Medicaid expansion would save Alabama mothers from preventable deaths, boost treatment resources for mental health and substance use disorders

Alabama Arise and Cover Alabama partner organization logos

Nearly 70% of Alabama’s pregnancy-related deaths in 2016 were preventable, according to a report this month from the state Department of Public Health and Maternal Mortality Review Committee. The committee recommended that Alabama improve maternal health by expanding Medicaid coverage and increasing resources and services for women with mental health and substance use disorders. The report also recommended improving Medicaid reimbursement for providers and encouraging broader education of mothers and families regarding the various health issues identified as maternal death risk factors and their warning signs.

Partner organizations in the Cover Alabama Coalition released the following statements Thursday in response:

Jane Adams, Campaign Director, Alabama Arise:

“Thirty-six Alabama mothers died in 2016 from causes linked to their pregnancies. Their children will go to bed tonight – and every night – without their birth mother there to tuck them in. And for 70% of these kids, their mother’s death was preventable. This report is a haunting reminder that poverty and access to health insurance are significant drivers of maternal mortality in Alabama. We encourage Gov. Kay Ivey, Commissioner Stephanie Azar and our legislators to save lives and protect families by expanding Medicaid to cover mothers before, during and after pregnancy.”

Jada Shaffer, Government Relations Regional Director, American Heart Association:

“We urge the Legislature and Governor Ivey to immediately implement the reforms the Maternal Mortality Review Committee recommends. In 2016, cardiovascular-related conditions were the leading underlying cause of pregnancy-related deaths in Alabama. When women lack health insurance, they are less likely to get treatment for preexisting conditions and are much more likely to die during or after pregnancy. Improving maternal health outcomes will require expanding Medicaid and equitably providing access to care for all Alabama families.”

Dr. John S. Meigs, President, Medical Association of the State of Alabama:

“The Medical Association of the State of Alabama commends the Maternal Mortality Review Committee (MMRC) for its diligence in researching the factors that impact maternal deaths, in hopes to mitigate and prevent future maternal deaths. It is very concerning for physicians throughout the state that 70% of the deaths reviewed by the MMRC were preventable and that women of color are disproportionately affected. Alabama mothers deserve the best medical care that we can offer. To that end, the Medical Association supports the MMRC’s recommendation of expanding Medicaid coverage for women postpartum beyond where it is today, as well as informing our communities that mental health and substance abuse issues can contribute to maternal mortality. Physicians have a responsibility to help mothers get the medical care that they need and deserve.”

Dr. Nadia Richardson, Executive Director, No More Martyrs:

“In Alabama, Black women are dying at three to four times the rate of white women from pregnancy-related complications. In 2016, thirty-six mothers died because they did not have consistent access to care. We fail mothers when they are forced to drive two counties over to see their OB-GYN for a check-up because they live in one of 29 Alabama counties that have lost obstetrical services.

“Now is not the time to turn a blind eye to health disparities rooted in injustice and indifference. Now is not a time to ignore the impact that this continued neglect has on the mental, physical and holistic wellness of Black women in our state. Now is not the time to pretend that these inequities are not remnants of a history that we have yet to come to terms with – a history of racism and sexism that remains embedded throughout our health care system. Now is the time to demand more. Alabama leaders must accelerate progress on ending maternal mortality by investing in access to quality and affordable health care.”

Britta E. Cedergren, MPH, MPA, Associate Director, Postpartum Care, March of Dimes:

“The health of a society is measured by the health of its moms and babies. In Alabama, we are not only facing the crisis of one in eight babies being born too sick, too soon, but mothers dying from potentially preventable causes. In the inaugural report by the Alabama Maternal Mortality Review Committee, we found that two-thirds of women die between 43 and 365 days postpartum. When moms have access to high-quality, equitable and uninterrupted care, outcomes can improve. Fully expanding, or even extending Medicaid for a full year postpartum, while only one step in combating the crisis of moms dying from pregnancy related causes, is a big step that can improve the health and well-being of all Alabamians.

Rev. Carolyn Foster, Faith in Community Coordinator, Greater Birmingham Ministries:

“It is our moral responsibility to care for one another. ‘Do unto others as you would have them do unto you’ is a mandate in many of our faith traditions. It is the most basic command in our religious tradition. We cannot stand by or look the other way or cross on the other side when people suffer. To do so is to turn one’s back on God because ‘when you do it to the least of these, you do it to me.’ Access to health care would be life-giving to many who are vulnerable. We are our sister’s and brother’s keepers. And we must bear one another’s burdens. Dr. Martin Luther King Jr. said, ‘Our lives begin to end the day we become silent about things that matter.’ We strongly urge the Legislature and Gov. Kay Ivey to increase access to quality affordable health insurance by expanding Medicaid.”

Holly Caraway McCorkle, Executive Director, Alabama Council for Behavioral Healthcare:

“The Alabama Council for Behavioral Healthcare urges policymakers to act quickly to increase access to coverage by expanding Medicaid in Alabama. Sadly, the Alabama Maternal Mortality Review Committee found that mental health and substance use disorders were identified as key contributors in almost half of pregnancy-associated and pregnancy-related deaths. These deaths are preventable, and Medicaid expansion will offer women who suffer from mental health and substance use disorders life-saving coverage and access to critically needed resources and services before, during and after pregnancies.”

Kim Cochran, Vice President, External Affairs, The Women’s Fund of Greater Birmingham:

“A recent report by Alabama’s Maternal Mortality Review Committee revealed that the maternal mortality rate is rising in the United States. Alabama’s rate is the second highest in the nation and disproportionately affects Black women. Even more alarming, 70% of the maternal deaths in Alabama were deemed preventable. As identified by the Maternal Mortality Review Committee, Medicaid expansion could reduce Alabama’s maternal deaths and change the narrative for women. A region, state or county’s ability to keep women and children alive during and after childbirth speaks volumes about our economic, social and political fabric. I urge our lawmakers to stand up for women and expand Medicaid to help reduce our state’s maternal mortality rate and provide health care coverage for an additional 152,000 women.”

ACA lawsuit could end health coverage for 122,000 Alabamians

At least 122,000 Alabamians would lose health coverage if the U.S. Supreme Court strikes down the Affordable Care Act (ACA), according to a new analysis from the nonpartisan Urban Institute. The state’s uninsured rate would increase by 25% as a result.

That number also doesn’t include hundreds of thousands of uninsured or underinsured adults with low incomes who would gain coverage if Alabama expands Medicaid. If the lawsuit succeeds, the ACA’s 9-to-1 federal funding match for Medicaid expansion would disappear.

“Repealing the ACA would throw our health care system into chaos in the middle of a pandemic and a deep recession,” Alabama Arise executive director Robyn Hyden said. “Tens of thousands of Alabamians would lose health coverage when they need it most. And hundreds of thousands would pay more for coverage or lose protections for their preexisting conditions.”

The White House and 18 states, including Alabama, are asking the Supreme Court to strike down the entire ACA. Oral arguments before the Supreme Court are scheduled for Nov. 10.

More than 21 million Americans would lose coverage in 2022 if the ACA falls, according to the Urban Institute. Coverage losses could be even larger next year, as the COVID-19 pandemic and recession likely still will be ongoing.

“The ACA has been a health lifeline for many Alabamians during the pandemic,” Hyden said. “It provides coverage options for people who have lost their jobs or seen sharp reductions in their income. And it ensures people aren’t denied insurance just because they got sick.”

Ending the ACA would undermine racial equity, harm people with preexisting conditions

The ACA made important progress in reducing racial disparities in health care that often stem from structural racism. But large coverage losses from ending the ACA would reverse many of those gains, the Urban Institute finds. Overturning the ACA would strip health coverage from nearly one in 10 Black and Latino Americans under age 65. More than one in 10 Native Americans nationwide would become uninsured.

