Nearly 300,000 Alabamians with low incomes would benefit from Medicaid expansion.
People in the coverage gap earn too much to qualify for Medicaid, but not enough for an affordable private health insurance plan on the Marketplace. This leaves them in the health coverage gap.
The vast majority of people who would gain coverage through Medicaid expansion are working. More than 100,000 Alabamians in the coverage gap hold jobs that are important but pay low wages. Thousands more are self-employed, serve as caregivers or attend school.
We can afford it. Closing the health coverage gap comes with a $619 million signing bonus.
States that close their coverage gap will receive a 5-percentage-point increase in the federal match rate for Medicaid for two years. This is thanks to an incentive in the American Rescue Plan Act.
An increased federal match rate would bring $619 million to Alabama over the next two years.
The state’s cost to close the gap in the first two years would be roughly $423 million. That means nearly $200 million in additional federal funding would come to our state above and beyond the cost to extend Medicaid coverage up to hard-working Alabamians.
Closing the coverage gap helps workers stay employed.
Nearly half of Alabama workers do not get employer-sponsored health insurance. Closing the coverage gap could help employees get access to the health care services they need.
States that have closed the coverage gap have seen a greater increase in labor force participation among people with low incomes than in non-expansion states.
Injuries or manageable illnesses like diabetes can get so severe for those without health coverage that they prevent people from working or leading healthy lives.
Nineteen rural hospitals are at immediate risk of closing. Medicaid expansion can keep them operating.
Alabama’s rural hospitals are on life support, but research shows that a rural hospital being located in a Medicaid expansion state decreases the likelihood it will close by an average of 62%.
Expanding Medicaid will help more rural residents afford health care services and reduce the financial losses experienced at hospitals from serving uninsured patients or providing uncompensated care.
5,000 Alabama veterans have no military insurance and can’t afford health coverage.
It’s a common misconception that people who serve in the U.S. military automatically receive lifetime eligibility for health coverage and other benefits. In reality, veterans’ health benefits depend on their length of service, military classification, type of discharge and other factors.
14.2% of veterans are employed in the service industry, while 13.7% work in construction and maintenance. These are among the professions that would most benefit from Medicaid expansion.
Medicaid coverage was a vital lifeline for Saraland resident Jolene Dybas as she recovered from a health emergency. But after losing that coverage during the Medicaid unwinding period, she has had to go without needed health care. (Photo courtesy of Jolene Dybas)
When I first spoke with Jolene Dybas, 2023 was coming to an end. Lots of people were attending in-person events confidently and hoping the worst of the COVID-19 pandemic was firmly behind us.
Jolene, however, was still coming to terms with a new reality after moving to Mobile from Florida in 2019.
“I barely go out,” she said. “And when I do, I don’t want people to see me like this.”
I asked her why she preferred to keep such a low profile. That’s when she shared the full story of what it’s like living in Alabama’s health coverage gap. This gap includes nearly 300,000 people who earn too much to be eligible for Medicaid but not enough to afford private health coverage. Alabama’s Medicaid income eligibility limit for adults is one of the country’s most stringent.
“I’ve lived in many other states, and I never saw a person with no teeth until I moved here. I never thought that it could happen to me, but here we are,” she said in disbelief.
The toll of a medical emergency
Jolene’s story begins with good news. Her daughter was accepted to the University of South Alabama (USA) to study nursing. Jolene moved to Saraland, right outside Mobile, to help support her.
Soon after, though, a medical emergency threw a wrench in her family’s new beginning.
Jolene woke up one day and realized something was off. When she began experiencing heavy bleeding, her fears were confirmed. She rushed to the hospital and was told she needed an emergency hysterectomy to save her life. Jolene also would need intensive treatments, and she would have to stop working while she recovered.
“I quit counting after 10 ER visits and two hospital visits,” she said, describing her new reality of living with chronic pain and recovering from surgery.
Jolene soon lost health coverage when she was no longer able to work full-time as a customer service agent. Her financial situation got so bad that debt collectors began issuing threats of wage garnishment.
“My hours dropped down to part-time. I couldn’t afford emergency medical bills,” she said. “I’m in a place where I’m no longer self-sufficient, and it is killing me.”
When the hospital bills and prescription costs started to pile up, one of Jolene’s doctors at the USA Hospital encouraged her to apply for financial assistance through the hospital.
“I want people to know that I had a medical emergency and needed blood transfusions,” she said. “If it weren’t for USA Hospital taking up my case, I wouldn’t be here today.”
