‘It’s time for someone to stick up for us’: Walker County’s need for Medicaid expansion

Rev. Robin Hinkle stands in front of the sign for St. Mary's Episcopal Church
Rev. Robin Hinkle is the rector at St. Mary’s Episcopal Church in Jasper. Her ministry has greatly scaled up food assistance to the community to help ease financial suffering during the COVID-19 recession. (Photo courtesy of St. Mary’s Episcopal Church)

Walker County has gained notoriety in recent years as one of the epicenters for Alabama’s opioid epidemic. Overprescribing, lack of health care access and extreme poverty seemed to form a cursed trifecta leaving residents of the rural county to rebuild and recover.

Outside the headlines, community organizations and rural health advocates have been earning praise for their efforts to bring as many resources as possible to the northwest Alabama county of 67,000 people.

“If there’s a problem, you don’t have to look far for someone to help,” said Rev. Robin Hinkle of St. Mary’s Episcopal Church in Jasper.

Hinkle’s ministry has scaled up its food assistance to the community exponentially in the last year. The church went from distributing about 250 bags of food a week to more than 1,000 bags a day. Hinkle said the COVID-19 pandemic and its associated recession left more people than ever in need.

“The system is absolutely not working as it is, especially with the state and local governments,” she said.

Hinkle said many people she works with do receive Supplemental Nutrition Assistance Program (SNAP) benefits or other public assistance. But the income restrictions attached often force people to make painful decisions.

“I see it all the time,” Hinkle said. “When you lose your insurance and paycheck, what used to be $5 at the pharmacy is now $40. And the first thing you give up is medicine.”

‘A big, giant problem’

Hinkle said she has been offering more financial assistance than expected to families on the margins of the middle class. Many of these households have been hit hard by the pandemic, too. And resources can be scarce for families who make too much to qualify for public assistance, but still not enough to reliably pay the bills.

These are the families who are in Alabama’s health coverage gap. They make too much money to qualify for Medicaid under the state’s stringent eligibility limits but not enough to get a subsidy to help pay for a private insurance plan on the health care marketplace.

Alabama is one of 12 states that have not expanded Medicaid to cover adults with low incomes. Even before the pandemic, more than 220,000 Alabamians were caught in the coverage gap. And another 120,000 were stretching to pay for coverage they can’t afford.

“This is a big, giant problem,” Hinkle said. “Once you lose a job or are forced to work minimum wage, it’s very hard to be poor because of all the gaps in our system.”

Medicaid expansion would relieve the burden on families and those deciding whether to pay for medicine or buy groceries, Hinkle said.

“If we had better access and treatment options, it’s better all around,” she said. “Every dollar counts. If we could just get the resources, we can work to solve the problem just like we’ve done before.”

Removing barriers and strengthening rural clinics

Over the past decade, community organizations have come together to form networks bringing more money and treatment options into the county. Spearheaded by the Walker County Community Foundation, the Healing Network of Walker County includes 25 organizations providing prevention, intervention, treatment and recovery resources for mental health and substance use disorders.

One of those partners is Capstone, a group of rural health clinics located across Walker and neighboring Winston counties.

“Over half of our patients are uninsured, and the majority of the others receive Medicare or Medicaid,” said Dr. F. David Jones, executive director of Capstone Rural Health in Parrish.

Jones is one of more than 300 medical professionals who signed a joint letter last week urging Gov. Kay Ivey to expand Medicaid.

Photo of Dr. F. David Jones
Dr. F. David Jones is executive director of Capstone Rural Health in Parrish. He said Medicaid expansion would allow clinics like his to grow and serve more people across Walker County. (Photo courtesy of Capstone Rural Health)

Capstone’s clinics often house primary care, dentistry, pharmacy, social work and mental health care under one roof. While this one-stop shop can be invaluable for rural communities, Jones said access barriers are always involved when someone is struggling to make ends meet.

“We do still need to see valid ID, a bill showing your current address, and proof of income, which can be hard to get if you’re unemployed or don’t have a license,” he said.

