a better job with children, children and families. Up to 146% of the poverty level can get coverage for the children, but their parents cannot get coverage. So, we’re dealing with an extremely low income limit in Alabama, which means we have a lot of folks who are walking around Alabama working every day in jobs that we all depend on. You know, all the service industries and just a variety of jobs, manufacturing and all kinds of jobs, that cannot qualify for Medicaid.


You know, a lot of these Alabamians are people who are on the front lines. They are the ones who are keeping us going right now. Am I correct?


Oh, exactly. I mean, we’re depending on them more than ever right now. Exactly.


Why is it important at this time for Alabama to expand Medicaid?


You know, it’s been important for 10 years, but it is more urgent than ever right now. There are there are many, many reasons. And I’d like to hit some highlights. One is that Alabama is a high-poverty state. We estimate that we have more than 200,000 Alabamians who are trapped in the coverage gap. They simply cannot afford to buy private or employer-based coverage, and they earn too much to qualify for our very restrictive Medicaid. So they are without an option. And as you pointed out, they are the people who are working the jobs that we have deemed essential. They are cleaning our hospitals, cashiering at our grocery stores, docking the shelves of our drug stores and grocery stores. They are keeping produce rolling from the farms to the stores. They are the people that we are all more aware of probably right now than we have been in a long time.

Essential workers without health coverage

I think everybody is tuned in now to the crucial jobs that those employees are serving and fulfilling in our state right now. And I know that I’m finding myself thanking the checkout clerk much more consistently than used to be, really trying to tell them that we appreciate their critical service at this time. These are people who are much too often going without health coverage. Similarly, people in the food service industry, while most of that has shut down, there are still people who are working to provide meals that can be picked up or delivered. And too often, those are folks who are going without health coverage. We also know that we’re going to come out of this shutdown, and people are going to be reentering the workforce with that same hindrance.

They are still going to be going without health coverage, unless we can do something now. One thing that I especially want to point out is that the recent measures that Congress has taken to address the coronavirus have made sure – and I’m grateful that they have – but they’ve made sure that there is free testing available. We hope that that is becoming more and more widely available, but there should be free testing rolling out across all of the states.


What happens if Alabama doesn’t act now to expand Medicaid?


We’ve just learned recently that there will be payments for hospitals to serve COVID-related illnesses for patients who were uninsured. But they don’t have— those same people don’t have coverage for anything else that may be wrong with them or that may happen to them in the meantime. So for an uninsured worker, for example, the idea of having to deal with illness from COVID, it can mean personal financial disaster. It can mean medical debt that is simply unsustainable.


When I hear you say these things, I think about my own perception of Medicaid and health care. You know, I always just thought that health care was one of those elements we needed to maintain a certain standard of living.


You hit the nail on the head. You know, one thing I’m hopeful about amid all this despair that we’re experiencing and the alarm is this bright light that we are seeing now on our health system and on our community networks and all of those infrastructural kinds of things that kind of go hidden or unnoticed. One result that I’m hoping to see is that our conversation will lead us to consider what really is the role of our public financing for the common good. What do we as communities really owe each other and ourselves in regard to a baseline safety net of public services that we all ultimately depend on?

I think never in my lifetime have we seen such a stark picture of how public services work, how they should work and how they sometimes fail. And I’m hoping that those failures and that sharp, bright light can help us reevaluate and have a really serious, productive conversation about our investment in the common good.


Talk to me a little bit about our health care system and the impact of the hospital system in Alabama.


Alabama is a state that has allowed its hospital system to become frayed. As you know, we’ve lost eight rural hospitals over the last 10 years and six hospitals in urban and suburban areas. So we are already— before the COVID-19 even emerged, we were suffering from a beleaguered hospital system.

The emergency is only going to tax those hospitals further to the limit in terms of their capacity to deliver care and their capacity to sustain the financial impact of the epidemic. Our hospitals are in more need than ever of the federal support that would come through Medicaid expansion.


But Jim, beyond the conversations, it seems like someone needs to be making things happen. And who is it? Is it the governor? Is it the Legislature?


