Issue: Health

New report profiles essential workers most likely to lack health coverage in Alabama

By Chris Sanders

Medicaid expansion would increase access to life-saving health care while also advancing racial and gender equity in Alabama, according to a new report by the Georgetown University Center for Children and Families (CCF). Expansion also would ensure coverage for tens of thousands of essential workers in industries like health care, retail and construction.

“Everyone in Alabama has relied on these essential workers in some way during the COVID-19 pandemic,” Alabama Arise policy director Jim Carnes said. “Now it’s our turn to help them get reliable, affordable health insurance so they can continue to do their jobs and care for their families. It’s time for Alabama to accept generous federal funding to expand Medicaid to our state’s uninsured workers.”

Alabama is one of 12 states that have not yet expanded Medicaid to cover adults with low incomes. This inaction has denied hundreds of thousands of Alabamians access to quality, affordable health care.

Approximately 204,100 uninsured adults – 49% of Alabama’s uninsured adult population – would gain coverage if Alabama expands Medicaid, Georgetown CCF estimates. That estimate is in line with prior projections that Medicaid expansion would benefit more than 340,000 Alabamians who are uninsured or struggling to afford coverage.

These residents earn too much to qualify for Medicaid under the state’s stringent income limit but too little to qualify for subsidized marketplace plans under the Affordable Care Act. As a result, they are stranded in a health coverage gap.

Expanding Medicaid would save lives, advance racial and gender equity

Women and Black people account for a disproportionate share of low-wage uninsured working Alabamians, the Georgetown CCF report finds. Black people represent about 27% of Alabama’s overall population but 39% of the state’s low-wage uninsured workers. Women also are overrepresented in this category, making up 55% of low-wage uninsured Alabamians.

These uninsured residents work in vital but low-paid jobs. More than one-third of Alabamians working without health insurance (35.2%) are in the hospitality or retail industries, the report finds. Another one in five work in construction or in health care and social assistance.

Alabama’s uninsured rate for working people (12.1%) exceeds the national average. In 11 counties, more than 15% of working people are uninsured, Georgetown CCF finds. The highest rates are in DeKalb County (19.2%) and Dale County (18.2%).

The map below shows the range of uninsured rates for working adults across Alabama. Hover over the map to see the rate in your county.

Nearly seven in 10 Alabamians support expanding Medicaid to reduce these disparities, a statewide poll found in February. And the American Rescue Plan Act offers federal incentives that would more than offset Alabama’s initial cost to expand Medicaid.

If Gov. Kay Ivey agrees to expansion, the law would give the state a 5-percentage-point increase in federal funding for its traditional Medicaid coverage for two years. That would bring Alabama an additional $732 million over two years, based on an average of federal, state and independent estimates.

Alabama Arise Action 2021 annual meeting

By Alabama Arise

The Arise policy and campaign teams gave updates on criminal justice reform, voting rights, Medicaid expansion and other issue priorities during Alabama Arise Action’s annual meeting last week. Sen. Kirk Hatcher, D-Montgomery, also called in to provide insight from the legislative side of the 2021 regular session.

(Note: The video captions were generated live during the meeting and include some typos. We apologize for any resulting confusion or inconvenience.)

‘It’s time for someone to stick up for us’: Walker County’s need for Medicaid expansion

By Whit Sides
Rev. Robin Hinkle stands in front of the sign for St. Mary's Episcopal Church
Rev. Robin Hinkle is the rector at St. Mary’s Episcopal Church in Jasper. Her ministry has greatly scaled up food assistance to the community to help ease financial suffering during the COVID-19 recession. (Photo courtesy of St. Mary’s Episcopal Church)

Walker County has gained notoriety in recent years as one of the epicenters for Alabama’s opioid epidemic. Overprescribing, lack of health care access and extreme poverty seemed to form a cursed trifecta leaving residents of the rural county to rebuild and recover.

Outside the headlines, community organizations and rural health advocates have been earning praise for their efforts to bring as many resources as possible to the northwest Alabama county of 67,000 people.

“If there’s a problem, you don’t have to look far for someone to help,” said Rev. Robin Hinkle of St. Mary’s Episcopal Church in Jasper.