Ending the ACA also would eliminate protections for people with preexisting conditions. This would allow insurers to charge higher rates to people with conditions like asthma, cancer, diabetes or COVID-19. Insurance companies also could refuse to offer them coverage at any price. One in three Alabamians under age 65 have a preexisting condition that would have been “declinable” before the ACA.

ACA repeal would harm people who have health insurance through their jobs, too. Their plans could reintroduce annual and lifetime coverage limits. Requirements for plans to cover essential benefits and provide free preventive services would disappear. So would the requirement for insurers to allow young adults to be covered through their parents’ plans.

Striking down the ACA would be a tax windfall for wealthy people, large corporations

Wealthy people and some large corporations would be among the few winners if the lawsuit succeeds. They would get billions of dollars in tax cuts, the nonpartisan Center on Budget and Policy Priorities finds:

  • The highest-income 0.1% of households would receive tax cuts averaging about $198,000 per year. This group has annual incomes of more than $3 million. A portion of these tax cuts would come at the expense of the Medicare Trust Fund, which would lose about $10 billion in revenue each year.
  • Pharmaceutical companies would pay $2.8 billion less in taxes each year. Meanwhile, millions of seniors could pay billions of dollars more for prescription drugs annually. That’s because eliminating the ACA could reopen the “donut hole” gap in Medicare’s prescription drug benefit.

“The ACA has left Alabama better equipped to fight COVID-19 and rebuild our economy after the recession,” Hyden said. “And those benefits would be even greater if Alabama would adopt Medicaid expansion.

“Striking down the ACA would harm the Alabamians who have suffered the most during the pandemic and the recession. It would deprive our state of the opportunity to save lives and strengthen our health care system by expanding Medicaid. And it would shower huge tax cuts on rich people while making life harder for everyone else. Alabama officials should stop seeking to undermine the ACA and start investing in a healthier future for our entire state.”

Town Hall Tuesdays: What we heard from Arise supporters

Listening is often an underdeveloped skill, yet it is critical for mutual understanding and working together for meaningful change. That’s why Arise is committed to listening to our members, to our allies and most importantly, to those directly affected by the work we do together. We depend on what we hear from you to guide our issue work and our strategies.

This year’s COVID-19 pandemic challenged us to be creative in finding ways to listen. Instead of our usual face-to-face meetings around the state, we hosted a series of six statewide online Town Hall Tuesdays. We held events every two weeks, starting in June and ending Sept. 1. We averaged 65 attendees at each session. Here’s some of what we heard from members and supporters:

  • Affirmation for Medicaid expansion, untaxing groceries and other current Arise issues as important for achieving shared prosperity.
  • Empathy for those who were already living in vulnerable circumstances further strained by the pandemic.
  • Concern about ongoing, intentional barriers to voting, especially during the pandemic.
  • Desire to see more resources to meet the needs of our immigrant neighbors.
  • Alarm about payday and title lending and its impact on people’s lives and our communities.
  • Passion and concern about many other issues, including housing; living wages and pay equity; prison and sentencing reform; gun safety; juvenile justice reform; defunding the police; the Census; environmental justice; quality and funding of public education; and food insecurity and nutrition.
  • Willingness to take informed actions to make a difference in the policies that impact people’s lives.
  • Hope that Alabama can be a better place for all our neighbors to live despite systemic issues and ongoing challenges.

Notes from each town hall

Overviews of the town halls are below. Click the title for a PDF of the notes from the breakout sessions at each town hall.

June 23 – Money talks
We examined how to strengthen education, health care, child care and other services that help Alabamians make ends meet. And we explored ways to fund those services more equitably.

July 7 – Justice for all
We discussed Alabama’s unjust criminal justice system and how to fix it.

July 21 – Getting civic
Discussion focused on protecting voting rights and boosting Census responses during a pandemic.

Aug. 4 – Shared prosperity
We looked at policy solutions to boost opportunity and protect families from economic exploitation.

Aug. 18 – Feeding our families
We explored ways to increase household food security during and after the recession.

Sept. 1 – Closing the coverage gap
Discussion focused on how everyone can help expand Medicaid to ensure coverage for hundreds of thousands of struggling Alabamians. We also heard about the expansion campaign strategies of the Cover Alabama Coalition, headed by Arise campaign director Jane Adams.

Get in touch and stay in touch with Arise

Remember, we didn’t stop listening because the town halls ended. We want to hear from you, and we encourage you to contact the Arise organizer in your area:

We hope to see you at Arise’s online annual meeting Oct. 3!

Groups urge Dismukes’ resignation, ask Legislature to dismantle white supremacy through policy change

Alabama Arise logo     Alabama NAACP logo    Greater Birmingham Ministries logo

The following is a joint statement from Alabama Arise, the Alabama State Conference of the NAACP and Greater Birmingham Ministries:

Our elected officials and appointed leaders should respect the full dignity, worth and humanity of all people they represent. We urge all political parties and public officials to acknowledge the harm that white supremacy continues to inflict upon Alabama. And we call upon them to dismantle white supremacist structures through intentional policy changes.

The cause of white supremacy permeates our state’s fundamental governing document. When the president of the 1901 constitutional convention, John Knox, was asked why Alabama needed a new constitution, his answer was clear: “to establish white supremacy in this state.”

Any celebration of Nathan Bedford Forrest of the Ku Klux Klan – a white supremacist terrorist organization – is contrary to the values that Alabamians expect from our leaders, elected officials and neighbors. In celebrating Forrest, Rep. Will Dismukes revealed he is unable or unwilling to represent the best interests of his constituents and his state. We condemn his actions in the strongest possible terms. We also understand this is not the first time Dismukes has celebrated the Confederacy or Forrest in such a manner. Therefore, we join with many other individuals and organizations across Alabama in calling for Dismukes to resign immediately.

Racial equity requires action, not just words

Alabama’s need for racial justice and healing reaches far beyond any one individual. All elected officials must take a hard look at both their actions and the impacts of their policy decisions. Most lawmakers claim to support racial equality, but the results of their policy choices often do not match this claim.

Examples of this mismatch are unfortunately common in our state. The 2017 Memorial Preservation Act prevents localities from removing statues that “honor” the Confederacy without paying a steep fine or getting approval from a panel of legislators that to our knowledge has not approved a removal since the law was enacted. Lawmakers’ failure to expand Medicaid leaves a disproportionate share of African Americans without health insurance during a pandemic. And the absence of racial impact data prevents communities and legislators from evaluating the full effects of state policy choices.

The harsh reality of racial disparities in Alabama

While Dismukes dismisses the need for racial reconciliation in today’s society, we cannot remain ignorant of the truth. We all must reckon with these disparities created and maintained by structural policy barriers:

It’s time for more than talk. Denouncing and rejecting white supremacy is only the beginning. Lawmakers also must enact meaningful policy changes to break down institutional barriers to opportunity and justice for all Alabamians.

Working in Alabama during the COVID-19 pandemic: Who faces the danger?

Many Alabamians have modified their work circumstances in recent months to reduce the risk of contracting COVID-19. But tens of thousands of people still must work in public-facing jobs that put them at increased risk of illness.

Front-line workers in grocery stores, hospitals and pharmacies perform necessary tasks to keep our communities functioning during the pandemic. The burden of facing those health risks is unevenly distributed, though. Workers in jobs like health care, food service and child care are disproportionately likely to be people of color or women. And state and national policy failures on COVID-19 are more likely to hit them the hardest.

Gender disparities and low wages increase risk

Differing employment levels in the health and retail fields particularly have forced more women to risk coronavirus infection. Two-thirds of Alabama’s essential workers are women, though women comprise just under half of the state’s total workforce.

