Liz Church was recently diagnosed with breast cancer.  Medicaid has paid the $90,000 medical bills she has accrued. She is photographed at her apartment building in Washington, D.C. on July 2, 2014. (Photo by Marvin Joseph/The Washington Post)

Her love life was disrupting her health insurance. So the woman battling breast cancer weighed her options:

A) Part with her boyfriend, her gainfully employed soulmate, to stay in Washington and keep her Medicaid benefits.

B) Follow that boyfriend to Virginia, lose her Medicaid benefits and rack up hospital debt.

C) Follow him to Virginia, get new medical insurance, keep up her cancer treatments and stay out of debt, simply by doing the one thing she swore she’d never do again: get married.

Health-care incentives dictate a lot of Americans’ decisions today. Some people cling to jobs they hate to keep their families covered; others work less than they could just to keep government coverage. The Affordable Care Act is only beginning to scramble those incentives and push them into more intimate choices.

That includes where people live — and maybe even whom they love, and how.

Liz Church, 59, will lose her taxpayer-funded insurance plan if, come fall, she moves 20 miles from D.C. to Reston in order to stay with Bill Couette, her partner of 15 years. She will need to find and pay for new health care, some way, if she clings to her deep-rooted, life-worn belief that “Marriage is awful.” But if she marries Couette, she’ll gain access to his private health benefits.

Twenty-six states — and the District of Columbia — have accepted federal dollars, offered under the new health law, to expand Medicaid and provide no-cost care for a larger pool of low-income workers. The rest, so far, have said no thanks. In states that took the deal, unmarried adults under 65 who earn up to 133 percent of the federal poverty level, or about $15,000, qualify for the benefit. In the states that said no, the income threshold can be dramatically lower.

Virginia has not expanded Medicaid. Church doesn’t qualify there.

Her dilemma — marriage or Medicaid? — has something to frustrate conservatives and liberals alike. It’s born of the patchwork way the health care law has extended health coverage to low-income people across the country.


Seven months ago, two friends discovered suspicious lumps. We’re getting to that age, Church thought. So she Googled, Where’s the closest Mammovan? She found a mobile breast exam clinic — much cheaper than a doctor’s appointment — in Southeast D.C., marked by a big pink ribbon.

Two weeks later, the letter came: We want to run another test, it said. Next was an ultrasound, an MRI, a biopsy. By February, the diagnosis: breast cancer, early stage.

Church, a chatty soul singer with wide green eyes, whose lacquered nails flash with each hand gesture, stood shocked. “It’s not like I’ll be in a Playboy spread anytime soon,” she said finally, forcing a smile. “I’ll do whatever it takes.”

— Her dilemma — marriage or Medicaid? — has something to frustrate conservatives and liberals alike.

Before we go any further, a nurse told her, you need a health-care plan. She was uninsured. And as a part-time contracted nurse’s aide, she made $14 an hour.

“I tried to get on Bill’s insurance,” Church said, “but they wouldn’t let me.”

You could get married, the nurse said.

She had been married — three times. At 19, Church wed her first husband in rural Illinois, where she grew up. He cheated on her. It ended 18 months later.

Her second husband drank too much. They divorced when she was 29, with a 15-month-old son.

Her third husband convinced her marriage was a curse, a spark killer. An Army officer, he took her to Cairo. The hotel phone rang: “Your husband is having an affair,” a voice said before abruptly hanging up.

Church was 39.

“That was it,” she said. “I was done with that. People start feeling like they own each other. They mistreat each other. They take each other for granted.”


The afternoon of her diagnosis, Church, choking back tears, went to the Whitman-Walker Clinic in Northwest D.C., a public agency that guides uninsured patients to health coverage under the Affordable Care Act. She expected chaos. “I tried to enroll in Obamacare twice,” she told the staff. “But I couldn’t get through the Web site. To be honest, I didn’t think about it until — bam! I had cancer.”

“Did you bring recent pay stubs?” asked a patient navigator.

She nodded.

The navigator determined Church was eligible for Medicaid under the state expansion. It did not matter that she lived with Couette, who earned much more, in an apartment complex with a pool on the roof, five blocks from the White House. They didn’t share a child. She hadn’t signed a lease.

Church’s breast cancer treatment required at least four weeks of radiation, starting in June. Halfway through, her combined medical bills totaled nearly $100,000, she said. Her Medicaid plan covered it all: Xanax to help her sleep. A new pair of reading glasses. “This,” she said, “is so much better than any private plan I’ve ever had.”