Yes. Well, there is in Alabama— each state is different with regard to how its Medicaid works. It’s a federal-state partnership that gives states a lot of leeway. There’s the federal government sets kind of a baseline of services. But the states have a lot of flexibility. And when it comes to how they make Medicaid funding decisions, the states are really individual deciders on that.

In Alabama, the governor could initiate Medicaid expansion by approving a rule change. It’s a simple rule change that would raise our income limit for Medicaid benefits. Once she did that, there is a review process that would take that rule change to a legislative committee, and they wouldn’t even have to actively approve it. They could they could not object. In other words, they could allow the rule change to pass. They wouldn’t have to do anything. They would just have to turn the other way and let the governor do it.

The governor has that authority, but it still requires some consent, even passive consent, from a legislative committee. Once that happens, it would go to Washington for approval. And I cannot imagine that in this environment they wouldn’t expedite an approval.

I know that the Trump administration has not favored Medicaid expansion, but it’s almost impossible to believe they would deny it in this environment. Then it would go into effect. The Legislature would have to provide the extra funding for covering more people. But we think that’s an investment that would have immense return.


Now, in dollars, what’s that amount? What are we talking about here?


The estimates that we had before COVID-19 were that that year one would be that the highest costs for the state. The federal government pays 90% of the expansion cost. So in other words, the costs for enrolling and serving the new enrollees through the expansion. It’s a 9-to-1 federal program for expansion. Alabama’s cost, we estimate, would be $168 million. And then the feds would pick up the rest.

In subsequent years, we would begin to see the return on that investment. We would see new tax revenues from the increased economic activity. We would see new state savings in programs that we’re currently paying for entirely out of state dollars, particularly some mental health programs, and those would get the 90% match. So it would make new state money available. So in subsequent years, the estimate is that the state would pay about $25 million a year going forward for expansion. In return, we estimate about 340,000 Alabamians— you would get those people who are currently uninsured in the coverage gap, plus some eligible people who would then choose to take the Medicaid coverage in lieu of straining their family budget to pay for their private or employer-based coverage. So, we think about 340,000 people would get it.


Will COVID-19 change these projections? And if so, how?


We have to adjust those expectations a little bit, because COVID is going to make more people eligible, because more people are losing their jobs and losing their income. So more people would become eligible. However, the return that we would get on having those federal— that federal support for the health care for those Alabamians would be immense. I mean, that would just be an enormous gain for the state.

If we are saddled with even more uninsured people who are now facing even more health challenges in a hospital system that has not gotten that extra support it needs, then that just spells disaster for the state. So the hospital system itself is another beneficiary. Obviously, we would get to infuse those federal dollars into our struggling hospitals. That in turn would help revitalize our community economies, because, as you know, our state and local economies are going to be reeling from this blow.

So the best leverage we can use right now, just thinking beyond the health care system and beyond COVID— the best leverage we can use for bringing federal dollars into the state to respond and recover from the emergency is to expand Medicaid. We will get nine times the funding we put up as a state. So it’s a 9-to-1 gain. For a dime on a dollar, we could bring in billions of federal dollars to help our state recover and bounce back.


Let’s just say this moves through the process, through the governor’s office, through the Legislature. And then how long will it actually take for us to get Medicaid expansion in place in Alabama?


Our best guess is that it would take about six months for the coverage to get up and rolling. However, there’s a wonderful provision that allows Medicaid coverage to be retroactive in the quarter in which it starts. So the sooner we start – we’re now in the second quarter of the year, it’s the third quarter of the fiscal year – the sooner we start, we can retroactively cover from April 1.

So although it would take about six months to get the actual machinery up and running, so to speak, on getting coverage, we could we could actually build some of that retroactively. So we would have good financial coverage there. However, in the meantime, Alabama needs to use every tool in the Medicaid toolbox. That means going ahead and initiating all of the flexibilities that you mentioned earlier that we can to make enrollment easier, to make getting services easier, to make it easier for medical providers to get their payments. There are just all kinds of streamlining that we can do to expedite or fast-track our startup on Medicaid expansion.

Now is the time. Every day we waste is a day that puts more Alabamians at risk, that puts more hospitals at risk and more communities at risk of financial disaster.


This has been Cover Alabama Conversations. Thanks for listening.