Health care workers overall are much more likely to be women, and they face drastically heightened risk of infection at work. Among Alabama workers, women comprise 81% of health care workers and 89% of child care and social services workers. Jobs in these fields often require consistent exposure to large numbers of people.

Pie charts: Alabama front-line workers are much more likely to be women. Women are 66.4% of all Alabama front-line workers and 80.6% of Alabama health care workers.

Health care accounts for more than one in 10 jobs in Alabama. And the higher proportion of women in this field contributes to a gender-based disparity for COVID-19 exposure. In many cases, personal protective equipment (PPE) has run short for doctors, nurses and other health care professionals. This structural failure has forced many of these workers to reuse PPE, posing potentially severe health risks.

The wages and work conditions for essential front-line workers often don’t reflect the importance of their work. Many workers received higher hourly wages early in the pandemic, but now some employers have begun eliminating hazard bonuses. In the retail sector – already filled with low-wage jobs with sparse benefits – major employers like Amazon, Kroger and Target have stopped their wage bonuses.

Returning to work at unsustainably low wages amid a pandemic isn’t the only way many hard-working Alabamians are being squeezed. The state also has placed workers at risk of homelessness with an ill-timed wave of unemployment insurance (UI) benefits cutoffs coupled with the lifting of a two-month moratorium on evictions for nonpayment of rent. And a federally funded $600 weekly UI benefit increase during the pandemic will expire this month unless Congress renews it.

Racial disparities in employment and health coverage shape risk

Structural factors leave Black and Latino Alabamians at increased risk from COVID-19. Black and Latino people account for a disproportionate share of workers in essential jobs. And because of long-term, systemic racism that creates barriers to regular health care, Black people are more likely to have underlying conditions that worsen coronavirus outcomes.

Table: More than 1 in 3 of Alabama's front-line workers are people of color. 31.8% of Alabama front-line workers are Black, compared to 25% of the labor force. 2.3% of front-line workers are Latino and 1.3% are Asian Americans or Pacific Islanders.

Even among essential workers, people of color are more likely to face heightened exposure in certain public-facing industries. In Alabama, the share of Black people working in grocery or convenience stores is two and a half times larger than in the U.S. workforce overall. The share of Asian Americans and Pacific Islanders who work in grocery and convenience stores is double their percentage of Alabama’s overall population.

Despite these elevated risks, Black and Latino Alabamians are far more likely than white people to lack health insurance coverage. And because Alabama hasn’t expanded Medicaid, Black and Latino residents are more likely to fall into the health coverage gap, earning too much to qualify for Medicaid but too little to afford insurance. People of color make up 34% of Alabama’s population but comprise 49% of uninsured Alabamians with low incomes.

This table shows the disproportionate burden that women, people of color and low-wage workers face across several essential employment fields:

Table: Women, people of color and low-wage workers are at greater risk of coronavirus exposure in front-line jobs across Alabama. Women are 47.9% of total workers in Alabama but 66.4% of front-line workers. People of color are 31.7% of all workers but 36.4% of front-line workers. 34.5% of front-line workers have incomes below 200% of the poverty line, compared to 31.9% of all workers.

Unfortunately, the chart’s data cannot account for differing exposure rates based on specific jobs within those career fields. But given that women in medical fields often face bias inhibiting their promotion into supervisory roles, women are likely at greater risk of coronavirus infection than their high proportion in the health care industry indicates. And overall, people of color are more likely to work non-supervisory jobs with higher public exposure in many front-line fields.

Shortsighted policy choices harm the economy and virus containment

Refusal to expand Medicaid and attempts to slash UI benefits are harmful policy decisions that fly in the face of the reality of the pandemic. And the burden of these cruel choices falls more heavily on people who already face disadvantages in the labor market.

More than 600,000 people have filed UI claims in Alabama since the pandemic reached the state in March. Thousands of Alabamians are already losing UI benefits for refusing to return to work in conditions they see as unsafe. Each person prematurely knocked off the UI rolls loses not only the $275 monthly state benefits, but also the $600 monthly federal supplement guaranteed through July. Alabama is forfeiting millions of federal dollars as a result.

That money would help shore up flagging state revenues for education, health care and other vital services. It also would help people meet basic needs and limit the coronavirus’s spread during an unprecedented economic and health crisis. Forcing people back to workplaces while COVID-19 is still rampant is a dangerous attempt to restore Alabama’s inequitable economic structure.

Alabama should move forward, not return to past failures

The pandemic has shined a light on many of Alabama’s policy mistakes. The state can take this opportunity to fix harsh, shortsighted policies that devalue and harm Alabamians. And our leaders must take the lead on implementing helpful policies because of a lack of comprehensive federal action. The U.S. Department of Labor has issued no guidance allowing workers in high-risk groups to stay home and retain benefits. And the department has not reinforced health and safety protections for workers whose employers don’t take proper coronavirus precautions.

As a result, many older adults, cancer survivors and immunocompromised people face a stark choice between their lives and livelihoods. They must either subject themselves to a higher chance of death from COVID-19 or risk hunger and homelessness when the state cuts off UI benefits. Black and Latino people, women and struggling families will bear the brunt of this callous undermining of the safety net.

Alabama can and should do better. Instead of forcing people back into workplaces prematurely, lawmakers should fix failed policies like the 2019 cuts to UI benefits. Gov. Kay Ivey should expand Medicaid to ensure everyone can get the life-saving health care they need. And our state should abandon the impulse to punish people for inability to find work, especially during a deep recession. Instead, Alabama should enact policies that support and value people both while they work and when they lose their jobs.

69,000 Alabama workers lost coverage when they may need it most, new report finds

Job losses during the COVID-19 economic crash kicked 69,000 Alabamians off their health insurance between February and May, according to a new report by Families USA, a nonprofit research organization based in Washington, D.C.

Those coverage losses increased Alabama’s uninsured rate for non-elderly adults to 19%, the report finds. That is the ninth highest rate in the nation and 3 percentage points higher than in 2018. As workers and their families lose comprehensive health insurance, their risk of delayed care and complications from the virus increases. So does their risk of financial devastation.

“Even before COVID-19, Alabama’s failure to expand Medicaid left more than 220,000 adults uninsured,” Alabama Arise campaign director Jane Adams said. “Further coverage losses during the recession will bring health and financial suffering for even more families across our state. More people will go without needed health care. More hospital bills will go unpaid. And all Alabamians will bear the additional strain on our health care system. This report’s findings should be a blaring emergency siren for our state leaders.”

The number of uninsured adults jumped by 5.4 million nationally between February and May. The increase in those few months was 39% higher than any annual increase ever recorded, Families USA finds. The report also shows a disturbing overlap between states with the highest adult uninsured rates and the worst COVID-19 case trends.

“COVID-19 is putting lives, livelihoods and economic security at risk for thousands of Alabama workers. And many communities face long-term challenges for health care capacity and economic recovery,” Adams said.

“Alabama Arise and Cover Alabama urge Gov. Kay Ivey to save lives and stabilize our local hospitals by expanding Medicaid. We ask the Legislature to provide the needed state share of this pro-family, pro-health, pro-community investment in our future. And we ask Congress to strengthen Medicaid funding and help Alabama shore up our health care infrastructure.”

Adams directs Cover Alabama, a coalition of more than 90 organizations pushing for Medicaid expansion in Alabama. Arise is a founding member of the coalition.

Medicaid Matters: Charting the Course to a Healthier Alabama

The cover page of the report - Medicaid Matters: Charting the Course to a Healthier Alabama

Introduction

ALABAMA MEDICAID supports the health care system that serves us all. Whether you have employer health coverage, a private plan, public insurance like Medicaid or Medicare, or no coverage at all, you will likely benefit at some point from facilities and services that Medicaid makes possible.

