Issue: Health

High uninsured rates plague Alabama’s rural areas, show need to expand Medicaid

By Chris Sanders

Alabama’s small towns and rural areas have among the highest rates of uninsured low-income adult citizens in the country, and residents there are more likely to be uninsured than those in metro areas, according to a new report released Sept. 25, 2018, by Georgetown University’s Center for Children and Families (CCF) and the University of North Carolina’s NC Rural Health Research Program.

The uninsured rate for Alabama adults with low incomes is 36 percent in rural communities and small towns, and 29 percent in metro areas. Both rates are much higher than the national averages of 26 percent for rural areas and 18 percent for metro areas. Even in states that have not expanded Medicaid to cover adults with low wages, those rates have declined on average over the last decade.

But that progress has not reached many parts of Alabama, where the uninsured rate for low-income adults in rural areas and small towns was virtually unchanged between 2008-09 and 2015-16, the report found. And the Medicaid “work requirement” plan that Alabama has submitted for federal approval would drive the uninsured rate even higher by stripping Medicaid coverage from thousands of parents in poverty. Virtually all of those parents would be left with no realistic alternative for affordable coverage.

“Not only has Alabama failed to move forward on health coverage, but now our state is seeking to move backward by leaving even more people uninsured,” Alabama Arise policy director Jim Carnes said. “Alabama should drop its cruel efforts to punish people living in poverty and focus instead on expanding Medicaid so all Alabamians can get the care they need to become and stay healthy. Medicaid expansion would save hundreds of lives, create thousands of jobs and keep rural hospitals and clinics open to serve residents across our state.”

States that expanded Medicaid saw more than three times as large a decline in the uninsured rates for low-income adults living in rural areas and small towns than non-expansion states experienced between 2008-09 and 2015-16, the report found. Nationally, the uninsured rate for low-income adults fell by more than half – from 35 percent to 16 percent – in rural areas and small towns in states that expanded Medicaid. For states that have not expanded, the decline was much smaller: from 38 percent to 32 percent.

“Medicaid expansion would reduce the uninsured rate for residents across the entire state; however, the most dramatic improvement likely would be felt in small towns and rural areas of Alabama,” Georgetown CCF executive director Joan Alker said. “Improved coverage rates typically translate to a more stable health care system and help rural areas and small towns maintain availability of health care providers in areas where shortages are all too common. Access to rural health providers is especially important to women of child-bearing age and those with chronic conditions like asthma.”

In Alabama and elsewhere, jobs tend to be scarcer in rural areas and small towns, meaning fewer people have health insurance through their employers. And many of the jobs available in these communities – like farming and small businesses – are less likely to come with health benefits. Ten of the 11 Alabama counties with the highest unemployment rates in July 2018 were rural counties.

Alabama’s persistently high rate of uninsured adults shows the need for Medicaid expansion

By Chris Sanders

New U.S. Census data show that the share of uninsured Alabamians increased between 2016 and 2017 and remained higher than the national average. Alabama Arise policy director Jim Carnes issued the following statement in response on Thursday, Sept. 13, 2018:

“The White House’s efforts to undermine the Affordable Care Act and Alabama’s refusal to expand Medicaid are making life worse for hundreds of thousands of people across our state. These bad policy choices are serving as barriers separating people from affordable health coverage.

“Alabama’s steady gains in health insurance coverage since 2013 took a turn for the worse last year, this week’s new Census data show. The share of Alabamians without health insurance coverage rose to 9.4 percent in 2017, up from 9.1 percent the previous year and above the national average of 8.8 percent. These are trends in the wrong direction, and they’re the result of intentional policy choices.

“The Trump administration eroded ACA coverage by slashing funding for federal outreach and advertising to promote open enrollment for Marketplace coverage. In Congress, repeated attempts to repeal the ACA created public confusion over the status of the law. And in Alabama, the state’s ongoing refusal to expand Medicaid has left about 300,000 people trapped in a coverage gap, making too much to qualify for Medicaid but too little to receive subsidies for Marketplace plans.

