The workforce benefits of Medicaid expansion in Alabama

For nearly a decade, Alabama has been outside looking in on a good deal. While hundreds of thousands of Alabamians continue to struggle without health insurance, state leaders have failed to expand Medicaid. A few loud voices have politicized an issue that never should have been political. And our state has paid the price in lost dollars, lost jobs and lost lives.

Strong evidence suggests that having reliable access to health care encourages folks to work and keeps workers healthy. That’s one reason 39 states and the District of Columbia have recognized the importance of Medicaid expansion. They have chosen to ensure their residents can afford necessary medical care. They have prioritized a healthy populace and a stronger workforce over partisan politics.

Alabama is one of 11 states that has yet to expand Medicaid. And that inaction has left more than 220,000 Alabamians in a health coverage gap. A family of three must make less than $4,475 a year ‒ just 18% of the federal poverty level ‒ for the parents to qualify for Alabama Medicaid. But unless that family makes at least $24,860 a year, they will not qualify for subsidies to buy a private plan on the marketplace created under the Affordable Care Act.

Medicaid expansion would end that injustice and close that large coverage gap for adults with low incomes. It is the single best solution available for lawmakers to strengthen Alabama’s ailing health care system. And it is one of the best solutions to help cure many of our state’s economic and workforce woes.

Medicaid expansion would help Alabamians stay in the workforce

Some state officials have expressed concerns about Alabama’s labor force participation rate, which is lower than in many neighboring states. Fortunately, Medicaid expansion is a proven solution to help people join and stay in the workforce. States that have expanded Medicaid have seen a greater increase in labor force participation among people with incomes below 138% of the poverty line than states that have not expanded. These are the very people Alabama would help by closing the coverage gap.

As lawmakers grapple with how to increase workforce participation, it’s worth considering how many Alabamians have had to leave their jobs due to ailments that access to adequate health care could help prevent or solve. One in three adults in Alabama have a disability, according to 2022 CDC data, including nearly two out of every five veterans. Here, too, Medicaid expansion would help. People with disabilities are more likely to be employed in states that have expanded Medicaid than in states that haven’t.

The personal and economic harms of being uninsured are all too real. For many folks, going without health coverage means going without treatment for manageable illnesses and injuries. Those conditions often turn into long-term problems that prevent them from living healthy lives or returning to work. For example, imagine being an uninsured person with diabetes, a condition affecting nearly one in seven Alabamians. While severe, diabetes is detectable and treatable with regular care. However, if untreated, it can cause disability or long-term and permanent damage like foot amputation or vision loss.

That person is now living a more difficult life, and returning to work is now more difficult, if not impossible. These are the kinds of situations that uninsured Alabamians face every day. And expanding Medicaid coverage could prevent this type of needless suffering.

Health care policy is workforce policy

As Alabama works hard to attract industries and new workers, adequate health coverage is essential infrastructure. Why would a family move to Alabama (instead of elsewhere) for employment opportunities when our state refuses to invest in workers’ health like so many other states do? And how long will businesses keep relocating to Alabama if our workforce isn’t healthy enough to fill vacant jobs? They could just as easily go to Arkansas, Louisiana, Kentucky, Missouri, Oklahoma, Virginia or West Virginia instead.

These mostly conservative Southern states all recognized the importance of a healthy workforce and chose to expand Medicaid. That’s because it is impossible to separate health care policy from workforce policy. In fact, health care policy is workforce policy.

Medicaid expansion would help working Alabamians stay healthier and more productive. Expansion also likely would boost labor force participation in Alabama, as it has in other states. Arguments to the contrary lack strong evidence and rely on false stereotypes about low-wage workers.

Many of the Alabamians who stand to benefit most from Medicaid expansion are working folks caught in the coverage gap. Having access to health insurance, regardless of the source, doesn’t keep people from working. But you know what does? Having an unhealthy workforce with folks who struggle to afford health care and are forced to work when they’re sick. Or worse: being pushed out of the workforce entirely due to ailments that worsen or go unaddressed because people can’t afford treatment for them.

Medicaid expansion would keep a wide range of workers healthier

Alabamians work hard every day to provide for themselves and their families. But hundreds of thousands of them aren’t paid enough to afford health coverage. Fast food workers, cashiers, carpenters and hotel desk clerks are just a few examples of the people who work hard at low-paying but essential jobs that often don’t provide health insurance. They are among the Alabamians who would benefit most from expanding Medicaid.

Graphic of the top nine occupations that would benefit from expanding Medicaid in Alabama: food service, sales, construction, cleaning and maintenance, office and administrative support, production, transportation, personal care and support, and installation and repair.

The false belief that expanding health coverage would somehow disincentivize work is insulting to Alabamians who work every day to provide for their families but don’t receive health insurance through their employers. Improving health care access is workforce development, and having health insurance makes working possible.

Likewise, the unfounded notion that many people would drop out of the workforce after gaining health coverage is not grounded in reality. In fact, it is fundamentally rooted in outdated, false stereotypes about people with low incomes. And it takes an absurdly reductive view of the economic realities of everyday life.

Health insurance helps people get health care, but it doesn’t pay for other needs like food, clothing or housing. Indeed, many Alabamians who want a job can’t enter the workforce ‒ or have to leave it ‒ because they can’t afford the health care they need to stay healthy enough to work.

Other states have shown Medicaid expansion is an economic boost

For 12 years, Alabama has failed to accept generous federal incentives to expand Medicaid to cover adults with low incomes. In that time, our lawmakers have watched as other fiscally conservative states (including Kentucky, Louisiana, Montana and Utah) expanded Medicaid and remained budgetarily sound. For a decade, expansion states have enjoyed budget savings, revenue gains and overall economic growth after expansion.

