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.