Issue: Health

Alabama mothers, children bear brunt of proposed new Medicaid restrictions

By Chris Sanders

Alabama’s bid to impose a work requirement on parents receiving Medicaid could cost as many as 8,700 people their health coverage in the first year, mainly affecting mothers whose children also would feel the impact, according to a new analysis by the Georgetown University Center for Children and Families (CCF) and Arise Citizens’ Policy Project (ACPP).

The proposal would create a Catch-22 for these families who already live well below the poverty line: Any parent working the 20 to 35 hours required under the state proposal would make too much money to qualify for Medicaid – but likely not enough to afford private insurance. These harsh new restrictions would disproportionately hurt families living in Alabama’s rural communities and small towns where jobs are scarce.

“Alabama’s proposal creates more barriers to Medicaid coverage and will not help families rise out of poverty. In fact, the opposite is true – many parents and children are likely to lose health coverage, which exposes them to greater financial instability,” said Joan Alker, director of the Georgetown University research center. “It’s hard enough to raise a family on such a limited income without someone putting more roadblocks in the way.”

Alabama is not the first state to seek a work requirement, but it is one of the first to do so without accepting federal funding to expand Medicaid to adults with incomes slightly above the poverty line (138 percent of the federal poverty level). Around 300,000 Alabamians are caught in the coverage gap, earning too much to qualify for Medicaid but too little to qualify for subsidies for marketplace coverage through the Affordable Care Act.

In Alabama, only the poorest parents and caregivers, those making 18 percent of the poverty level or less – $3,740 a year for a family of three, or about $312 a month – now qualify for Medicaid. That is the strictest eligibility requirement in the nation (along with Texas). Because Alabama has not expanded Medicaid, the work requirement would apply only to parents with extremely low incomes.

The analysis found that among this population:
•    More than 85 percent are women.
•    60 percent are not in the workforce, in many cases because they are caring for someone else or have an illness or disability; 24 percent describe themselves as unemployed. The remainder are already reporting some work.
•    58 percent are African American; 40 percent are white.
•    35 percent are young parents under age 30.

A proposal for a Medicaid work requirement, now undergoing a state public comment period before submission to the federal government, could prove disastrous for many Alabama families, ACPP policy director Jim Carnes said.

“The goal of this cruel, counterproductive plan is to take health insurance away from thousands of Alabamians who are living in desperate poverty,” Carnes said. “By creating barriers to coverage rather than promoting it, Alabama’s work requirement fails the most fundamental test for Medicaid policy changes.”

Alabama’s proposal also seeks to trim eligibility for Transitional Medical Assistance – despite the fact that TMA is designed specifically to provide stability in health coverage for families whose incomes are increasing because they are working more.

In addition, the proposal could fuel an increase in the number of Alabama children without health coverage, according to the report, because uninsured parents are more likely to have uninsured children. Alabama’s rate of uninsured children – just 2.4 percent – is the lowest in the South. Overall, children and families in Alabama’s rural communities and small towns are more likely to use Medicaid coverage to meet their health care needs than those in metropolitan areas, a 2017 Georgetown University CCF/University of North Carolina study showed.

“As a pediatrician practicing in rural Alabama for 37 years, I have seen firsthand what happens when parents cannot access health care: Their children’s health suffers,” said Dr. Marsha Raulerson, who is a pediatrician in Brewton and a member of the American Academy of Pediatrics. “If approved, the Alabama Medicaid work requirement would be a step backwards for a state that has been a national leader in covering children.”

The impact of Alabama’s proposed Medicaid work requirement on low-income families with children

By Alabama Arise

Alabama is seeking federal permission through a Section 1115 Medicaid demonstration waiver to require parents and caregivers who rely on Medicaid to work 20 to 35 hours a week, prove they are looking or training for a job or do community service before receiving Medicaid. This proposal targets the very poorest and most vulnerable families with children in Alabama – many of whom will lose their health coverage, according to a new report by Arise Citizens’ Policy Project and the Georgetown University Center for Children and Families.