A temporary lifeline
Thanks to USA Hospital’s financial assistance programs, Jolene received assistance with her medical debt. She also learned she was eligible for a lifeline: Medicaid coverage. Since she was a parent who was too sick to work and had no income, she was one of the few working-age adults eligible for Medicaid under Alabama’s restrictive guidelines.
“Not many good things came out of the pandemic, but hey, it allowed me to get the help I needed and stay on Medicaid when I needed it most,” she said. “That all came crashing down, though.”
After the COVID-19 public health emergency ended in 2023, Jolene found out her health coverage was about to end. Like thousands of other Alabamians, she was rolled off Medicaid coverage during a process known as “unwinding,” or a return to pre-pandemic eligibility requirements.
Jolene had resumed working part-time as her health allowed – and that small amount of income made her ineligible under Alabama’s bare-bones Medicaid eligibility limits. Parents in a two-person household, for example, do not qualify for Alabama Medicaid if they make more than just $3,684 a year.
Jolene said she felt like she had just gotten to a good place managing her health, but losing Medicaid coverage left her with no other options for affordable health insurance. The worst thing about her ordeal wasn’t her surgeries or learning to live with chronic pain, she said. It was finding out she could no longer afford daily medications or dental care.
“Losing Medicaid will leave me with no choice but to go to the ER when my conditions get worse because I can’t afford my medications,” she said.
‘I don’t want them to see me like this’
Living without coverage means making more sacrifices than Jolene had imagined.
“When I lost my insurance, I wasn’t able to go to the dentist,” she said. “My teeth got worse and worse. I only have four teeth left because all I can do is get them pulled when I have a problem.”
Jolene hasn’t visited family since moving to Alabama.
“I can’t even go home to visit because I can’t show them the shape I’m in. I don’t want them to see me like this,” she said. “Where I come from, you don’t see people with no teeth in their head, but in Alabama, I can’t even afford dentures.”
Jolene has lived in several other states before, including Minnesota, Mississippi and North Dakota. She said Alabama’s refusal to expand Medicaid creates unnecessary hardship for its residents.
“If people were well in Alabama, they’d be able to work more. I know I would,” she said.
Minnesota has chosen to expand Medicaid and make other investments in its residents’ well-being. In 2021, lawmakers there passed a historic dental health package that helped ensure Medicaid participants could access dental care and eased administrative burdens for providers.
“They just don’t see things like this,” Jolene said of living in other states with more access to health care and coverage. “There’s no support [in Alabama]. I just thought things were the same everywhere.”
Jolene said living in the coverage gap in a state that hasn’t expanded Medicaid has her missing home.
“If I went home to Minnesota, there is no way I would have this problem,” she said.
‘It can be different’
Jolene’s experience has turned her into an advocate for all Alabamians facing the same problems she does.
“A lot of people in this state don’t know that it can be different. You deserve more,” she said. “Your state leaders are failing.”
Alabamians’ quality of life is suffering the longer we wait to expand Medicaid, Jolene said.
“This has got to be the most expensive place I’ve ever lived. Alabama has taught me a really hard lesson: They don’t care about us,” she said.
Living in other states has offered Jolene a window into the costs of Alabama’s failure to ensure health care access for all of its residents.
“I feel like the death rate is higher here because we all have to wait for adequate care until it’s too late,” she said. “So instead of taking care of that, we’re letting our money slip out of our hands to pay for expansion in other states.”
Jolene said she believes shifting our state’s policy priorities is crucial.
“Why does Alabama still have a grocery tax? I’ve never had to pay that before. Then, we don’t have Medicaid expansion but they’re worried about building bridges and prisons?” she said. “It’s very, very selfish.”
Taking action for a brighter future
After learning nearly 300,000 other Alabamians like her would benefit directly from Medicaid expansion, Jolene started reaching out to lawmakers urging change.
“I’ve written letters to my legislators and Governor Ivey. I’ve called TV stations. I don’t know how they can’t afford to expand Medicaid because people are desperate,” she said. “What does money matter when it’s already there and it is costing lives not to use it?”
One of the states Jolene previously lived in, Mississippi, recently saw meaningful progress toward closing its coverage gap. The Republican-led Mississippi House passed a bill in February to extend Medicaid coverage to more than 200,000 adults with low incomes. That legislation now awaits consideration in the Senate.
Expanding Medicaid is “a topic that should transcend politics,” Mississippi House Medicaid Committee Chairwoman Missy McGee told reporters. “Sometimes, it’s OK to do the right thing because it’s the right thing.”
