Lahna Bland is a service worker who has struggled at times making ends meet while paying for her own insurance. She grew up in Little Switzerland, a small dot on the map about 45 minutes east of Asheville off the Blue Ridge Parkway. She started working as a server at the Switzerland Inn’s restaurant when she was 15.

 

In North Carolina, 94,261 people who work in the service industry lack health insurance. More than half of those workers – 56,557 –  are women, the liberal nonprofit NC Justice Center estimates. 

 

Health insurance is rarely offered in the service sector, forcing workers to go to the marketplace for coverage. Still, the costs can be too high given often fluctuating and sometimes seasonal paychecks.

 

“The service industry and the summer, that particular flow of just seasonal work is a really big element of tourism and is a really big part of my county, and most western North Carolina counties,” Bland said.

 

By 33, Bland had worked in all of Little Switzerland’s restaurants in some capacity. For all 18 years working in the area, she never had employer-provided health insurance – even when she was working in management positions.

 

Bland also has Ectrodactyly Ectodermal Dysplasia Cleft Lip/Palate (EEC) syndrome. The genetic disorder has many physical manifestations, none of which have affected her ability to work, but sometimes can lead to vision and hearing loss.

 

She continued to work until 2019, when her eyesight began to seriously deteriorate. She now receives disability compensation. She has had health insurance through the Affordable Care Act (ACA) since 2010, with a costly high tier plan that would cover everything she needs because of her EEC symptoms. 

 

Her husband has also worked as a sous chef in multiple restaurants in Little Switzerland as well, making a lower but more consistent wage. Between Bland and her husband’s medium-low tier coverage, they were paying $300-400 monthly for health insurance— their biggest expense each month aside from rent. 

 

“Usually for the entirety of our marriage, I was the one who was making the most but his job was steadier, because of the fact that he was always making that ~$18 an hour, a very consistent check each week. But mine usually in the better months would bring in a lot more during certain parts of the year,” she said.

 

Bland’s experience not receiving health insurance through her service industry jobs and a varying income making it hard to afford insurance at all is not an uncommon one. There is often a tradeoff of working and not receiving benefits but making too much money to qualify for government programs, but not making enough to comfortably afford marketplace insurance. This tradeoff affects thousands of workers across the state who work in the service sector.

 

Her high-tier package helped cover various expensive procedures, such as her cochlear implant. Receiving a cochlear implant enabled her to provide better service to her guests as she was extremely hard of hearing because of EEC syndrome. A procedure that would normally cost about $15,000 only cost her about $2,000. The tradeoff of having these procedures is missing work;  recovery from the cochlear implant cost her a week of pay.

 

“You don't want to seem super replaceable. But you don't want to not allow your body to heal,” said Bland. “That's the constant struggle of most service industries. You don't want to just peace out and be like, ‘I need to take care of this,’ which is a responsible and healthy thing to do.”

 

Bland’s income varied throughout all her years in the industry, with having 4 months out of the year on seasonal unemployment and in all of her different roles in hospitality in the area. In her management role at the Switzerland Cafe she was making $7-12 an hour plus tips, or around $28,000-30,000 annually. When she transitioned to a management position at the Inn, although the job title carried more weight, she was only making $12 an hour with no tips, or around $24,000 annually. The average salary for servers in North Carolina was $23,170 as of May of 2021, according to the Bureau of Labor Statistics.

 

Even with higher paychecks during peak season, she doesn’t think they were ever making significantly more than $30,000 a year as a household. Having to pay $300-400 a month is a significant amount of that income. Although on ACA, Bland would have been making too much to qualify for Medicaid at the time to lower her monthly insurance payments.

 

Income Tradeoff Issues

 

Bland quit working at the Inn in July 2019 to apply for disability. She had to quit before applying because you cannot be actively employed in order to qualify.

 

“All I could think about was how much money I was going to lose. I thought, ‘I need to stick this out until I can draw unemployment and then file for disability then because then I'll be making unemployment. If I leave right now, then I can't draw unemployment.’ My main thought was, ‘I cannot not have any money coming in,’” said Bland.

 

Admitting that she couldn’t work was psychologically traumatizing, but the tradeoff was lifting the financial burden of having to pay expensive insurance bills every month and being fully covered.

 

She was denied her first application for disability due to the difficulties of being able to prove she could not work, hired a lawyer in 2020 and was able to start receiving benefits in May 2020.

 

Lack of access to affordable health insurance and paid time-off isn’t just a problem in local seasonal establishments, it is in large corporations as well. Under the ACA, companies that employ more than 50 employees are required to offer at least the minimum essential health insurance coverage. That does not ensure it’s affordable for the employees.

 

Jamey Gunter works full-time at a McDonald’s in Madison, North Carolina and is a leader for the Union of Southern Service Workers, a labor union formed last year with roots in the Fight for $15 movement. Gunter does not have health insurance because the packages McDonald’s offers are too expensive, especially considering what she makes; the current hourly wage for McDonald’s workers in North Carolina is around $11 an hour.

 

“Nobody gets their insurance because it takes up half their check. It's too much. By the time you go to the doctor and pay a copay, you might as well just pay the doctor out of pocket,” Gunter said. “ By the time you get their insurance, you don't have enough to get the other necessities that you need.”

 

Gunter was approved for emergency Medicaid to have an open-heart surgery in October of 2022, but it was only for the month of October. 

 

“So they had to get me out of that hospital by October 31. That's what they did too, because I wasn't gonna have no health insurance. Which I probably wasn't ready to go, but you know, they had to let me go,” said Gunter.

 

According to Gunter, she does not qualify for Medicaid because her husband receives too much on his disability income. This has long been a problem for service workers, making too much for Medicaid but not enough to afford other available packages. In North Carolina, many service workers fell in this Medicaid coverage gap–the same gap that Bland would have fallen into if not on the ACA.

 

The Medicaid Coverage Gap

 

North Carolina finally passed a law expanding Medicaid, granting over 600,000 North Carolinians Medicaid coverage. It was the 40th state to do so, after years of legislative battles. With the expansion, Medicaid now covers incomes up to 138% of the federal poverty level, meaning individuals earning up to $20,120 a year will now be eligible for Medicaid in North Carolina. 

 

Since the average server in North Carolina makes $23,170 annually and there are approximately 56,557 uninsured female-identifying workers in the service industry, many of these workers will now be covered under the expansion.

 

Prior to the expansion, marketplace subsidies started at 100-400 percent of the federal poverty level, so anyone making under the poverty level could not get coverage if they didn’t qualify for Medicaid, according to Nicole Dozier, the director of the Health Advocacy Project at the NC Justice Center.

 

“It was intended to work together. The ACA subsidies are here to here, and then Medicaid expansion will cover from here to here. We have over 642,000 people, at least, in our state, who are falling into that gap,” said Dozier.

 

The Medicaid expansion in North Carolina means that workers such as Lahna Bland and Jamey Gunter may finally be eligible for affordable health insurance coverage.

 

With an extraordinarily optimistic view of her situation, Bland speaks to me with as much cheeriness as she did when serving my family at the Switzerland Cafe and Pizza Shop for many summers during my childhood. With Bland’s eyesight improving through specialized stem cell treatments, she hopes to be able to return to work.

 

“I fully would like to not only enjoy a sighted world but also be able to work. It feels really abnormal to not be working,” said Bland. “The goal is definitely to restore as much sight as possible with the goal of me getting off disability and getting back into the workforce in some capacity.”