Alabama enrollment navigators provide help, but options are limited without Medicaid expansion

A woman sits at a booth at an event.
Enroll Alabama navigator Rebecca Sylvester staffs a table at a community event in Huntsville. (Photo courtesy of Enroll Alabama)

Rebecca Sylvester spends her days answering phone calls from desperate Alabamians.

As an enrollment navigator for Enroll Alabama, a grant-funded organization dedicated to helping people find health coverage, she faces a daily battle with the harsh realities of Alabama’s health care system.

But despite her dedication to finding resources for everyone who calls, she is forced to deliver heartbreaking news to most of her callers: There might not be any options for them. Especially for people caught in Alabama’s health coverage gap, who earn too much to qualify for Medicaid but too little to qualify for insurance subsidies under the Affordable Care Act (ACA).

“I think that I can count one mom who was able to get back on Medicaid out of hundreds of people I spoke to,” Rebecca said.

Even then, this mother was a special exception. She was part of a brief window that allowed those who were enrolled in Medicaid during the COVID-19 pandemic to maintain coverage during the federal public health emergency (PHE). But because the PHE declaration ended in 2023, navigators are now hearing from people who are losing their Medicaid coverage during a process known as “unwinding,” or a return to pre-pandemic eligibility requirements.

Adults between ages 18 and 64 in Alabama have to meet some of the strictest income eligibility requirements in the country to have Medicaid coverage. Parents in a two-person household, for example, do not qualify for Alabama Medicaid if they make more than just $3,684 a year.

The wide range of people in Alabama’s coverage gap

The frustration in Rebecca’s voice is palpable. The coverage gap is a consequence of Alabama’s decision not to expand Medicaid to cover adults with low incomes under the ACA. That policy failure has left nearly 300,000 residents without affordable access to health care.

This means Rebecca talks to a very diverse group of people every day. They include young adults aging out of ALL Kids (Alabama’s Children’s Health Insurance Program). Many are working adults who don’t get insurance through their employer. Some are older adults who are approaching age 65 but are not yet eligible for Medicare.

Rebecca’s work is more than just finding coverage solutions. It involves discussing complicated and systemic failures with confused and often desperate callers who are learning about it for the first time.

“I don’t think I’ve had a single client where I’ve been like, ‘You’re in the Medicaid coverage gap,’ and they knew what that was,” she said.

The stories never stop coming

Two people at a booth speak with a person visiting that booth.
Enroll Alabama navigators answer questions at a community event in Montgomery. (Photo courtesy of Enroll Alabama)

Many people are shocked to learn how few resources exist for all the Alabamians living in the gap.

Rebecca discussed one conversation that was particularly hard. The caller not only had lost health coverage but also had become homeless and reached out for help.

“This person genuinely believed that there was some sort of help out there for people who really needed it,” Rebecca said.

She said the harsh truth is that, without Medicaid expansion, such public resources are virtually non-existent in our state. And while she tries to find free or sliding scale clinics to help, they can’t be the fix for everything.

Enroll Alabama helps people navigate the often confusing landscape when trying to find health coverage, but the resources they can offer are limited. Our state’s failure to expand Medicaid leaves hundreds of thousands of people scrambling to find a patchwork of temporary solutions to their health issues.

By not accepting federal funds that would ensure health coverage for those in the coverage gap, our state continues to deny Alabamians the peace of mind that folks in 40 other states have.

‘It’s heartbreaking’

One young woman Rebecca helped was attending community college and needed ongoing mental health support. She lost coverage when she turned 19, aging out of ALL Kids, and her small campus didn’t offer student health resources that larger universities do. Her mother received disability payments, and her family couldn’t afford private insurance premiums of more than $400 a month.

“She apologized to me for needing Medicaid,” Rebecca said. “I couldn’t believe it!”

Rebecca says navigators come face to face every day with stories like these every day. These situations highlight how stigma and misunderstanding surrounding public assistance programs hurt so many people across Alabama. Rebecca’s frustration is evident when she talks about not being able to assist everyone who reaches out for help.

“It’s heartbreaking to tell someone there’s nothing I can do for them,” she said. “They fall in the gap, and there are just no options available.” She said this sense of helplessness is shared among other navigators who see firsthand the gaps in the system.

A growing network of navigators

Mark Linn, assistant project director for Enroll Alabama, also does navigator work. He said that though navigators often hit roadblocks when working with folks in the coverage gap, they still keep their phones and schedules open for anyone who needs them.

A crowd of people pose for a photo.
The Enroll Alabama navigator team gathered at their 2023 annual meeting at the Tutwiler Hotel in Birmingham. (Photo courtesy of Enroll Alabama)

“Everyone is different, and no situation is permanent,” Mark said. “If we can, we’re going to find something for you.”

There are enrollment navigators all across Alabama, including nine navigators within United Way. Two other navigators work within hospitals (DCH in Tuscaloosa and East Alabama Medical Center in Opelika). Another navigator based at The Right Place serves individuals and families who have low incomes or face homelessness in Anniston.

And this year, resources are becoming available in areas where they weren’t before. New navigators are serving Black Belt communities, as well as areas in northeast Alabama like Fort Payne, Rainsville and Scottsboro.