National research has shown no significant increases in spending from state funds as a result of Medicaid expansion. These positive effects occurred in expansion states even as Medicaid enrollment growth initially exceeded projections in many states.

Examples abound. Studies in Louisiana and Montana showed that expansion pumped large amounts of federal money into those states’ economies and produced significant state budget savings. In Kentucky, Medicaid expansion infused $1.16 billion into the state’s health care system and overall economy in the first year of expansion. Similarly, after Medicaid expansion, Louisiana also showed increases in overall state and local tax receipts.

Every year that Alabama has refused to expand Medicaid, Alabamians’ federal tax dollars have helped foot the bill for Medicaid expansion in other states. More than 220,000 Alabamians remain caught in a health coverage gap that expansion would close. Another 120,000 who would benefit from expansion continue to stretch to pay for coverage they can’t truly afford. All the while, our tax dollars are being used to fund expansion elsewhere.

Medicaid expansion would make economic sense for Alabama

Expansion opponents sometimes acknowledge the financial benefits of expanding Medicaid. But they often underplay the magnitude of these potential gains. Medicaid expansion could save Alabama nearly $400 million a year over the next six years, a report by the Public Affairs Research Council of Alabama (PARCA) found.

Those savings ‒ from the federal government covering expenses that Alabama now pays ‒ would be more than enough to cover the state cost for expansion, according to PARCA. Medicaid expansion also would generate nearly $2 billion of annual economic growth for Alabama during those six years, PARCA projected.

The benefits wouldn’t stop there. Medicaid expansion also would support more than 20,000 new jobs a year on average, PARCA projected. It would extend health coverage to more than 220,000 folks who don’t have it. And most importantly, it would save lives.

A graph showing the economic impact of Medicaid expansion, including saving the state nearly $400 million per year.

Expanding Medicaid would save the state money, boost economic growth and create jobs. For many newly insured Alabamians, Medicaid coverage would help them stay healthy enough to keep working. For others, it would provide the medical security they need to join or rejoin the workforce.

Alabama can’t afford not to expand Medicaid

Alabamians with low incomes pay twice the share of income in state and local taxes that the wealthiest households pay. Adding to that injustice, Alabama’s overall tax system raises much less money for vital public services than most other states. In 2019, only about 38% of our state revenue came from state taxes ‒ one of the lowest percentages in the nation. Meanwhile, Alabama gets almost as much of its revenue (nearly 37%) from federal funds.

Federal funds are already a significant source of state revenue in Alabama and have been for decades. That money has helped us meet vital needs like educating our children, maintaining our roads and keeping our water clean.

Medicaid expansion would meet another vital need for our state: saving and improving lives. When it comes to expansion, Alabama would be getting a fantastic deal: a 9-to-1 federal match of state funds. That’s nearly 20 percentage points higher than the matching rate Alabama usually gets for other Medicaid services. And as already mentioned, Medicaid expansion could save Alabama enough money on other services to cover most or all of the state cost.

Why not take the 90% the federal government is offering to fund Medicaid expansion in exchange for a 10% state match? Why not invest in a healthier future for Alabama?

Alabamians across the political spectrum agree: It’s time to expand Medicaid

While some have tried to make Medicaid expansion into a partisan issue, it simply isn’t. Several other Southern states, and conservative states elsewhere in the country, already have expanded Medicaid. Some even did so by bypassing their state legislatures through ballot measures (an option we lack in Alabama). This isn’t a partisan issue, though many in our state want to make it one.

Graphs showing support for Medicaid expansion in Alabama.

To argue that we shouldn’t help our neighbors see a doctor based on the false premise that it might encourage them not to work is deeply troubling. Is that the state we want to be: one that pits the health of its people against cynical political posturing? That’s not what Arise wants, and it’s not what the vast majority of Alabamians want either.

Alabama is one of only 11 states that have not yet accepted the generous federal incentives to expand Medicaid. Most people across our state want that to change. More than seven in 10 Alabamians (71.5%) support Medicaid expansion, an Arise poll found last year. That includes nearly two-thirds of Republican voters.

Alabama needs to do the right thing by prioritizing the health of our people and our workforce over the political gamesmanship that so often dictates state decision-making. It’s time to ensure health coverage for all of our neighbors who can’t afford it.

It’s the only decision that makes sense, and it’s a choice that would help make this the state our people deserve. Let’s put the people of Alabama first and expand Medicaid.

See the Gap: ‘You’ve got to be able to deliver when folks need you to’

Trent Thomas, a stylist, poses for a photo at Orbit Salon in Birmingham.
Trent Thomas is a stylist at Orbit Salon in Birmingham. He receives health insurance through his job, but he spent more than a decade before then living without coverage. Being uninsured meant enduring pain and deferring needed care. (Photo by Whit Sides)

Trent Thomas, 42, has been doing hair for a while now. And the first thing he’ll tell you is how much of a good thing he’s got going. 

“I love it here for a million reasons – some superficial – but it really is such a great place to be,” he said, showing off his boss’s massive plant collection visible from the street outside.

Trent was able to keep his job and his paycheck at Orbit Salon, in Birmingham’s Five Points South neighborhood, even when the world slowed down in 2020.

“This neighborhood’s always been so cool and aspirational,” he said. “I think that’s what a lot of stylists look for when going into the industry and what a lot of clients look for in a salon, too.”

Trent said he is grateful for their support and knows not everyone is so lucky.

“It’s not every day you get full-time benefits,” he said. “It’s not a normal thing to have insurance through a salon, like I do. It’s incredibly expensive, and not every salon or stylist in town can afford it.”

Pre-ACA: Life in the coverage gap

Things weren’t always so good, particularly when it came to health coverage. Trent decided to attend cosmetology school in his 30s and started getting insurance at work shortly before he turned 40.

