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.