More than a million Alabamians — mostly children in families with low incomes, seniors in long-term care and people with disabilities — have Medicaid coverage that allows them to get the regular, timely medical care they need. By building on this foundation to make affordable coverage more widely available, we can strengthen our health system, our workforce, our communities and our economy.

This report looks at Alabama Medicaid from four angles: how it works now, how it’s improving coverage, who’s still left out and how we can make it stronger.

Click on the icons below to read each section of our report. Please continue below the icons for our conclusion, editor’s note and acknowledgments. You can click any image in this report to enlarge it. To read our news release on the report, click here.

How does Medicaid work in Alabama? (Section 1)
How is Medicaid improving coverage? (Section 2)
Who’s still left out of health coverage? (Section 3)
How can we make Alabama healthier? (Section 4)

Conclusion

All Alabamians deserve the opportunity to get the health care they need to survive and thrive. Medicaid is a lifeline for one in four Alabamians and an economic engine for communities across our state. Extending Medicaid coverage to adults with low incomes would make life better for Alabamians of all races, genders, hometowns and incomes — and it would only cost the state a dime on the dollar. Here’s why Medicaid expansion is a bargain Alabama can’t afford to pass up:

Medicaid expansion would ensure health coverage for:

  • People who work low-wage jobs and can’t afford private coverage
  • Workers who are between jobs
  • Adults caring for children or other family members at home
  • People who have disabilities and are awaiting SSI determinations
  • College students
  • Uninsured veterans
  • People harmed by racial and ethnic health disparities

Medicaid expansion would help more Alabamians have:

  • Regular primary care and preventive checkups
  • Earlier detection and treatment of serious health problems
  • Regular OB/GYN visits without referral
  • Less dependence on costly emergency care
  • Better health and greater financial peace of mind

Medicaid expansion would bring our federal tax dollars home to support:

  • Better outcomes on critical health challenges like infant mortality, obesity and substance use disorders
  • Stronger rural hospitals and clinics
  • A stronger network of community mental health and substance use disorder services
  • A needed boost in jobs and revenue for state and local economies

Editor’s note

As we publish this report, Alabama and the world are facing the public health emergency of the COVID-19 pandemic. The duration and fallout of the crisis are impossible to predict, but every level of our health care system will be severely tested in the months ahead. The pandemic is taking a disproportionate toll on African American and Latino communities where people are more likely to live in poverty and without health insurance. And the number of uninsured Alabamians — already shockingly high before the pandemic — will continue to grow as unemployment mounts.

In times like these, state leaders play a crucial role in protecting the public from physical, mental and financial harm. One of the most important tools available to both elected officials and their constituents is accurate information about how state services promote the common good — and how we can make them stronger.

While this report took shape before the COVID-19 crisis erupted, we hope it will help Alabamians understand the available health care solutions and their important economic benefits. Emergencies demand rapid response, and an understanding of the “preexisting conditions” in our state’s health care system can make those responses more appropriate and more effective.

Through this pandemic and the next one — and the more ordinary times in between — all Alabamians will depend on a health care system with Alabama Medicaid at its core. The stronger Medicaid is, the better the prognosis for all of us will be.

The COVID-19 emergency has brought several temporary changes to the information in this report, including the following:

Section 1

Silvia Hernandez has suspended services at Go Play Therapy but hopes to reopen after the economy stabilizes.

Section 1

Congress has increased the federal share of Medicaid funding for all states by 6.2 percentage points for the length of the pandemic. Some lawmakers have proposed further increases.

Section 2

If someone had Medicaid coverage during March 2020, Alabama will not end that coverage during the pandemic unless the person cancels it or moves out of state. This temporary halt to coverage cuts includes people receiving postpartum coverage that normally ends after 60 days.

Acknowledgments

This Alabama Arise report was made possible by a generous grant from The Women’s Fund of Greater Birmingham. The findings and conclusions presented in this report are those of Arise and do not necessarily reflect the opinions of The Women’s Fund.

Arise policy director Jim Carnes was the primary author of this report, and Valerie Downes of Montgomery designed it. Arise communications associate Matt Okarmus interviewed many of the individuals profiled in this report. Other report editors and contributors included Arise executive director Robyn Hyden; communications director Chris Sanders; policy analyst Carol Gundlach; organizing director Presdelane Harris; organizers Stan Johnson, Mike Nicholson and Debbie Smith; and intern Kayla Thompson.

Special thanks to Jesse Cross-Call and Tammie Smith at the Center on Budget and Policy Priorities and Stephen Eisele and Paul Gels at Community Catalyst for their guidance and support.

Medicaid Matters – Section 1: How does Medicaid work in Alabama?

MEDICAID BASICS

What you need to know …

Young girl holding sign reading #IamMedicaid
(Photo: #IamMedicaid)
  • Medicaid is a joint federal/state program providing health coverage for certain categories of people with low incomes and limited resources.
  • More than 1.2 million Alabamians qualify for Medicaid coverage.
  • Medicaid payments support doctors’ offices, hospitals, clinics and nursing homes that serve all Alabamians.
  • Children make up more than half of Alabama Medicaid beneficiaries.
  • Medicaid also provides essential coverage for seniors, pregnant women, and people with disabilities.
  • Alabama Medicaid’s eligibility limits are among the nation’s most restrictive.

Medicaid is the backbone of our health care system

More than 1.2 million Alabamians, or 25% of our state’s population, qualified for Medicaid coverage in fiscal year 2017. Looking closer, that’s:

Infograph visualizing who qualified for Medicaid coverage in fiscal year 2017: 1 in 4 Alabamians, 1 in 2 births, 1 in 2 children, 1 in 3 people with disabilities, 2 in 3 nursing home residents, 1 in 5 seniors

Medicaid pumps $7 billion in federal and state money into our health care system every year. Without Medicaid funding, many of the doctors’ offices, clinics, hospitals and other medical facilities that all Alabamians depend on would have to cut services or close.


SPOTLIGHT

Meet Silvia Hernandez

A portrait of Silvia Hernandez
Silvia Hernandez of Fort Payne opened Go Play Therapy after her son’s speech challenges revealed a shortage of therapists in her area. (Photo: Matt Okarmus)

To get her son the speech therapy he needed a few years ago, Silvia Hernandez of Fort Payne had to drive him two hours each way to the recommended therapist in Birmingham. Her top priority was her son’s health care, but Silvia saw firsthand the hurdles of time and resources that some parents in her area would have trouble getting over.

When Silvia encounters a problem, she goes to work — this time literally. Today, she is the owner of Go Play Therapy, a practice she built and opened in response to the provider shortage in her area. Go Play specializes in occupational, physical and speech therapy for children up to age 18. There are two Go Play locations, in Fort Payne and Centre.

Hernandez estimates 90% of her clients have Medicaid.

If Medicaid didn’t exist, we’d have to shut our doors,” Silvia says. She adds that extending Medicaid coverage to adults with low incomes — not just their children — would help even more people gain access to the care they need. As a business owner, she sees another advantage to Medicaid expansion: It would allow her to expand her therapy office and hire additional employees.


Who is Alabama Medicaid?

A circle graph with the question of "Who is Alabama Medicaid?" Different shades filled in are: 52% are children in families with low incomes; 9% are people 65 and older who are in poverty; 17% are pregnant women, parent caretakers or family planning patients and 22% are people with disabilities.
Source: Alabama Medicaid

Alabamians in every county qualify for Medicaid

About one in every six Alabamians lives in poverty. For children, the rate is nearly one in four. Even Alabama’s most prosperous counties have significant numbers of households living below or near the poverty level. That means Medicaid is a lifeline for families across the entire state.