Hinkle’s ministry has scaled up its food assistance to the community exponentially in the last year. The church went from distributing about 250 bags of food a week to more than 1,000 bags a day. Hinkle said the COVID-19 pandemic and its associated recession left more people than ever in need.

“The system is absolutely not working as it is, especially with the state and local governments,” she said.

Hinkle said many people she works with do receive Supplemental Nutrition Assistance Program (SNAP) benefits or other public assistance. But the income restrictions attached often force people to make painful decisions.

“I see it all the time,” Hinkle said. “When you lose your insurance and paycheck, what used to be $5 at the pharmacy is now $40. And the first thing you give up is medicine.”

‘A big, giant problem’

Hinkle said she has been offering more financial assistance than expected to families on the margins of the middle class. Many of these households have been hit hard by the pandemic, too. And resources can be scarce for families who make too much to qualify for public assistance, but still not enough to reliably pay the bills.

These are the families who are in Alabama’s health coverage gap. They make too much money to qualify for Medicaid under the state’s stringent eligibility limits but not enough to get a subsidy to help pay for a private insurance plan on the health care marketplace.

Alabama is one of 12 states that have not expanded Medicaid to cover adults with low incomes. Even before the pandemic, more than 220,000 Alabamians were caught in the coverage gap. And another 120,000 were stretching to pay for coverage they can’t afford.

“This is a big, giant problem,” Hinkle said. “Once you lose a job or are forced to work minimum wage, it’s very hard to be poor because of all the gaps in our system.”

Medicaid expansion would relieve the burden on families and those deciding whether to pay for medicine or buy groceries, Hinkle said.

“If we had better access and treatment options, it’s better all around,” she said. “Every dollar counts. If we could just get the resources, we can work to solve the problem just like we’ve done before.”

Removing barriers and strengthening rural clinics

Over the past decade, community organizations have come together to form networks bringing more money and treatment options into the county. Spearheaded by the Walker County Community Foundation, the Healing Network of Walker County includes 25 organizations providing prevention, intervention, treatment and recovery resources for mental health and substance use disorders.

One of those partners is Capstone, a group of rural health clinics located across Walker and neighboring Winston counties.

“Over half of our patients are uninsured, and the majority of the others receive Medicare or Medicaid,” said Dr. F. David Jones, executive director of Capstone Rural Health in Parrish.

Jones is one of more than 300 medical professionals who signed a joint letter last week urging Gov. Kay Ivey to expand Medicaid.

Photo of Dr. F. David Jones
Dr. F. David Jones is executive director of Capstone Rural Health in Parrish. He said Medicaid expansion would allow clinics like his to grow and serve more people across Walker County. (Photo courtesy of Capstone Rural Health)

Capstone’s clinics often house primary care, dentistry, pharmacy, social work and mental health care under one roof. While this one-stop shop can be invaluable for rural communities, Jones said access barriers are always involved when someone is struggling to make ends meet.

“We do still need to see valid ID, a bill showing your current address, and proof of income, which can be hard to get if you’re unemployed or don’t have a license,” he said.

Jones said the clinic tries to treat everyone who comes in. But even with local help, they can’t do it all.

“Communities can keep casting off the poor by just ignoring all their problems or burdening the church, but they need us more than they realize,” he said.

Medicaid expansion’s life-saving potential in Walker County

An injection of money from Medicaid expansion could be a lifesaver, Jones said. The funding could ease the burden placed on community health centers and UAB to treat areas of Walker County with low access.

“Medicaid expansion is a no-brainer,” he said. “With that kind of money coming in, we would grow. We could bring professionals in, and it could prop up a lot of the other community health centers that do good work.”

Jones said he hopes Alabama can put aside partisan politics and finally take advantage of the taxes we already use to pay for Medicaid expansion in other states.

“I hope the governor will sign on,” he said. “It’s time for someone to stick up for us. We should’ve been at that table a long time ago.”

About Alabama Arise and Cover Alabama

Whit Sides is the story collection coordinator for Alabama Arise. Arise is a nonprofit, nonpartisan coalition of congregations, organizations and individuals promoting public policies to improve the lives of Alabamians with low incomes.