Enroll Alabama’s partnership with 211 also makes it accessible for anyone in the state to reach out and get connected with clinics, programs or resources close to home.

“Our navigators are familiar with all the resources in their area and have a list right beside them,” Mark said. “So if someone calls from Chilton County, but I’m not there, I can plug them in with our navigator from that area… on top of them just calling 211. It’s really a great resource.”

Navigating unfamiliar territory together

Mark agreed with Rebecca that a lot of folks reaching out to navigators for help are in unfamiliar territory, facing not having coverage for the first time. Through a partnership with social workers at UAB, Mark said, he often helps patients in heart failure navigate their new situation. He also meets them where they are.

“I do make house calls and go out to hospitals. A lot of times, I’m meeting in the library or at McDonald’s,” he said.

Mark said a lot of Enroll Alabama’s work focuses on helping people submit Medicaid applications, or checking to see if they are eligible for tax credits through the ACA. But in Alabama, the income eligibility restrictions can make the path forward very narrow.

“Beyond that, when they’re in the coverage gap, sometimes the best we can do is give them a phone number and pass them along to charity care, which doesn’t feel great.” Mark said.

It’s also important for people to know that even if they don’t qualify for a special enrollment period, ACA tax credits or Medicaid, other community resources like low-cost clinics may be available. Mark still encourages everyone to call 211 or set up an appointment with a navigator directly if they are uncertain about finding care or resources.

“You are never bothering us. ‘Navigator’ is right there in the name,” he said. “We are always here to help.”

It’s time for Alabama to join our neighbors

The benefits of Medicaid expansion are clear. States like Arkansas and North Carolina that have expanded Medicaid report lower uninsured rates, improved access to care, and better health outcomes. Rural hospitals, which have been closing at alarming rates in non-expansion states like Alabama, have access to life-saving funds that allow them to stay open and serve their communities.

Recently, Alabama’s Joint Health Committee held a hearing where legislators spoke with lawmakers from Arkansas and North Carolina about their experiences with Medicaid expansion. The testimonies highlighted the positive impact, emphasizing how expansion has bolstered rural hospitals and provided vital health coverage to those who needed it.

Arkansas lawmakers shared that expansion has decreased their uninsured rate and improved overall health outcomes. And North Carolina officials pointed to the financial stability it has brought to rural health care facilities.

Expanding Medicaid in Alabama could have similar positive health and economic outcomes, a recent study by the Public Affairs Research Council of Alabama (PARCA) found. Medicaid expansion would create more than 20,000 local jobs and bring significant federal funding into Alabama’s economy, PARCA projected. Most importantly, it would ensure health coverage for nearly 300,000 Alabamians and save hundreds of lives every year.

Remaining hopeful for change

Rebecca said she still listens to everyone who calls asking for help, even when there aren’t many resources available. However, there is an important way that folks in the coverage gap can get involved. 

“We encourage anyone who is struggling to access health care to call their legislators and let them know the issues they’re having,” said Debbie Smith, Alabama Arise’s Cover Alabama campaign director.

“Legislators need to hear from real people that this is a real issue. It can be easy for legislators to overlook a statistic,” Debbie said. “It’s much more difficult to ignore when someone is suffering because they can’t access the medical care they need.”

Navigators play a vital role in the coalition of private partners, providers and nonprofits working every day to address the issues facing Alabamians in the coverage gap.

We’re thrilled to partner with Enroll Alabama,” Debbie said. “We’re so thankful that there is an organization that can help people find the resources that are available to them even though our state has shamefully created gaps in coverage.”

If you or someone you love would like help navigating the health care marketplace, applying for Medicaid or finding a federally qualified health care clinic in your area, please visit Enroll Alabama’s website to set up an appointment with a navigator. You also can call them directly at 844-248-7698.

If you don’t always have access to a computer, you can download an application to print and share later here.

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: whit@alarise.org.

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.

‘I just thought things were the same everywhere’

A close-up photo of a white woman's face. She has dark hair and is wearing glasses.
Medicaid coverage was a vital lifeline for Saraland resident Jolene Dybas as she recovered from a health emergency. But after losing that coverage during the Medicaid unwinding period, she has had to go without needed health care. (Photo courtesy of Jolene Dybas)

When I first spoke with Jolene Dybas, 2023 was coming to an end. Lots of people were attending in-person events confidently and hoping the worst of the COVID-19 pandemic was firmly behind us.

Jolene, however, was still coming to terms with a new reality after moving to Mobile from Florida in 2019.

“I barely go out,” she said. “And when I do, I don’t want people to see me like this.”

I asked her why she preferred to keep such a low profile. That’s when she shared the full story of what it’s like living in Alabama’s health coverage gap. This gap includes nearly 300,000 people who earn too much to be eligible for Medicaid but not enough to afford private health coverage. Alabama’s Medicaid income eligibility limit for adults is one of the country’s most stringent.

“I’ve lived in many other states, and I never saw a person with no teeth until I moved here. I never thought that it could happen to me, but here we are,” she said in disbelief.

The toll of a medical emergency

Jolene’s story begins with good news. Her daughter was accepted to the University of South Alabama (USA) to study nursing. Jolene moved to Saraland, right outside Mobile, to help support her.