Jones said the clinic tries to treat everyone who comes in. But even with local help, they can’t do it all.

“Communities can keep casting off the poor by just ignoring all their problems or burdening the church, but they need us more than they realize,” he said.

Medicaid expansion’s life-saving potential in Walker County

An injection of money from Medicaid expansion could be a lifesaver, Jones said. The funding could ease the burden placed on community health centers and UAB to treat areas of Walker County with low access.

“Medicaid expansion is a no-brainer,” he said. “With that kind of money coming in, we would grow. We could bring professionals in, and it could prop up a lot of the other community health centers that do good work.”

Jones said he hopes Alabama can put aside partisan politics and finally take advantage of the taxes we already use to pay for Medicaid expansion in other states.

“I hope the governor will sign on,” he said. “It’s time for someone to stick up for us. We should’ve been at that table a long time ago.”

About Alabama Arise and Cover Alabama

Whit Sides is the story collection coordinator for Alabama Arise. Arise is a nonprofit, nonpartisan coalition of congregations, organizations and individuals promoting public policies to improve the lives of Alabamians with low incomes.

Arise is a founding member of the Cover Alabama Coalition. Cover Alabama is a nonpartisan alliance of more than 100 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.

‘Everything is fine, until it isn’t’

Elizabeth works at a sewing machine in the family’s home. (Photo courtesy of Geoff)

Part 1: A hard winter ahead

Winter has been a long time coming for Geoff* and his wife, Elizabeth*. He didn’t think he could actually feel more anxious than he had since March, when he and his family began isolating along with the rest of the country.

(*Geoff and Elizabeth agreed to share their story using pseudonyms to protect their privacy.)

Every day since has been essentially the same. Geoff wakes up early to go for a run around his neighborhood in Montgomery. He gets back in time to get the kids ready for their long day of virtual learning.

But this morning, Geoff felt himself dragging.

“I am a young dude, but I get a new creak or squeak every day,” he says jokingly. Running used to be so much easier when he was in his 20s, he said. He’s now in his mid-30s.

His tone begins to shift, and his voice becomes heavy. “I lay down to go to sleep and everything is fine, until it isn’t,” he says.

Back in May, like millions of other Americans, Geoff started to realize his job was becoming less secure. Finally, in September, he was let go. “That’s when I started experiencing panic attacks,” Geoff said. “And like, who wouldn’t in my situation?”

Geoff lost his income, his daily routine and his health insurance on Oct. 1. He has found it hard to sleep ever since.

Alabama’s coverage losses have soared during the pandemic

The COVID-19 pandemic and resulting economic crash have caused the greatest health insurance losses in American history, according to research published by the nonpartisan research organization Families USA in July.

An estimated 5.4 million workers became uninsured because of job losses they experienced from February to May this year. And 69,000 of those are in Alabama.

“Even before COVID-19, Alabama’s failure to expand Medicaid left more than 220,000 adults uninsured,” Alabama Arise campaign director Jane Adams said. Adams directs Cover Alabama, a coalition of nearly 100 organizations pushing for Medicaid expansion in Alabama. Arise is a founding member of the coalition.

“Further coverage losses during the ongoing economic 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 more families will fall into poverty.”

‘All the things I had that I suddenly don’t’

For Geoff, this coverage loss means every choice he makes could bring a new risk.

“I just lay there and my brain reminds me of all the things I had that I suddenly don’t, and it changes the way I interact with the world,” he said.

Geoff and his wife both remain physically active, he said. He used to take comfort in the alone time that running provided. But after he lost insurance, every crack in the pavement or acorn on the sidewalk gives him yet another thing to worry about.

“I have nothing,” he said. “If I fall and twist my ankle, that’s it. I won’t be able to provide for my family.”

Part 2: Sacrifice

Geoff and Elizabeth own a small event business in Montgomery. They have relied heavily on working weddings and other public events to pay the bills since losing his salary. Without these gigs, he said, he has no idea how they would make it after losing his salaried job.