Arise is a founding member of the Cover Alabama Coalition. Cover Alabama is a nonpartisan alliance of more than 100 advocacy groups, businesses, community organizations, consumer groups, health care providers and religious congregations advocating for Alabama to provide quality, affordable health coverage to its residents and implement a sustainable health care system.

Money matters: Budgets top priority for session; lawmakers also discussing Medicaid expansion, criminal justice reform, voting rights this year

By Jim Carnes

As the Alabama Legislature approaches the 2021 regular session’s final days, both state budgets are halfway to passage. The Education Trust Fund (ETF) budget has passed in the Senate and is in the House’s education budget committee. The General Fund (GF) budget, which funds all non-education services, has cleared the House and awaits Senate committee approval. Despite the COVID-19 recession, both budgets eked out small increases – 3% in the GF and 6% in the ETF. This will allow pay raises for teachers and state employees. It also will fund one-time additional 2022 teacher units and a new salary matrix for certified math and science teachers.

While budgets progressed, the Senate divided over whether to pass a gambling bill that would increase revenue for one or both. After Sen. Del Marsh’s lottery and gaming bill failed March 9, Sens. Garlan Gudger, R-Cullman, and Jim McClendon, R-Springville, introduced lottery bills. Meanwhile, Marsh, R-Anniston, introduced both a new lottery and a new gaming bill.

The Senate may consider some combination of these measures later this session. If approved by legislators and voters, expansion of gambling could increase state revenues anywhere from $118 million to $550 million. (Arise takes no position for or against gambling legislation.)

Health care

A big change on the health care front this year is the prominent role of Medicaid expansion in legislative discussions, both on and off the chamber floors. Gov. Kay Ivey can propose expansion through administrative steps, but lawmakers still control the purse strings. So legislative advocacy is essential!

As the pandemic highlights the need for rigorous health data, Alabama had been one of only two states lacking a statewide hospital discharge database. Now we’ll be shedding that dubious distinction with the enactment of HB 210 by Rep. Paul Lee, R-Dothan, a bill that Arise supported.

The Alabama Department of Public Health (ADPH) has been the target of several proposals to increase political control over the agency’s leadership and decision-making. McClendon’s SB 240, for example, would abolish the State Board of Health, the medical body that appoints the state health officer, and make ADPH’s director a gubernatorial appointment. Other bills would limit state and county health officials’ authority to declare health emergencies. One such measure, SB 97 by Sen. Tom Whatley, R-Auburn, passed the Senate in early April.

Criminal justice reform

Several criminal justice improvements have moved forward this year. These include partial reform of sentencing under the Habitual Felony Offender Act (HFOA) and expanded alternatives to imprisonment. Bigger reforms like HFOA repeal and abolition of driver’s license suspension have been slowed due to opposition, though. That inaction has persisted even in the face of a U.S. Department of Justice lawsuit over unconstitutional prison conditions.

Voting rights

Efforts to protect and expand voting rights continue to face an uphill battle. Bills prohibiting curbside voting have advanced, despite the practice’s success in Mississippi and other states. Meanwhile, a bill allowing no-cause absentee voting stalled, as did measures on early voting and same-day voter registration. Legislation improving voting rights restoration did advance, but only after removal of a provision that would have ended a de facto poll tax: the requirement for people with convictions to pay all fines and fees before regaining voting rights.

American Rescue Plan Act offers path to recovery

By Chris Sanders

As vaccinations continue across Alabama, COVID-19’s viselike grip on our lives is loosening. The pandemic has caused immense physical, emotional and economic suffering, and those aftereffects will not fade quickly. But the American Rescue Plan Act – the federal relief package that President Joe Biden signed March 11 – includes many important policies to begin the healing.

Some of the most crucial investments come in health care. The law increases subsidies for marketplace health coverage under the Affordable Care Act. It also creates new incentives that would more than offset the cost of Medicaid expansion. The incentives would remove Alabama’s last financial barrier to extending coverage to more than 340,000 adults with low incomes.

If Gov. Kay Ivey agrees to expand Medicaid, Alabama would receive between $740 million and $940 million over two years. That would result from a 5-percentage-point federal funding increase for traditional Medicaid coverage.

Alabama State Capitol in Montgomery

“Medicaid expansion is the single biggest step Alabama can take to recover from the pandemic,” Alabama Arise campaign director Jane Adams said.

