Issue: Health

Alabama’s rate of uninsured children plunged to 2.4 percent in 2016

By Chris Sanders

Nearly 49 of every 50 children in Alabama had health coverage in 2016, according to U.S. Census data released the week of Sept. 12, 2017. Alabama’s share of uninsured children fell to 2.4 percent last year, far below the national average and an improvement on the state’s 2015 rate of 3.1 percent.

A huge piece of the credit for those recent coverage gains belongs to Medicaid and ALL Kids, Arise Citizens’ Policy Project executive director Kimble Forrister said Thursday. Together, the programs cover nearly 800,000 Alabama children who live in households with low or moderate incomes.

“All children deserve consistent, appropriate health care, and Alabama does a good job of helping them get it,” Forrister said. “Medicaid and ALL Kids help kids stay healthy so they can learn, play and thrive. It’s essential to ensure these programs have the funding they need to continue providing health coverage for our most vulnerable residents.”

Alabama’s low rate of uninsured children stands out even more when considering that nearly one in four children (or 24.3 percent) in the state lived in poverty last year. That rate was the sixth highest in the country and far worse than the 19.1 percent national rate. Overall, 17.1 percent of Alabamians lived below the poverty line in 2016, and 9.1 percent of the state’s residents lacked health insurance.

Congressional decisions in the coming weeks will shape the future of Medicaid and ALL Kids for years to come. Federal funding for the Children’s Health Insurance Program (known as ALL Kids in Alabama) is set to expire Sept. 30 unless Congress renews it. And a health care plan offered by Sens. Bill Cassidy, R-La., and Lindsey Graham, R-S.C., would impose Medicaid funding caps that would force deep cuts to coverage for children, seniors, and people with disabilities over time.

“Children’s health care is too important to be left up to chance,” Forrister said. “We urge Congress to protect Medicaid and ALL Kids and work together in a bipartisan way to make health care more accessible and more affordable for all Americans.”

New Alabama Medicaid reform plan must include strong consumer engagement and oversight

By Chris Sanders

Arise Citizens’ Policy Project policy director Jim Carnes issued the following statement Thursday, July 27, 2017, in response to Alabama Medicaid’s announcement that it will pursue an “alternative” to the regional care organization (RCO) reform plan:

“Alabama Medicaid’s decision to end its effort to develop homegrown managed care through regional care organizations is a disappointment but not a surprise. We’ve seen the Legislature’s support for the plan wane since it passed unanimously in 2013, as expectations for its budgetary impact shifted. Medicaid policy changes promised by Congress and the White House after the November election further clouded the prospects for RCO success.

“From the start, Arise has believed that strong consumer oversight is an essential component of Medicaid reform. That’s why we’ve worked hard with our partners at the Disabilities Leadership Coalition of Alabama to fulfill the consumer engagement role spelled out for us in the RCO law. We regret that this innovative, collaborative experiment has run aground, but we welcome the opportunity to apply those same consumer-focused principles in whatever alternative reforms Medicaid pursues.

“State ‘flexibility’ for Medicaid is a hot topic in Washington right now, and RCOs were a good example of state-based decision-making about health care delivery. But ‘flexibility’ cannot be a code word for undermining the basic promise of Medicaid by cutting essential benefits, shortchanging health care providers or taking away coverage from children, seniors, pregnant women, and people with disabilities across Alabama. Medicaid is the backbone of our state’s health care system, and we must keep it strong.”

ACA repeal plans would hurt everyday Alabamians

By Chris Sanders

Arise Citizens’ Policy Project policy director Jim Carnes issued the following statement Tuesday, July 25, 2017, in response to the U.S. Senate vote to begin limited debate on repealing the Affordable Care Act:

“The Senate’s 51-50 vote to fast-track a health care plan before even deciding which plan to consider was beyond reckless, but this process is far from over. Senators should oppose any bill that would increase insurance costs for struggling families or send us back to the bad old days of limiting benefits and discriminating against people with pre-existing conditions. We especially urge lawmakers to reject cruel cuts to Medicaid, which provides essential health coverage for children, seniors, pregnant women, and people with disabilities across Alabama and across the country.

