This is a guest opinion column

My UAB colleague was visibly upset as she approached me with a heartbreaking yet all too common story. A patient who had been mired in deep poverty most of her life was thrilled that she finally had a job offer that might eventually help her alleviate her family’s financial struggles. Except – she was a diabetic on insulin currently covered by Medicaid, and accepting the job would put her squarely in the infamous “health coverage gap”. Without health insurance, she would no longer be able to afford the insulin, which would put her health and possibly her life in serious jeopardy. My colleague was struggling with how to break the news to this patient, knowing it would brutally dash her hopes of employment and a path towards pulling her family out of poverty.

As tenured professor in the UAB School of Public Health’s Department of Health Policy & Organization, and the Blue Cross Blue Shield Endowed Chair in Health Economics, I have spent decades studying the interplay of health policy, social determinants of health, health outcomes and workforce participation. And it has become glaringly clear that in Alabama the debate over Medicaid expansion is not just about health care coverage; it is a crucial workforce matter that affects the very fabric of our state’s economic future.

Alabama is facing a historically low unemployment rate. However, on the flipside of that coin, we are facing a shortfall in workforce – it is projected that by 2030 our worker shortfall will exceed 111,000 and by 2040 it will exceed 181,000. Employers across various sectors are already struggling to find workers to fill essential roles, and this problem will worsen – which will hamstring the state’s ability to attract new businesses and dampen economic growth. At the same time, it is supremely ironic that numerous individuals across Alabama are trapped in a lose-lose situation of being mired in poverty but unable to accept any paying job because of the lack of Medicaid expansion.

In Alabama, an adult with two children in the household only qualifies for Medicaid in Alabama if their annual family income is less than $5000 per year! Even a minimum-wage job for 20 hours a week would make their family income “too high” for that adult to receive Medicaid, while such a job would certainly not give employment-based coverage, and definitely not allow them to buy insurance privately. Yet, such part-time jobs often are the first steps on the road out of deep poverty to eventually getting a job with a decent salary and benefits. However, in the absence of Medicaid expansion, any adult in Alabama who takes that road also faces living with no health insurance for an uncertain period of time, during which a single adverse health event might mean devastation.

Thus, the absence of Medicaid expansion in Alabama is actually contributing to a cycle of poverty and dependence on government assistance programs, forcing individuals to stay out of the workforce, creating generational poverty and perpetuating the strain on social welfare programs. By expanding Medicaid, we empower individuals to break free from this cycle, have the dignity of a paycheck and a career path, and reduce reliance on government assistance in the long term.

By neglecting expansion, we are incurring significant economic burdens. For example, Alabama Medicaid covers screening and treatment for breast and cervical cancer for otherwise uninsured poor women. However, without a regular primary care physician and a routine of preventive care, women with undiagnosed cancer often do not seek screening till they are experiencing substantial physical discomfort – which means screening and detection often occur when the cancer is far advanced. This means treatment is much more expensive, while the patient’s chances of survival are much lower. This is an area where Medicaid expansion provides opportunity to both save lives and reduce treatment costs via early detection. And of course, numerous individuals lacking access to essential treatments for other health conditions often end up seeking medical attention in emergency rooms, driving up uncompensated care costs. These costs are either absorbed by the providers or passed on to other patients – thus driving up everyone’s health costs.

Medicaid expansion has proven to be a sound economic strategy for states. Studies have consistently demonstrated that expanding Medicaid leads to job creation, increased economic activity and savings in health care spending, and more and more states continue to adopt it. Within Alabama, reports by nonpartisan research organizations have projected that Alabama also stands to reap substantial economic benefits through Medicaid expansion.

Closing Alabama’s health coverage gap is not just a matter of providing health care to the poor; it’s a critical component of addressing our workforce development and economic growth strategy. By expanding Medicaid, we not only cover more people and increase access to health care, we also remove barriers to employment, alleviate financial burdens on individuals, grow a robust workforce that attracts more businesses to the state and build a healthier, more prosperous future for all Alabamians. As policymakers and citizens, we must recognize that closing the health care coverage gap is not just the right thing to do — it’s the smart thing to do.

Dr. Bisakha (Pia) Sen is tenured Professor and the Blue Cross Blue Shield Endowed Chair in Health Economics. Her primary interest is investigating the determinants of health for vulnerable populations, with a focus on the role of policy and interventions at institutional, state and federal levels. She has developed an extensive research agenda focusing on health outcomes among Alabama residents, with funding support from Alabama Medicaid Alabama Children’s Health Insurance Program, NIH, CDC and several foundations, and published over 125 peer-reviewed journal articles.