Getting a raise is supposed to make life easier. That assumption — that more income automatically unlocks better access to healthcare — collapses fast in a state like Alabama, where a structural coverage gap quietly traps working families who earn just enough to lose their subsidies, but not nearly enough to pay full premiums on their own.
I met Garrett McBride on a Tuesday afternoon in January 2026 at a Walgreens on Fifth Avenue South in Birmingham. I was waiting for a prescription of my own when I overheard him at the pharmacy counter — his voice measured, but clearly working through something — asking the technician whether they had information on manufacturer assistance programs. He was holding a printed insurance summary. “My wife takes this every month,” he said. “I just can’t keep paying two-ninety.”
I introduced myself after he stepped away from the counter. He was cautious at first: a broad-shouldered man in a Birmingham City Schools polo shirt, not someone who readily advertises when things are hard. But we talked for twenty minutes in the parking lot, and he agreed to meet me the following week at a diner on Crestwood Boulevard.
Garrett is 31 years old. He drives a school bus for Birmingham City Schools and has done so for six years. His wife, Denise, stays home with their three children — ages 4, 7, and 9. Until about eighteen months ago, he told me, their household finances felt manageable. Even good.
The Raise That Upended the Budget
In June 2024, Garrett received a merit raise that brought his annual salary from approximately $34,500 to $42,000. It was the largest single raise he had received in his career, and he felt it. “I thought we’d finally turned a corner,” he told me. “We went out to dinner more. I put a down payment on a used truck. We weren’t throwing money away — I just thought we deserved it.”
What Garrett did not account for was what that raise would do to his family’s marketplace health insurance. The previous year, his household income had kept his premium tax credit high enough that his family’s monthly premium on a Silver plan through the ACA marketplace ran approximately $260 a month. After the raise, when he re-enrolled during open enrollment in late 2024, that credit shrank sharply.
His new monthly premium for the same Silver plan jumped to roughly $690 a month. “I sat there doing the math on my phone and I thought, that’s almost eight thousand dollars a year just to have insurance,” he said. “I didn’t know what to do.” He paid the first two months of 2025, then let the policy lapse in March. The three children remained enrolled in Alabama’s ALL Kids program — the state’s CHIP program — which was unaffected. But Garrett and Denise were now uninsured. Denise has hypothyroidism and takes two medications monthly; without coverage, her out-of-pocket costs at the pharmacy ran between $270 and $310 a month. That was the bill Garrett was staring at when I overheard him at the Walgreens counter.
Alabama’s Coverage Gap Did Not Happen by Accident
Garrett’s situation is not unique to his household. Alabama is one of roughly ten states that have still not expanded Medicaid under the Affordable Care Act, which means that adults without qualifying disabilities face an income threshold for Medicaid that is extraordinarily low. According to KFF’s coverage gap analysis, Alabama parents of dependent children qualify for Medicaid only if their income falls at or below 18 percent of the federal poverty level — an annual figure of roughly $6,500 for an individual adult.
This means Garrett was never going to qualify for Medicaid, no matter how tight his budget became. He was caught between two systems: too financially burdened to afford marketplace premiums, and too far above the floor to qualify for the program designed to help people like him. This is the definition of the coverage gap — a structural problem, not a personal failing, even when it feels like one from the inside.
“I kept thinking I was missing something,” Garrett said. “Like there had to be a form I hadn’t filled out, a program I didn’t know about. I spent four months looking and there just wasn’t one.” As he explained his search — calls to 211, visits to the Jefferson County Department of Human Resources, hours on Healthcare.gov — what came through clearly was not confusion but exhaustion. He had done the work. The system had a hole where he stood.
The Weight of What He Kept from His Wife
One of the harder parts of Garrett’s story is how long he carried the knowledge alone. For months after dropping the marketplace plan, he did not tell Denise they were uninsured. He paid her prescription costs out of pocket, shifting money between accounts, telling her the insurance card was “being reissued” when she asked in May 2025. His credit score — already weakened by a period of credit card overuse in 2022 and 2023, when he had accumulated roughly $9,400 in card debt after a previous, smaller raise triggered a similar lifestyle expansion — slipped further as he leaned on credit to cover the gap. By late summer 2025, his score had fallen to 581.
Denise found out in September 2025, when their youngest needed a clinic visit for an ear infection and Garrett could not produce an insurance card for either adult. “She wasn’t angry the way I expected,” Garrett told me. “She was scared. And that was worse than angry.” The two of them sat down together that week and went through the full picture of their finances for the first time in over a year.
What Garrett Found — and What He Did Not
After September 2025, Garrett and Denise began working through their options together. Their three children’s ALL Kids coverage remained intact — the program’s income threshold for a family of five sits well above their household income, and the children had never been in jeopardy. That was one stable piece. The question was what to do for the two adults.
The results were partial. Garrett and Denise entered 2026 with a Bronze plan they can technically afford — $410 a month — but one that offers minimal real protection until they spend $7,500 out of pocket in a given year. Denise’s prescription costs dropped from roughly $290 a month to about $18. That is a real and meaningful change. But the high-deductible plan underneath it remains fragile.
“It’s better than nothing,” Garrett told me, and he said it without irony. “I know what nothing feels like now. So yeah — it’s better.”
Where Things Stand, and What Garrett Carries Forward
When I spoke with Garrett again in late February 2026, he had been back on insurance for two months. His credit score had ticked upward to 601 after he enrolled in a structured debt management plan through a nonprofit credit counseling agency, and he was paying down the $9,400 in old card debt at approximately $280 a month under a negotiated agreement. Progress, but not resolution.
Garrett’s story does not resolve cleanly. His family is covered, but under a plan that provides limited protection if something serious happens. The prescription assistance programs bridged a real and immediate gap. The underlying structural problem — that Alabama has not expanded Medicaid, that the benefits cliff is steep, that a raise of $7,500 a year can destabilize a family’s healthcare access entirely — has not changed for anyone.
The pharmacy conversation that started all this ended without an answer that day. The technician gave Garrett a pamphlet and a phone number. He told me later that he went home, set the pamphlet on the kitchen counter, and Denise found it — and that was how she finally learned what had been happening. A pharmacy pamphlet. “Funny how it worked out,” he said. He did not sound like he found it funny at all.
Camille Joséphine Archer is the Senior Benefits & Social Programs Writer for Benefit Reporter, based in the American South.
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