“Every health care plan that Congress has considered so far this year would send out-of-pocket costs soaring and would leave millions more Americans, including tens of thousands of Alabamians, without health coverage. If ‘higher costs and a higher uninsured rate’ is your answer on health care, you’re asking the wrong question.

“The Senate should take a deep breath and work together in an open, thoughtful, bipartisan way to preserve the Affordable Care Act’s consumer protections, reduce insurance costs and extend quality, affordable health care to all Americans.”

Now is the time to repair, not repeal, the Affordable Care Act

By Chris Sanders

Arise Citizens’ Policy Project executive director Kimble Forrister issued the following statement Tuesday, July 18, 2017, in response to the collapse of U.S. Senate efforts to “repeal and replace” the Affordable Care Act:

“The defeat of the Senate’s awful health care bill was a victory for Alabama families. This cruel plan would have gutted Medicaid, which provides essential health coverage for children, seniors, and people with disabilities in every corner of our state, to pay for huge tax cuts for rich people and big corporations. It would have hammered rural hospitals and nursing homes while sending insurance costs soaring for many older Alabamians. And it would have sent us back to the bad old days of limiting benefits and discriminating against folks with pre-existing conditions.

“Powerful advocacy from everyday people across Alabama and across the country stopped the bad Senate bill in its tracks. We urge senators to stop trying to repeal the Affordable Care Act and start trying to make it work better for everyone. Our lawmakers should work together in an open, thoughtful, bipartisan way to strengthen the ACA, reduce insurance costs and extend quality, affordable health care to all Americans.”

What’s at stake for Alabama Medicaid?

By Alabama Arise

Our state simply can’t afford any more Medicaid cuts. Alabama’s Medicaid program is essential, and it has already been cut to the bone. More than 1 million people — or one in five Alabamians — have Medicaid coverage, and almost all of them are children, seniors, pregnant women, or people with disabilities. Medicaid covers thousands of people in every Alabama county, and cuts like the federal funding cap that Congress is considering would be devastating for low-income Alabamians and rural communities across the state.

This fact sheet explains who is covered under Alabama’s barebones Medicaid program, how Medicaid cuts would hurt vulnerable Alabamians and how slashing Medicaid would deal a serious blow to local economies and the health care infrastructure that benefits our entire state.

U.S. Senate health care bill would be bad for Alabama

By Chris Sanders

Arise Citizens’ Policy Project executive director Kimble Forrister issued the following statement Thursday, June 22, 2017, in response to the release of the U.S. Senate’s proposed health care bill:

“The Senate bill would be devastating for children, seniors, working families, and people with disabilities across Alabama. This mean-spirited plan would slash Medicaid and force millions of low- and middle-income Americans to pay more for insurance that covers less.
“Rural communities, older people, and folks with pre-existing conditions would suffer under the Senate plan, all for the sake of a massive tax cut for big corporations and wealthy households. The Senate bill is bad for Alabama and bad for America, and it deserves a swift defeat.”

U.S. Senate should protect Americans’ health care by rejecting House’s reckless ‘repeal and replace’ plan

By Chris Sanders

Arise Citizens’ Policy Project policy director Jim Carnes issued the following statement Thursday, May 4, 2017, in response to the U.S. House’s passage of the American Health Care Act:

“Today’s narrow U.S. House vote to repeal the Affordable Care Act in exchange for a giant tax cut for the wealthiest Americans sends a harsh message to Alabamians, but it’s not the final word. Unless the Senate rejects it, this bill would force harmful cuts to Medicaid, which covers more than 1 million children, low-income seniors, pregnant women and people with disabilities across Alabama. For everyone else, the bill would turn back the clock to a time when insurers could discriminate against people who got sick and could deny coverage for life-saving treatments by imposing annual and lifetime benefit caps.