Before then, Trent spent many years without health insurance. After aging out of his parents’ plan in 2003, he spent the next 15 years without employer-provided benefits.

“I grew up in the Birmingham punk scene, and I learned to find resources as close to the ground and as close at hand as I possibly could,” he said. “You make it work from within.”

Trent Thomas styles a client's hair.
Trent Thomas styles his client Jason’s hair at Orbit Salon in Birmingham. (Photo by Whit Sides)

Trent has worked many jobs, including punk rock show promoter and clerk at an art supply store. His story of making things work through sacrifice is one of many – and one that resonates with many stylists.

After the Affordable Care Act was signed into law, Trent found a plan that worked for him and paid out of pocket for premiums. That came after more than a decade of putting off care or finding help through non-traditional means.

Even with ACA coverage, he still lacked dental or vision coverage.

“Everything was always out of pocket,” Trent said. “I paid out of pocket in full for glasses. I used coupons when I could. I used the UAB School of Dentistry for a few fillings and extractions.”

He said the school is an amazing resource for uninsured patients in Birmingham. But he also said the services still require payment up front.

Trent’s biggest sacrifice healthwise came when he suffered a hernia and needed it repaired. He waited years to get surgery to ease the pain.

Access to care for LGBTQ beauty workers in Alabama

Trent also had to find a way to get his daily medications regularly without prescription coverage. Many workers in the beauty industry identify as LGBTQ, and that includes Trent. He’s a gay man who takes PrEP to help protect against HIV, which disproportionately affects gay men.

Pre-exposure prophylaxis (or PrEP) is highly effective for preventing HIV when taken as prescribed. PrEP reduces the risk of getting HIV from sex by almost 99%, according to the Centers for Disease Control and Prevention (CDC). The medication is much less effective when not taken as prescribed, so interruptions in access could raise risk.

During his time in the coverage gap, Trent signed up for clinical research trials to gain access to the life-saving drug. Fortunately, access to PrEP is much easier these days. A few years ago, the manufacturer, Gilead, began offering the drug at low or no cost for anyone who has a prescription.

Patients in central Alabama also can pick up PrEP at local health clinics that offer LGBTQ-focused care. Trent regularly gets his primary care at a practice called the Magic City Wellness Center. The center’s mission is to meet the needs of and reduce disparities in care for LGBTQ people in central Alabama. It is affiliated with Birmingham AIDS Outreach.

Trent made it through the pandemic relatively unscathed until he finally caught COVID-19 in December. He said being able to get regular care from his primary care physician has been a godsend during his recovery.

“I was lucky enough to find a doctor that treats LGBTQ folks like myself for free or on a sliding scale,” he said.

Having health coverage and regular access to preventive care has allowed Trent to recover from COVID-19 on his own time. It also has reduced his risk of becoming more ill or losing his job.

The COVID-19 pandemic forces reevaluations 

Trent said recovering from COVID-19 both physically and functionally will be a steep learning curve not just for him, but for the beauty industry as a whole.

“Working on commission, you’ve got to be able to deliver when folks need you to,” he said. “COVID, just like any other disabling condition stylists deal with, comes with nuances that make that sometimes impossible.”

Many stylists are reevaluating their schedules, Trent said. Some are cutting down to three or four days a week. Many are spending less time on their feet whenever they have a spare moment. Striking a balance even when healthy is hard, he said.

“It’s not like doing one haircut is all that taxing. It’s when you’re at the end of the day and you’ve done seven or eight of them,” he said. “Your shoulders and back start to scream at you.”

Many stylists are leaving their jobs or quitting the industry altogether because of rough physical conditions, Trent said. He said he is happy to see more salons working to accommodate disabled and older workers in response. He also called it a “timbre of the times” to see some younger workers organizing for better conditions.

How expanding Medicaid could help an expanding industry

Trent Thomas stands outside Orbit Salon in Birmingham.
Trent stands outside Orbit Salon in Birmingham’s Five Points South neighborhood. (Photo by Whit Sides)

It’s not all sacrifice. There’s plenty of success to go around.

Trent said the future is bright for young stylists. But that better tomorrow will require investments in the industry’s most important assets: people and their health. Trent said he believes full-time benefits and health coverage should be the norm and not the exception for stylists.

About 10,000 stylists and other personal care workers across Alabama would benefit from Medicaid expansion. In total, more than 220,000 Alabamians are caught in the coverage gap, unable to afford health insurance. Another 120,000 or more are stretching to pay for private or employer-based insurance.

Trent said he sees how other states and even other countries ensure their residents can get health care. And he wishes Alabama would step up, too.

“I feel like if our state really did expand Medicaid, it would mean money in the pockets of salons and stylists all over,” Trent said.

He said he believes state leaders should do everything they can to support working Alabamians, including expanding Medicaid.

Trent said the Alabama mindset is often hampered by a “pull yourself up by the bootstraps” philosophy, but state officials aren’t doing enough to equip people to thrive.

“I think that we live in the richest country in the world, and I wish we funded our health care system properly so we weren’t so reliant on for-profit businesses to take care of us,” Trent said. “If there’s money on the table to expand and we’re just letting it sit there, who does that benefit?”

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.

See the Gap: ‘Someone’s got to do something for working folks’

A picture of Katie Franklin, a nail technician and manager at a salon outside Birmingham.
Katie Franklin is a mother of two who works as a nail technician and front office manager at a salon outside Birmingham. She works full time but cannot afford health insurance. Medicaid expansion could empower her to get medical care when she needs it. (Photo courtesy of Katie Franklin)

 

When I first met Katie Franklin, she was juggling requests from three guests at the same time.

I’ve been visiting Nail World II, right outside Birmingham, for nearly 20 years, but this visit was different. Someone new was greeting me at the door.

