Budget hearings show need for Alabama to expand Medicaid, boost public investments

Alabama needs to expand Medicaid and invest more in education and other human services. Those were key takeaways from this week’s state budget hearings in Montgomery. The hearings highlighted a range of policy challenges and illustrated the connections between many of them.

We heard a lot of talk this week about the need to strengthen Alabama’s “infrastructure.” Many legislators say the state just doesn’t have enough money to make further investments in human infrastructure – the services like health care, child welfare and public safety that serve as a basic measure of what we value. But that’s incorrect.

Alabama’s lack of money for education, health care, child care and other services isn’t a natural force like the weather. It’s the result of decades of policy choices, as our Tax & Budget Handbook shows. And better choices can lead to better outcomes for Alabama.

Medicaid expansion could cut costs for corrections, DHR

Numerous agency leaders identified Alabama’s fraying rural health care system as a major concern. Rural hospital closures hurt communities and make it harder to get care. A lack of mental health care takes a toll on families, schools and workers. And both challenges increase financial strain on the corrections system.

The opioid epidemic is one problem that cuts across multiple areas: corrections, education, human resources, law enforcement, Medicaid, mental health and public health. Many parents fighting addiction lose child custody to the Department of Human Resources (DHR), which struggles to recruit foster parents for an average $16 daily allowance.

While bare-bones health agencies tackle the epidemic’s medical consequences, Alabama’s corrections system has emerged as the largest provider of mental health services, with many of them linked to substance use disorders.

That’s true even as Alabama’s prison overcrowding remains staggeringly high. The state prison system once operated at nearly double its designed capacity. Recent sentencing reforms helped cut that rate to 163 percent, and Corrections Commissioner Jeff Dunn expects it to sink to 145 percent. But further reductions are unlikely without broader changes, Dunn said.

Rural hospital closures affect prison overcrowding, too. Sen. Cam Ward, R-Alabaster, said a private prison in Perry County is vacant despite an appropriation to buy it. The county has no hospital, which would make it hard to use the prison even if the state bought it, Ward said.

Medicaid expansion would cut costs and improve lives across all these areas of concern. It would stem the tide of rural hospital closures. It would expand access to mental health and substance use treatment. And that would save many Alabamians from going to jail or losing child custody. Arise members and other advocates must keep making the case for Medicaid expansion throughout 2019.

Decades of inadequate funding cause unmet needs, staff shortages

Our state’s upside-down tax system requires most Alabamians to pay twice the share of income in state and local taxes that the richest households pay on average. It also means Alabama struggles to raise enough money to fund health care, child welfare and other important services.

Staff shortages were a running theme at this year’s budget hearings. Alabama’s corrections and mental health commissioners both emphasized problems with hiring and keeping qualified employees. DHR cited high turnover in child welfare staff, who are first on the scene when children’s safety is at risk. And the Alabama Law Enforcement Agency (ALEA) needs more state troopers to ensure highway safety.

DHR Commissioner Nancy Buckner asked lawmakers for an additional $21 million for 2020. Buckner said DHR struggles to retain staff, especially in the stressful child welfare division, which has 36 percent turnover. “Anything you can see on TV, we probably have multiple cases,” Buckner said.

The new money would allow for salary increases, technology improvements, and higher payments for foster families, Buckner said. Foster parents are difficult to recruit, she said, and the opioid epidemic has left more children in foster care.

For corrections, Dunn asked for another $42 million to hire and retain 500 prison guards and improve mental health services. (Low unemployment makes it harder to retain officers, Dunn said, because they often can earn more at safer jobs.) A federal judge has ordered Alabama to address its guard shortage and inadequate health services in state prisons.

ALEA Secretary Hal Taylor requested another $8.7 million to provide raises and hire 50 new state troopers. Up to 200 troopers could retire soon, Taylor said, and ALEA must compete with other departments for officers.

K-12 schools seek to hire more teachers, expand mental health support

Alabama schools discussed their needs for 2020 as well. State school Superintendent Eric Mackey requested an additional $295 million from the Education Trust Fund. With that money, schools could hire more teachers in grades 4-6 and invest more in the Alabama Reading Initiative. They also could hire more school nurses and provide a $600 allowance per teacher for classroom supplies.

Mackey asked for an extra $270 per student to teach about 25,000 students for whom English is a second language. And he requested another $22 million for school safety improvements and school-based mental health services.

Mackey echoed other agency heads by raising concerns about future personnel shortages. A recent survey of high school seniors found only 4 percent want to become teachers, down from 12 percent in previous surveys, Mackey said.

Sen. Vivian Figures, D-Mobile, asked Mackey to address the state Department of Education’s listing of 76 schools as “failing.” Most of those schools are in low-income areas and serve mostly black students. Mackey said the Alabama Accountability Act requires him to designate the lowest performing 6 percent of schools as “failing,” no matter how well they may educate students. The Accountability Act, enacted mere hours after introduction in 2013, diverts tens of millions of dollars a year from public schools to private school scholarship funds.

ALL Kids, pre-K, SNAP offer models for success

The budget hearings painted a stark picture of Alabama’s challenges, but they brought good news, too. Lawmakers heard numerous examples of how investments in health care and education are paying off.

Alabama’s rate of uninsured children is among the South’s best, and ALL Kids is a big reason why. The program provides health coverage for children whose low- and middle-income households don’t qualify for Medicaid. ALL Kids was the country’s first Children’s Health Insurance Program, and it remains a national performance leader in children’s health coverage.

The Program for All-Inclusive Care for the Elderly (PACE) provides an exemplary community-based long-term care option for residents of Mobile and Baldwin counties. The state’s commitment to pre-kindergarten has created a model for early childhood education. And aggressive workforce training programs in K-12 and two-year colleges are boosting Alabama’s economic potential.

Medicaid Commissioner Stephanie Azar highlighted investments in long-term care reform and primary care reform. The statewide Integrated Care Network (ICN) has already launched its case management system, designed to steer more long-term care patients into home- and community-based services. On the primary care side, Alabama Coordinated Health Networks (ACHNs) will launch in seven regions this fall. That move will bring Medicaid decision-making closer to communities and emphasize preventive and coordinated care.

Buckner thanked DHR’s Food Assistance Division for ensuring Alabamians received benefits under the Supplemental Nutrition Assistance Program (SNAP) during the recent federal government shutdown. Facing a Jan. 20 deadline to distribute February benefits, employees worked nights and weekends to approve 1,700 SNAP applications.

Buckner also praised the Food Assistance Division for earning federal bonuses of $2.4 million for timely processing of applications and low error rates in benefit calculations. Unfortunately for Alabama, which has a highly efficient and accurate SNAP program, Congress ended future bonuses in the 2018 Farm Bill.

It’s time to invest in a brighter future

Successful investments like these aren’t “one and done.” Alabama must resume providing some state money for ALL Kids next year as full federal funding ends. PACE seeks to expand, but its requests have been rejected so far. Only one-third of Alabama’s 4-year-olds are enrolled in pre-K. And gearing up for the 21st century will require even bolder workforce development.

Treading water is not enough. Education, Medicaid and other vital services need more funding so they can do more than the bare minimum. Smart investments in these services will pay off in a stronger, healthier future for all Alabamians.

Policy director Jim Carnes, policy analyst Carol Gundlach and communications director Chris Sanders contributed to this post.