Elizabeth also does freelance work that allows their kids to be covered under her private insurance. When Geoff first learned he’d be laid off, he immediately asked his wife if he could join her plan.

“You just take this stuff for granted, right?” Geoff said. “I had great insurance under my parents. Then, I was covered in college, and right after, I was blessed to get a good job,” he said.

But when he saw the monthly premium to get coverage with the rest of his family, he knew it wasn’t an option.

“It was thousands of dollars just to add me!” he said, exasperated. “She doesn’t even make that much altogether!”

Beyond just money, Geoff said he fears most for his children.

A simple hospital visit would cost several thousand dollars thanks to a high deductible, he said. Even a quick trip to the doctor for his children would set them back on groceries for a few weeks.

“I make sacrifices,” he said. “I haven’t bought anything for myself since April, but I still can’t give my kids everything they need, and that is terrifying.”

Geoff and his wife have relied on word of mouth to book business. Their work often means taking jobs that leave the family at higher risk of contracting COVID-19.

“I’m a healthy guy, but every day you see a news story with bodybuilders… guys bigger than me hospitalized and their bodies just ravaged by this virus,” he said.

Parental coverage loss hurts children, too

“COVID-19 is jeopardizing lives and economic security for thousands of Alabama workers just like Geoff,” Adams said.

And now that case numbers are rising exponentially as the United States faces its third wave of COVID-19, many local communities are facing long-term challenges for health care capacity and economic recovery.

Geoff and Elizabeth’s children at the dinner table. (Photo courtesy of Geoff)

But Geoff said he has more to worry about than just the virus. “I’m getting used to the panic attacks because even though I’m undiagnosed, I know it’s a product of the situation I’ve been put in,” he said. “It’s not so easy when I think of my daughter.”

Geoff and Elizabeth’s young daughter was diagnosed with autism spectrum disorder at a young age and was receiving regular care from a specialist. After months of research to find a provider, it would take them even longer to get an appointment.

“And that was with great insurance,” Geoff said.

After losing his job, they could no longer afford the $150 out of pocket per visit. They stopped going to appointments.

“We are left with a child who spends all day at home with two parents who are very clearly not experts for autism. Not even close,” Geoff said.

Part 3: The shock of it all

It’s becoming harder and harder for Geoff to relax. What weighs the most, he said, is the shock of it all – even this long into the pandemic.

“I mean, look, I’ve been blessed my whole life,” he said. “I’m a white guy in Alabama. I have a college degree. My parents set me up for success. But things are falling down all around us.”

Geoff said he would vote for Medicaid expansion if it were on the ballot.

“Growing up in Alabama, you always gotta expect the worst but still try to vote for the best,” he said.

For the first time in his 30 years of living in Alabama, Geoff said he feels like state leaders might finally shore up the safety net that keeps so many Alabamians afloat.

“We have got to give up this long legacy of Scotch-Irish stubbornness passed on from our state’s founders hundreds of years ago,” he said. “It’s 2020. You can no longer pretend that you don’t know who you’re hurting by not offering folks help.”

Geoff’s family enjoying the beach. (Photo courtesy of Geoff)

‘I feel like I did everything right’

Recovering from the COVID-19 recession – as families, as a workforce, as a state – is going to require every tool and resource available. Closing the health coverage gap for tens of thousands of hard-working Alabamians like Geoff is the single biggest step our state can take to protect families from delayed health care and medical debt, strengthen our economy and move Alabama forward.

Geoff said if this year has taught him anything, it’s that being nimble is just as important as planning.

“I feel like I did everything right,” he said. “I did everything right, and still I woke up one day and none of that matters. I need help just like everybody else.”

About Alabama Arise and Cover Alabama

Whit Sides is the story collection coordinator for Alabama Arise. Arise is a nonprofit, nonpartisan coalition of congregations, organizations and individuals promoting public policies to improve the lives of Alabamians with low incomes.

Arise is a founding member of the Cover Alabama Coalition. Cover Alabama is a nonpartisan alliance of nearly 100 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.

