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

By Whit Sides, Cover Alabama storyteller, Alabama Arise

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

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.

“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.

Stories help to put a human face on the health care policy issues. By sharing your story, you help speak for people who may be facing issues just like yours.