Katie is a presence who is not easily forgotten. I learned she was the new salon manager. Honestly, it felt like she was right at home.

She made greeting 25 to 30 customers an hour look easy. Her maternal aura and gregarious nature shone bright through all the hustle and bustle.

It was Homecoming Week for many high schools in the Over the Mountain suburbs of Birmingham. Her salon’s clients were stacked back to back for several days in preparation for the big games and dances. And this was on top of the steady stream of walk-ins like me.

“I mean, I’m here all day, every day,” she said. “There’s no days off for me.”

Working full time but still uninsured

Katie is a mother of two who lives in Morris, about 20 miles north of Birmingham. She recently earned her license as a nail technician. A natural extrovert, she soon became a supervisor in one of metro Birmingham’s busiest nail salons.

“I needed a new start. I’m good at it and I get to help people, which is what I love,” Katie said with an infectious grin. “It’s my passion. If I can make someone feel better, then it’s all worth it.”

We exchanged numbers, and over the next month, she shared her story with me.

Katie is one of more than 220,000 Alabamians in the state’s health coverage gap. Like all of them, she cannot afford private health insurance but is ineligible for Medicaid coverage.

Katie is a single mom, working to take care of two teenagers as well as her parents. Both of her children are eligible for health care through ALL Kids, the Children’s Health Insurance Program (CHIP) in Alabama. But since she earns about $2,000 a month, she’s left in a lurch.

Even though Katie works full-time hours, she doesn’t receive benefits like health insurance. Caretakers like her only qualify for Alabama Medicaid if their income is less than 18% of the federal poverty line. For a family of three, that amount is just $4,145 a year.

“I don’t know who makes these numbers, but I’m not rich. Suddenly earning $1,000 every two weeks doesn’t mean I can afford hundreds of dollars a month for health insurance,” Katie said about Alabama’s stringent Medicaid income eligibility guidelines.

‘Imagine the difference this would make’

When Katie needs medical care, she puts off doctor’s visits and treats at home. But sometimes, it’s not enough. That’s when she goes where many other uninsured folks around Birmingham end up: UAB’s emergency room.

“I try not to go unless I absolutely have to,” she said.

Katie said she wishes there were more options for patients paying out of pocket.

She has been to urgent care centers before but dreads the bills that arrive weeks later in the mail.

“I actually spent my COVID stimulus check paying off medical debt,” she said. “I hate debt, and I’m not the kind of person who doesn’t pay my bills.”

Katie said Alabama’s leaders have to do more to support those in need of health care and coverage.

“Someone’s got to do something for working folks,” she said. “I feel like the middle class doesn’t get any of the help that these big companies get.”

She said Medicaid isn’t perfect, but just knowing her kids can see a doctor without her having to sacrifice money for bills or groceries is a big relief. Katie said she hopes Gov. Kay Ivey will expand Medicaid sooner rather than later.

“If all it takes is a stroke of a pen, then I’m all for it,” Katie said. “Imagine the difference this would make for small businesses like mine, struggling to make ends meet.”

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.

See the Gap: How Medicaid expansion would improve life for Alabama’s hairstylists and barbers

Throughout our lives, there are many milestones.

We go to school dances. We graduate, and we get married.

But we don’t get to those moments alone.

Mark Hyde, founder of Forecast Salon in Homewood, performs a color service on a client. (Photo by Whit Sides)

When we look back at the photos to relive our happiest moments, we see the faces of our friends and family smiling back. But there were other folks who aren’t always pictured.

They’re the hairstylists, barbers and nail techs who listened as we unloaded our anxieties. They always took our call when we realized (at the last minute!) we needed to do something a little extra to look and feel our best. And they deserve the security of knowing they can get affordable health care in their own times of need.

More than just a haircut

Hoover hairstylist Madison Tidwell styles a client’s hair and makeup for a wedding. (Photo courtesy of Madison Tidwell)

It was summer 2018. I was on a new medicine that solved my medical issues but had a gnarly side effect: I started losing my hair in chunks. I spent hours crying in the shower. After a few weeks of trying to convince myself I was a hat girl, I took a radical step and shaved my head. I didn’t dare do it myself. I barely had enough energy to pick up the phone and book the appointment. But when I showed up: There was Jamie.

From the minute I sat in her chair, I felt at ease. My nerves were shot, but her calm demeanor convinced me everything would be OK. Jamie turned what was a disaster into a new identity for me.

When Jamie moved out of state shortly after, I was crushed. We’d been through so much. It was like dating: I didn’t want to put myself out there all over again for a completely new person.

A few weeks (and several Instagram searches) later, I found Madison Tidwell.

Madison was a lot like me. She loved houseplants, grew up in a small town and stayed on top of trends.

Whit Sides and her stylist, Madison Tidwell, go from yellow to red in one (very long and patient) session in Hoover. (Photo by Whit Sides)

It’s been two years, and I don’t trust anyone else to touch my hair. We’ve been through growing out a pixie, evening out mullets – even going purple, green and yellow!

My experience is not uncommon. Many folks trust their hairstylists and barbers with their deepest secrets. And when you find someone you trust, you soon depend on them for more than just a haircut.

Living in the gap: How we got here and how we can fix it

Over the past few months, I’ve met with more than 30 beauty professionals in Alabama.

Some work at busy, upscale salons. Others rent booths in hometown shops. Some created their own business model by joining collectives of small, independent suites.

All have something in common: They all are uninsured or paying out of pocket for medical treatment. And along with nearly 10,000 other personal care and support workers, they would benefit from Medicaid expansion.

Because our state has failed to expand Medicaid, more than 220,000 Alabamians are caught in the coverage gap, unable to afford health insurance. Another 120,000 or more are stretching to pay for private or employer-based coverage.