“It’s time to stop undermining health coverage and start investing in it. The White House should stop attacking the ACA. Congress should shore up funding for Marketplace outreach and enrollment assistance. And Gov. Kay Ivey should expand Medicaid to save our rural hospitals, create thousands of jobs and make Alabama healthier.”

Medicaid expansion, end to grocery tax highlight Alabama Arise’s 2019 priorities

By Chris Sanders

Medicaid expansion and legislation to end the state sales tax on groceries are among the top goals on Alabama Arise’s 2019 legislative agenda. More than 200 Arise members picked the organization’s issue priorities at its annual meeting Saturday, Sept. 8, 2018, in Montgomery. The seven issues chosen were:

  • Tax reform, including untaxing groceries and closing corporate income tax loopholes.
  • Adequate funding for vital services like education, health care and child care, including approval of new tax revenue to protect and expand Medicaid.
  • State funding for the newly created Public Transportation Trust Fund.
  • Consumer protections to limit high-interest payday loans and auto title loans in Alabama.
  • Legislation to establish automatic universal voter registration in Alabama.
  • Reforms to Alabama’s criminal justice debt policies, including changes related to cash bail and civil asset forfeiture.
  • Reforms to Alabama’s death penalty system, including a moratorium on executions.

“Public policy barriers block the path to real opportunity and justice for far too many Alabamians,” Alabama Arise executive director Robyn Hyden said. “We’re excited to unveil our 2019 blueprint to build a more just, inclusive state and make it easier for all families to make ends meet.”

Alabama’s failure to expand Medicaid to cover adults with low wages has trapped about 300,000 people in a coverage gap, making too much to qualify for Medicaid but too little to receive subsidies for Marketplace coverage under the Affordable Care Act. Expanding Medicaid would save hundreds of lives, create thousands of jobs and pump hundreds of millions of dollars a year into Alabama’s economy. Expansion also would help keep rural hospitals and clinics open across the state.

The state grocery tax is another harmful policy choice that works against Alabamians’ efforts to get ahead. Alabama is one of only three states with no sales tax break on groceries. (Mississippi and South Dakota are the others.) The grocery tax essentially acts as a tax on survival, adding hundreds of dollars a year to the cost of a basic necessity of life. The tax also is a key driver of Alabama’s upside-down tax system, which on average forces families with low and moderate incomes to pay twice as much of what they make in state and local taxes as the richest Alabamians do.

Alabama’s costly catch-22 Medicaid waiver plan would punish parents in poverty

By Chris Sanders

Arise Citizens’ Policy Project policy director Jim Carnes issued the following statement Monday, July 2, 2018, in response to Alabama Medicaid’s submission of a “work requirement” proposal for federal approval:

“Alabama Medicaid’s work requirement proposal would create a no-win situation for thousands of parents living in deep poverty. They’ll lose health coverage if they don’t get a job – and if they do.

“This proposal is a catch-22. Because Alabama hasn’t expanded Medicaid, a mother with two kids is ineligible if she works just 10 hours a week at minimum wage. If she met the proposed work requirement, she would earn too much for Medicaid, but not nearly enough to afford private coverage. When parents lose their insurance, children are less likely to have regular doctor visits and more likely to become uninsured themselves.

“On the same day Alabama submitted its proposal, a federal court struck down Kentucky’s plan to impose a work requirement and other restrictions on people covered by Medicaid expansion. That ruling, against a state with a much more generous Medicaid program than Alabama’s, highlights our state’s risk of a similar costly lawsuit.

“Any way you look at it, this proposal is nothing more than an expensive plan for denying health coverage to parents in deep poverty. Instead of punishing struggling families, our leaders need a vision for a healthier Alabama. We urge Gov. Ivey to save tax dollars, cut red tape and save lives by withdrawing this misguided plan.”

Proposed CHIP cut would hurt Alabama’s working families

By Chris Sanders

Arise Citizens’ Policy Project policy director Jim Carnes issued the following statement Wednesday, May 9, 2018, in response to President Trump’s proposal to cut $7 billion from the Children’s Health Insurance Program (CHIP):

“The last thing Alabama parents need is yet more uncertainty about their children’s health coverage. But just four months after Congress reached an agreement on long-term CHIP funding, President Trump is seeking to go back on the deal by cutting $7 billion from the program. Violating this year’s bipartisan agreement would sound an alarm not just for CHIP but for the prospect of meaningful action on any other vital issues facing Congress in the future.