Jolene said her daughter will graduate soon, and she thinks her family’s time in Alabama is coming to an end. Jolene said the cost of waiting on our state to expand Medicaid is simply too high.
“I thought Mississippi was bad, but it’s not this bad,” she said. “I’m sick of Alabama not caring. If they can’t get their act together, I’m not staying here.”
About Alabama Arise and Cover Alabama
Whit Sides is the Cover Alabama storyteller forAlabama Arise, a statewide, member-led organization advancing public policies to improve the lives of Alabamians who are marginalized by poverty. Arise’s membership includes faith-based, community, nonprofit and civic groups, grassroots leaders and individuals from across Alabama. Email: whit@alarise.org.
Arise is a founding member of the Cover Alabama coalition.Cover Alabama is a nonpartisan alliance of 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.
The Alabama Legislature is coming back into session after taking off last week. Arise’s Akiesha Anderson provides updates on what’s happened most recently — including unfortunate news on anti-DEI legislation — and gets you ready for another busy week ahead. Legislation we’re monitoring this week includes a bill to reform Alabama’s felony murder rule and a proposal to remove the sales tax from baby supplies and feminine hygiene products.
Full video text:
Hello, my name is Akiesha Anderson, and if you’re new to these videos, I’m the policy and advocacy director for Alabama Arise. After a much needed break from the State House last week, I am back to give you an update on what happened during the fifth week of the legislative session and what we’re expecting during this upcoming week.
As you likely know, legislators were not at the State House last week. Rather, they were in their districts for a constituent work week in which they were hopefully making time to talk to you and others that they represent. However, the week prior to that workweek, a whole lot happened.
Most notably, the House unfortunately passed both SB 29, which was the anti-diversity, equity and inclusion bill, and SB 1, the bill that restricts access to absentee voting. Both of these bills will be back in the Senate, where the Senate must approve of them before they will be sent off to the governor. There were some minor changes made to both in the House, and so I do not anticipate that the Senate will put up a fight, unfortunately. But most likely, these bills will get a vote this week in the Senate and then be sent off to the governor.
Also, by the time the Legislature left to take last week off, they had officially utilized half of their allocated legislative days. This means that at the time of this recording, we are officially halfway through the legislative session. While this pace feels a bit unprecedented, it is likely that the Legislature will continue its three-day workweek this week before going on a spring break next week, and then they will hopefully slow their pace somewhat in April. I’m being told that in April they will begin utilizing two-day work weeks instead of three. Two-day workweeks are definitely a bit a bit more typical, and this will allow them to buy time to pass the budgets.
Before sharing what’s happening this week, I do want to give you some status updates on bills that you’ve heard me talk about in prior weeks. So to begin, HB 29, which is the CHOOSE Act, and which could divert a minimum of $100 million in public education funds to private or home schools, was signed into law by the governor. SB 35 by Sen. Smitherman, which would require that history instruction be fact-based and inclusive, has passed out of a Senate committee and is waiting to be deliberated by the full Senate. HB 32 by Rep. England, which would reform and clarify Alabama’s felony murder rule, had a public hearing the week before last. Thus, we expect the House Judiciary Committee to vote on this bill this Wednesday, March 20.
HB 102 by Rep. Susan DuBose and SB 53 by Sen. Arthur Orr would both eliminate the eligibility to work form that children ages 14 and 15 are required to get signed by their schools before being employed. Both versions of this bill are expected to be considered by the full House sometime soon or at least to be in position to be considered by the full House sometime soon. The Senate version of this bill does still need to make it out of a House committee. However, it’s possible that that could happen as early as this week.
Other bills that we are watching this week include HB 188 by Rep. Terri Collins. This bill would create a uniform and improved process for the suspension or expulsion of public school students. The House Education Policy Committee has been assigned this bill, and they are expected to deliberate it this week. Also, HB 236 by Rep. Rafferty and SB 62 by Sen. Orr would both eliminate the sales tax for diapers, baby supplies, baby formula and feminine hygiene products. The Senate version of this bill is expected to be in House committee, whereas the House version of this bill is already positioned to be deliberated by the full House. That means that both or either of these bills will likely be in a position by this week to be deliberated by the full House.
And then lastly SB 31, which has been making a lot of news, will be in committee this week. And so SB 31 is a bill introduced by Sen. Waggoner. It has already made it out of the Senate and is in a House committee this week. But this is the bill that would be that is designed to get the state to give Birmingham-Southern a loan. It is also scheduled for a public hearing on Tuesday, March 19, at 11:30 a.m., and that public hearing will take place in the Ways and Means General Fund Committee.