Stylists usually work six or seven days a week, with little fanfare and long hours on their feet. They open early and stay late, especially on weekends when customers need them. However, most beauty professionals have no safety net in case of their own emergency. Most stylists don’t get health insurance through their employers. And even those who are self-employed often don’t earn enough to afford private premiums.

Like so many working Alabamians, these stylists and beauty professionals still don’t have health coverage or access to affordable care. I want to cover their stories in my See the Gap series. Our series will begin next week and continue over the coming months.

It’s important to share the sacrifices those in the service industry often make in their own lives to take care of everyone else. These stories will show what life is like in the coverage gap: from finding health care services and paying out of pocket for medical expenses to providing for a family when you work for yourself.

Working families in the gap are all around us. Their stories matter.

First, we’ll hear from beauty professionals about what works and what doesn’t. Some of them have graciously offered me a deep glimpse into life in one of the most physically demanding and emotionally taxing fields.

We also will discover what having health care coverage would mean for hairstylists, barbers and their families. And we will talk to workers and salon owners about how simple policy changes – like Gov. Kay Ivey expanding Medicaid – could improve these folks’ lives exponentially.

Nearly every stylist I’ve spoken with says they chose their profession so they could change lives. They center their work around people but are often left unsupported by employers and Alabama’s leaders.

Investing in the health of Alabama’s working families should be a priority for all of us. Why don’t our state’s elected officials expand Medicaid? It’s a question that deserves an answer.

Working people in Alabama are paying the price every day for our state’s failure to expand Medicaid. Imagine what investing in those who do so much for our communities could do for all of us. Imagine what would happen if we see the gap and make life better for those living in it.

Please follow @AlabamaArise and @CoverAlabama on social media to make sure you don’t miss our See the Gap series. And sign up for Arise’s action alerts so you can be ready to speak out for Medicaid expansion and other needed policy changes in Alabama.

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.

Alabama Arise unveils 2023 roadmap for change in Alabama

Expanding Medicaid and ending the state sales tax on groceries will remain top goals on Alabama Arise’s 2023 legislative agenda. More than 400 members voted on Arise’s issue priorities in recent days after the organization’s annual meeting Saturday. The seven issues chosen were:

  • Adequate budgets for human services like education, health care and child care, including Medicaid expansion to make health coverage affordable for all Alabamians.
  • Tax reform, including untaxing groceries and capping the state’s upside-down deduction for federal income taxes, which overwhelmingly benefits rich households.
  • Voting rights, including automatic universal voter registration, removal of barriers to voting rights restoration for disenfranchised Alabamians, and other policies to expand and protect multiracial democracy in the state.
  • Criminal justice reform, including retroactive application of state sentencing guidelines and repeal of the Habitual Felony Offender Act.
  • Death penalty reform, including a law to require juries to be unanimous in any decision to impose a death sentence.
  • Public transportation to empower Alabamians with low incomes to stay connected to work, school, health care and their communities.
  • Payday and title lending reform to protect consumers from getting trapped in debt.

“Arise believes in dignity, equity and justice for everyone,” Alabama Arise executive director Robyn Hyden said. “Our 2023 issue priorities reflect the need to work together to break down policy barriers that keep people in poverty, and that disproportionately harm Black and Hispanic Alabamians. We must build a healthier, more just and more inclusive future for our state.”

Displaying Arise's 2023 Policy Priorities: Tax reform, Adequate state budgets, Voting rights, Criminal justice reform, Death penalty reform, Public transportation, Payday and title lending reform

The time is right to expand Medicaid in Alabama

One essential step toward a healthier future for Alabama is to ensure everyone can afford the health care they need. Arise members believe Medicaid expansion is a policy path to that destination, and research provides strong support for that position.

Expanding Medicaid would reduce racial health disparities and remove financial barriers to health care for more than 340,000 Alabamians. It would support thousands of new jobs across the state. And most importantly, it would save hundreds of lives every year.

Medicaid expansion would ensure health coverage for more than 220,000 Alabamians caught in the coverage gap. These residents earn too much to qualify for the state’s bare-bones Medicaid program but too little to afford private plans. Expansion also would benefit another 120,000 Alabamians who are stretching to pay for coverage they cannot readily afford.

Alabama is one of only 12 states that have not yet expanded Medicaid to cover adults with low incomes. But an Alabama Arise poll earlier this year found that more than seven in 10 Alabamians (71.5%) support Medicaid expansion. That figure included 65.8% of Republican voters.

“Medicaid expansion would boost our economy and improve the lives of hundreds of thousands of Alabamians,” Hyden said. “It’s time for Gov. Kay Ivey and lawmakers to say yes to the generous federal incentives for Medicaid expansion. Making this crucial investment in Alabamians’ well-being now will make our state better for decades to come.”

Why and how Alabama should untax groceries

Alabama’s state grocery tax makes it harder for people with low incomes to make ends meet. The tax adds hundreds of dollars a year to the cost of a basic necessity for families. And most states have abandoned it: Alabama is one of only three states with no sales tax break on groceries.

The state sales tax on groceries brings in roughly 6% of the Education Trust Fund’s annual revenue. But lawmakers have a path available to end the state grocery tax while protecting funding for public schools. Arise will continue to support legislation to untax groceries and replace the revenue by capping the state income tax deduction for federal income taxes (FIT).

The FIT deduction is a skewed tax break that overwhelmingly benefits the richest households. It is also exceedingly rare: Alabama is one of only two states to allow this deduction in full. The FIT deduction and grocery tax are two policies that contribute heavily to Alabama’s upside-down tax system. On average, Alabamians with low and moderate incomes must pay twice as much of what they make in state and local taxes as the richest households do.