On scented pink paper, she wrote a letter to the American Cancer Society: “I expected to walk into a run-down clinic filled with homeless individuals. But to my surprise, as I walked up to the admissions desk in beautiful + clean surroundings, I was greeted with a huge smile and asked how they could help me.”

Life on the safety net is not so plush for many of America’s 62 million Medicaid recipients. If the expansion passed in every state, half the people who would be eligible for coverage already subsist on food stamps.

Four years ago, the District expanded Medicaid under Obamacare, and childless adult enrollment has increased from about 2,300 to 50,000, according to the Department of Health Care Finance. Single residents like Church qualify for the benefit if they make less than $2,042 a month. One in three District residents receive Medicaid.

Across the line in Virginia, where the expansion has not passed (despite Gov. Terry McAuliffe’s contentious, ongoing push), Medicaid does not cover any adults without children. Republicans who oppose the expansion say it would give people more incentive to stay on welfare and that the costs — which the federal government will fund entirely for the first two years — will eventually burden state taxpayers.

Church hadn’t thought about the country’s health-care discrepancies until Couette said, “Honey, we might have to move.”

Liz Church and boyfriend Bill Couette near Devil’s Tower in Hulett, Wyo. Date not given. (Photo courtesy of Liz Church)

After her third divorce, Church became a flight attendant, eager to explore the world on her own terms. That’s when she met Bill Couette, a pilot in Dallas. They locked eyes on a flight to Lafayette, La. “I hope he’s not married,” she remembers thinking.

Couette was everything the other men weren’t: smart, polite, respectful, loyal. His Minnesota accent betrayed a Midwest gentleness. “I knew I found the one,” Church says. “Isn’t he handsome? Isn’t he sweet?”

Fifteen years later, they still hold hands on strolls to the Lincoln Memorial. They ride motorcycles through Wyoming. They donate sacks of clothes to an apartment janitor whose family is growing. They cook pork chops and au gratin potatoes. They plan to retire together in his family’s old cabin on a Minnesota lake.

People ask: Why don’t you get married already?

“We don’t want to,” Church says. “We don’t have to. No one can make us.”

“I know I love her,” Couette chimes in. “We’re a little too old to have children. I’m staying with her through every trial, anyway. I will never walk away. I know that. So what’s the point?”

The law is a fairly big point, all the sudden. After nearly 30 years of flying planes, Couette is now a pilots’ union representative. The union wants him to move to a larger Virginia office. The tentative deadline: October. Church would have to start all over. Last she checked, the cheapest private insurance plan she found cost $600 monthly.

By fall, her radiation should be done. But with cancer, she said, you never know. It could stay away. It could creep back. She needed an insurance plan, someway.

Refusing to marry — or marry for readily available benefits — isn’t cheating the system, Church says. It’s asserting your freedom. It’s your right as an American. Pick your dependency — the state, or a partner.


By July, Church is half-finished with cancer treatments. Stage zero, it hasn’t spread. The radiation, five days each week, makes her a little more tired. A little anxious. That’s all she’ll admit. She won’t know for at least six months if it’s working.

She tries to stay upbeat, dance with Couette at country concerts and find cheap plays around D.C. to keep her mind off the cancer, the future, what it all means.

On this evening, she’s sporting a black cowboy hat, shooting a homemade iPhone video for a national retiree talent show. The best singer wins $5,000 and a trip to San Diego. Church performs “Crazy” by Patsy Cline in her apartment’s rooftop pool bathroom. The acoustics there are better.

“Woo-rry, why did I let myself woo-rry?” she belts. “Wooondering, what in the world did I doo-oo-oo?”

Couette stands outside the door, arms crossed, poised to explain to pool-dwellers: She’ll be done in a second! Church loves that about him. He’s there for all of her crazy plans — like the time they petted a tiger in Thailand or drove through a Minnesota blizzard to a bar on a Tuesday.

“I’m crazy for crying, and crazy for trying. I’m crazy for loving you.”

She will always choose Couette . Over Medicaid. Over certainty. Venturing into the unknown with him sounds better than chaining herself to an insurance plan. Even if it’s the best one she’s ever had.

Church has decided. She will B) follow her boyfriend to Virginia. Beyond that, she says, who knows?