Other things to keep an eye out for this week are new bills that legislators may introduce. So for example, the child tax credit bill that has been touted in the news as well by Lt. Gov. Ainsworth and others is expected to be introduced by Sen. Gudger and Rep. Daniels as early as this week. If legislators are hoping to get any legislation passed that has not been introduced yet, it is definitely to their benefit, especially for the sake of time, to try to have those bills filed as soon as possible. This week is ideal given the fact that they will be on the spring break next week.
Now the last thing to make sure you have on your radar is Arise’s upcoming advocacy day. So if you have not already marked your calendars to join us at the State House on Tuesday, April 2, please do. We hope to have as many people as possible to talk to legislators about our various issues, so register to join us. All you have to do is visit alarise.org and click on “Get Involved” and then click on “Upcoming Events.” That will take you directly to the page that you need to utilize to sign up. We definitely need you to let us know that you’re coming so that we can make sure we have an adequate head count, enough room for everyone, as well as meals for everyone. So I look forward to hopefully seeing you there, and in the meantime, take care.
Inspired by Pandemic EBT (P-EBT), Summer EBT provides $120* in SNAP benefits per categorically eligible child throughout the summer months. (*Indexed for inflation).
What Can Alabama Do Today?
Alabama can pull down federal matching funds in 2024 to support implementation in 2025, according to the USDA’s Interim Final Rule for the program.
This would require a $15 million state appropriation to help refine Alabama’s application process.
Why Does it Matter?
1 in 4 Alabama children are experiencing food insecurity. Hundreds of thousands of Alabama children struggle with hunger even more during the summer because they no longer receive free school meals.
Who Would Benefit?
545,000 children across Alabama
What would be the Economic Impact?
$98 Million to $117 Million annually
Join Alabama Arise
Visit alarise.org to sign up for alerts and donate to become an Arise member today!
Arise’s Akiesha Anderson breaks down a flurry of legislation that kept us busy last week. She discusses bills filed in response to the Alabama Supreme Court’s decision on in vitro fertilization (IVF), updates us on anti-DEI legislation and examines the CHOOSE Act, a bill that would redirect public school funding to private schools and homeschooling. She also previews what’s ahead this week, including committee action on a harmful bill that would impose limits on absentee voting and a good bill that would increase help for those who can’t afford a lawyer when charged with a crime.
Full video transcript:
Hi there. My name is Akiesha Anderson, and as you know, I am the policy and advocacy director for Alabama Arise. I’m here once again to provide you with another weekly legislative update.
If you by any chance were following what happened at the State House last week, then you, like me, were probably somewhat exhausted if not depleted by the time the week was over. So before I delve into this week’s update, I do want to hold space for that reality and to thank you for all that you do to help to make this state better. Even in response to the tough political terrain that we often find ourselves in, it’s people like you that continue to show up and stay engaged with the political process that help to position us to create that Alabama that we hope to see.
Also, my apologies in advance — I know that these videos typically aren’t very long, but given all that happened last week and what’s slated to come up this week, I do think that I would be doing you a disservice by not talking about each of the things that I’m about to discuss.
Within the first three weeks of the legislative session, we have already seen a host of attacks targeting women’s health; diversity, equity and inclusion; public education funding; people’s rights to free speech and peaceful assembly; protecting our children from child labor and exploitation; and voting rights.
With regard to last week specifically, we started off with news about the Supreme Court ruling that embryos are human — something that has already had significant implications on women like me whose doctors have recommended IVF or other medical procedures in response to complications with conceiving naturally. In response to that decision, however, I am grateful that legislation like HB 225 designed to protect people’s ability to access IVF treatment without fear of prosecution has been filed by House Minority Leader Anthony Daniels.
Also less than ideal last week, we saw SB 129, the anti-diversity, equity and inclusion bill, be quickly introduced and placed on a committee agenda. Basically was heard the next day, within hours of being placed, or within hours of dropping in the Senate. This legislation unfortunately has already passed out of the Senate at an unprecedented speed. If passed into law, this bill would essentially ban diversity, equity and inclusion departments, programs and staff from existing on the campuses of our public institutions, namely colleges and universities. It would also rob many students of color of one of the few safe spaces that we often feel like we have while on the campuses of predominantly white institutions, or PWIs.