“The Affordable Care Act has helped millions of people and saved thousands of lives across Alabama. Nearly 200,000 Alabamians have signed up for insurance through the ACA. More than 2 million Alabamians have pre-existing conditions that would have made it hard or impossible for them to get full coverage before the ACA lifted coverage caps and guaranteed their access to insurance. And the ACA has significantly reduced the number of uninsured young Alabamians by allowing 35,000 of them to remain on their parents’ plans until age 26.

“Instead of improving the current law with sensible, targeted changes, the House has voted to reverse the ACA’s gains and put our nation’s health care in peril. Alabamians have spoken out loud and clear against the House vote. It’s time to turn our voices to the Senate, where we’re counting on our senators to stand up for a healthier Alabama and stop this reckless bill in its tracks.”

Defeat of House health bill is a victory for children, seniors and families across Alabama

By Chris Sanders

Arise Citizens’ Policy Project policy director Jim Carnes issued the following statement Friday, March 24, 2017, in response to U.S. House leaders’ withdrawal of the American Health Care Act:

“The House health plan would have taken coverage away from 24 million Americans and put essential protections at risk for tens of millions more. It would have forced devastating Medicaid cuts that would have hurt children, seniors, and people with disabilities across Alabama. And it would have done all that to fund huge tax cuts for wealthy people and big corporations. It was a bad bill that deserved to die, and we’re glad it did.

“Defeating this bad bill was essential, but it was only the first step. Everyday Alabamians must keep up the pressure on lawmakers to strengthen the Affordable Care Act and make quality health coverage a reality for everyone. We urge Gov. Robert Bentley to expand Medicaid immediately to ensure that low-wage workers and struggling families across Alabama can get the care they need to stay healthy and productive.”

Budgets that would do little to boost investments in education, health care advance in Alabama Legislature

By Carol Gundlach

Running in place was the emerging theme this week as Alabama lawmakers advanced state budgets that would provide little additional money for education, Medicaid, mental health care and other essential services. Both the Education Trust Fund (ETF) and General Fund (GF) budgets await further action when the Legislature returns from spring break on April 4.

The House voted 72-28 Tuesday to pass a GF budget that would lean heavily on one-time money to prevent deep cuts to Medicaid, mental health care, corrections and other vital services. The next day, the Senate’s education budget committee approved an ETF budget that would provide essentially flat funding for K-12 and universities. The Senate debated the budget Thursday, adopting several changes, but postponed a final vote on it until April. However, senators did pass a plan Thursday to allow the construction of several new men’s prisons in Alabama.

Federal health care changes could send state Medicaid, ALL Kids costs soaring

As in past years, Medicaid funding is a major concern for both legislators and advocates in the GF debate. A one-time infusion of $105 million from the state’s BP oil spill settlement will help prevent massive Medicaid cuts in both 2017 and 2018, but it is not a long-term funding solution for the program that insures more than one in five Alabamians – mostly children, seniors, and people with disabilities.

The House budget would allocate $701.4 million from the GF to Medicaid, $42.2 million short of Bentley’s request. The agency could keep providing basic services at that funding level but would have to “evaluate” its ability to proceed with regional care organization (RCO) reforms that would emphasize preventive care, Medicaid spokeswoman Robin Rawls told the Montgomery Advertiser last week. Alabama would give up $747 million in promised federal funds if it fails to complete RCO reforms by October 2017.

The House’s $1.84 billion GF budget would set aside $97 million as a buffer against potential major changes to federal health care programs like Medicaid and ALL Kids, but that still might not be enough to avoid a special session later this year. U.S. House leaders have proposed a per capita (or per-person) cap on federal Medicaid funding, which accounts for about 70 percent of Alabama Medicaid’s support. That change could force coverage cuts and leave the state on the hook for cost increases in the event of a sudden disease outbreak.