“This proposed cut would undermine CHIP, which provides health coverage for 173,000 Alabama children, including 85,000 on ALL Kids. The cut would do major damage to a rainy day account that protects CHIP against unexpected enrollment increases caused by economic downturns or natural disasters. It also could set the stage for lower federal support for CHIP in the future.

“Alabama knows all too well how suddenly calamities can occur, and it’s essential to ensure CHIP can afford to cover all the kids who need it. Millions of American families, including tens of thousands across Alabama, already endured months of uncertainty after Congress let CHIP funding expire before approving a 10-year extension. These hard-working parents deserve to know those worries are behind them.

“Early statements from the administration have sent mixed messages about what effect the cuts will have. But no matter how you slice it, a $7 billion reduction in CHIP funding would be bad news for children’s health coverage. Alabama’s members of Congress should protect children and working families by rejecting this harmful cut.”

Alabama Arise submits comments in opposition to Alabama’s ‘flagrantly cruel’ Medicaid work requirement proposal

By Alabama Arise

Alabama’s proposed new Medicaid work requirement waiver would be costly, counterproductive, ineffective and harmful to thousands of families who live in deep poverty, Arise wrote in comments submitted to the Alabama Medicaid Agency on Thursday, March 22. Click the “Download” button to read the full comments.

About 1 million Alabamians – mostly children, seniors, people with disabilities, and pregnant women – have Medicaid coverage. Out of that population, the state’s waiver would target about 75,000 adults with extremely low incomes who qualify for Medicaid as parents or other caretaker relatives of children (POCR). Alabamians in this group are ineligible for Medicaid if their incomes exceed 18 percent of the federal poverty level (about $312 a month for a family of three).

Because Alabama has not expanded Medicaid, the state’s work requirement plan would create a “catch-22 that forces people into the coverage gap,” Arise wrote in its official comments. Parents who work just 10 hours a week at minimum wage earn too much to qualify for Medicaid. But the state’s proposal would require them to work between 20 to 35 hours a week. That would put those parents in a no-win situation: They would lose Medicaid coverage if they don’t work – and also if they do.

“Threatening loss of health care in an attempt to force work efforts, without providing the supports that would make those work attempts successful, is flagrantly cruel and will result in no outcome other than poorer, more desperate and less healthy Alabama families,” Arise’s comments concluded.

‘Flagrantly cruel’ Medicaid changes would mean ‘poorer, more desperate and less healthy Alabama families,’ Arise tells state officials

By Chris Sanders

Alabama’s proposed new Medicaid work requirement waiver would be costly, counterproductive, ineffective and harmful to thousands of families who live in deep poverty, Arise Citizens’ Policy Project wrote in official comments submitted to state Medicaid officials on Thursday, March 22, 2018.

“Threatening loss of health care in an attempt to force work efforts, without providing the supports that would make those work attempts successful, is flagrantly cruel and will result in no outcome other than poorer, more desperate and less healthy Alabama families,” Arise’s comments concluded.

Medicaid covers about 1 million Alabamians. Of that total, the waiver would target 7.5 percent of them – about 75,000 adults with extremely low incomes who qualify for Medicaid as parents or other caretaker relatives of children. Alabamians in this group are ineligible for Medicaid if their incomes exceed 18 percent of the federal poverty level (about $312 a month for a family of three).

Because Alabama has not expanded Medicaid to cover adults with incomes below the poverty level, the state’s work requirement plan would create a “catch-22 that forces people into the coverage gap,” Arise wrote. About 300,000 Alabamians already are caught in the coverage gap, earning too much for Medicaid but too little to qualify for federal subsidies for Marketplace plans.

Parents who work just 10 hours a week at minimum wage earn too much to qualify for Medicaid. But the state’s proposal would require them to engage in work-related activities between 20 to 35 hours a week. That would leave thousands of Alabama parents in a no-win situation: They would lose their Medicaid coverage if they don’t work – and also if they do. Virtually all of them would end up uninsured, without access to employer-provided coverage or an affordable private plan.