A map of Alabama that shows the percentage of people in each county who qualified for Mediacid in 2017: Autauga - 22% Baldwin - 19% Barbour - 38% Bibb - 28% Blount - 23% Bullock - 38% Butler - 38% Calhoun - 30% Chambers - 33% Cherokee - 27% Chilton - 29% Choctaw - 34% Clarke - 34% Clay - 31% Cleburne - 28% Coffee - 25% Colbert - 27% Conecuh - 39% Coosa - 25% Covington - 32% Crenshaw - 37% Cullman - 24% Dale - 28% Dallas - 49% DeKalb - 22% Elmore - 21% Escambia - 32% Etowah - 29% Fayette - 33% Franklin - 32% Geneva - 33% Greene - 51% Hale - 47% Henry - 28% Houston - 30% Jackson - 25% Jefferson - 25% Lamar - 31% Lauderdale - 22% Lawrence - 27% Lee - 18% Limestone - 19% Lowndes - 47% Macon - 36% Madison - 17% Marengo - 39% Marion - 29% Marshall - 22% Mobile - 29% Monroe - 32% Montgomery - 31% Morgan - 22% Perry - 52% Pickens - 31% Pike - 28% Randolph - 31% Russell - 32% St. Clair - 21% Shelby - 13% Sumter - 42% Talladega - 31% Tallapoosa - 31% Tuscaloosa - 22% Walker - 31% Washington - 27% Wilcox - 54% Winston - 29%
Source: Alabama Medicaid
A graph showing Medicaid eligibility through fiscal year 2017 as represented by the percent of population by county. The highest were Wilcox (54%), Perry (52%), Greene (51%), Dallas (49%), Lowndes (47%) and Hale (47%). The lowest were Shelby (13%), Madison (17%), Lee (18%), Limestone (19%) and Baldwin (19%).
Source: Alabama Medicaid

How do people qualify for Medicaid coverage in Alabama?

When an individual or family applies for Medicaid, a number of factors determine whether they’re eligible and which program would best serve their needs. Age, income, family size and certain health conditions like pregnancy or disability all play a part.

The household income limit for a particular program is expressed as a percentage of the federal poverty level (FPL) — often in shortened form, such as “146% of poverty.” The higher the percentage, the more income an individual or family may have and still qualify for Medicaid.

The income limits for Alabama Medicaid’s eligibility groups are shown below. In 2020, the FPL was $12,760 for an individual and $26,200 for a family of four.

Graph showing Medicaid eligibility in Alabama. The percentage noted for each is its percentage of the federal poverty level in 2020 ($12,760 for an individual and $26,200 for a family of four). Former foster youth up to age 26 (no income limit), Children under 19 (146% - Note: Children in families earning more than the Medicaid income limit but under 317% of the federal poverty level can get coverage for an income-based premium with ALL Kids, Alabama's state Children's Health Insurance Program (CHIP)), Breast and cervical cancer patients (250%), People in nursing homes or community care (222%), Pregnant women (146%), Family planning (146%), People who are aged, blind or disabled (76%), Parents of dependent children (18%) and adults without dependent children (not eligible). Source: Alabama Medicaid
How does Alabama’s Medicaid eligibility compare?

Children’s health coverage has long been a point of pride for Alabama. We were the first state to launch a Children’s Health Insurance Program (CHIP) after Congress created that option in 1997. While our family income limit for children in Medicaid is the third lowest in the country at 146% FPL, ALL Kids covers children above the Medicaid limit up to 317% FPL. That puts Alabama among the top 10 states for CHIP eligibility. For working-age adults, however, Alabama Medicaid’s income limits tell another, far more troubling story.

Graph showing income limits on adult Medicaid eligibility. FPL means federal poverty level. For pregnant women, Alabama's 146% FPL income limit ranks 45th nationally. The U.S. median is 200% FPL. For parents and other caretaker relatives, Alabama's income limit of 18% FPL ranks 49th nationally. The U.S. median is 138% FPL. For adults 19-64 with no children, Alabama provides no coverage. The U.S. median is 138% FPL.

National ranking: 49th

For adults without children or a disability, we’re one of 14 states that offer no Medicaid coverage. And only Texas makes it harder than Alabama for parents of dependent children to get Medicaid coverage.

How does Medicaid funding work?

A circle graph representing the 73% federal match for Alabama Medicaid funding in 2021 and the states responsibility of 27%.

The federal government pays at least half of each state’s Medicaid costs. The percentage (called the Federal Medical Assistance Percentage, or FMAP) is set annually through a complicated formula based on per capita (or per person) income. The lower the state’s per capita income, the higher the FMAP, up to a maximum 83%. Alabama’s FMAP for FY 2021 will be 72.58%. This means we get roughly $7 in federal money for every $3 Alabama pays for Medicaid. Alabama Medicaid’s total annual budget is about $7 billion.

Two stacks of money showing the roughly 30% state vs. 70% federal match for Medicaid.

State money for Medicaid comes from a number of sources, including the General Fund (GF), special trust funds, and transfer payments from public hospitals. Because the revenues earmarked for the GF come from minor taxes, fees and interest payments that grow slowly, Medicaid and other GF services remain permanently shortchanged.

How does Alabama’s Medicaid investment compare?

One simple way to compare Medicaid programs across states (and the District of Columbia) is to rank their spending per enrollee in major Medicaid eligibility groups. Spending is only one factor in the delivery of care, but it does indicate the investment that the state is willing to make in the health of residents with low incomes. Here’s how Alabama measures up on that count:

A graph showing Alabama's investment in health per Medicaid enrollee. For all full-benefit enrollees, Alabama's spending of $3,837 ranked 49th nationally. The U.S. average was $5,736. For children, Alabama's spending of $2,085 ranked 44th nationally. The U.S. average was $2,577. For adults, Alabama's spending of $2,043 ranked 49th nationally. The U.S. average was $3,278. For individuals with disabilities, Alabama's spending of $7,249 ranked 51st nationally. The U.S. average was $16,859. For seniors, Alabama's spending of $7,987 ranked 46th nationally. The U.S. average was $13,063.
Source: Kaiser Family Foundation, State Health Facts 2014

What services does Medicaid cover?

To qualify for federal funding, state Medicaid programs must cover:

  • Well-child check-ups, known as EPSDT (Early Periodic Screening, Diagnosis and Treatment, including dental services), for all Medicaid-eligible children under age 21. Because most Medicaid beneficiaries (also known as members) are children, EPSDT is the most wide-reaching Medicaid service.
  • Inpatient and outpatient hospital care.
  • Doctor services.
  • Laboratory and X-ray services.
  • Skilled nursing.
  • Family planning services.
  • Pregnancy-related services.
  • Ambulance services.

Alabama is one of only three states where Medicaid does not cover any dental care for adults.

The federal government also identifies optional Medicaid services that states may offer. Alabama offers only a few of these, including adult prescription drug coverage, adult prosthetics and community-based hospice care. In addition, Alabama has waivers, or special permission, to offer home- and community-based long-term care and regionally based coordinated primary care.

IN FOCUS

Children with special health care needs

Alabama Medicaid and ALL Kids together cover more than 105,000 children with special health care needs. These children are at increased risk for chronic physical, developmental, behavioral or emotional conditions. They require services tailored to these needs.

The Medicaid portion of this population includes more than 21,000 children who received Supplemental Security Income (SSI) in 2018. A child receiving SSI has a medically determinable physical or mental impairment, including emotional or learning problems, that results in marked and severe functional limitations and has lasted or can be expected to last for a continuous period of at least 12 months.