The future of ALL Kids is another major question mark. Congress must reauthorize the Children’s Health Insurance Program (CHIP), which supports ALL Kids in Alabama, by Sept. 30. The state didn’t have to put up any of its own money in 2016 or 2017 to support the ALL Kids program, which insures children whose low- and moderate-income families don’t qualify for Medicaid. But if Congress reverts to an earlier CHIP formula, Alabama once again would have to pay a share of ALL Kids’ cost. Medicaid and the Department of Public Health would need an additional $91 million to meet such a requirement.

Most state agencies would receive flat funding under the House budget, making it increasingly difficult for Alabama to meet changing needs in the face of growing costs and population increases. The Department of Public Health, for example, asked for a $4.6 million increase (not including ALL Kids funding) to help boost preparations for potential widespread epidemics like the Zika virus, or more localized epidemics like last year’s tuberculosis epidemic in Perry County. But the House’s 2018 GF budget would provide public health with exactly the same amount it received in 2017.

Other level-funded services would include mental health care, corrections and the Department of Human Resources, which oversees crucial services like child protection, child care and food assistance. Collectively, these three agencies had asked for an additional $125.8 million for 2018. The House budget also would not give state employees a raise, a point of deep contention throughout Tuesday’s debate.

Regular shortfalls for services like Medicaid, mental health care and child care are a common refrain. The GF relies on a hodgepodge of revenue sources, most of which grow slowly even in good economic times. That leaves the GF with a structural deficit, meaning revenue growth is not strong enough to keep pace with ordinary cost growth. Read The Alabama Tax & Budget Handbook for more on how this deficit came to be and how Alabama can end it.

Increases for pre-K, juvenile probation officers in otherwise relatively flat education budget

As with the GF, funding increases in Alabama’s education budget next year would be the exception, not the rule. The Senate’s education budget committee Wednesday approved a $6.42 billion ETF budget that would boost state education support by only 1.4 percent next year. The K-12 Foundation Program would see a $14.5 million increase, allowing schools to hire about 150 new teachers in grades 4-6. Operating budgets for two-year colleges and universities would receive flat funding.

The ETF’s small increase would not be spread evenly across all educational services. K-12 schools would receive just 0.36 percent more. But debt service, primarily for university construction projects, would increase by more than $10 million – a 42 percent jump in one year. State-funded college scholarships for many Alabama veterans and their families are projected to cost $26.5 million more in 2018 than in 2017 – a 40 percent increase. SB 315, sponsored by Sen. Gerald Dial, R-Lineville, would tighten eligibility requirements for those scholarships in an effort to reduce the state’s future obligations.

Sen. Vivian Figures, D-Mobile, was one of several senators concerned about growing debt service costs because, she said, it was not immediately clear which projects had incurred those debts. “I’m sure none of us pay bills at home when we don’t know what they are,” Figures said.

Pre-K and juvenile probation officers are two major services that would receive more ETF money. Pre-K, which enjoys broad bipartisan support at the Legislature, would get an extra $15 million, a 23 percent increase. The state also would boost funding for juvenile probation officers by 19 percent, providing an additional $1.25 million from the ETF and an extra $500,000 from the GF.

Pared-down prison construction plan clears Alabama Senate

The budgets themselves weren’t the only major budgetary news at the Legislature this week. The Senate passed a major milestone in its two-year prison construction debate when it voted 23-11 Thursday for a plan that would fund construction of up to three new men’s prisons. The bill now awaits House action.

SB 302, sponsored by Sen. Cam Ward, R-Alabaster, would allow local jurisdictions, such as counties or regional associations of counties, to bid to build prisons. Successful bidders would be allowed to issue bonds to build two or three prisons to Department of Corrections (DOC) specifications and then lease the prisons back to the DOC for 30 years. The state would gain ownership of the prisons at the end of the lease period. The state would close all but three existing men’s prisons, leaving six total.

The bill would allow the state to borrow up to $325 million to build one new prison and renovate others, including Julia Tutwiler Prison for Women in Wetumpka, but only if localities agreed to build at least two new prisons. Those numbers are down sharply from Ward’s original plan, which would have let Alabama borrow $800 million to build four new prisons.

