Series
Adjacent Gaps
Some of the populations in this collection were never inside the small group benefits architecture by design. Others are legally covered but facing gaps created by default plan choices nobody reviewed. The series names both categories and distinguishes them precisely: structural mismatches where the employer cannot fix the system, and design gaps where the self-funded employer controls a lever they have simply never been told exists.
ADJ.01
The Caregiver Household: When the Coverage Unit and the Care Unit Are Not the Same Thing
63 million Americans provide unpaid care to adults or children with chronic or disabling conditions. 27 percent have reduced hours or left the workforce. The IRC Section 152 …
ADJ.02
The 26-Year-Old Cliff: Disabled Adults Aging Off Parental Coverage
For young adults with serious disabilities who cannot enter the workforce, the ACA's age-26 bridge lands on nothing. SSDI has a 24-month Medicare waiting period. The employer who …
ADJ.03
The 62-to-64 Gap: Too Old for the Individual Market Economics, Too Young for Medicare
At 64, a couple at 402 percent of FPL may face unsubsidized marketplace premiums exceeding half of household income in 2026. Medicare begins at 65. HSA-funded HDHPs and DPC …
ADJ.04
The Multi-1099 Worker: When None of Your Employers Is Responsible
The multi-1099 professional pays 15.3 percent FICA on health insurance premiums. The W-2 employee pays zero FICA on the same coverage under IRC Section 106. The Section 162(l) …
ADJ.05
The Veteran at a Small Employer: TRICARE Coordination Nobody Manages
1.9 million veterans work at small businesses. TRICARE Reserve Select costs $263 per month for family coverage. Most small employer plans cost $150 to $400 per month. The broker …
ADJ.06
The Seasonal Agricultural Workforce: Coverage That Cannot Follow Work That Moves
2.4 million migrant and seasonal agricultural workers cross state lines during ACA marketplace open enrollment windows. A Texas marketplace plan is not valid in Washington. The …
ADJ.07
The S-Corp Spouse: The Co-Owner Locked Out of the Company's Own Benefits
The S-corporation co-owning spouse cannot pay health premiums through the company's Section 125 cafeteria plan. Every non-owner employee can. The Section 1372 partner treatment …
ADJ.08
The Rural Independent: Network Desert Plus No Employer Plus Thin Marketplace
A rural county marketplace may have one carrier, a provider directory listing physicians with six-week waits, and a hospital whose specialists are out-of-network despite the …
ADJ.09
The LGBTQ+ Employee in a Self-Funded Plan: Legal Coverage Is Not the Same as Actual Access
The plan covers PrEP because federal law requires it. The plan document does not say so, the employee was never told, and the physician never prescribed it. The self-funded …
ADJ.10
The Chronically Comorbid Employee: When the Plan Is Designed for Events and the Member Has Conditions
The diabetic employee who stops taking metformin in January because the $2,500 deductible made the prescription unaffordable presents with uncontrolled A1c in Q3 and a stop-loss …
ADJ.11
The Autism Spectrum Family: When Benefit Design Determines Whether Therapy Happens
ABA therapy costs $45,000 to $65,000 annually for early intensive intervention. 47 state mandates require fully insured plans to cover it. Those mandates do not apply to …
ADJ.12
The Union-Adjacent Worker: On the Wrong Side of the Recognition Line
An IBEW electrician in a multi-employer plan pays zero premium and faces a $250 deductible. The non-union electrician at the adjacent shop pays $200 per month and faces a $2,500 …
ADJ.13
The Transgender Employee in a State With Active Legislative Hostility
ERISA preemption likely protects the self-funded plan from state laws excluding gender-affirming care, just as it protects the plan from mandates requiring it. A state that bans …
ADJ.14
The Returning Citizen at a Small Employer: The Coverage Gap Nobody Talks About
600,000 people are released from prisons annually. Most states terminate Medicaid on incarceration; reactivation takes 30 to 90 days. A 90-day employer waiting period stacks on …
ADJ.PRE
The Gaps That Do Not Have a Series
Some populations were never inside the architecture's design. Others are legally covered but systematically underserved by default plan choices no one reviewed with them in mind. …
ADJ.SYN
The Architecture's Blind Spots: What a Genuinely Inclusive Small Employer Benefit System Would Require
Fourteen populations. Eight the architecture was never designed for. Six it nominally covers but systematically underserves. The structural gaps share one origin. The …