An image of Bryant-Denny Stadium in Tuscaloosa, Alabama.
A SENSE OF SCALE: 105,000 children are more than the capacity of Bryant-Denny Stadium (101,821). (Photo: AP Images)

SPOTLIGHT

Meet Mattisa Moorer and Kerstin Sanders

A portrait of Kerstin Sanders and her mother, Mattisa Moorer.
Kerstin Sanders and her mom, Mattisa Moorer, have become champions for special education services in Lowndes County schools. (Photo: Judy Barranco)

Like many teenagers, Kerstin Sanders enjoys movies, being out in the crowd, chilling out and sleeping in. Cerebral palsy, Dandy Walker Syndrome, epilepsy, scoliosis and restrictive lung disease are facts of her life, but they aren’t her life.

Kerstin is a treasure to anyone who takes the time and effort to know her, says her mother, Mattisa Moorer.

As Kerstin ages, her care becomes more complex. For example, multiple surgeries and procedures have made it necessary to change her feeding tube more frequently. Medicaid pays for most of the medications and supplies that Kerstin needs every month.

“It’s been a life-saver,” Mattisa says.

The Lowndes County single mom realized she would need to be an advocate for her daughter when Kerstin entered Head Start. At first, the school’s special education coordinator listened carefully and designed a plan that allowed Mattisa to be a classroom aide. But a change of administration caused the plan to unravel.

“I saw that I need to continuously advocate for Kerstin’s inclusion and, at middle school, her access,” Mattisa says. That calling now has expanded to include working part-time as a parent consultant with Family Voices of Alabama and serving as a consumer representative with her local Alabama Coordinated Health Network (ACHN).

While patient advocacy has come with struggles — waiting lists, paperwork, hard-to-obtain information — Mattisa values her successes. She considers the camaraderie of others in similar situations to be one of her biggest wins.


Medicaid Matters (Main Section)
How is Medicaid improving coverage? (Section 2)
Who’s still left out of health coverage? (Section 3)
How can we make Alabama healthier? (Section 4)

Medicaid Matters – Section 2: How is Medicaid improving coverage?

MEDICAID IMPROVEMENTS

What you need to know…

A woman and child with a sign reading #IamMedicaid
(Photo: #IamMedicaid)
  • New Medicaid changes seek to improve health and cut costs by rewarding timely and preventive care.
  • The statewide Integrated Care Network (ICN) is coordinating long-term care for about 23,000 Alabamians.
  • Seven regional Alabama Coordinated Health Networks (ACHNs) are coordinating primary and specialty care for about 750,000 Alabamians.
  • The ICN and ACHNs have Consumer Advisory Committees and consumer representatives on their boards.
  • ACHNs have identified infant mortality, obesity and substance use disorders as top priorities for improvement.

Steps in the right direction

Recent changes in the way Medicaid members get their care are promising moves in the right direction. By rewarding prevention and appropriate, timely care, Medicaid hopes to improve health outcomes, while bringing costs down in the process.

The new plans can be a significant improvement over the old Medicaid system, if they keep the focus on better health. One way to improve the chances for success is to have a strong consumer voice at the policy table. The changes are happening on two tracks:

  1. Long-term care for people who need assistance with activities of daily living.
  2. Primary care for children and pregnant mothers.

Public policy is better and more responsive when people have a say in decisions that affect their health and well-being. And Alabama Medicaid reforms are lifting those voices.

Rethinking Medicaid long-term care

A circle graph showing that 70% of Integrated Care Network members lived in a nursing facility in 2019 while 30% lived at home.For long-term care patients, Medicaid has a new plan called the Integrated Care Network (ICN). The ICN coordinates care for Medicaid members who live in nursing facilities or receive certain home- and community-based waiver services. There are only about 23,000 of these members across Alabama, so one statewide ICN serves all of them.

In 2019, roughly two-thirds of people served by the ICN lived in nursing facilities, and about one-third were living at home. The goal of the program is to help more people get long-term care services in their home and community, if that’s what they want. The ICN works with the 13 Area Agencies on Aging across the state to coordinate long-term care for Medicaid members who qualify.

The ICN also has a strong consumer voice at the policy table. Four consumer advocates serve on the governing board. And the Consumer Advisory Committee (CAC) includes eight consumer representatives. The chairperson of the CAC (Dr. Eric Peebles, featured below) receives home-based long-term care services through a Medicaid waiver.

A map showing the coverage area for each of Alabama's 13 Area Agencies on Aging (plus the Regional Planning Commission of Greater Birmingham). Visit alabamaselect.com to learn more about the regional organization in your area.
AREA AGENCIES ON AGING: Thirteen Area Agencies on Aging (plus the Regional Planning Commission of Greater Birmingham) provide care coordination for ICN members. Visit the ICN website at alabamaselect.com to learn more about the regional organizations. (Source: Alabama Department of Senior Services)

SPOTLIGHT

Meet Dr. Eric Peebles

A portrait of Dr. Eric Peebles
For Dr. Eric Peebles of Auburn, the path of advocacy for independent living began in an upstate New York elementary school. (Photo: Matt Okarmus)

School officials in the New York community where Eric Peebles grew up tried every excuse in the book to prevent him from starting school. “We can’t find him an appropriate classroom aide,” they said. Or “his power wheelchair is a danger to the other students.”

It was the mid-1980s, and federally mandated special education was still a relatively new policy. But those officials didn’t know what they were getting into when they threw roadblocks in the path of Eric and his mom, Pat. Two years, multiple runarounds and a lawsuit later, Eric’s school district found itself under federal supervision, and all district administrators involved in his case lost their jobs. His mother was appointed to the search committee for their replacements.

Thanks to his mom, Eric got an early education in self-advocacy. That groundwork served him well 25 years later when he moved to Alabama to complete his doctorate and join the undergraduate faculty in rehabilitation and disability studies at Auburn University. His personal experience with spastic cerebral palsy (resulting from oxygen deprivation at birth) gives him an insider’s perspective on disability policy and services — and on stereotypes. One misconception he fights hard to dispel is the assumption that his advocacy is aimed solely at asserting his own rights and opportunities, rather than those of all people with disabilities.

‘Greater things to come’

When Eric moved here nearly 10 years ago, Alabama Medicaid’s long-term care services were so sparse that he maintained his residency in another state until the menu of services expanded. Today, he enjoys community self-sufficiency through his participation in the Alabama Community Transition (ACT) waiver. In addition to running his own research and consulting business, Accessible Alabama, Eric serves on the board of the Disabilities Leadership Coalition of Alabama and chairs the Medicaid Integrated Care Network (ICN) Consumer Advisory Committee. In 2019, Gov. Kay Ivey appointed him to the State of Alabama Independent Living Council.

Those long-ago school officials left a mark they couldn’t foresee. Among all his achievements, Eric counts the success of his own former students as a special point of pride. But his advocacy story is still being written, he says. “It feels like these accomplishments are forerunners of greater things to come.”


A regional approach to Medicaid primary care

Under Alabama Medicaid’s new structure, seven regional Alabama Coordinated Health Networks (ACHNs) coordinate primary care for Medicaid children, pregnant mothers and people who receive family planning services. Primary care includes well-child visits; EPSDT (Early Periodic Screening, Diagnosis and Treatment) for children; adult screening, diagnosis and treatment; and preventive care.

Each member can choose a primary care doctor to be their “patient-centered medical home.” Each ACHN has a phone line to call when a Medicaid participant has a health problem. The basic idea is that nurses, social workers and care coordinators working with the primary care doctor can help people get the right care for the right problem without going to the emergency room whenever they get sick.

A map of Alabama showing the coverage areas of the seven regional networks that provide primary coordination for ACHN members: Northwest, Northeast, East, Jefferson-Shelby, Central, Southwest and Southeast.
Seven regional networks provide primary care coordination for ACHN members. Visit medicaid.alabama.gov to learn more about the ACHNs.

Medicaid ACHNs bring a new focus on consumer engagement and better health

The regional network plan gives Medicaid new tools for improving health outcomes. The ACHN can help patients identify health goals, create a care plan and connect with community resources that promote better health. The new plan serves about 750,000 Medicaid members across seven regions. Each ACHN has a consumer representative on its board, in addition to a Consumer Advisory Committee (CAC).