Ward estimated that the additional prison space would allow Alabama to reduce the population of each prison to less than 150 percent of capacity and reduce DOC operating and personnel costs. That would free up funds for lease payments to local governments, he said.

Sen. Linda Coleman-Madison, D-Birmingham, argued strongly during floor debate that the state needed to build a new women’s prison, as Ward’s original plan would have. “There are only 800 women in Tutwiler, and they’re not rioting or attacking guards,” she said, accusing the Legislature of ignoring the needs of incarcerated women. “The foundation is crumbling. Water is leaking. There is nowhere to sit other than your bed.”

Ward agreed that Tutwiler needed replacement or major renovations. But he said the cost savings from closing it wouldn’t be enough to pay the lease on a new prison.

The Southern Poverty Law Center also has criticized Ward’s bill, saying it would not solve problems with staffing, overcrowding and mental health care access in Alabama prisons. The bill is not a wholesale solution to the state’s corrections issues but is a step in the right direction, Ward told AL.com.

By Carol Gundlach, policy analyst, and Chris Sanders, communications director. Posted March 16, 2017.

Kicking the can: Windfall temporarily cushions shortfalls for Medicaid, other General Fund services in Alabama

By Carol Gundlach

The state budget hearings that ended Tuesday made one thing clear: There’s still no long-term answer to Alabama’s budget woes. The state once again likely will use one-time money next year to delay hard decisions about how to provide sustainable funding for vital services like Medicaid, child care and mental health care. And even though funding for K-12 and higher education will grow slightly in 2018, Alabama still hasn’t restored education support to where it was before the Great Recession.

Sen. Trip Pittman, R-Montrose, who chairs the Senate’s General Fund (GF) budget committee, said Alabama isn’t collecting enough money to support essential services in the long term. “We’re going to need more revenue if we’re going to live up to the responsibilities of our state,” Pittman said.

One-time money shields Medicaid from massive cuts – for now

GF revenues will be essentially flat in 2018, despite the growing costs of services like Medicaid and corrections, according to Legislative Fiscal Office (LFO) projections. The GF, which supports non-education services in Alabama, will have $1.94 billion available next year, LFO Deputy Director Kirk Fulford said. That’s about $4 million less than this year’s funding level.

Alabama’s funding problems would be much larger if Medicaid weren’t receiving a one-time infusion of $105 million in BP oil spill settlement money in 2018. With that money unavailable for 2019, the state’s budget picture will be bleak without significant new revenue to support health care and other services.

GF revenue may not have grown, but the costs of the services it supports have. GF agencies asked for nearly $140 million more than they received in 2017, Fulford said.

The largest request was from Medicaid, which asked for an additional $63.5 million (for a total of $869 million) from the GF to maintain current services and move forward with regional care organization (RCO) reforms designed to save money and keep patients healthier by focusing on preventive care. Alabama’s return on those state dollars is significant: Medicaid insures more than 1 million Alabamians – mostly children, seniors, and people with disabilities – and nearly 70 percent of its funding comes from the federal government.

Medicaid Commissioner Stephanie Azar warned lawmakers that if enough money isn’t available to complete RCO reforms by October 2017, the federal government will withdraw the Medicaid waiver that allows the changes to move forward. That would end the RCO reforms and cost Alabama nearly $750 million in promised federal funds.

Gov. Robert Bentley’s proposed $1.924 billion GF budget would provide $23 million more for Medicaid and level funding for most other services. Bentley also has requested $19 million to give state employees a 4 percent cost of living increase.

ALL Kids’ uncertain fate could force special session; DHR, courts, ALEA all request more funding

The future of ALL Kids is another major question mark for the GF. Congress must reauthorize the Children’s Health Insurance Program (CHIP), which supports ALL Kids in Alabama, by Sept. 30. The state didn’t have to put up any of its own money in 2016 or 2017 to support the ALL Kids program, which insures children whose low- and moderate-income families don’t qualify for Medicaid. But if Congress reverts to an earlier CHIP formula, Alabama once again would have to pay a share of ALL Kids’ cost. Medicaid and the Department of Public Health would need an additional $91 million to meet such a requirement, Fulford said. That could force the Legislature to return for a special session later this year.