Alabama’s proposed work requirement and subsequent coverage losses would disproportionately affect mothers, African Americans and families living in rural communities. Many of these women will likely become uninsured, as employer-sponsored insurance for low-wage workers is sparse.

The proposal creates a Catch-22: Any parent working the 20 to 35 hours required would make too much money to qualify for Medicaid — but likely not enough to afford private insurance. An analysis of the state’s estimates finds that 8,700 parents would be removed from Medicaid in the first year alone. When their parents lose health coverage, children suffer. The families face increased debt, and children are less likely to visit the doctor regularly and more likely to become uninsured themselves. Children in these families are already disproportionately uninsured.

White House’s proposed cuts to nutrition, health care and housing would hurt struggling Alabamians

By Chris Sanders

Arise Citizens’ Policy Project executive director Kimble Forrister issued the following statement Tuesday, Feb. 13, 2018, in response to the release of the White House’s proposed 2019 federal budget:

“The White House’s budget proposal lays out a vision of a dark and troubling future for struggling families across Alabama. This plan would slash services like nutrition assistance, health care and affordable housing, making it even tougher for hard-working Alabamians struggling to make ends meet. Life would become harder for everyday families, even as big corporations and wealthy people would continue to enjoy the huge federal tax cuts that were just enacted.

“This budget plan would cut more than $200 billion over the next decade from SNAP assistance, which helps one in five Alabama families put food on the table. It would cost Alabama more than $140 million in federal funding for affordable housing next year, even as the state faces a shortage of more than 76,000 affordable and available homes for households with extremely low incomes. And it would cut hundreds of billions of dollars by 2028 from Medicaid, which provides health coverage for one in five Alabamians – almost all of whom are children, seniors, pregnant women, or people with disabilities.

“Public policies should make it easier, not harder, for working families to get ahead. This budget is a wake-up call about the legislative goals and values of this administration. It paints a bleak picture for our country’s future, and we can’t afford to allow that vision to become a reality. Alabama’s members of Congress should reject this misguided agenda and instead work to ensure that families have the resources and opportunities they need to reach their full potential.”

New Medicaid hurdles would create barriers to health in Alabama

By Alabama Arise

The Trump administration is encouraging states to impose work requirements on “non-elderly, non-pregnant adult Medicaid beneficiaries who are eligible for Medicaid on a basis other than disability.” State Medicaid Commissioner Stephanie Azar told lawmakers the agency likely will seek approval for such a requirement this year. SB 140, sponsored by Sen. Arthur Orr, R-Decatur, and HB 331, sponsored by Rep. Arnold Mooney, R-Birmingham, would mandate this policy and place other statutory conditions on Medicaid eligibility. The bill would:

  • Require Alabama Medicaid to “request approval of the firmest but nonetheless most reasonable work requirements allowed” by the federal government.
  • Require semi-annual, rather than annual, eligibility verification for Medicaid beneficiaries, including a review of financial resources.

Unlike Alabama, most states seeking to impose work requirements have expanded Medicaid to cover low-income working adults. Most of Alabama’s Medicaid beneficiaries are children in low-income families. The next largest groups are people with disabilities, low-income seniors and pregnant women. Only about 75,000 parents and other caretaker relatives of Medicaid children qualify for Medicaid coverage. Nearly 90 percent of them are women. The income limit for Medicaid parents is just 18 percent of the federal poverty level ($307 per month for a family of three).

SB 140 and HB 331 leave many questions unanswered:

  • Given Alabama’s stringent Medicaid eligibility for adults, what group or groups will a work requirement target?
  • What training and work supports will Alabama offer to help affected beneficiaries find and keep jobs? For example, will the state’s wait-listed program for subsidized child care be expanded?
  • Given Alabama’s strong support for children’s health insurance, how will the state mitigate the harm that occurs to children when parents lose coverage?
  • How will the work requirement apply to parents who are in school? To those awaiting disability determination? To those who lack reliable transportation? To those who live in areas with high unemployment?
  • Is Medicaid equipped and funded to monitor compliance with the new requirements while making sure no individuals eligible for Medicaid fall through the new procedural cracks?
  • Since the Affordable Care Act ended asset tests for Medicaid, how does a semi-annual verification of “financial resources” comply?
  • If health coverage is a privilege for working people, why hasn’t Alabama expanded Medicaid to cover low-income workers who don’t get employer coverage and can’t afford private plans?