Soon after, though, a medical emergency threw a wrench in her family’s new beginning. 

Jolene woke up one day and realized something was off. When she began experiencing heavy bleeding, her fears were confirmed. She rushed to the hospital and was told she needed an emergency hysterectomy to save her life. Jolene also would need intensive treatments, and she would have to stop working while she recovered.

“I quit counting after 10 ER visits and two hospital visits,” she said, describing her new reality of living with chronic pain and recovering from surgery.

Jolene soon lost health coverage when she was no longer able to work full-time as a customer service agent. Her financial situation got so bad that debt collectors began issuing threats of wage garnishment.

“My hours dropped down to part-time. I couldn’t afford emergency medical bills,” she said. “I’m in a place where I’m no longer self-sufficient, and it is killing me.” 

When the hospital bills and prescription costs started to pile up, one of Jolene’s doctors at the USA Hospital encouraged her to apply for financial assistance through the hospital.

“I want people to know that I had a medical emergency and needed blood transfusions,” she said. “If it weren’t for USA Hospital taking up my case, I wouldn’t be here today.”

A temporary lifeline

Thanks to USA Hospital’s financial assistance programs, Jolene received assistance with her medical debt. She also learned she was eligible for a lifeline: Medicaid coverage. Since she was a parent who was too sick to work and had no income, she was one of the few working-age adults eligible for Medicaid under Alabama’s restrictive guidelines.

“Not many good things came out of the pandemic, but hey, it allowed me to get the help I needed and stay on Medicaid when I needed it most,” she said. “That all came crashing down, though.”

After the COVID-19 public health emergency ended in 2023, Jolene found out her health coverage was about to end. Like thousands of other Alabamians, she was rolled off Medicaid coverage during a process known as “unwinding,” or a return to pre-pandemic eligibility requirements.

Jolene had resumed working part-time as her health allowed – and that small amount of income made her ineligible under Alabama’s bare-bones Medicaid eligibility limits. Parents in a two-person household, for example, do not qualify for Alabama Medicaid if they make more than just $3,684 a year.

Jolene said she felt like she had just gotten to a good place managing her health, but losing Medicaid coverage left her with no other options for affordable health insurance. The worst thing about her ordeal wasn’t her surgeries or learning to live with chronic pain, she said. It was finding out she could no longer afford daily medications or dental care.

“Losing Medicaid will leave me with no choice but to go to the ER when my conditions get worse because I can’t afford my medications,” she said.

‘I don’t want them to see me like this’

Living without coverage means making more sacrifices than Jolene had imagined.

“When I lost my insurance, I wasn’t able to go to the dentist,” she said. “My teeth got worse and worse. I only have four teeth left because all I can do is get them pulled when I have a problem.”

Jolene hasn’t visited family since moving to Alabama.

“I can’t even go home to visit because I can’t show them the shape I’m in. I don’t want them to see me like this,” she said. “Where I come from, you don’t see people with no teeth in their head, but in Alabama, I can’t even afford dentures.”

Jolene has lived in several other states before, including Minnesota, Mississippi and North Dakota. She said Alabama’s refusal to expand Medicaid creates unnecessary hardship for its residents.

“If people were well in Alabama, they’d be able to work more. I know I would,” she said.

Minnesota has chosen to expand Medicaid and make other investments in its residents’ well-being. In 2021, lawmakers there passed a historic dental health package that helped ensure Medicaid participants could access dental care and eased administrative burdens for providers.

“They just don’t see things like this,” Jolene said of living in other states with more access to health care and coverage. “There’s no support [in Alabama]. I just thought things were the same everywhere.”

Jolene said living in the coverage gap in a state that hasn’t expanded Medicaid has her missing home.

“If I went home to Minnesota, there is no way I would have this problem,” she said.

‘It can be different’

Jolene’s experience has turned her into an advocate for all Alabamians facing the same problems she does.

“A lot of people in this state don’t know that it can be different. You deserve more,” she said. “Your state leaders are failing.”

Alabamians’ quality of life is suffering the longer we wait to expand Medicaid, Jolene said.

“This has got to be the most expensive place I’ve ever lived. Alabama has taught me a really hard lesson: They don’t care about us,” she said.

Living in other states has offered Jolene a window into the costs of Alabama’s failure to ensure health care access for all of its residents.

“I feel like the death rate is higher here because we all have to wait for adequate care until it’s too late,” she said. “So instead of taking care of that, we’re letting our money slip out of our hands to pay for expansion in other states.”

Jolene said she believes shifting our state’s policy priorities is crucial.

“Why does Alabama still have a grocery tax? I’ve never had to pay that before. Then, we don’t have Medicaid expansion but they’re worried about building bridges and prisons?” she said. “It’s very, very selfish.”

Taking action for a brighter future

After learning nearly 300,000 other Alabamians like her would benefit directly from Medicaid expansion, Jolene started reaching out to lawmakers urging change.

“I’ve written letters to my legislators and Governor Ivey. I’ve called TV stations. I don’t know how they can’t afford to expand Medicaid because people are desperate,” she said. “What does money matter when it’s already there and it is costing lives not to use it?”