Bonus payments for doctors who reach quality benchmarks are another feature aimed at improving care. Each ACHN also is conducting Quality Improvement Projects (QIPs) targeting three health measures for improvement:

  • Infant mortality
  • Obesity
  • Substance use disorders
A group photo of Medicaid consumer representatives and other advocates.
Medicaid consumer representatives in Alabama have teamed up for training and peer support. (Photo: Renée Markus Hodin)

SPOTLIGHT

Meet Audrey Trippe

A photo of Audrey Trippe and her child.
Navigating the complicated system of mental health and substance use services motivated Audrey Trippe of Attalla to step up and serve as a Medicaid consumer representative. (Photo: Courtesy of Audrey Trippe)

Audrey Trippe, a resident of Attalla in Etowah County, has worked in mental health care since 2013, serving as a peer support specialist, peer supervisor, youth peer and certified addiction counselor. She and her husband are the proud parents of two boys, one of them a newborn.

Audrey considers herself in long-term recovery from major depression and substance use disorder. She has spent most of her young adulthood in the coverage gap, relying on urgent care clinics and the ER. Being heard has been a challenge.

“There have been times I’ve felt like a chart and not a person,” she says. “I’ve felt overmedicated at times because I couldn’t communicate what feelings were from my mental issues and what feelings were normal for substance use recovery.”

For a while, Audrey and her husband had enough income to purchase Marketplace insurance, which covered her first pregnancy. But a series of financial setbacks put her back in the gap — and her baby into Medicaid coverage. She qualified for Medicaid herself with her second pregnancy. Now that the baby is born, Audrey’s coverage will expire 60 days after delivery.

‘Great hope for the future’

Navigating these ins and outs, ups and downs has motivated Audrey to help others find their way. That’s why she said yes when a friend at the Alabama Disabilities Advocacy Program asked her to be a consumer representative for her local Alabama Coordinated Health Network (ACHN). She wants to be an “authentic voice” for consumers.

“I want to educate individuals about the options they have and teach them how to have helpful conversations with their own care providers,” she says.

While Audrey faces returning to the coverage gap when her pregnancy coverage expires, she maintains a positive outlook.

“I believe things are getting better all around, and I have great hope for the future,” she says. “There are still things that need to change, but change — like recovery — takes time.”


Priority for improvement

Infant mortality

Alabama’s regional Medicaid networks have identified infant mortality as a key target for improving health outcomes. That’s a promising step. Evidence from Medicaid expansion states shows that providing women continuous health coverage — not just during pregnancy — would make a life-saving difference. Lowering the high rate of African American infant deaths is the key to overall improvement.

National ranking: 45th
A bar graph showing infant mortality rates by race in Alabama in 2017. Infant mortality rate = deaths before age 1 per 1,000 live births. The rates were 11.3 for black Alabamians, 5.6 for white Alabamians and 5.2 for Hispanic Alabamians. The Alabama average was 7.4, while the national average was 5.8.
Source: VOICES for Alabama’s Children, 2019 Kids Count Data Book

A hidden crisis: Maternal mortality

In late 2019, the Alabama Department of Public Health (ADPH) announced the infant mortality rate for 2018 at a record low 7.0 per 1,000 live births. National comparisons are not yet available. Alabama’s infant mortality rate is improving but remains one of the highest in the country, and racial disparity in birth outcomes is widening.

A particular concern is the continuing increase in the percentage of births with no prenatal care, which rose to 2.4% in 2018, ADPH reports.

A bar graph showing Alabama's maternal mortality rate, defined as deaths per 100,000 live births. The rate is 61.7 for black Alabamians and 23.7 for white Alabamians. Alabama's average is 34.5. The national average is 29.6.
Source: America’s Health Rankings, 2019 Health of Women and Children Report

The chief medical causes of infant death include congenital abnormalities, low birth weight and preterm births, Sudden Infant Death Syndrome (SIDS) and bacterial sepsis, according to ADPH. Health researchers are discovering how social factors like place of residence, environmental influences and available resources play a role in determining different outcomes for different racial groups.

Maternal deaths in childbirth occur more rarely than infant deaths, but they are a stark indicator of racial disparities in health care. Black mothers in Alabama die in childbirth at nearly three times the rate of white mothers, and nearly double the overall statewide rate.

Priority for improvement

Obesity

Alabama’s regional Medicaid networks are working to reduce the state’s obesity rate. Extending Medicaid coverage to adults with low incomes would allow thousands more Alabamians to benefit. That would mean healthier families and a healthier workforce.

National ranking: 45th
Bar graphs showing Alabama's obesity rates. Alabama's overall rate is 36.2%, compared to the 30.9% national average. The rate for Alabama children ages 10-17 is 35.5%, compared to the national average of 31.2%.
Source: America’s Health Rankings, 2019 Annual Report

A leading cause of obesity is food insecurity, or the inability to provide adequate food for one or more household members because of lack of resources. Families experiencing food insecurity may rely on low-cost, high-energy foods and beverages, which can lead to overconsumption of calories and result in obesity.

16.3% of Alabama households experienced food insecurity in 2019, for a national ranking of 46th. The national average was 12.3%.

Healthy foods, such as fresh fruits and vegetables, are more expensive and less available in some communities than in others. A CDC study found that only 6.1% of Alabama adults meet the daily vegetable intake recommendation. And only 8.8% of Alabama adults meet the daily fruit intake recommendation. Medicaid programs in other states are exploring ways to make healthy foods more accessible and affordable where people live, work, learn and play. (Source: America’s Health Rankings, 2019 Health of Women and Children Report)

Priority for improvement

Substance use disorders

Alabama’s regional Medicaid networks seek to boost the availability of treatment for
substance use disorders. In the past five years, drug deaths in Alabama increased 37%, from 11.7 to 16.1 deaths per 100,000 people. Despite the increase, Alabama’s drug death rate remained below the national average of 19.2 deaths per 100,000. (Source: America’s Health Rankings, 2019 Annual Report)

Infographic states the following: Alabama ranked #1 in per capita opioid prescriptions, equivalent to 1.1. prescriptions for every person in the state in 2017. Geographical disparity: Lowndes County has 0.004 prescriptions per person, which is the lowest in the state, while Walker County has 2.2 prescriptions per person, which is the highest in the state. Alabama's overall ranking for mental health is 40th. When addressing substance use disorders, it can be helpful to consider the broader context of mental health. Alabama's national ranking for overall mental health is 40th. Alabama's ranking for access to mental health care is even worse - 46th. On the measure of frequent mental distress, Alabama's ranking of 45th is among the nation's worst. 15.6% of Alabama adults surveyed reported their mental health was not good on 14 or more days in the past 30 days. Racial disparity: American Indian (30.9%), Black (15.4%), Multiracial (21.5%), White (15.7%). Sources: Centers for Disease and Prevention; The State of Mental Health in America 2020, Mental Health America; America's Health Rankings, 2019 Annual Report.


 

Medicaid Matters (Main Section)
How does Medicaid work in Alabama? (Section 1)
Who’s still left out of health coverage? (Section 3)
How can we make Alabama healthier? (Section 4)

 

 

Medicaid Matters – Section 3: Who’s still left out of health coverage?

MEDICAID COVERAGE GAP

What you need to know …

A smiling woman's face.
(Photo: Courtesy of Audrey Trippe)
  • More than 220,000 Alabamians are caught in the state’s health coverage gap, earning too much to qualify for Medicaid and too little to afford private insurance.
  • Another 120,000 Alabamians are stretching to pay for coverage they can’t afford.
  • Tens of thousands of Alabamians in the coverage gap are between jobs or are working in essential, low-paying fields like child care, construction and food service.
  • 13,000 Alabama veterans and adult family members have no military insurance and can’t afford private plans.
  • Nearly 65,000 rural Alabamians are caught in the coverage gap.
  • Eight rural Alabama hospitals have closed since 2011.
  • 88% of the state’s rural hospitals operate at a loss.