BOTTOM LINE: Creating work requirements and more eligibility hurdles for Alabama Medicaid would erect unreasonable barriers to health care. Making Alabama’s bare-bones Medicaid even more stringent is the wrong way to promote a healthier workforce.

Four reasons to oppose work requirements for Alabama Medicaid

By Chris Sanders

(1) The vast majority of enrollees are children or otherwise exempt. Medicaid covers about 1 million Alabamians (roughly one in every five people in the state), and most of them are children. Almost all of the rest are seniors, pregnant women, or people with disabilities who would be exempt from work requirements. Only about 7.5 percent of enrollees – roughly 75,000 people in the “parent and other caretaker relative” category – could be subject to a requirement.

(2) Many Alabamians who would face work requirements have serious barriers to employment. Nearly 90 percent of the 75,000 parents and caretakers covered by Alabama Medicaid are women. Many are going to school or caring for young children at home. Medicaid work requirements would not make child care, transportation or job training more accessible for them.

(3) Adults who lose Medicaid would fall into the coverage gap. Most states seeking to impose work requirements have expanded Medicaid for working-age adults. But Alabama hasn’t. About 300,000 Alabama adults are caught in a coverage gap. They earn too much for Medicaid but too little to receive subsidies for Marketplace coverage.

(4) Work requirements would create a catch-22 for people in poverty. Alabama parents can’t qualify for Medicaid if their income is above 18 percent of the poverty line. Someone working just 20 hours a week at minimum wage earns too much to qualify for Medicaid in Alabama. It’s unfair to require people to work to keep health coverage, only to take it away when they do.

By Chris Sanders, communications director, and Jim Carnes, policy director. Last updated Jan. 26, 2018.

CHIP renewal is overdue good news for parents of 85,000 Alabama children on ALL Kids

By Chris Sanders

Arise Citizens’ Policy Project policy director Jim Carnes issued the following statement Monday, Jan. 22, 2018, in response to the U.S. Senate’s vote to renew federal funding for the Children’s Health Insurance Program (CHIP) for six years:

“The parents of more than 85,000 children with ALL Kids coverage finally received some overdue good news today: Their kids aren’t about to lose health insurance. Congress’ agreement to renew CHIP funding for six years will allow ALL Kids to avoid an enrollment freeze and continue providing life-saving coverage for Alabama children.

“Families across Alabama deserve to breathe a sigh of relief, but it never should have come to this. CHIP funding deserved a quick, straightforward renewal before it expired nearly four months ago. Delaying the renewal and tying it to other important issues was unnecessary and irresponsible.

“A big untold story is the stress that Congress’ inaction placed on millions of hard-working parents across the country who lost the certainty that their children would be able to get the health care they needed. Instead of protecting children’s health coverage, congressional leaders spent month after month trying to undermine the Affordable Care Act. Then they focused on passing a tax bill that disproportionately benefited rich people and large corporations.

“CHIP, known as ALL Kids in Alabama, is a proven success story that played a big part in cutting our state’s uninsured rate for children from 20 percent to just 2.4 percent over the last two decades. Other states have seen similar improvements.

“Letting CHIP funding expire and remain in doubt for months was an attack on families. Congress should make sure this sad chapter can’t be repeated. It’s time to fund CHIP permanently and guarantee that all children can receive the health care they need to grow and thrive.”

Alabamians must keep urging Congress to protect health care

By Chris Sanders

Arise Citizens’ Policy Project policy director Jim Carnes issued the following statement Friday, Jan. 13, 2017, after the U.S. House approved a resolution that would make it easier for Congress to repeal portions of the Affordable Care Act:

“Protecting access to quality, affordable health care is more important than ever. Congress voted this week to make it easier to repeal parts of the Affordable Care Act, but that wasn’t the end of this debate. Now comes the hard work of ensuring that tens of millions of Americans don’t lose their health coverage and important consumer protections in the process.