Also unfortunate last week, the CHOOSE Act, or HB 129, was voted out of the out of the House Ways and Means Education Committee. While I myself was someone who attended what would be considered a failing or an underperforming school while growing up here in Montgomery, Alabama, and while I definitely understand the desire of parents to have access to quality education, the truth is we cannot as a state ignore the fact that too many students are being failed by the public education system because of the fact that we have failed to properly fund the education system. Meaning our public schools need more, not less, resources in order to give our children the access to quality education that they deserve. Unfortunately, however, the CHOOSE Act, which would possibly help defund public education, is being backed by some powerful representatives and senators, Rep. Garrett in the House and Sen. Orr in the Senate, as well as being backed by Gov. Ivey. Thus it seems slated to be passed out of the House as early as this week.
Last week, we also saw a piece of legislation sponsored by Sen. Orr that would curb people’s ability to protest in residential areas. In particular, this bill would prohibit any protest near the residence of a public official that’s designed to “disturb” that official. Thus, this bill would have drastically undercut the right to protest public officials — and to be clear, all protests by nature are designed to disturb the peace of people in power. The right of Alabamians to make their voices heard is something that has been a bedrock to our democracy and has long been a tool utilized to transform both local and national policies. This right is also something that’s protected by both the First Amendment and the Alabama Constitution. Yet if passed, SB 57 would undermine both of those.
Looking ahead into this coming week, I am happy to report that things aren’t all bleak and grim. While many of the bills I just discussed may continue to move through the legislative process and advance this week, so too may other bills, including some that we are supportive of.
For example, HB 77 by Rep. Rigsby passed out of the House Health Committee last week, as well as the full House last week. Thus, it is positioned to be heard by the Senate at any point. If passed, this newborn screening bill would help advance some of our goals related to our new issue priority surrounding maternal and infant health.
Similarly, related to another new issue priority, HB 32 by Rep. England is slate to be heard in the House Judiciary Committee this Wednesday at 1:30 p.m. While a public hearing has been called on this bill and a vote won’t take place on it until next week, if passed, this bill could bring Alabama in line with the majority of states regarding the way that we apply the felony murder rule. As you may recall, working on this new issue under our criminal justice portfolio was proposed and approved by our Arise members last fall.
And for the sake of brevity, I’ll simply try to name a few other good bills to have on your radar, as they will be in committee this week as well.
SB 35 by Sen. Smitherman would require all history lessons to be fact-based. SB 83, also by Sen. Smitherman, would help more people in need of indigent defense by increasing the compensation that attorneys get for representing clients that need court-appointed counsel. Currently, many attorneys simply can’t justify taking on court-appointed cases given the low rate at which they’re currently compensated for such work. Also, HB 188 by Rep. Collins would create a uniform due process, procedure, standards and rights for schools to follow when taking certain disciplinary actions against students.
Also worth having on your radar, however, are going to be some bills of alarm that will also be in committee this week. Those include SB 1 by Sen. Gudger. If you recall, this is the bill that criminalizes certain forms of helping people with delivering their absentee ballot. This bill will have a public hearing in Room 418 at 9 a.m. on Wednesday, and if you are interested in testifying or being in that room to witness what happens, I definitely encourage you to show up early, because that is a very small room and the seats are limited.
Also, HB 102 by Rep. DuBose, which is a piece of legislation that mirrors Sen. Orr’s legislation that weakens protections against child labor in the state, will be deliberated in a House committee on Wednesday as well.
And honestly, y’all, I know that that is a lot, and it’s probably not as hopeful as we would like it to be. But those are this week’s updates on what happened during the third week of the legislative session and what we’re on the lookout for as we enter into the fourth week of session.
So hopefully the next time I come to you is with a more upbeat update, and just better news regarding what’s happening at the State House. In the meantime, take care, y’all.
I am honored to join the Alabama Arise team to help address one of the most pressing issues facing our state: maternal health. My name is Victoria, and I am Arise’s new maternal health fellow. I come to Arise with a deep passion for improving maternal health outcomes for all individuals in our state.
About me
My professional journey spans several industries, including higher education, corporate wellness, disease intervention and event management. These experiences provided me with a unique and diverse perspective in all my pursuits. With a bachelor’s degree in health care management and a Master of Public Health degree from the University of Alabama at Birmingham (UAB), I have dedicated my academic and professional endeavors to understanding the complexities and nuances of health.