One of the states Jolene previously lived in, Mississippi, recently saw meaningful progress toward closing its coverage gap. The Republican-led Mississippi House passed a bill in February to extend Medicaid coverage to more than 200,000 adults with low incomes. That legislation now awaits consideration in the Senate.

Expanding Medicaid is “a topic that should transcend politics,” Mississippi House Medicaid Committee Chairwoman Missy McGee told reporters. “Sometimes, it’s OK to do the right thing because it’s the right thing.”

Jolene said her daughter will graduate soon, and she thinks her family’s time in Alabama is coming to an end. Jolene said the cost of waiting on our state to expand Medicaid is simply too high.

“I thought Mississippi was bad, but it’s not this bad,” she said. “I’m sick of Alabama not caring. If they can’t get their act together, I’m not staying here.”

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: whit@alarise.org.

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.

‘No one should have to go through what I did’

Diana Isom (right) smiles alongside her husband, Luke, and their son, Keenan. Diana, a resident of Athens, Ala., was uninsured during her pregnancy and struggled to find affordable options for the health care she needed. (Photo courtesy of Diana Isom)

When Diana Isom became pregnant with her first son, Keenan, back in 2021, it was what she’d always wanted.

“My husband and I had been trying for years. I was so happy, but immediately started thinking about timing,” Diana said.

Timing is always a big consideration for most first-time parents, but for Diana and her husband, Luke, things were a little more complicated. When Luke lost his job suddenly, he had to start training in a new technical field. This meant he lost the private health coverage they had previously.

Even though Diana was working full-time hours as a health care worker, she was paid hourly and offered no benefits. She faced a frightening new future: being pregnant with no health coverage.

“I knew I was fully on my own when the medicine I needed was $200 a month and I’m out here with no insurance. Zero options,” Diana said.

Diana, now 26 years old, was raised in Vestavia Hills. Her parents, native to Panama, moved to the United States more than two decades ago when she was 4 years old.

“When I was a child, my parents came to this country so I could have a better life and a better education. I was taught that America was freedom and happiness… and that hard work can get you whatever you want,” Diana said.

Building a life despite uncertainty

As she got older, Diana said she remained positive and worked hard so she could have opportunities her parents never did.

“When the DACA [Deferred Action for Childhood Arrivals] (policy) was passed in 2012, kids like me, who grew up here in America, qualified as ‘Dreamers.’ I was so excited to be able to get a work permit! I’ve been working ever since,” she said.

Under federal DACA provisions, Diana also could access her driver’s license, a Social Security card and other important documents. These documents could help her secure a job, a home or even just a doctor’s visit.

When Diana and Luke got married, she received a green card. But she decided she would begin the lengthy immigration process in 2017, to make everything “official.”

She grew up in Alabama and wanted to start her own family here. Even so, she had to spend five years – and thousands of dollars – to gain citizenship status.

“My life is here,” she said. “I don’t want to have to go back to Panama. My friends are here. My job and family are here.”

When she was growing up, Diana said, other kids bullied her about her status. Even though Alabama was all she had ever known, she still felt a gnawing sense of insecurity.

“In really bad times in my life, people would threaten to call immigration or ICE on my family,” Diana said. “So I jumped through all these hoops and saved up thousands of dollars to make sure that never happens again. Not for me, and not for my son.”

The stress of being uninsured during pregnancy

In 2021, the Isoms received the good news that Diana would finally receive her citizenship. There was only one hitch: It wouldn’t take effect until three months after her baby was due.

Most Alabama mothers with low incomes now are eligible for Medicaid coverage for up to one year after childbirth, thanks to the state’s postpartum coverage extension in 2022. Even though Diana now had her green card, she had to pay out of pocket for health care during and after pregnancy because of a five-year Medicaid eligibility waiting period.

So she faced it alone.

“I had horrible prenatal depression. No one talks about that. It’s awful,” Diana said. “All the stress of not having insurance and my husband working on a temp basis. He either gets hired on or he’s fired. Every time. That stress is crazy!”

Diana said finding the care she and her baby needed while pregnant became like a second job.

“It’s so mentally draining,” she said. “Ever since they rejected me from Medicaid, I’ve been crying and crying. I’m so numb with the whole process, but I couldn’t give up.”

When she realized the couple’s private insurance had lapsed and no other lifelines were in sight, she began researching resources. She went to a free primary care clinic serving mostly Hispanic patients. But she found it difficult to navigate materials provided in Spanish because her first language growing up was English. And the clinic couldn’t provide all the prenatal screenings she needed.

The experience left Diana lonely and struggling to bond with her child throughout her pregnancy.

“Most people get regular ultrasounds. Without insurance, the hospital I went to only offered me the bare minimum. I got to see my baby two times: at the beginning and at the end. That was it,” she said.

‘I shouldn’t have ever been left behind’

Diana’s local hospital was her only option. As she continued to be billed for more than $1,500 a visit, she said she spent many nights wondering how her new family could afford it all.

“You do what you have to do, and I made it all work for my child because that’s what my parents did for me,” she said. “I shouldn’t have ever been left behind, and now neither should my baby.”

After a 19-hour complicated labor and delivery, baby Keenan was born in early 2022. Three months later, Diana joined him in gaining full American citizenship.