Cover Alabama Conversations: Alabama Arise’s Jim Carnes

Alabama Arise’s Sherrel Wheeler Stewart talks to Arise policy director Jim Carnes about how Medicaid expansion would save lives and reduce suffering for hundreds of thousands of adults with low incomes across Alabama. They also discuss how expansion would help the state combat the COVID-19 pandemic and rebuild in its aftermath.

Listen to the full interview below:

Arise is a proud member of the Cover Alabama Coalition, which is urging Medicaid expansion in our state. Click here to share your health care story with Arise and Cover Alabama today.

Full transcript


Our state, our nation and our world are at a crisis point right now. The global pandemic COVID-19 is claiming thousands of lives, flooding hospitals with patients and wrecking the economy. In Alabama, it’s exposing a serious gap in health care for poor people in our state.

Now a coalition of partners, Cover Alabama, is working together to help bring change, expanded access to Medicaid now and a better quality of life in the years ahead.

I’m Sherrel Wheeler Stewart, story collection coordinator for Alabama Arise. I’m talking by phone with Jim Carnes, the Alabama Arise policy director. He tells us why Medicaid expansion is needed in Alabama right now.


So recently, the vice president said states have been given some flexibility in using their Medicaid dollars to help the uninsured at this time. What does it mean for Alabama? If anything?


If anything, there is that basic question offered by the Affordable Care Act. You know, will you expand Medicaid to cover this population of people who are earn up to 138% of the poverty level?

Alabama is one of 14 states that have not accepted that option. What’s happened with the COVID-19 pandemic is that states have some additional flexibilities. Now, a lot of these are flexibilities that states always have, but emergencies kind of open that door. And there are things Alabama could do through several different mechanisms, through a waiver process or an amendment process. The technical mechanisms differ, but the general idea is that there are a whole host of things that Alabama could do to broaden our coverage and to streamline coverage and services. For example, we could suspend a lot of the administrative processing required for people to get certain kinds of services or to get coverage that they qualify for.


In other words, what you’re saying is, get rid of some of the red tape?


Exactly, exactly. There is an opportunity now to get rid of a lot of the red tape. Alabama has made some moves in that direction. We have passed for and gotten permission to do a few things. But there are many more options available to Alabama that we have not yet sought.

Now, the option to expand Medicaid coverage to those adults, working-age adults, is something that is obviously still available. And Alabama has not chosen to do that. That is not, however, a new flexibility that is prompted by the emergency. There is not really an emergency expansion opportunity. We can roll out services in a new way, and we can make enrolling in coverage easier. But if we want to expand coverage outright, the opportunity still stands. We could do it. The word “expand” is the key there.

There are two things to bear in mind. No. 1 is that the Affordable Care Act 10 years ago gave states the authority to expand their Medicaid programs to cover low-income adults up to 138% of the federal poverty level and to include adults without children. Here in Alabama, which has the second most restrictive Medicaid program – we have the second strictest program after Texas – we allow adults under age 65 who do have a disability, which is sort of one way to distinguish between adults who qualify and adults who don’t. People with disabilities can get Medicaid coverage under certain conditions. But looking at what some people call able-bodied adults – that is, adults who are working-age without a disability. In Alabama, No. 1, you have to have a dependent child. And No. 2, your earnings cannot exceed 18% of the federal poverty level.


In dollars, what are we talking about here?


Yeah, well, for a family of three, that would be, you can’t earn more than $329, I believe. So it’s under $350 a month, if you think of it in big round numbers. If you earn more than $100 a week in Alabama, you can’t get Medicaid.


Well, that doesn’t sound like a whole lot. It sounds like what you get when you pick up lots of cans and just take them down to be recycled.


Yeah, exactly. I mean, you’re talking about not being able to hold a job and get Medicaid in Alabama. It’s extraordinarily restrictive.

We do a better job with children, children and families. Up to 146% of the poverty level can get coverage for the children, but their parents cannot get coverage. So, we’re dealing with an extremely low income limit in Alabama, which means we have a lot of folks who are walking around Alabama working every day in jobs that we all depend on. You know, all the service industries and just a variety of jobs, manufacturing and all kinds of jobs, that cannot qualify for Medicaid.