“The Affordable Care Act has helped millions of people and saved thousands of lives across Alabama. Nearly 200,000 Alabamians have gained insurance through the ACA, and the vast majority of them receive tax credits to make their coverage more affordable. About 2 million Alabamians have pre-existing conditions that would have made it hard or impossible for them to get full coverage before the ACA lifted coverage caps and guaranteed their access to insurance. And the ACA has significantly reduced the number of uninsured young Alabamians by allowing 35,000 of them to remain on their parents’ plans until age 26.

“We urge Alabamians to continue pressuring their members of Congress not to repeal the Affordable Care Act without an immediate replacement that offers comparable coverage and consumer protections. ‘Repeal and delay’ is a dangerous and unacceptable path.”

Medicaid work requirements, ALL Kids, prison mental health funding among top 2019 budget challenges in Alabama

By Jim Carnes

Alabama Medicaid had good news for legislators last week, but it won’t last long. Lower-than-expected prescription drug costs will help Medicaid carry $53 million forward into 2019, meaning the agency will need less General Fund (GF) money next year than initially expected, Medicaid Commissioner Stephanie Azar said during state GF budget hearings Thursday. But that still won’t solve Medicaid’s need for stable, adequate long-term support.

Medicaid funding is just one of many GF challenges for Arise and other advocates this year. In a move that would create new barriers to health care for many low-income households, Alabama may seek to increase copays and impose work requirements for some Medicaid patients. The future of federal funding for ALL Kids, which provides health coverage for more than 85,000 children across the state, remains uncertain. Alabama also faces a federal court order to invest more in mental health care and other health services in state prisons.

Those issues and many others stand against the backdrop of a GF that struggles with a long-term structural deficit. That means GF revenue growth is not strong enough to keep pace with ordinary cost growth for Medicaid, mental health care, corrections and other services.

But lawmakers may be able to get through this year without addressing those deeper budgetary problems. The GF will carry forward $129 million into next year, enough to cover most of the requested increases for Medicaid, mental health care and corrections if Congress provides full federal funding for ALL Kids over the next two years.

The Legislature will have to finalize budgets for both the GF and the Education Trust Fund during a fast-moving 2018 regular session, which began Tuesday and is expected to end in March.

Temporary ‘good news’ won’t solve long-term Medicaid funding woes

Medicaid provides health coverage for one in five Alabamians – most of whom are children, seniors, pregnant women, or people with disabilities. The federal government provides about 70 percent of Medicaid funding in Alabama. The rest comes from the GF (11 percent) and other state sources like provider taxes on hospitals, nursing homes and pharmacies (19 percent).

Medicaid received $806 million from the GF last year, of which $105 million was one-time money from the state’s share of the BP oil spill settlement. Medicaid’s 2019 GF request is for $757 million. That would be 6 percent less than the agency’s total GF allocation last year, but 8 percent more than the amount that Medicaid received out of recurring GF revenues.

The end of Medicaid’s regional care organization (RCO) initiative in July 2017 also drew great legislative interest during the hearings. Azar discussed an “RCO pivot,” which will preserve several features of the RCO plan, with a broader scope and some structural changes. The basic idea of coordinating patient care to produce better health outcomes will continue to drive the reforms, Azar said. But new federal rules will allow Alabama to include more categories of patients in the new system.

Like the RCOs, the “pivot” plan will build on existing care management initiatives known as “health homes,” Azar said. Health homes seek to cut costs and keep patients healthier by using primary care doctors to coordinate enrollees’ health care. Alabama Medicaid has operated health homes since three regional pilot projects launched in 2010.

Arise is committed to ensuring strong consumer oversight and community engagement in whatever shape the new Medicaid reforms take. In a written proposal to Medicaid last fall, Arise emphasized that our statutory responsibility to provide consumer representatives for RCO advisory committees and governing boards gave Arise and our partners at the Disabilities Leadership Coalition of Alabama both a wealth of experiential learning over the last three years and a team of trained appointees eager to participate in the transition.