Diana thought her citizenship ceremony would lift her spirits and give her family the celebration they needed after a stressful pregnancy, but the process proved a bit impersonal and underwhelming.

“We drove nearly four hours to the immigration office. When I sat down, there was just an officer calling in on Zoom. I was looking at an iPad screen when I ‘became an American,’” she said.

Diana said she is grateful for her new status, but her time as an uninsured mother was a stark reminder that the playing field is not equal for everyone who lives in Alabama.

“People like me who have been in this country for so long… we pay taxes,” she said. “You’re telling me I pay into it, but not benefit from it?”

Though most undocumented immigrants live in a family with a full-time worker, they have limited access to employer-sponsored coverage, a Kaiser Family Foundation report found. And while they pay the same taxes as citizens, they often are employed in low-wage jobs and industries that are less likely to offer employer-sponsored coverage, like Diana is.

Medicaid expansion is the path to a healthier future for Alabama parents

Diana was ineligible for Medicaid after her pregnancy, both because she was not yet a citizen and because Alabama had not yet extended postpartum coverage to one year.

She would now qualify for Medicaid coverage during and immediately after future pregnancies if she met the income eligibility standards. 

Alabama remains one of 10 states yet to expand Medicaid. That means tens of thousands of Alabama parents still have no affordable long-term path to the health care they need as they seek to provide for their families.

Hundreds of thousands of Alabamians stand to gain access to health coverage if our state expands Medicaid. In the Huntsville metro area where Diana and her family live, that includes more than 11,000 people in Madison County and nearly 3,000 people in Limestone County.

Diana said her difficult journey has turned her into a fierce advocate for Alabama mothers.

“Medicaid expansion is a given,” she said. “The stuff I had to deal with in my pregnancy; the days I had to cry myself to sleep. I was always thinking, ‘Today is gonna be the day that something bad happens to my baby.’”

The Isoms’ new son, Keenan, is now insured under Alabama’s Medicaid program. Diana recently returned to work, and her husband was hired on full time after completing workforce training. They soon will be covered by his health insurance. 

Diana said having coverage for both baby and mom has been such a relief to their family.

“I’ve been able to let go of so many things I was worried about before: being deported and away from my child, or how I was going to be able to go to the doctor, even just sleeping at night,” she said. “No one should have to go through what I did. No one.”

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: whit@alarise.org.

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 benefit stylists – and every Alabamian

Over the last year, Alabama Arise has collected the stories of some of the nearly 10,000 personal care workers who would benefit from Medicaid expansion in our state. We spent months getting to know folks in one of our state’s most vibrant industries. And we want to be sure you see the last few stories in this series.

You can find all of our See the Gap stories in one place here.

We kicked off our series with a personal story about how beauty professionals make sacrifices to support us, but often have no safety net of their own. That’s especially true when it comes to having access to affordable health care for themselves or their families.

Now, as we close the series, we’re lifting up even more stories that speak to a vital question: “How would life be better for so many people if Alabama expanded Medicaid?”

Stories from Alabama’s coverage gap

Like Kayla, a young stylist who is at the pinnacle of her career. Even so, she has reservations about becoming pregnant and having a child while she has no health insurance. There are some possibilities that she just can’t afford.

An image showing a hairstylist performing a color service on a client.
Kayla performs a color service on a client at her salon in downtown Birmingham. (Photo by Whit Sides)

Or Eryn Mullins, a new mom from Sumiton. She opened up to share her heart-wrenching story of navigating the mental health landscape in our state as a new stylist with no employer-provided health coverage. She needed help but couldn’t afford it.

The stories didn’t stop there. We highlighted the challenges facing many stylists seeking mental health care. We spoke to LGBTQ stylists about sacrifices they make both professionally and personally when it comes to finding care safely. And in our final piece in the See the Gap series, we talked to salon owners about what our state can and should do to improve lives and protect the health of those working in the beauty industry.

A path forward to close the coverage gap in Alabama

Hundreds of thousands of Alabamians are in the health coverage gap. Most of them are working at low-paid but essential jobs. They’re folks we see every day but may not realize are living without access to health care. Medicaid expansion would ensure they have the health coverage they need to survive and thrive.

With so many working folks in the gap, Medicaid expansion is an essential solution to save lives and make Alabama a healthier place. It would help real people across our state. And it would be an enormous financial boost for workers and businesses.

Expanding Medicaid would provide our state with more than $400 million a year to provide more than 280,000 people with health coverage. Click here to see the economic impact in our state, and click here to see it in your county.

Mert McNaughton smiles behind her desk in the Forecast Salon in Homewood. (Photo by Whit Sides)

Read the final story in our See the Gap series.

We encourage y’all to share these stories with state leaders in your district, as well as Gov. Kay Ivey. There’s never been a better time to, as Mert said herself, create more revenue for local businesses and put more money into workers’ pockets.

It’s been a privilege to collect these powerful stories and share them with the world. And we can’t wait to tell even more stories in the months to come. Thank you for your support of Arise and for being part of our work to make life better for all Alabamians.

See the Gap: ‘Medicaid expansion would end up creating more revenue for the business’

Just outside the Forecast Salon in Homewood is a gigantic mural painted along the wall. It features every color of the rainbow jumping out into the street. You’re up close with a 10-foot disco ball painted right beside a unicorn and two massive blue and purple manicured coifs.