“Congress did their job. Now it’s time for the governor and state lawmakers to do theirs.”

The act also slashes poverty by boosting unemployment insurance and nutrition assistance benefits and expanding the Child Tax Credit and Earned Income Tax Credit. It funds rental and mortgage assistance to help prevent evictions and foreclosures. And it provides Alabama’s state and local governments with $4 billion of federal assistance to help avoid cuts to education and other vital services.

Persistent disparities – and how to end them

The relief package provides opportunities to begin dismantling longtime structural barriers in Alabama. Arise offers many such policy recommendations in our recent report, The State of Working Alabama 2021, which details how COVID-19 cost hundreds of thousands of Alabamians their jobs and fueled a rapid surge of hunger and hardship across our state.

COVID-19’s toll has been especially heavy for women and people of color, the report finds. The pandemic exacerbated Alabama’s preexisting racial, gender and regional disparities in health care, housing, nutrition and economic opportunity. These inequities – the legacy of bad policy decisions – prevent Alabama from reaching its full potential.

“Alabama’s economic, racial and gender inequities are preventable and reversible,” Arise policy director Jim Carnes said. “By making better policy choices now and in the future, we can chart a path toward a more equitable economy.”

A healthier Alabama is just over the horizon

By Jim Carnes

340,000+ Alabamians need our help. The time is now! Together, we can expand Medicaid.I am thrilled to report that Alabama is closer to expanding Medicaid today than we’ve ever been before! Thanks to your strong advocacy, our leaders are beginning to see the connections between the COVID-19 pandemic and unequal access to health care. They’re facing the fact that rural communities, primary care providers and everyday Alabamians are buckling under the weight of a broken health care system.

Hundreds of thousands of friends and neighbors with low incomes have had to navigate the pandemic without health insurance. Alabama can do better. We can close the coverage gap now.

Alabama Arise has a goal of raising $50,000 before June 30 to accelerate our efforts to expand Medicaid in 2021. Will you consider making a contribution of any amount you feel comfortable giving?

How your support has helped protect and improve health coverage

For nearly 11 years now, Alabama’s leaders have stemmed the national tide of Medicaid expansion. They’ve let the three-year grace period of full federal funding for Medicaid expansion expire. They’ve watched most rural hospitals teeter on the brink and eight of them close.

Our lawmakers have allowed hundreds of thousands of Alabamians with low incomes to face a pandemic without health insurance. And they’ve ignored a report from their own legislatively authorized review committee recommending Medicaid expansion as the single biggest step to address Alabama’s maternal mortality crisis. Meanwhile, 38 states and the District of Columbia have opened Medicaid coverage to adults with low incomes. No state has reversed this life-saving decision.

It might feel like an 11-year stalemate, but we have slowly moved the ball forward. And your persistence has changed the game. Arise members and our partners have engaged policymakers on their own terms to protect and improve Medicaid.

  • When they said we couldn’t expand a “broken” system, you helped shape reforms that brought community voices to the Medicaid policy table.
  • When they said we needed to scrap the Affordable Care Act and risk losing Medicaid altogether, you pushed back and stopped the effort cold.
  • And when they said Medicaid consumers needed more “skin in the game,” you helped collect more than 1,800 public comments opposing a Medicaid work requirement and blocked the proposal.

Photos of Alabama Arise members speaking out for Medicaid expansion at our annual meeting and Legislative Day.

Medicaid expansion is now within reach in Alabama

Now, as news reports confirm that Alabama policymakers are no longer “dug in” against Medicaid expansion, 11 years of hard work and steady vision have brought the prize within reach. As you know, the federal government pays 90% of the cost for Medicaid expansion. In Alabama, more than 340,000 adults with low incomes would receive affordable health coverage in the bargain. The state would chip in just a dime on the dollar for their care.

That bargain would pay wider dividends as the new funding creates jobs and generates new tax revenues throughout the economy. As one Alabama hospital executive put it, if our state recruited a new factory with the same economic impact as Medicaid expansion, we would have a parade from Huntsville to Mobile!