Azar reaffirmed her support for consumer involvement after the budget hearing, but advocates must keep up the pressure to ensure that principle becomes reality. To that end, Arise and our allies will provide comments on the draft Medicaid reform plan when it is unveiled in coming weeks.

Medicaid work requirement, copay proposals would hurt low-income Alabamians

Arise will seek to minimize the harm from proposals to increase Medicaid copays and impose work requirements on some Medicaid beneficiaries. Azar mentioned the possibility of increasing Medicaid copays but offered few details, other than noting that federal law would limit them to no more than 5 percent of a household’s annual income. She also said it remains unclear whether it would cost the state more to implement such a program than it would raise in return.

Azar’s discussion of work requirements was much more robust. Alabama soon will request a federal waiver to impose a work requirement for Medicaid beneficiaries in the “Parent and Other Caretaker Relative” category, Azar said. That group includes about 75,000 of the more than 1 million Alabamians with Medicaid coverage. Caretaker responsibilities, disabilities and other factors preclude many of them from working outside the home.

On an encouraging note, Azar highlighted the importance of an “exclusion list” of circumstances that would exempt many members of this group from the requirement. The scope of such a list will be a primary focus of Arise’s advocacy.

The White House has welcomed states to impose or increase work requirements and other “personal responsibility” measures for Medicaid patients, and Alabama is moving in that direction. For the vast majority of people served by Alabama Medicaid – children, seniors, and people with disabilities – the expectation of employment is not appropriate.

Most states requesting work requirements so far have expanded Medicaid to cover low-income adults without disabilities, which Alabama has not done, Azar pointed out to lawmakers Thursday. Research shows that Medicaid work requirements would limit access to the health care that many beneficiaries need to stay in the workforce while doing little to increase employment among low-income families.

ALL Kids’ future still in limbo as Congress drags feet on federal CHIP funding

Congress’ failure to provide long-term federal funding for the Children’s Health Insurance Program (CHIP) is another threat to affordable health care in Alabama. That inaction jeopardizes ALL Kids coverage for more than 85,000 Alabama children whose low- and moderate-income families earn too much to qualify for Medicaid.

ALL Kids’ future has been uncertain since long-term federal CHIP funding expired on Sept. 30, 2017. As available funding dwindled, ALL Kids in December announced that the program would end Feb. 1 without additional money. Congress approved temporary CHIP funding in December, which forestalled that move. But if the uncertainty continues, ALL Kids officials said Thursday, they will mail letters this month announcing that the program will freeze enrollment in February and terminate in March.

Under the Affordable Care Act, states have been receiving an enhanced federal match for their CHIPs, which in Alabama amounted to 100 percent federal funding. It remains unclear how Congress will handle this funding formula in a long-term funding plan. The Department of Public Health has requested an extra $53.6 million from the GF next year in case Congress requires Alabama to resume providing state matching money for ALL Kids.

For Medicaid, the loss of CHIP funding would mean that an additional 87,000 children whose Medicaid coverage is paid for by ALL Kids – but cannot legally be terminated – will move to the Medicaid budget. That would increase the state’s cost to cover those children.

Alabama was the first state to win approval for its CHIP when Congress created the program in the late 1990s. It has played a huge role in reducing the state’s rate of uninsured children from 20 percent then to just 2.4 percent today. Arise and other advocates urge Congress to honor this historic commitment by moving forward with a five-year plan for full CHIP funding without further delay.

Federal lawsuit to force more state investment in mental health care in prisons

Mental health care in Alabama prisons is “horrendously inadequate,” a federal judge ruled last summer. That led to an order for the state to solve the chronic understaffing in its prison system, particularly among corrections officers and mental health professionals. Corrections Commissioner Jeff Dunn has requested an additional $80 million in GF support over the next two years to address those issues.