Forecast’s owner Brittany McNaughton (friends call her Mert) chose the bright and welcoming mural as a manifestation of her personal philosophy.

“Big! Bold! Sunshine!” she says as we look at it. “The vibes are all there!”

The mural outside the Forecast Salon in Homewood, after its completion in February 2023. (Photo by Whit Sides)

Mert and Forecast’s co-owner, Mark Hyde, had a lot to look forward to in February 2020.

They had just reopened their salon in Homewood, just south of Birmingham, after an extensive expansion. Forecast had to shut its doors for three weeks. The renovations brought the space up to 16 chairs and almost doubled the original floorspace. The future looked bright.

Then the COVID-19 pandemic hit, and their world stopped.

“We’d been open for five years, but when 2020 happened, it felt like I had to go dark,” Mert said. “This massive adrenaline rush told me I had to stop expanding and keep my business afloat.”

Mert had just brought on some new stylists, and she said she probably could have hired even more. But soon she learned that the pandemic was shifting her focus from growth to her staff’s “mental capacity.”

Mert said that’s when she realized the shutdown would be longer than three weeks. And it wasn’t just about closing the physical doors to the shop.

“We went from managing everyone’s safety to all of a sudden seeing where our staff was just not doing so well,” she said.

More than just a paycheck

In a rare move in the salon industry, Forecast offers to pay for a portion of its stylists’ health insurance. After two years, they also contribute to employees’ 401(k) retirement accounts.

Another benefit that Mert said was useful during the pandemic was flexible scheduling. She said stylists are encouraged to take personal days off, especially for mental health.

“Whenever you have someone that’s not doing great personally or mentally outside of work, they bring that energy in with them into the workspace, and it can affect the people around you,” Mert said.

Mark Hyde serves a client at the Forecast Salon in Homewood. (Photo by Whit Sides)

Gov. Kay Ivey allowed barbershops and salons to reopen in May 2020 after the initial wave of pandemic shutdowns. It was a first step toward returning to business as usual. But for stylists, that meant getting up close and personal again – and many weren’t ready.

“We work in such an intimate space,” said Mark, Forecast’s co-owner. “We’re up close, touching our clients. It sometimes takes years for these young stylists to build up trust but also build up a shell that can protect them from negative energy or venting clients day in and day out.”

A focus on mental health

Mark and Mert decided to shore up the salon’s career development offerings beyond just continuing education on hair. They brought in local therapists, healers and self-help experts to discuss mental health. Their goal was to help teach stylists how not to take the stresses of personal care work home with them.

“Moving out of the pandemic, I saw a need to bring in programming focusing specifically on mental health and not just hair,” Mert said.

Mark and Mert agree that they can’t do it all. But they said they try their hardest to provide as much as they can for their staff.

“Nowhere is perfect,” Mert said. “I set standards for mental health here in the salon, but I’m not trained to treat anyone’s problems. I’m trained to do hair. That’s where therapists and doctors come in.”

More money in the pocket for both stylists and salon owners

Mert said she hopes that one day all salons will offer health insurance and other benefits. But she also said she knows that’s not a realistic option for all salons. And unfortunately, that means many stylists will have no affordable option for health coverage unless Alabama expands Medicaid.

Across Alabama, about 10,000 stylists and other personal care workers would benefit from Medicaid expansion. 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.

Part of Forecast’s recent renovation was expanding to hire more younger stylists and apprentices into their already robust education program. Not everyone at Forecast would qualify for coverage under Medicaid expansion, but most newer stylists likely would, Mert said. 

Both owners agree that it would be nice to be able to pay stylists an extra $200 to $400 every month. That amount could help cover their groceries or a car payment.

“It’s expensive to provide insurance as a business. That’s why a lot of people don’t do it,” Mert said. “Medicaid expansion would end up creating more revenue for the business and put more money into that stylist’s pocket.”

Mert McNaughton smiles behind her desk in the Forecast Salon in Homewood. (Photo by Whit Sides)

The benefits for the local economy wouldn’t end there. Jefferson County could realize upwards of $298.6 million in additional economic impact in year one as a result of closing the health coverage gap. Medicaid expansion also would extend coverage to more than 22,500 county residents who didn’t have it before.

I asked Mert what Forecast Salon would do with the extra money when the day finally comes.

“As a business owner, I already know what I’m gonna do with that money,” she said. “Invest it right back into our people.”

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: whit@alarise.org.

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: ‘I needed help but couldn’t afford it’

A smiling husband and wife.
Eryn Mullins (left) smiles alongside her husband, Zach. Eryn is a hairstylist from Sumiton who struggled to afford mental health care after becoming uninsured at age 26. (Photo courtesy of Eryn Mullins)

Social media can be overwhelming. Like a lot of people, I’ve found myself stepping back from it lately. There is one thing I will never scroll past, though: baby pictures. (Well, that and jokes.)

And Eryn Mullins is good for both.

Eryn is a new mom and hairstylist from Sumiton, a small town in Walker County in northwest Alabama.

I spoke to her the week she returned to work after her maternity leave. Thanks to her husband’s insurance, she and her baby were well cared for during labor, delivery and the postpartum period.