“By untaxing groceries and capping the FIT deduction, lawmakers can make Alabama’s tax system more just and equitable,” Hyden said. “This plan would empower more families to keep food on the table while also protecting funding for our public schools. The Legislature should seize this opportunity to make life better for every Alabamian.”

Here’s what Alabama Arise heard from you in summer 2022!

We deeply value the input we get from Alabama Arise members, our allies and most importantly, those directly affected by the work we do together. We depend on what we hear to help guide our issue work and our strategies.

Despite the ongoing challenges of connecting in person, we kept working at finding ways to listen. We did another series of three statewide online Town Hall Tuesdays. And we held seven additional listening sessions around the state, engaging about 200 people.

The town halls happened every two weeks, starting July 12 and ending Aug. 9. Other meetings took place throughout the summer. Below are summaries of what we heard in those meetings.

Town Hall Tuesdays

Food and health

Most participants deeply cared about Medicaid expansion. They discussed how it would help many people, including rural communities struggling with access to care. Many were frustrated that Gov. Kay Ivey has not yet expanded Medicaid in Alabama. Others discussed the connection between health and access to healthy food and nutrition. Some participants noted that other barriers like transportation also directly impact health, nutrition and employment.

Related issues raised were the needs to address the racial wealth gap and increase wages for front-line workers. Many people expressed appreciation for food banks and pantries but acknowledged that they cannot meet all food security needs. Participants encouraged Arise to remain vigilant about the threat to impose stringent work requirements for Medicaid and SNAP food assistance. Many participants also mentioned untaxing groceries as a way to improve food security.

Democracy and justice

Many participants expressed concerns about legislative attempts to suppress voting rights and said Election Day should be a state holiday. Others also expressed concerns about ballot access for people with disabilities, limited numbers of voting precincts and gerrymandering. Bottom line: We should make it easier to vote, as ballot access is key to a strong democracy.

Several participants expressed concerns about the need for more services for people leaving incarceration. We need to expand community corrections programs, enact real prison reform and get rid of unjust fines and fees.

Some participants identified language accessibility as a potential barrier to receiving many services and participating fully in our democracy. Others were concerned about allocation of American Rescue Plan Act funds and wanted more funding for the Housing Trust Fund.

The path forward

This town hall was an opportunity to talk about any issues of concern people wanted to highlight. Participants raised the following needs and concerns:

  • Expand Medicaid in Alabama now and address health disparities, including women’s health issues.
  • Untax groceries and improve our regressive tax system.
  • Improve voting access, including restoration of voting rights for people who were formerly incarcerated.
  • Address environmental issues, including working to improve air quality in schools.
  • Improve affordable housing access and language access, fully fund the child home visitation program and address gun violence.

Group and regional listening sessions

Session participants around the state strongly affirmed Arise’s work on the current 2022 issue priorities. They also emphasized the ongoing work to be done in those areas. Current issues highlighted were Medicaid expansion, criminal justice reform (particularly in the area of unjust fines and fees), more funding for child care and first class pre-K, public transportation and death penalty reform.

Session participants also discussed issues that aren’t on the Arise agenda but are of concern to them and their communities. Some of those issues include:

  • Affordable housing, with a focus on increased funding and availability. One example was discussion of whether to limit the number of vacation rental properties one person could own in an area, as this can contribute to the shortage of affordable housing. Many renters also discussed the soaring prices of rent.
  • Automatic organ donor registration linked to getting and renewing driver’s licenses.
  • Broadband internet extension to reach more rural households and Alabamians with low incomes.
  • Constitutional reform.
  • Government intrusion on private medical decisions. One example shared was concern over lawmakers interfering with rights of transgender teens to seek medical care. Another concern raised was doctors being able to provide medical care during pregnancy and decide the right time to intervene on a pregnancy that threatens the life of the mother.
  • Gun violence prevention.
  • Marijuana sentencing reform.

New Census data reveals how good policy choices can cut poverty, keep Alabamians healthier

People-friendly federal policies reduced poverty and made it easier for people to get health care in 2021, U.S. Census figures released this week show. Perhaps the most eye-opening improvement was a dramatic reduction in child poverty nationwide.

The recent Child Tax Credit (CTC) expansion alone kept 5.3 million Americans above the poverty line. The one-year expansion under the American Rescue Plan Act (ARPA) made the full CTC available to children living in families with low or no earnings. It increased the maximum credit to $3,000 per child and $3,600 per child under age 6. And it extended the credit to 17-year-olds. The expansion expired in 2022 after Congress failed to renew it, but lawmakers could revisit that decision later this year.

Child Tax Credit improvements fuel record drop in U.S. child poverty

CTC expansion helped reduce disparities for Black and Hispanic children. It also drove the U.S. child poverty rate to a record low of 5.2% under the Supplemental Poverty Measure (SPM). Unlike the traditional poverty measure, the SPM reflects the poverty-reducing effects of tax credits and non-cash benefits like food assistance.

Alabama’s official child poverty rate was 22% last year under the American Community Survey (ACS), a more traditional measure that accounts for fewer factors than the SPM. That was an apparent increase from the pre-pandemic level of 21.1% in 2019, though within the margin of error. (ACS data for 2020 is unavailable due to pandemic-related data collection disruptions.)

SPM data paints a fuller picture of the poverty-reducing power of supports like the expanded CTC. Alabama’s three-year average overall poverty rate under the SPM was 10.3% in 2019-21. By contrast, the state’s overall ACS poverty rate moved from 15.5% in 2019 to 16.1% in 2021. That change was not statistically significant.

“The success of the Child Tax Credit expansion was undeniable,” Alabama Arise executive director Robyn Hyden said. “This policy slashed child poverty and helped families make ends meet across our state and our country. Congress needs to renew the Child Tax Credit expansion and make it permanent. And our state lawmakers should do their part to help Alabama families keep food on the table by ending the state grocery tax and replacing the revenue in a responsible way.”