Alabama’s proposal does not project the state’s cost to track Medicaid enrollees’ work activities and exemptions. It also does not identify whether or how the state would invest in child care, job training, transportation and other supports that low-income parents need to get and keep work.

Arise’s full comments on Alabama’s proposed Medicaid work requirement waiver are available here.

Education budget, landlord-tenant changes, HIV drug bill advance in Alabama Legislature

By Chris Sanders

K-12 teachers in Alabama wouldn’t get a raise next year under the Education Trust Fund (ETF) budget that a House committee approved Wednesday. The House is expected to vote on the plan next week.

The committee’s $5.9 billion budget would restore $10 million of state funding for Alabama State University that the Senate had removed. It also would include slight increases for K-12 and higher education, though next year’s ETF funding still would not come close to pre-recession levels. Check out AL.com’s report for more details.

Landlord-tenant revisions move closer to becoming law

Bills that would adjust several parts of Alabama’s landlord-tenant law in property owners’ favor are on the move in the Legislature. Without debate, the House voted 98-0 Tuesday for HB 523, sponsored by Rep. Paul Beckman, R-Prattville. A day later, a House committee approved SB 291, sponsored by Senate President Pro Tem Del Marsh, R-Anniston.

Both proposals would give landlords more time to refund a security deposit or give notice of why they are keeping some or all of it. The bills would increase that window from 35 days to 60 days. The measures also would allow landlords to treat a property as abandoned if electrical service is cut off for at least a week. In addition, landlords would have to provide only a seven-day written notice if they plan to terminate the lease for a violation that does not involve failure to pay rent. That would be down from the current 14-day timetable.

The only difference between the bills involves renters’ right to correct problems cited as a lease violation without getting the landlord’s written consent. SB 291 would give renters four chances every 12 months to correct such problems, while HB 523 would provide only two chances every 12 months.

Senate panel OKs bill to allow redistribution of some unopened HIV drugs

Pharmacies that dispense HIV medications for or in HIV clinics could redistribute certain unopened drugs under a bill that the Senate Health Committee approved Wednesday. SB 437, sponsored by Sen. Linda Coleman, D-Birmingham, moves to the Senate. A nearly identical House bill – HB 138, sponsored by Rep. Patricia Todd, D-Birmingham – passed the House 99-0 last week and awaits the Senate committee’s consideration.

HIV clinics now must destroy unopened medications if patients do not show up for treatment. HB 138 and SB 437 would allow pharmacies to dispense those drugs to other patients and would set controls on handling and oversight of the drugs. Arise and other consumer advocates last year urged Gov. Robert Bentley to support this policy change as his Medicaid Pharmacy Study Commission met to look at ways to reduce costs in the state’s Medicaid drug assistance programs.

Lawmakers will return Tuesday for the 25th of 30 allowable meeting days during the 2014 regular session, which is expected to last until early April.

By Chris Sanders, communications director. Posted March 14, 2014.

‘Simply cruel’: Testimony from Alabama Arise’s Carol Gundlach against Alabama’s Medicaid work requirements plan

By Carol Gundlach

Arise policy analyst Carol Gundlach testified against Alabama’s proposed Medicaid work requirements waiver during a public forum on Monday, March 5, 2018, in Montgomery. Here is the full text of Gundlach’s prepared remarks:

It is important for us to recognize that the people who will be affected by this proposed policy are exclusively the parents or guardians of children, often very young children. Over 90 percent of them are women. They are among the poorest people in Alabama, with an average monthly income of less than $400 for a family of three. These poor families are an extraordinarily vulnerable population to target for the potential loss of health care assistance.

Alabama offers few supports for people transitioning to work. While the waiver request says that people will be referred to supportive services, there is no reason to expect that they will be able to actually receive these services. Subsidized child care, in particular, is a necessity for a parent who works.