The smiles in her family photos jump through the screen. It’s hard not to think she’s got it all together.

But Eryn will be the first to tell you that it wasn’t always this way. Things were much different for her just a few years ago.

‘A million things to worry about’

“Straight out of beauty school, there’s a million things to worry about,” Eryn said. “When I was 20, I suffered from extreme panic attacks, and I needed to be hospitalized. After that, it still took eight months and four or five different medications to get to a steady place.”

Eryn was diagnosed with a panic disorder that gave her “anxiety that you couldn’t just fix.” Her condition required regular doctor’s visits and consistent medication. Thanks to her dad’s insurance, she was able to keep everything under control.

Then Eryn turned 26. That’s the age when young adults are no longer eligible for their parents’ insurance under the Affordable Care Act. And things started to look very different.

“I was on my dad’s insurance, and then suddenly, I wasn’t. I was uninsured for three years after that,” Eryn said.

“I got a hospital bill for $2,500, and that’s when I decided I was going to try my hardest to not go to the doctor ever again.”

Cold turkey

One thing Eryn didn’t plan for was having to come off all her medications immediately. For her, “cold turkey” meant no prescription refills. It also meant no talk therapy and no visits with a psychiatrist to manage her mental health.

“I experienced so many adverse side effects that put me back in the hospital, suffering from withdrawal,” she said. “We all have brains; not all of them are healthy. Mine wasn’t.”

Any way Eryn looked at it, she was paying hundreds of dollars out of pocket every few months. Sometimes it was for a hospital stay. Once, she spent $400 for just one routine visit with a mental health provider.

“I worked in a high-stress environment my first year as a stylist,” she said. “It’s a vicious cycle. I needed mental help but couldn’t afford it.”

Being uninsured is expensive. And without consistent medical or mental health coverage, those expenses mount for many stylists. After facing a $2,500 medical bill while uninsured, Eryn told herself she would do whatever she could to avoid going to the doctor.

Unfortunately, Eryn is not alone in receiving eye-popping medical bills while uninsured. Most of her coworkers are uninsured, she said, and seeing them navigate that is heartbreaking. More than 22% of people in Walker County are facing medical debt along with her right now.

In all, 6,108 people in Walker County do not have health coverage. That number would drop by more than half if Alabama expanded Medicaid to cover adults with low incomes.

Across Alabama, about 10,000 stylists and other personal care workers would benefit from Medicaid expansion. 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.

‘Hanging up the apron’

Hairstylists often can set their own schedule, but that means income fluctuates. And especially in the beginning, they are paying for all their own supplies and losing a lot of money.

“Starting off as a new stylist is the hardest part,” Eryn said. “There’s no method to the madness.”

Eryn said it is becoming more common to see coworkers “hang up their apron.” That’s code for leaving the hair business altogether, often to train in another industry.

“It’s exhausting,” she said. “I feel like everyone I know is always putting money back, for every little (and big) thing. And you have to be really lucky to even have any left over for medical bills.”

Eryn said she loves what she does and doesn’t plan on quitting anytime soon, though she jokes about it sometimes.

“There are days where I debate working at Big Lots or Walmart. It’s steady, and they probably get insurance at full time,” she said.

A path forward

After seeing so many friends walk away from behind the chair, Eryn said she didn’t know how she would make it as a mom and a stylist.

“We were expecting our first baby soon, and I had no idea how I would handle maternity leave,” she said. “I was able to make a deal on my booth rental, but that’s it. If I didn’t have the support of my husband, I don’t know if I could even afford a child.”

A husband and wife with their newborn child.
Eryn Mullins (right) enjoys a moment with her husband, Zach, and their newborn child in March 2023. (Photo courtesy of Eryn Mullins)

Through it all, Eryn said she still would choose to become a stylist all over again.

“I’m glad I stuck with it,” she said. “It was a rough few years, but now I get to coordinate my life and schedule the way I want, which is much better for my mental health. I think that’s probably true of any career.”

Eryn said she hopes discussing her experiences can help improve life for hairstylists and other Alabamians living without health coverage.

“I wanted to share my story because it’s worth it to me if even one person feels less alone,” she said.

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: whit@alarise.org.

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.

Walker County Medicaid town hall 2023

Alabama Arise and Cover Alabama co-hosted a Medicaid town hall in Jasper on April 10, 2023. Speakers discussed the importance of Medicaid expansion and how our state can afford it, as well as the cruelty of the Medicaid coverage gap. To learn more and join our movement to expand Medicaid in Alabama, visit coveralabama.org.

Cover Alabama Lobby Day 2023

The Cover Alabama coalition held its first Lobby Day on March 21 on the steps of the State House in Montgomery. Faith leaders, community advocates and people living in Alabama’s health coverage gap spoke about the importance of Medicaid expansion for their families and communities. Advocates then met with lawmakers to urge them to save lives and create jobs by expanding Medicaid.

Brewton community event on Medicaid expansion in Alabama

“Our rural hospital is the first line of care for the people in our community. If someone’s really sick, they need to be stabilized. They can be stabilized here quickly and efficiently. If our hospital closed … people will die.”
That was the blunt reality that Dr. Marsha Raulerson shared at a health care panel that Alabama Arise co-hosted Feb. 27 in Brewton. As we heard from her and many other people that night, Medicaid expansion is a crucial step to save lives and protect health care access in Escambia County and throughout Alabama.