For 11 years, our leaders have left this offer on the table, claiming a dime was too much to pay for a dollar’s worth of health care. Now, the pandemic has put Alabama’s health care – and our health itself – in a harsh new light. Our state leaders are finally getting the message.

It’s been a long 11 years, some of them dark and dreary. But you’ve kept pushing, and the light is breaking through.

We have bipartisan Medicaid support. We have a new administration in Washington that has dedicated funding to incentivize Medicaid expansion. And we have a community of more than 340,000 Alabamians who deserve access to affordable medical care.

We need your support now more than ever to support what we hope is our final push. Will you consider making a donation of any amount today to help Arise reach our goal? Please give today to support our Medicaid expansion campaign.

Arise legislative recap: April 5, 2021

By Matt Okarmus

Arise’s Jim Carnes provides an update on several good bills that won committee approval, including legislation to repeal Alabama’s broken and harmful Habitual Felony Offender Act. He also acknowledges a disturbing trend of bills that aim to limit the power of Alabama’s public health officials to respond to pandemics and other emergencies.

New Medicaid expansion incentive clears the path to a healthier Alabama

By Jim Carnes

The American Rescue Plan Act of 2021 answers a question Alabama policymakers have been asking for years: How can we pay for Medicaid expansion? It’s a solution that lawmakers should embrace immediately to build a better, healthier future for our state. And it’s a step you can urge the governor to take today.

An incentive in the new federal COVID-19 relief package means Medicaid expansion in Alabama effectively would pay for itself. Medicaid expansion would bring peace of mind to more than 340,000 adults with low incomes who are uninsured or struggling to afford health coverage. It also would save lives, create jobs and help protect rural hospitals across our state.

If Alabama agrees to expansion, the law will reduce the state’s costs to provide Medicaid coverage for the much larger non-expansion population for two years. This offer would add 5 percentage points of federal funding to the generous match Alabama already receives for Medicaid expenditures.

The enhanced federal match would create more than enough General Fund (GF) “breathing room” to cover the state’s 10% share of Medicaid expansion costs for the first two years, which are the most expensive. Since 2014, Alabama taxpayers have paid $4 billion in federal taxes to help support Medicaid expansion in other states. This new provision is an unprecedented opportunity to bring some of those tax dollars home to cover Alabamians.

How the new federal Medicaid incentives work

Alabama’s “regular” Medicaid match rate (known as the Federal Medical Assistance Percentage, or FMAP) adjusts slightly from year to year. It will be 72.37% for 2022. And the state already is receiving an additional 6.2-percentage-point boost until the COVID-19 public health emergency ends. That brings the overall federal share to 78.57%.

With the additional 5 percentage points, Alabama’s federal match to cover current Medicaid enrollees would increase to 83.57% until the emergency ends. (It would revert to 77.37% for the remainder of the two-year incentive period after the emergency.) An even higher federal match of 90% will apply permanently to coverage for people newly eligible under Medicaid expansion.

Estimates of the value of Alabama’s incentive over the two years range from $740 million (Kaiser Family Foundation) to $940 million (Center on Budget and Policy Priorities). Even at the lower end, the increase would free up far more than the state’s estimated net share of the first year of Medicaid expansion ($168 million).

Research findings from UAB – and other states’ experiences – suggest Alabama’s net costs will drop dramatically after Year 1. (A UAB study projects the state’s net cost for expansion will be around $25 million a year in Alabama.) That’s because the increased federal funding would produce new tax revenues and offset previous state spending on newly covered services.

Alabama is one of 14 states eligible for the new incentive. They include two states – Missouri and Oklahoma – that have passed expansion by referendum but haven’t implemented it yet. They also include the 11 other states, mostly in the South, that have not yet moved to expand Medicaid. Those states are Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin and Wyoming.

Why the time for Alabama to expand Medicaid is right now

Timing is a critical factor. While the two-year incentive offer remains available for 10 years, current conditions are especially favorable for Medicaid expansion in Alabama. Medicaid will enter the 2022 budget year with a $252 million “carryforward” from this year.

That surplus likely will allow lawmakers to reduce Medicaid’s GF appropriation next year and keep some funds in reserve. The 2022 GF budget that legislators are considering also was written before the new 5-percentage-point boost became available. So the difference truly would be a windfall.