Victoria Enyinda Petty, Alabama Arise’s maternal health fellow
I am a fourth-year Ph.D. student in the Community Health Promotion program at UAB, where my research focuses on maternal health disparities and interventions to improve health outcomes for mothers. Throughout my professional and academic career, I have been consistently driven by a desire to make a meaningful impact on the population’s health and well-being, particularly in the realm of maternal health.
Why I do this work
I believe every Alabamian deserves access to high-quality maternal health care, regardless of their race, income or ZIP code. Pregnancy and childbirth should be moments of joy and celebration. But for far too many individuals in Alabama, they are shadowed with challenges, barriers and tragedy.
Maternal health in Alabama
Alabama has some of the worst maternal mortality rates in the country, particularly among Black residents. Many counties in Alabama also are considered “maternity care deserts.” This means pregnant individuals there lack access to essential obstetric services close to home. Additionally, the shortage of obstetricians and other maternal health care providers in rural areas further compounds maternal health challenges.
Without adequate access to prenatal care and skilled providers, pregnant individuals are at higher risk of experiencing complications during pregnancy and childbirth. This lack of access not only exacerbates existing health disparities, but it also puts lives at risk.
These are just a few examples of why our work in maternal health advocacy is so crucial. By advocating for policies that expand access to prenatal care, address racial disparities in maternal health outcomes and invest in maternal health care infrastructure, we can make a tangible difference in the lives of countless individuals and families across Alabama.
This year, I look forward to working with our community partners as we strive to create a future where individuals in Alabama have the opportunity to thrive during pregnancy and beyond.
Healthy parents and healthy children mean a healthier future for Alabama. Comprehensive maternal and infant health care investments are crucial to ensure the health and safety of both infants and Alabamians of child-bearing age, especially postpartum mothers, pregnant women and future mothers.
Alabama Arise envisions a world in which each successive generation is ensured a secure and healthy future. By adopting policy solutions to increase the number of health care providers and extend health coverage to more people, Alabama lawmakers can help turn that vision of a brighter future into a reality.
No one specific factor is solely responsible for the poor maternal and infant outcomes in Alabama. Rather, numerous challenges have combined to cause and worsen the situation. Listed below are a few of the key ones.
Maternity care deserts: Perhaps the most alarming factor is the prevalence of maternity care deserts in Alabama. A maternity care desert is defined as a county or area where there is a lack of access to maternity care resources. These areas often have no obstetric providers and no birth centers or hospitals offering obstetric care.
More than one-third of Alabama counties are maternity care deserts, with some people having to drive up to 100 miles to reach the nearest labor and delivery department. The lack of essential delivery and prenatal care in the Black Belt and other areas worsens the state’s maternal and infant health disparities, especially for women with low incomes.
Lack of Medicaid expansion: Alabama has a high rate of women of childbearing age who are uninsured. Nearly 300,000 Alabamians find themselves in the state’s health coverage gap. They make too much money to qualify for Medicaid, yet too little to afford private health insurance. In Alabama, 1 in 6 women aged 18 to 44 – or roughly 16% – are uninsured.
Chemical endangerment laws also lead many doctors to forgo screenings that could help catch addiction-related issues for expecting parents. Instead of incentivizing appropriate screening, treatment and harm reduction, these laws criminalize addiction and cause more harm, according to the Alabama Maternal Mortality Review Committee.
Administrative choices for Medicaid: Numerous other policy changes could promote better health for parents and infants across Alabama. Among the March of Dimes’ recommendations are “improved integration of the midwifery model of care, reimbursement for doula care, and increasing the availability of telehealth services.” Medicaid also could allow reimbursement for donor breast milk.
Impacts of the abortion ban: Alabama’s abortion ban is considered one of the nation’s most restrictive. Infants born in states with the most restrictive abortion laws are “significantly more likely to die before their first birthday than [a]re those born in states with no restrictions,” a 2020 study in the International Journal of Environmental Research and Public Health found. In addition, the exceptions to Alabama’s ban are inadequate to protect the health of the parent.
Where do we go from here?
Alabama Arise is committed to learning more about and advocating for policy solutions to improve maternal and infant health outcomes in the state. This will include advocacy for Medicaid expansion to close Alabama’s health coverage gap. We also will monitor and aim to support administrative efforts to promote better maternal and infant health.
23% of school-age children in Alabama are food insecure.
Universal school breakfast could guarantee a morning meal for nearly 280,000 Alabama children during their required school day.
Address chronic absenteeism.
Alabama’s statewide chronic absenteeism more than doubled from 8% to 18% in 2023 after schools stopped serving universal school meals.