In Alabama, however, subsidized child care receives no state funding. As a result, most subsidized child care subsidies serve the highest priority categories, including foster children, children receiving protective services, and children who are in families that receive TANF (Temporary Assistance for Needy Families). In September 2017, there was a waiting list of over 1,000 children and significantly more pent-up need for subsidized day care. The same could be said for other support services, including job training and public transportation, which are essential job supports.

The waiver request says that people who can’t find services like transportation or child care will be exempt. But the way this section is written is particularly confusing and unclear. The waiver request says people “compliant with JOBS are exempt.” And it says that anyone exempt or deferred from JOBS (Job Opportunities and Basic Skills) will not be required to engage in work activities. To be either participating or exempt from JOBS, though, one must be receiving TANF.

There are around 4,000 adults receiving TANF and 75,000 people in the POCR (Parents and Other Caretaker Relatives) Medicaid capacity. While it appears to be implied, the actual language of the waiver request is silent or whether any of the other 71,000 participants not receiving TANF will be deferred if they don’t have child care or transportation.

The waiver request says the Medicaid work program would be “modeled” on the JOBS program. And the proposed memorandum of understanding with DHR (the Department of Human Resources) seems to indicate that non-deferred POCRs will actually be enrolled in the JOBS program or another program administered by DHR that is very similar to JOBS.

A critical element of the JOBS program is access to emergency and job support services, including auto repair, emergency housing assistance, transportation assistance, uniforms and other needs. One of the most important supports in the JOBS program is priority access to subsidized child care without having to be placed on a waiting list.

Will POCR recipients also become eligible for these TANF/JOBS-funded services? And if so, would those auxiliary services by paid for with the already inadequate TANF block grant? If so, this waiver proposes to try to expand services now covering 3,700 people to an estimated additional 17,000 individuals, further stressing an already underfunded JOBS program and reducing assistance now reserved for TANF participants mandated to participate in JOBS.

The waiver request says “every adult in the household” would be required to participate. If this is the case, is the plan to terminate the Medicaid of a compliant or exempt Medicaid recipient if a non-recipient who lives in the same household doesn’t participate? Besides the deep unfairness of punishing the Medicaid recipient for the behavior of another household member, this policy empowers the non-recipient to use the threat of the loss of insurance to abuse and control the Medicaid recipient.

Ultimately, this waiver request raises more questions about what is being proposed than it answers. Most of the answers will apparently be found in the yet unspecified MOUs with the Department of Human Resources and the Department of Labor – MOUs that may not be available to the public before they are implemented.

We need not to overlook that the intent of this proposal is to take health insurance away from targeted women who are unable, for whatever reason, to comply with employment and training activities. The request speaks to the benefits of work for children and families, and we certainly agree that, with the right supports, families are better off when there is earned income.

But I cannot see how the loss of parental health insurance can possibly benefit children. If Mom cannot afford her asthma medicine or her insulin because her Medicaid has been discontinued, then she gets sick and can’t work, or ends up in the hospital, or doesn’t buy the food, clothing or other necessities for her children in order to buy the medicine she needs. Any of these outcomes will hurt the family and the children.

The dignity of work, and the income it produces, does of course benefit families. But to use health care as the stick to force work efforts, without providing the supports that make work attempts successful, is simply cruel and will result in no outcome other than poorer, more desperate and less healthy Alabama families.

‘Alabama’s new catch-22’: Testimony from Alabama Arise’s Kimble Forrister against Alabama’s Medicaid work requirement plan

By Kimble Forrister

Arise executive director Kimble Forrister testified against Alabama’s proposed Medicaid work requirements waiver during a public forum on Monday, March 5, 2018, in Montgomery. Here is the full text of Forrister’s prepared remarks:

When we compare Medicaid’s waiver proposal to DHR’s welfare reform proposal in 1996, what’s most striking is Medicaid’s lack of data. How can we analyze the target population when Medicaid can’t give us information on the adults in the POCR (Parents and Other Caretaker Relatives) population?

I learned a lot when I served on Gov. Fob James’ Welfare Reform Commission. First, we analyzed Gov. James’ unjustified claims that the AFDC program (that was Aid to Families with Dependent Children, the cash welfare program now called TANF) incentivized teen pregnancy, and that AFDC was a budget-buster. In fact, it just didn’t make sense that any woman on welfare would get pregnant just to gain an additional $29 a month in welfare benefits. And with cash welfare amounting to one-half of 1 percent of the General Fund budget, it was hardly a budget-buster.