Staffing in Alabama’s prison system is at only half of its expected level, Dunn told lawmakers Thursday. In some facilities, that number is as low as 30 percent, he said. Sentencing reforms have helped reduce the state’s prison overcrowding from 190 percent of designed capacity to 160 percent in recent years, but Alabama still has the nation’s “highest overcrowding percentage,” Dunn said.

State education funding up but still lower than a decade ago

Alabama’s education funding will be up again next year, but it still will be well below its inflation-adjusted level from 2008, before the Great Recession. The Education Trust Fund (ETF) funding cap for 2019 will be $6.6 billion. That’s $216 million, or 3.4 percent, higher than this year’s allocations. The Rolling Reserve Act sets the cap annually based on a moving average of the previous 15 years of ETF revenues. Gov. Kay Ivey’s proposed ETF and GF budgets include cost-of-living raises for both education employees and state employees.

By Jim Carnes, policy director, and Chris Sanders, communications director. Posted Jan. 9, 2018.

Children’s health care takes a back seat as Congress rushes to cut taxes for corporations, wealthy people

By Chris Sanders

Arise Citizens’ Policy Project executive director Kimble Forrister issued the following statement Wednesday, Dec. 20, 2017, in response to Congress’ passage of a tax bill that disproportionately benefits rich people and corporations:

“Congress’ misplaced priorities were on clear display today. Nearly 84,000 Alabama children are about to lose their ALL Kids coverage because lawmakers allowed federal funding for it to expire months ago. But instead of solving that problem, Congress hurried to create a new one by increasing the deficit to give huge tax cuts to big corporations and wealthy people.

“This tax plan is a massive giveaway to the rich at the expense of everyday Americans. Over time, it will raise taxes on tens of millions of families at low and middle incomes. It will increase health insurance premiums for millions of people and leave millions more uninsured in exchange for permanent tax cuts for big corporations. And it will drive up the federal deficit, setting the stage for calls to cut Medicare, Medicaid, education, food assistance and other vital services next year.

“Struggling families shouldn’t have to pay for tax cuts for rich people. And tens of thousands of Alabama families can’t afford for Congress to wait any longer to renew federal funding for the Children’s Health Insurance Program. Lawmakers across Alabama and across the country should commit now to renew CHIP funding before a single child loses coverage and to reject budget cuts that would make it harder for families to make ends meet.”

Congress’ shameful neglect puts health coverage at risk for 84,000 Alabama children on ALL Kids

By Chris Sanders

Arise Citizens’ Policy Project policy director Jim Carnes issued the following statement Monday, Dec. 18, 2017, in response to the announcement of ALL Kids’ pending termination:

“Tens of thousands of Alabama working families learned today – one week before Christmas – that their children will lose health insurance Feb. 1 if Congress continues to delay funding for the Children’s Health Insurance Program (CHIP), known here as ALL Kids. Alabama officials had been holding their breath since Congress failed to reauthorize CHIP funding by Sept. 30. They were hoping reserve funds could tide the coverage over for a few months – surely enough time for Congress to act. But today those hopes were dashed.

“ALL Kids’ announcement that it would stop enrolling children in new coverage on Jan. 1 and end the program entirely a month later strikes a painful blow not only to 84,000 ALL Kids children and their families but also to Alabama’s nationally praised gains in children’s health coverage. In the two decades since ALL Kids became the first state CHIP authorized by Congress, our uninsured rate for children has dropped from 20 percent to 2.4 percent. That record has earned Alabama’s program national recognition as the ‘Star of the South.’

“Ending ALL Kids also places a strain on Alabama’s threadbare General Fund. CHIP funds now pay for the health care of around 75,000 children enrolled in Medicaid, who will continue to receive coverage but at new cost to the state.

“In this shameful development, Congress has turned children’s health care – a vital part of family well-being – into a political football. Toying with children’s coverage creates a health hazard in its own right – and an entirely preventable one. Alabama’s hard decision today is a sign of things to come as other states face the grim realities of Congress’ failure to address children’s health needs. Our lawmakers must come to their senses and act now. Every wasted day puts children’s health in greater danger.”