Alabama can’t use federal funds to match federal funds. But hundreds of millions of dollars of additional, unanticipated federal money would relieve pressure on state budgets. And that would free up enough state funds to pay for Alabama’s share of Medicaid expansion for many years.

The Medicaid expansion incentive is a part of federal COVID-19 relief funding for a reason. The pandemic has tested our health care system to its limits. Besides killing more Alabamians than all modern wars combined, the crisis has revealed deep gaps in care and coverage that leave hundreds of thousands of Alabamians extra vulnerable to the virus and unable to pay for the care they need. A “lost year” has left local communities, businesses and families reeling.

The single biggest step our leaders can take to bridge Alabama’s health care gap and accelerate our economic recovery is to expand Medicaid. The new federal incentive removes the last hurdle in our way. It’s time to expand Medicaid now.

You can speak up now for this investment in a healthier future for Alabama. Click here to email Gov. Kay Ivey and urge her to save lives and create jobs by expanding Medicaid.

Arise legislative recap: March 12, 2021

By Alabama Arise

Arise’s Carol Gundlach breaks down the American Rescue Plan and what it means for Alabama families including expansions to the Child Tax Credit and EITC helping to reduce poverty across Alabama.

Now is the time! Medicaid expansion talking points in Alabama

By Chris Sanders

Cover Alabama logo

Timing

On Thursday, March 11, 2021, President Biden signed the American Rescue Plan Act, which will bring back federal funding for states to newly expand Medicaid. Thanks to this law, if Alabama expanded Medicaid, the state would get an estimated $940 million boost in federal Medicaid funds over two years. This is enough money to fully fund Alabama’s share of the cost of Medicaid expansion for many years.

Messaging on cost

For years, Gov. Kay Ivey and legislative leaders have said the barrier to expanding Medicaid is the cost. Thanks to the enhanced federal funding, Alabama will have the money to cover the cost of expansion. Now more than ever before, we have the chance to ensure that no Alabamian has to choose between going to the doctor and putting food on the table.

Medicaid expansion is popular

A January 2021 poll from the Cygnal polling firm showed that nearly 70% of Alabamians support Medicaid expansion, including 64% of Republican voters. The poll also revealed that Alabamians support using a portion of funds from any gambling or medical marijuana legalization to expand Medicaid.

Medicaid is necessary for COVID-19 recovery

Recovering from the COVID-19 pandemic will require Alabama to reinvigorate our public health system. Medicaid is a health lifeline for one in four Alabamians and an economic engine for communities across our state. As we struggle with the COVID-19 pandemic, extending Medicaid coverage to adults with low incomes is the single biggest step Alabama can take to restore health, save our rural hospitals and boost economic recovery.

The vast majority who would gain coverage are working

More than 100,000 Alabamians in the coverage gap hold regular jobs that pay low wages. Thousands more are self-employed, serve as caregivers or attend school. Medicaid expansion has proved to incentivize work and create jobs.

Medicaid expansion would ensure coverage for 300,000 Alabamians, including:

  • People who work low-wage jobs and can’t afford private coverage
  • Workers who are between jobs
  • Adults who are caring for children or older family members at home
  • People who have disabilities and are awaiting SSI determinations
  • Adult college students
  • Uninsured veterans

Medicaid expansion would help more Alabamians have:

  • Regular primary care and preventive checkups
  • Earlier detection and treatment of serious health problems
  • Regular OB/GYN visits without referral
  • Less dependence on costly emergency care
  • Better health and greater financial peace of mind

Medicaid expansion would promote racial equity by:

  • Reducing racial disparities in coverage, which is more likely to leave out people of color with low incomes
  • Lowering the high rate of African American infant deaths
  • Lowering the high rate of African American maternal deaths
  • Covering chronic health conditions that disproportionately affect African Americans, making them more vulnerable to COVID-19 complications

Medicaid expansion would bring our federal tax dollars home to support:

  • Healthier families, workers and communities
  • Stronger rural hospitals and clinics
  • Stronger community mental health and substance use disorder services
  • A needed boost in jobs and revenue for state and local economies

Bottom line

Medicaid expansion is the single biggest step we can take to weather the pandemic and move Alabama forward. It’s time to invest in a healthier future for our state and our people.