Unmet GF needs extend far beyond health care. The state court system requested $106 million, a $9 million increase, citing a $3 million shortfall for juvenile probation officers and a $1.2 million shortfall for trial courts. Without the increase, the state would have to lay off juvenile probation officers, acting Chief Justice Lyn Stuart said. Sen. Vivian Figures, D-Mobile, raised serious concerns that such layoffs could lead to more juveniles falling into the adult corrections system.

The Department of Human Resources (DHR), which oversees crucial services like child protection, child care and the Supplemental Nutrition Assistance Program (SNAP), sought an additional $15.7 million, according to the LFO. The Alabama Law Enforcement Agency (ALEA), which oversees state troopers, requested an extra $37.4 million in GF money to continue current services, while the Department of Corrections asked for another $13.8 million. Bentley’s proposal to issue $800 million in bonds to build four new “mega-prisons” is likely to be a contentious topic at the Legislature this year.

‘We’ve got to start doing a better job of doing our job’

Many legislators expressed concerns about the Department of Mental Health, noting that it is at risk of federal court intervention. Rep. John Knight, D-Montgomery, made a passionate case for the state to invest more in community-based mental health care. “We’ve got to start doing a better job of doing our job,” Knight said.

Sen. Linda Coleman-Madison, D-Birmingham, said the state’s lack of investment in mental health care means many Alabamians who need treatment end up in the corrections system instead. Coleman-Madison emphasized that prisons cannot be treated as a substitute for mental health care. “Locking people up is not the answer,” she said. “We’re better than this.”

Regular shortfalls for services like Medicaid, mental health care and child care are a common refrain: The GF relies on a hodgepodge of revenue sources, most of which grow slowly even in good economic times. That leaves the GF with a structural deficit, meaning revenue growth is not strong enough to keep pace with ordinary cost growth. Read The Alabama Tax & Budget Handbook for more on how this deficit came to be and how Alabama can end it.

State Finance Director Clinton Carter pointed to declining revenue from Alabama’s oil and gas leases in the Gulf of Mexico as one of the causes for stagnant GF revenue. Since 2006, royalties from these leases, which flow into the Alabama Trust Fund (ATF), have dropped by more than $325 million. Because interest from the ATF helps support the GF, declining ATF revenues mean less money for GF services.

Carter did highlight some good news for the GF, though. Two years ago, the Legislature allowed “remote sellers” (online sellers that don’t have a physical presence in Alabama) to collect state and local sales taxes voluntarily on sales to Alabamians in exchange for keeping a small share of the revenue. The GF has received more than $50 million from these collections since 2016, Carter said.

But Carter said all the new revenue that has come into the GF since 2010 has gone to only two agencies: Medicaid and corrections. If those agencies are excluded from the calculation, funding for the remaining GF agencies has been essentially flat over this period.

Bentley seeks pre-K boost in slow-growing education budget

The funding picture is slightly better for the Education Trust Fund (ETF), which receives most of its support from sales taxes and income taxes that increase as the economy grows. Pre-K programs are a high priority in Bentley’s proposed ETF budget, which includes a $20 million (or 30 percent) increase for them. Bentley would direct $4.4 billion to K-12 education, $1.6 billion for higher education and $366.8 million for other expenses (such as rehabilitation services for children) supported by the ETF.

Nearly $6.42 billion will be available to fund education next year, Fulford said. That’s about $90 million (or 1.4 percent) more than was available in 2017. Challenges to the education budget include higher health insurance and retirement costs, Fulford said, as well as an open-ended commitment to cover higher education costs for spouses and children of deceased or disabled Alabama veterans.

By Carol Gundlach, policy analyst, and Chris Sanders, communications director. Posted Feb. 9, 2017.