Uninsured rates fall nationally despite tumult of COVID-19 pandemic

Federal policy choices also fueled a slight reduction in the number of uninsured Americans last year. The U.S. uninsured rate dropped to 8.6% last year, down from 9.2% in 2019. Alabama’s uninsured rate stayed relatively flat, moving from 9.7% in 2019 to 9.9% in 2021. That change was within the margin of error.

Alabama continued a years-long pattern of outperforming the national average in insuring children in 2021. The state’s rate of uninsured children (4%) remained the best in the Deep South last year. Much of that sustained success is attributable to ALL Kids, the state’s Children’s Health Insurance Program (CHIP) created in 1998. ALL Kids has played a crucial role in reducing Alabama’s rate of uninsured children from 20% in the late 1990s.

A key factor in the overall health coverage improvements was the federal requirement for state Medicaid programs to keep participants covered throughout the ongoing COVID-19 public health emergency declaration. That declaration may end later this year, underscoring the importance of helping many enrollees transition to new coverage.

Enhanced subsidies under ARPA also helped make health coverage more affordable for millions of Americans with private plans. This includes many of the 219,000 Alabamians with marketplace plans through the Affordable Care Act. Congress renewed subsidy enhancements through 2025 in the Inflation Reduction Act, which President Joe Biden signed into law last month.

“Medicaid, ALL Kids and ACA marketplace coverage have saved and improved the lives of millions of Alabamians,” Hyden said. “Alabama should build on these successes by expanding Medicaid to help more than 340,000 people who are uninsured or struggling to afford health insurance.

“It’s time for Gov. Kay Ivey to say yes to the generous federal incentives for Medicaid expansion. It’s time for her to say yes to a healthier future for Alabama.”

Inflation Reduction Act will make Alabama a healthier state

Alabama Arise executive director Robyn Hyden released the following statement Monday in response to the U.S. Senate’s passage of the Inflation Reduction Act on Sunday:

“The Inflation Reduction Act will help build a healthier future for people across Alabama. This plan will make health coverage more affordable for hundreds of thousands of Alabamians and millions of Americans. It will improve air quality by investing in clean energy and reducing emissions that fuel climate change. And it will pay for these investments by closing tax loopholes that subsidize profitable corporations and wealthy households.

“This plan will save money for patients and the federal government by allowing Medicare to negotiate certain prescription drug prices. It will cap the cost of insulin and other out-of-pocket drug expenses for Medicare enrollees. And it will extend enhanced subsidies that make health coverage more affordable for many of the 219,000 Alabamians with marketplace plans through the Affordable Care Act.

“We’re happy that the U.S. Senate passed this important legislation. And we look forward to the House approving it and sending it to President Joe Biden to sign into law.

“We also will continue advocating for state lawmakers to make other needed investments in families and communities. We’ll keep working for additional funding to make child care, housing and public transportation more affordable and available across Alabama. And we’ll continue pushing for Medicaid expansion to help more than 340,000 Alabamians who are uninsured or struggling to afford health insurance.

“These policy choices are essential to improve Alabamians’ quality of life and to boost our state’s economic prosperity. We’re determined to see each and every one of them across the finish line.”

A life-saving move: Alabama extends postpartum Medicaid coverage

Alabama is on its way to reducing maternal mortality and improving health for families across the state ‒ but we can’t stop here.

Lawmakers and Gov. Kay Ivey last month enacted a budget that extends postpartum Medicaid coverage to a full year after childbirth. That is up from the previous cutoff of only 60 days after birth. Alabama Arise and other members of the Cover Alabama Coalition will continue to work with the governor’s administration and legislators to ensure this program is sustainable and permanent.

Alabama has the nation’s third-worst maternal death rate. Each year, nearly 40 new mothers in the state die within one year after delivery. The toll on Black mothers is nearly three times that of white moms.

Research shows that outcomes improve when moms have access to high-quality, equitable and uninterrupted care. Extending the Medicaid postpartum coverage period is a big step to save lives and improve the health and well-being of families, communities and the entire state.

Arise story collection coordinator Whit Sides speaks at a March 9 rally in Montgomery to support extending postpartum Medicaid coverage. Arise joined the American Heart Association and other Cover Alabama partners at the event.

The work that remains

This is an exciting win, but we know that one year of coverage is, ultimately, not enough. And we know the solution: The most effective way to reduce maternal deaths is to make sure people giving birth have access to care before, during and after pregnancy. We need full Medicaid expansion, and we won’t stop until we get it.

Medicaid restrictions are not affecting only new parents. More than 220,000 Alabamians are caught in our health coverage gap, earning too much to qualify for Medicaid and too little to afford private insurance. And another 120,000 are stretching to pay for coverage they cannot afford. Expanding Medicaid would give these Alabamians the health care that they need to survive and deserve to thrive.

Postpartum Medicaid extension will be only the first of many wins toward creating a more equitable state health care system. It’s been a long fight, but I know we can do this.

Postpartum Medicaid extension brings a glimmer of hope for new mothers in Alabama

This story originally appeared on AL.com.

On Mother’s Day in 2014, I found out I was pregnant. For me, the existential dread set in just as deeply as the morning sickness.

Motherhood and its crushing weight had been drilled into me my entire life. I told myself it was too hard, that I just wasn’t strong enough to handle parenthood and all its pressures. And I feared that my family’s legacy would repeat itself.

Maude Wakefield, pictured with her husband, William (Andy) Ingle of Nauvoo, Ala. Maude is holding one of their 72 grandchildren. (Photo courtesy of Whit Sides)

One summer day in 1932, while pregnant with her 14th child, my great-grandmother Maude Wakefield finally reached her breaking point. She set off behind her home in Winston County and climbed high into a tree on my family’s land. She had been pregnant regularly since 1906 and decided enough was enough.