Alabama’s ‘bare bones’ Medicaid leaves out more than 340,000 people

A family of three with countable income of just $3,841 a year earns too much for the parents to get Medicaid coverage.

As we’ve seen, Alabama Medicaid serves mostly children and people with special health care needs. Only Texas makes it harder for working-age adults without a disability to get Medicaid. First, you have to be a parent of a dependent child. Second, you can’t earn more than 18% of the federal poverty level.

Because of our state’s stringent limits, about 223,000 Alabamians are caught in the coverage gap. Working low-wage jobs that often don’t offer health insurance, they earn too much to qualify for Medicaid and too little to afford private insurance. Some are caught because they’re family caregivers, students, waiting for a disability determination, or working part-time. About 120,000 more are stretching to pay for coverage they can’t afford.

Alabama’s working families need health security

They’re the folks who keep things going — the people who serve our food at restaurants, bag our groceries, patch our roofs and repair our cars. They work hard at economically essential jobs that pay low wages. Yet many of these Alabamians have no affordable health coverage option. As a result, they often struggle to work while dealing with health problems that sap their productivity, add stress to their households and worsen without timely care.

A graph that shows the top 9 occupations that would benefit from expanding Medicaid in Alabama and the number of people in each. Food service (fast food workers, cooks, restaurant servers) 28,000. Sales (cashiers, retail salespeople, travel agents) 23,000. Construction (carpenters, laborers, painters) 20,000. Cleaning and maintenance (housekeepers, janitors, landscapers) 18,000. Office and administrative support (hotel desk clerks, office clerks, messengers) 17,000. Production (butchers, laundry workers, tailors) 16,000. Transportation (bus drivers, taxi drivers, parking attendants) 14,000. Personal care and support (barbers, child care workers, personal care aides) 10,000. Installation and repair (mechanics, equipment installers, locksmiths) 6,000. Other jobs 32,000. Source: Center on Budget and Policy Priorities analysis of U.S. Census Bureau American Community Surveys, 2013-17.

IN FOCUS

Working Alabamians in the gap

They earn too much to qualify for Medicaid, and they can’t afford employer-based coverage or private insurance. Medicaid expansion would make life better for Alabama’s low-wage workers and strengthen our state’s workforce.

An infographic that breaks down the 58,000 uninsured working men who are caught in Alabama's health coverage gap by occupation: Construction (14,460); food services (8,830); landscaping (3,850); auto industry (1,770); warehousing (1,700); auto repair (1,560); home centers (1,530); animal processing (1,310); retail stores (1,000); security (910); other jobs (21,490).
Source: Center on Budget and Policy Priorities analysis of U.S. Census Bureau American Community Surveys, 2013-17

An infographic that breaks down the 50,000 uninsured working women who are caught in Alabama's health coverage gap by occupation: Food services (8,720); building services (2,370); gas stations (1,800); grocery stores (1,670); auto industry (1,490); hotels/motels (1,460); social services (1,370); child care (1,360); schools (1,330); retail (1,250); other jobs (26,980). Source: Center on Budget and Policy Priorities analysis of U.S. Census Bureau American Community Surveys, 2013-17.

Alabamians who aren’t formally employed need coverage, too

While it’s helpful to highlight the workers in the coverage gap, it’s equally important not to overlook people who don’t hold formal jobs. There are many reasons people in the coverage gap may not be working a regular job. Health coverage is a work support that helps people gain and maintain employment.

This graphic highlights some categories of people without traditional full-time employment who are caught in Alabama's health coverage gap: Entrepreneurs, contract workers, gig workers, people who work part-time, seasonal or varied work periods, people who care for children or older family members at home, people awaiting an SSI disability determination, people enrolled in school full-time or part-time, people who lack permanent housing and people who are between jobs.


SPOTLIGHT

Meet Kenneth Tyrone King

A portrait of Kenneth Tyrone King.
Like thousands of his fellow Alabamians, Kenneth Tyrone King of Birmingham works without health insurance, doing his best to keep chronic health problems under control. (Photo: Julie Bennett)

Kenneth Tyrone King is an “underemployed” resident of Birmingham, where he lives with his wife and daughter. He chooses the term “underemployed” carefully, as a testament to the difficulty of finding and keeping work in the face of chronic health challenges, including an irregular heartbeat. Volunteer work and community advocacy, including service on the Alabama Arise board, give him a sense of connection and purpose, but they don’t pay the bills.

“Most of the jobs I have are temporary,” he says. “And if they do sustain longer-term, they sometimes just end.”

Kenneth isn’t able to obtain health insurance because the work he can get doesn’t provide it. And he can’t afford coverage through the Marketplace.

“I’m thinking about longevity in life and being here for my daughter and my wife,” Kenneth says. “Hopefully, if I can get employment that would have health benefits, that would offset my concerns about my health overall.”


IN FOCUS

Veterans in the health coverage gap

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. Treatment for service-connected conditions has no time-of-service requirement, but other health benefits do.

Active-duty service members and their families receive health coverage through the Department of Veterans Affairs (VA). Most also receive “bridge” health insurance coverage in the 180 days before and after their active-duty service. But many Alabama veterans — including many National Guard and Reserve members — return home without military health care for the long term. For the 13,000 Alabama veterans and adult family members who have no military health insurance and can’t afford private plans, the consequences can be dire.

Returning to civilian life can be challenging enough without the added burden of being uninsured. Alabama can show its respect for veterans by giving them the health security they need.

An infographic on Alabama veterans without health coverage. Of the 5,062 veterans with low incomes who lack coverage, 3,250 are men and 1,812 are women. Of the 7,934 low-income adults who live with veterans who lack coverage, 3,231 are men and 4,703 are women. Source: Center on Budget and Policy Priorities analysis of U.S. Census Bureau American Community Surveys, 2013-17.

IN FOCUS

Rural Alabamians in the health coverage gap

Almost 65,000 rural Alabamians are caught in the health coverage gap, including nearly 4,000 farmers and farm workers. Inadequate health care funding is fraying Alabama’s rural hospital network.

Two state maps of Alabama showing counties with hospitals providing obstretics. In 1980, the following counties did not have hospitals providing obstetrics: Lamar, Blount, Cleburne, Coosa, Autauga, Lowndes, Butler, Conecuh and Bullock. In 2019, the following counties did not have hospitals providing obstetrics: Franklin, Lawrence, Marion, Winston, Blount, St. Clair, Cherokee, Lamar, Fayette, Pickens, Clay, Cleburne, Randolph, Greene, Hale, Perry, Chilton, Coosa, Chambers, Sumter, Marengo, Autauga, Lowndes, Macon, Bullock, Russell, Choctaw, Wilcox, Washington, Butler, Conecuh, Crenshaw, Pike, Barbour, Dale, Henry and Geneva.Rural hospitals in states that increased Medicaid eligibility and enrollment experienced fewer closures,” a 2018 report by the U.S. Government Accountability Office found. Alabama has lost obstetrical services in 29 counties since 1980. Expanding health coverage would protect Alabama’s rural families, hospitals and communities.

An infographic showing that 8 rural hospitals have closed since 2011, 88% of Alabama's rural hospitals operate in the red and only 16 of Alabama's 54 rural counties have obstetrical services.


Medicaid Matters (Main Section)
How does Medicaid work in Alabama? (Section 1)
How is Medicaid improving coverage? (Section 2)
How can we make Alabama healthier? (Section 4)