See The Gap: ‘Possibilities that we just can’t afford’

An image showing a hairstylist performing a color service on a client.
Kayla performs a color service on a client at her salon in downtown Birmingham. (Photo by Whit Sides)

Kayla is a talented, young hairstylist who has built up a successful clientele in one of Birmingham’s hippest salons. She’s been a stylist for 12 years and said she loves the independence it gives her. She sees dozens of clients every week and takes great pride in her work.

“It’s a great industry, but it’s not taken as seriously as it needs to be,” Kayla said. “Especially relative to the number of people that come through our doors to get their hair done.”

Kayla grew up in a small town in Walker County but started her career in an “Over the Mountain” suburb south of Birmingham. The salon served a wealthier clientele, but it didn’t offer many benefits to stylists. Among the benefits she didn’t have: employer-provided health insurance.

Kayla said lack of access to care is the norm in an industry where health coverage is often an afterthought.

“People love to say that college is too expensive now, so you should go into a trade,” she said. “Maybe the more dangerous trades offer benefits, but when you go into something like hair, we’re kind of left behind.”

Kayla said not many of her clients know she is working full-time while uninsured. And most don’t know how it affects her future in more ways than just going to the doctor.

“No one is talking about why we don’t have health coverage. They don’t usually even care if we have it in the first place,” she said. “No one has ever asked me. You’re the first one.”

When the cost is simply too high

During the COVID-19 pandemic, Kayla decided she needed a change and moved to a new salon. She was thrilled to learn that it offers health insurance to its stylists.

But when she and her husband ran the numbers, it just didn’t work for them. The cost was simply too high. She couldn’t justify the risk of adding such high expenses to her already stretched budget.

Kayla said she still considers herself lucky, though.

“I know I can’t afford it, but at least they offer it. Most places don’t,” she said. “None of the salons back in my rural hometown offered insurance. I don’t imagine that’s changed much since when I started in the industry.”

Kayla explored other options, but nothing panned out.

“The last time I looked at buying a plan online, I put in what I earned and it was still $600 a month,” she said. “I’m not rich. I can’t afford that.”

‘A pragmatic decision’

Kayla is one of more than 220,000 people in Alabama’s Medicaid coverage gap. She is ineligible for Alabama Medicaid or subsidized Marketplace coverage under the Affordable Care Act. And she is also unable to afford premiums for private insurance.

Kayla said she often gets anxious when she thinks about what would happen in an emergency. She said she researches what people do when they need emergency care or surgery and don’t have insurance.

Those long nights researching and worrying about costs led Kayla and her husband to the choice not to have children.

“We’re not going to have children,” she said. “I don’t even know how I’d do it, especially in Alabama.”

The budget is tight for Kayla and her husband. She said she feels it’s not fair to bring a child into the world without the resources to support one.

“Babies are just so expensive. I made a pragmatic decision to not have kids,” she said. “I’m uninsured, and these are all possibilities that we just can’t afford.”

Coverage gaps for prospective new mothers in Alabama

Kayla said she’s heard it’s easier in other states for newer moms. She’s right.

Women in Medicaid expansion states are more than twice as likely to already have coverage prior to becoming pregnant compared to women in non-expansion states, according to the Kaiser Family Foundation. Being enrolled in Medicaid throughout pregnancy means more consistent prenatal care. That leads to healthier pregnancies and reduced risk of complications or death.

An added risk in Alabama is that prospective mothers generally can’t qualify for Medicaid until they’ve confirmed they are pregnant. That means they are unable to access valuable prenatal care until later in the pregnancy.

In Alabama, Medicaid only covers pregnant people with an income up to 146% of the federal poverty level, or around $1,300 monthly for a couple. Working-age adults with no children and no disability do not qualify for Alabama Medicaid, no matter how little they make. This leaves Kayla and 50,000 other uninsured Alabama working women without any options for affordable health coverage.

Some good news for those in Kayla’s situation is that even though our state has some of the most restrictive income eligibility limits for adults, most children in Alabama are eligible for ALL Kids coverage. ALL Kids insures tens of thousands of Alabama children whose low- and middle-income households do not qualify for Medicaid.

Gov. Kay Ivey and lawmakers also recently extended postpartum Medicaid coverage for up to one year after childbirth. This would be great news for Kayla, if workers like her were eligible for ongoing Medicaid coverage. But without employer-sponsored health insurance or Medicaid expansion, Kayla said she and her husband can’t afford the high costs of prenatal care and childbirth.

‘I don’t know what I’m gonna do’

For now, Kayla said she is focusing on taking care of herself. She’s been healthy so far, but she wants to work on a plan for when she might not be

“I bought dental and vision insurance recently,” she said. “I can afford the small stuff, not the big stuff, you know?”

Kayla also sought out a clinic north of town that will work with her on copays for when she needs care for the occasional cold or injury.

“I can do $70 at a time, even though that’s kind of a lot,” she said. “That’s my only real plan. Otherwise, I don’t know what I’m gonna do.”

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: whit@alarise.org.

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.