Improve adolescent mental health.
Young adults who reported experiencing food insecurity during childhood also reported greater psychological distress in adulthood, according to National Health and Nutrition Examination Survey data.
Improve standardized testing and math scores in Alabama.
Alabama ranks 46th in average math ACT scores.
Student academic achievement increases, especially for math, when accessible breakfasts are made available to school-age children.
Alleviate behavioral problems and the school-to-prison pipeline.
Alabama children ages 10 and up are detained at nearly twice the national average, with children of color detained twice as frequently as their white peers.
The School Breakfast Program originated from a community pilot program that demonstrated the positive impact of universal breakfast for Black school-age children specifically.
Diana Isom (right) smiles alongside her husband, Luke, and their son, Keenan. Diana, a resident of Athens, Ala., was uninsured during her pregnancy and struggled to find affordable options for the health care she needed. (Photo courtesy of Diana Isom)
When Diana Isom became pregnant with her first son, Keenan, back in 2021, it was what she’d always wanted.
“My husband and I had been trying for years. I was so happy, but immediately started thinking about timing,” Diana said.
Timing is always a big consideration for most first-time parents, but for Diana and her husband, Luke, things were a little more complicated. When Luke lost his job suddenly, he had to start training in a new technical field. This meant he lost the private health coverage they had previously.
Even though Diana was working full-time hours as a health care worker, she was paid hourly and offered no benefits. She faced a frightening new future: being pregnant with no health coverage.
“I knew I was fully on my own when the medicine I needed was $200 a month and I’m out here with no insurance. Zero options,” Diana said.
Diana, now 26 years old, was raised in Vestavia Hills. Her parents, native to Panama, moved to the United States more than two decades ago when she was 4 years old.
“When I was a child, my parents came to this country so I could have a better life and a better education. I was taught that America was freedom and happiness… and that hard work can get you whatever you want,” Diana said.
Building a life despite uncertainty
As she got older, Diana said she remained positive and worked hard so she could have opportunities her parents never did.
“When the DACA [Deferred Action for Childhood Arrivals] (policy) was passed in 2012, kids like me, who grew up here in America, qualified as ‘Dreamers.’ I was so excited to be able to get a work permit! I’ve been working ever since,” she said.
Under federal DACA provisions, Diana also could access her driver’s license, a Social Security card and other important documents. These documents could help her secure a job, a home or even just a doctor’s visit.
When Diana and Luke got married, she received a green card. But she decided she would begin the lengthy immigration process in 2017, to make everything “official.”
She grew up in Alabama and wanted to start her own family here. Even so, she had to spend five years – and thousands of dollars – to gain citizenship status.
“My life is here,” she said. “I don’t want to have to go back to Panama. My friends are here. My job and family are here.”
When she was growing up, Diana said, other kids bullied her about her status. Even though Alabama was all she had ever known, she still felt a gnawing sense of insecurity.
“In really bad times in my life, people would threaten to call immigration or ICE on my family,” Diana said. “So I jumped through all these hoops and saved up thousands of dollars to make sure that never happens again. Not for me, and not for my son.”
The stress of being uninsured during pregnancy
In 2021, the Isoms received the good news that Diana would finally receive her citizenship. There was only one hitch: It wouldn’t take effect until three months after her baby was due.
“I had horrible prenatal depression. No one talks about that. It’s awful,” Diana said. “All the stress of not having insurance and my husband working on a temp basis. He either gets hired on or he’s fired. Every time. That stress is crazy!”
Diana said finding the care she and her baby needed while pregnant became like a second job.
“It’s so mentally draining,” she said. “Ever since they rejected me from Medicaid, I’ve been crying and crying. I’m so numb with the whole process, but I couldn’t give up.”
When she realized the couple’s private insurance had lapsed and no other lifelines were in sight, she began researching resources. She went to a free primary care clinic serving mostly Hispanic patients. But she found it difficult to navigate materials provided in Spanish because her first language growing up was English. And the clinic couldn’t provide all the prenatal screenings she needed.
The experience left Diana lonely and struggling to bond with her child throughout her pregnancy.
“Most people get regular ultrasounds. Without insurance, the hospital I went to only offered me the bare minimum. I got to see my baby two times: at the beginning and at the end. That was it,” she said.
‘I shouldn’t have ever been left behind’
Diana’s local hospital was her only option. As she continued to be billed for more than $1,500 a visit, she said she spent many nights wondering how her new family could afford it all.