You know, a lot of these Alabamians are people who are on the front lines. They are the ones who are keeping us going right now. Am I correct?


Oh, exactly. I mean, we’re depending on them more than ever right now. Exactly.


Why is it important at this time for Alabama to expand Medicaid?


You know, it’s been important for 10 years, but it is more urgent than ever right now. There are there are many, many reasons. And I’d like to hit some highlights. One is that Alabama is a high-poverty state. We estimate that we have more than 200,000 Alabamians who are trapped in the coverage gap. They simply cannot afford to buy private or employer-based coverage, and they earn too much to qualify for our very restrictive Medicaid. So they are without an option. And as you pointed out, they are the people who are working the jobs that we have deemed essential. They are cleaning our hospitals, cashiering at our grocery stores, docking the shelves of our drug stores and grocery stores. They are keeping produce rolling from the farms to the stores. They are the people that we are all more aware of probably right now than we have been in a long time.

Essential workers without health coverage

I think everybody is tuned in now to the crucial jobs that those employees are serving and fulfilling in our state right now. And I know that I’m finding myself thanking the checkout clerk much more consistently than used to be, really trying to tell them that we appreciate their critical service at this time. These are people who are much too often going without health coverage. Similarly, people in the food service industry, while most of that has shut down, there are still people who are working to provide meals that can be picked up or delivered. And too often, those are folks who are going without health coverage. We also know that we’re going to come out of this shutdown, and people are going to be reentering the workforce with that same hindrance.

They are still going to be going without health coverage, unless we can do something now. One thing that I especially want to point out is that the recent measures that Congress has taken to address the coronavirus have made sure – and I’m grateful that they have – but they’ve made sure that there is free testing available. We hope that that is becoming more and more widely available, but there should be free testing rolling out across all of the states.


What happens if Alabama doesn’t act now to expand Medicaid?


We’ve just learned recently that there will be payments for hospitals to serve COVID-related illnesses for patients who were uninsured. But they don’t have— those same people don’t have coverage for anything else that may be wrong with them or that may happen to them in the meantime. So for an uninsured worker, for example, the idea of having to deal with illness from COVID, it can mean personal financial disaster. It can mean medical debt that is simply unsustainable.


When I hear you say these things, I think about my own perception of Medicaid and health care. You know, I always just thought that health care was one of those elements we needed to maintain a certain standard of living.


You hit the nail on the head. You know, one thing I’m hopeful about amid all this despair that we’re experiencing and the alarm is this bright light that we are seeing now on our health system and on our community networks and all of those infrastructural kinds of things that kind of go hidden or unnoticed. One result that I’m hoping to see is that our conversation will lead us to consider what really is the role of our public financing for the common good. What do we as communities really owe each other and ourselves in regard to a baseline safety net of public services that we all ultimately depend on?

I think never in my lifetime have we seen such a stark picture of how public services work, how they should work and how they sometimes fail. And I’m hoping that those failures and that sharp, bright light can help us reevaluate and have a really serious, productive conversation about our investment in the common good.


Talk to me a little bit about our health care system and the impact of the hospital system in Alabama.


Alabama is a state that has allowed its hospital system to become frayed. As you know, we’ve lost eight rural hospitals over the last 10 years and six hospitals in urban and suburban areas. So we are already— before the COVID-19 even emerged, we were suffering from a beleaguered hospital system.

The emergency is only going to tax those hospitals further to the limit in terms of their capacity to deliver care and their capacity to sustain the financial impact of the epidemic. Our hospitals are in more need than ever of the federal support that would come through Medicaid expansion.


But Jim, beyond the conversations, it seems like someone needs to be making things happen. And who is it? Is it the governor? Is it the Legislature?


Yes. Well, there is in Alabama— each state is different with regard to how its Medicaid works. It’s a federal-state partnership that gives states a lot of leeway. There’s the federal government sets kind of a baseline of services. But the states have a lot of flexibility. And when it comes to how they make Medicaid funding decisions, the states are really individual deciders on that.