So she offered an ultimatum: She would return to her infinite load of daily household duties only if my great-grandfather would promise that this was it – no more babies. Not long after what would become her infamous last stand, she passed away due to a stroke worsened by postpartum hypertension. My grandmother was left to live without her mother at age 12.

Nearly a century later, during a routine blood pressure check, I was deemed high risk for the same life-threatening condition that killed my great-grandmother.

I didn’t want that same lonely future for my daughter.

The life-saving power of health coverage

Fortunately, I had health insurance. My blood pressure continued to rise to dangerous levels as my pregnancy progressed. After reviewing my family history, my doctor decided it was best for both me and the baby to deliver early under supervision to prevent preeclampsia, a condition that can lead to maternal death during or after delivery.

Because I had access to care, I was easily treated, and it ended up saving my life. Now, when I take my blood pressure pill every morning, I can’t help but think how things could have been different for my great-grandmother.

Hope can be hard to come by in Alabama. Stories like mine remind us how far we’ve come. But when you’re left without coverage, it’s never as simple as a pill and a copay.

Medicaid covers about half of all births in Alabama. And for many new moms, health coverage expires shortly after the baby is born.

Medicaid postpartum coverage extension is a step in the right direction

Some good news could be coming as soon as this fall. On April 7, Gov. Kay Ivey signed a new General Fund budget into law. It includes an extension of postpartum Medicaid coverage from 60 days of coverage to 12 months. This life-saving change will provide thousands of families consistency in care during the critical time after childbirth.

Alabama has the nation’s third-worst maternal death rate. Each year, roughly 40 new mothers in the state die within one year after delivery. Nearly 70% of those deaths are preventable, the state Maternal Mortality Review Committee found. And the toll on Black mothers is nearly three times that on white moms.

In Alabama, children living in households with low or middle incomes are widely eligible for coverage through Medicaid or ALL Kids, Alabama’s Children’s Health Insurance Program (CHIP). For adults, it is much harder to qualify for Medicaid. Just 17% of Medicaid participants in Alabama are adults under age 65 who do not have a disability.

Our state has some of the most stringent income limitations for Medicaid. For example, a single parent of two without a disability is ineligible if they make more than $346 a month. These harsh Medicaid eligibility limits mean affordable health insurance is simply not an option for many people in our state.

Medicaid expansion would ensure coverage for more than 340,000 Alabamians, including those left uninsured by these tight limits. These folks do not qualify for Medicaid, but they are unable to afford a marketplace plan or other private coverage. However, the new postpartum coverage extension means there will now be a brief inclusive window during and after pregnancy.

A lifeline in a time of need

Moms like my friend Brittany Kendrick of Blountsville call this coverage a lifeline.

Brittany lost her fiance, Dylan, in a car accident two months before her daughter Khaleesi was born. They had everything planned out, but her health insurance expired after Dylan’s death. Brittany turned to Medicaid to cover the costs.

Blountsville resident Brittany Kendrick holds her daughter Khaleesi. Medicaid was a lifeline for Brittany after her fiance, Dylan, died shortly before Khaleesi’s birth. (Photo courtesy of Brittany Kendrick)

Then, in August 2021, she made the hour-long drive to Children’s Hospital in Birmingham, where she found out her newborn had contracted COVID-19. After getting emergency care, her baby made a recovery. But as soon as they got home, Brittany tested positive and started to feel worse.

Being able to see a doctor and seek treatment quickly was just the blessing they needed during what Brittany calls the hardest year of her life.

“Medicaid paid for all of our hospital and doctor bills,” Brittany said. “It gave me a chance to use the money I had in savings for a safer car and a new apartment for me and the baby.”

Brittany hopes she will be among those eligible for the new postpartum extension. Having consistent care has brought balance to her life in more ways than one. “I can take medicine for anxiety and depression now. I need that, to stay strong for her,” she said.

Khaleesi Rider in April 2022. (Photo courtesy of Brittany Kendrick)

‘Why not offer this to all mothers?’

Extending Medicaid coverage doesn’t just support new or single parents.

Sarita Edwards of Madison is a mother of five and founder of the E.WE Foundation, a health care advocacy organization. She began her foundation after receiving a rare prenatal diagnosis of Edwards’ Syndrome (trisomy 18) for her son Elijah. The high mortality rate associated with her son’s diagnosis meant her family racked up thousands in medical debt before baby Elijah was even born.

Madison residents Kareem and Sarita Edwards hold their son Elijah. Sarita founded the E.WE Foundation after her son received a rare prenatal diagnosis. (Photo courtesy of Sarita Edwards)

Sarita says every day with Elijah has been a juggling act. Elijah’s condition is terminal, and his care can be exhausting and expensive. She now spends her time advocating for more equitable treatment and access in health care. She knows our leaders can do more, because she’s seen it firsthand.

“I know what our state can do when offering care to mothers and children with rare diseases,” Sarita said. “Why not offer this to all mothers?”

Elijah Edwards, age 5. (Photos courtesy of Sarita Edwards)

The new General Fund budget includes more than $8 million to extend Medicaid coverage for 12 months after childbirth. But the funding is guaranteed only for one year – on a trial basis.

This year marked another Mother’s Day when Alabama mothers are still dying from pregnancy and childbirth at twice the national rate. Reliable health coverage – and the access to care that comes with it – can prevent many of those deaths. Sarita sees no reason to hold off on making Medicaid’s postpartum coverage extension permanent.

“Our babies are taken care of, but what about the mothers?” Sarita asked. “I don’t know why it takes Alabama so long to do the right thing sometimes.”

About Alabama Arise and Cover Alabama

Whit Sides is the story collection coordinator 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 more than 115 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.