“You do what you have to do, and I made it all work for my child because that’s what my parents did for me,” she said. “I shouldn’t have ever been left behind, and now neither should my baby.”
After a 19-hour complicated labor and delivery, baby Keenan was born in early 2022. Three months later, Diana joined him in gaining full American citizenship.
Diana thought her citizenship ceremony would lift her spirits and give her family the celebration they needed after a stressful pregnancy, but the process proved a bit impersonal and underwhelming.
“We drove nearly four hours to the immigration office. When I sat down, there was just an officer calling in on Zoom. I was looking at an iPad screen when I ‘became an American,’” she said.
Diana said she is grateful for her new status, but her time as an uninsured mother was a stark reminder that the playing field is not equal for everyone who lives in Alabama.
“People like me who have been in this country for so long… we pay taxes,” she said. “You’re telling me I pay into it, but not benefit from it?”
Though most undocumented immigrants live in a family with a full-time worker, they have limited access to employer-sponsored coverage,a Kaiser Family Foundation report found. And while they pay the same taxes as citizens, they often are employed in low-wage jobs and industries that are less likely to offer employer-sponsored coverage, like Diana is.
Medicaid expansion is the path to a healthier future for Alabama parents
Diana was ineligible for Medicaid after her pregnancy, both because she was not yet a citizen and because Alabama had not yet extended postpartum coverage to one year.
She would now qualify for Medicaid coverage during and immediately after future pregnancies if she met the income eligibility standards.
Alabama remains one of 10 states yet to expand Medicaid. That means tens of thousands of Alabama parents still have no affordable long-term path to the health care they need as they seek to provide for their families.
Hundreds of thousands of Alabamians stand to gain access to health coverage if our state expands Medicaid. In the Huntsville metro area where Diana and her family live, that includes more than 11,000 people in Madison County and nearly 3,000 people in Limestone County.
Diana said her difficult journey has turned her into a fierce advocate for Alabama mothers.
“Medicaid expansion is a given,” she said. “The stuff I had to deal with in my pregnancy; the days I had to cry myself to sleep. I was always thinking, ‘Today is gonna be the day that something bad happens to my baby.’”
The Isoms’ new son, Keenan, is now insured under Alabama’s Medicaid program. Diana recently returned to work, and her husband was hired on full time after completing workforce training. They soon will be covered by his health insurance.
Diana said having coverage for both baby and mom has been such a relief to their family.
“I’ve been able to let go of so many things I was worried about before: being deported and away from my child, or how I was going to be able to go to the doctor, even just sleeping at night,” she said. “No one should have to go through what I did. No one.”
About Alabama Arise and Cover Alabama
Whit Sides is the Cover Alabama storyteller for Alabama Arise, a statewide, member-led organization advancing public policies to improve the lives of Alabamians who are marginalized by poverty. Arise’s membership includes faith-based, community, nonprofit and civic groups, grassroots leaders and individuals from across Alabama. Email: whit@alarise.org.
Arise is a founding member of the Cover Alabama coalition. Cover Alabama is a nonpartisan alliance of 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.
In April, Medicaid ended a continuous coverage eligibility period brought on by the public health emergency during the COVID-19 pandemic. What followed was a return to traditional eligibility requirements. This return to normal rules is called “unwinding.” Coverage losses have begun, and tens of thousands of Alabamians likely will lose their Medicaid coverage by June 2024.
A little more than halfway through the unwinding process, Alabama Medicaid members have a renewal rate of 68%. Only 4% of Medicaid members have been determined to be ineligible, while 27% of members lost coverage for procedural reasons.
From this information, we know more than 70% of Medicaid members have responded to requests for eligibility information from Alabama Medicaid. This response rate can be credited to Alabama Medicaid having a clear and concise communication plan. It also is a testament to the strong support of health care advocates in communities across Alabama.
But this does leave many thousands of people who are disenrolled for procedural reasons. And these losses are especially harsh for those who still may be eligible for coverage. When coverage loss occurs for procedural reasons, enrollees may need to submit further information to keep or maintain coverage. To prevent unnecessary coverage loss, please return any application materials to Alabama Medicaid, even if you do not think you are eligible. Only Alabama Medicaid can determine eligibility status.
If you have lost coverage, you may reapply with Alabama Medicaid. You also can contact Enroll Alabama for information on options for Marketplace insurance under the Affordable Care Act. If you feel that Medicaid terminated your coverage in error, you may appeal that decision. Call our partners at ADAP at 800-826-1675 for help.