Again today, we hear unjustified claims from our governor. Gov. Kay Ivey says she wants to save taxpayer dollars and reserve Medicaid for the people who need it most. But who needs Medicaid more than the mother who’s trying to support two kids on $312 a month or less?

Even the woman who works 10 hours a week at minimum wage makes too much to meet this standard. And if this new policy “succeeds,” and she gets a 20-hour-a-week job, she is no longer eligible for Medicaid – and that defeats the whole purpose. Her new low-wage job is unlikely to provide health coverage. Her income is unlikely to be high enough to allow her to buy coverage on the marketplace. She will be caught in Alabama’s new catch-22.

Changes like this can be game-changers – but they can change the game in a bad way. We learned it the hard way in the 1990s. Well-meaning professionals in the Family Assistance section of DHR (the Department of Human Resources) assured us that there were three kinds of people among the 26,600 adult recipients (note that this was about a third of the POCR population):

  • There were those who were only using cash welfare as a temporary program that would help them get back on their feet, and they would be back in the workforce in a three to six months. They had data to show that this was a large share of the caseload. And apparently today’s Medicaid Agency is unable to do a similar analysis of the POCR caseload.
  • At the other end of the spectrum were the hardship cases who faced extreme barriers to employment, and the professionals assured us that they would be protected from harsh consequences. They truly needed the program. We would think that these are among the 4,000 to 5,000 adults now on TANF, about a sixth of the original population.
  • The professionals assured us that a middle group – between the job-ready at one end and the hardship cases at the other – were the people who just needed a kick in the pants to get off welfare and into a job, any job, and that it was easier to move up the ladder from any job than from no job.

This analysis makes some sense, but only in the context of an understanding of the barriers: women on welfare consistently said that in order to enter the workforce, they needed four things: jobs, child care, transportation and health care.

DHR in fact made some effort in these areas. People could count on a year of Medicaid coverage and child care when they took a job, and they even got a few months of cash welfare to ease the transition to work.

But we analyzed the data from the first year of implementation and discovered that the numbers didn’t match the theory. An economist on our staff did a regression analysis and discovered that the numbers in the caseload did not line up with the numbers moving from welfare to work. Instead, the lower caseload numbers lined up with the lower number coming in the front door, not the number leaving for employment.

The reality was, these women could not overcome the challenges of child care and transportation to even go to the job interviews that were required before they could get TANF benefits. The theory – that a kick in the pants would lead to a job – did not explain the numbers. The reality, played out for thousands of women across the state, was that some our most vulnerable people – young mothers who can’t access child care and transportation – were denied the $50 a week we provide in TANF benefits.

We would urge the Alabama Medicaid Agency to take a hard look at its theories and compare the theories to the numbers. Are you actually cycling a significant number of cases through a transitional period of difficulty between jobs? If so, you probably don’t need a big increase in administrative costs to get them to work.

Medicaid’s own projections show that some 57,000 people in the POCR caseload will be exempted from work requirements. But the administrative cost of making that determination will add significantly to our famously low-overhead Medicaid budget. It won’t be so low-overhead anymore.

The group that’s left – perhaps 17,000 people who are not job-ready and not hardship cases – is the group that’s at risk of essentially being kicked while they’re down. If you can’t arrange child care and transportation to start on the path to a job, you’re not getting help. You’re getting the front door slammed in your face.

Bottom line: In a state with 18.5 percent of its people in poverty, this plan proposes to put about 1.5 percent of its people under a microscope, expecting to find about 1/3 of a percent they can move off Medicaid. Gov. Ivey is proposing to put a huge administrative effort into forcing this 1/3 of a percent of the population into jobs, with the result that a few thousand mothers might get jobs, but they surely will no longer have health care.

If Alabama seriously wants to test its ability to move people from POCR to the workforce, why not propose a one-year pilot program that offers work supports without the penalties that remove their health care?