In Alabama, the governor could initiate Medicaid expansion by approving a rule change. It’s a simple rule change that would raise our income limit for Medicaid benefits. Once she did that, there is a review process that would take that rule change to a legislative committee, and they wouldn’t even have to actively approve it. They could they could not object. In other words, they could allow the rule change to pass. They wouldn’t have to do anything. They would just have to turn the other way and let the governor do it.

The governor has that authority, but it still requires some consent, even passive consent, from a legislative committee. Once that happens, it would go to Washington for approval. And I cannot imagine that in this environment they wouldn’t expedite an approval.

I know that the Trump administration has not favored Medicaid expansion, but it’s almost impossible to believe they would deny it in this environment. Then it would go into effect. The Legislature would have to provide the extra funding for covering more people. But we think that’s an investment that would have immense return.


Now, in dollars, what’s that amount? What are we talking about here?


The estimates that we had before COVID-19 were that that year one would be that the highest costs for the state. The federal government pays 90% of the expansion cost. So in other words, the costs for enrolling and serving the new enrollees through the expansion. It’s a 9-to-1 federal program for expansion. Alabama’s cost, we estimate, would be $168 million. And then the feds would pick up the rest.

In subsequent years, we would begin to see the return on that investment. We would see new tax revenues from the increased economic activity. We would see new state savings in programs that we’re currently paying for entirely out of state dollars, particularly some mental health programs, and those would get the 90% match. So it would make new state money available. So in subsequent years, the estimate is that the state would pay about $25 million a year going forward for expansion. In return, we estimate about 340,000 Alabamians— you would get those people who are currently uninsured in the coverage gap, plus some eligible people who would then choose to take the Medicaid coverage in lieu of straining their family budget to pay for their private or employer-based coverage. So, we think about 340,000 people would get it.


Will COVID-19 change these projections? And if so, how?


We have to adjust those expectations a little bit, because COVID is going to make more people eligible, because more people are losing their jobs and losing their income. So more people would become eligible. However, the return that we would get on having those federal— that federal support for the health care for those Alabamians would be immense. I mean, that would just be an enormous gain for the state.

If we are saddled with even more uninsured people who are now facing even more health challenges in a hospital system that has not gotten that extra support it needs, then that just spells disaster for the state. So the hospital system itself is another beneficiary. Obviously, we would get to infuse those federal dollars into our struggling hospitals. That in turn would help revitalize our community economies, because, as you know, our state and local economies are going to be reeling from this blow.

So the best leverage we can use right now, just thinking beyond the health care system and beyond COVID— the best leverage we can use for bringing federal dollars into the state to respond and recover from the emergency is to expand Medicaid. We will get nine times the funding we put up as a state. So it’s a 9-to-1 gain. For a dime on a dollar, we could bring in billions of federal dollars to help our state recover and bounce back.


Let’s just say this moves through the process, through the governor’s office, through the Legislature. And then how long will it actually take for us to get Medicaid expansion in place in Alabama?


Our best guess is that it would take about six months for the coverage to get up and rolling. However, there’s a wonderful provision that allows Medicaid coverage to be retroactive in the quarter in which it starts. So the sooner we start – we’re now in the second quarter of the year, it’s the third quarter of the fiscal year – the sooner we start, we can retroactively cover from April 1.

So although it would take about six months to get the actual machinery up and running, so to speak, on getting coverage, we could we could actually build some of that retroactively. So we would have good financial coverage there. However, in the meantime, Alabama needs to use every tool in the Medicaid toolbox. That means going ahead and initiating all of the flexibilities that you mentioned earlier that we can to make enrollment easier, to make getting services easier, to make it easier for medical providers to get their payments. There are just all kinds of streamlining that we can do to expedite or fast-track our startup on Medicaid expansion.

Now is the time. Every day we waste is a day that puts more Alabamians at risk, that puts more hospitals at risk and more communities at risk of financial disaster.


This has been Cover Alabama Conversations. Thanks for listening.