Issue: Health

Alabama Arise toolkit on the Medicaid ‘unwinding’ period

By Alabama Arise

A promotional image for alarise.org/medicaidunwinding featuring a health insurance transaction between two adults.

Alabamians at every income level should be able to get the health care they need to survive and thrive. Medicaid plays a vital role toward meeting that goal, providing health coverage for more than 1 million Alabamians with low incomes. But tens of thousands of Alabamians may lose their Medicaid coverage by June 2024 in a process called “unwinding.”

Alabama Arise is working to minimize coverage losses during this period. As part of those efforts, we created this toolkit to explain the Medicaid unwinding and help connect people with other affordable coverage options for which they may be eligible.

Below is a table of contents for the resources in this Medicaid unwinding toolkit. Email info@alarise.org if you have any questions or recommendations for additional resources.

What is the Medicaid unwinding?
What Medicaid members should do next
How to appeal an eligibility determination
Where to look for new coverage
How has the Medicaid unwinding affected you?
Unwinding in the news
Additional resources

What is the Medicaid unwinding?

On April 1, 2023, Medicaid ended a continuous coverage eligibility period brought on by the public health emergency during the COVID-19 pandemic. What followed was a return to traditional eligibility requirements. This return to normal rules is called “unwinding.”

Alabama Medicaid has resumed its traditional process for verification of eligibility. More than 60,000 Alabamians may lose their coverage by June 2024 due to this change, researchers estimate. But Medicaid members who remain eligible can take steps to ensure they don’t lose coverage.

Current Medicaid members will receive mailings to their home addresses from Alabama Medicaid discussing these changes. Enrollees should ensure their most current and up-to-date information is on file by visiting the recipient portal here.

A notice from Alabama Medicaid to check your mail for important information beginning April 1.

 

Read Alabama Arise’s blog post about what Medicaid members need to know about the unwinding.

Read Arise’s blog post about how Alabama can protect health coverage during the unwinding.

What Medicaid members should do next

Click here to make sure Medicaid has your current contact information. Answers to some common questions about the unwinding period are below.

(1) How will I know it is time to renew my Medicaid application?

Medicaid enrollees will receive a recorded phone message, text message and/or email when it is time to renew – if you have provided that contact information to the Alabama Medicaid Agency. These automated messages will not ask for a response.

Please call Medicaid directly at 800-362-1504 if you have questions or need assistance.

(2) How will I get my renewal packet?

Medicaid enrollees will receive a renewal packet by mail prior to their renewal month. Click here to find out your renewal month.

(3) What do I do when I receive my renewal packet?

Please complete your form and follow instructions to return it to Alabama Medicaid. If you need assistance, call Medicaid at 800-362-1504 or go in person to a local Medicaid office.

(4) How will I know if I keep my Medicaid benefits?

Alabama Medicaid will make a determination on your eligibility. The agency also may ask for more information if needed. You will receive a decision on your eligibility directly from Alabama Medicaid.

(5) Do I need to fill out the renewal form if I know I don’t qualify for Medicaid anymore?

You should fill out the renewal form – even if you think you don’t qualify anymore. You can fill out the paper form or go online to submit the information. Or you can call the Medicaid office in your area to renew. Once you submit your information, you will be considered for any of the Medicaid programs for which you are eligible.

(6) Where can I find some helpful unwinding resources from Alabama Medicaid?

How to appeal an eligibility determination

Alabama Medicaid will make an eligibility determination and notify you of that decision. This notification will have a termination date if your benefits are ending.

(1) What if I received notice that I am no longer eligible for Medicaid?

You can appeal this decision, reapply for Medicaid benefits or contact Enroll Alabama to submit an application on the Health Insurance Marketplace portal.

(2) What if I want to stay on Medicaid but need to update my information? 

Click here to reapply to Medicaid with your updated information.

(3) What If I believe the termination notice from Medicaid is incorrect?  

The first step that you can take is to request a review of Medicaid’s decision or a conference to discuss your case. You or someone helping you must contact a Medicaid district office and request a review or conference. You may be asked to provide more information to Medicaid. A conference may be helpful when additional information is needed to support your eligibility claim.

(4) What do I do if Medicaid does not find me eligible after my review or conference?

The next step is to request a fair hearing. You must make your request in writing no later than 60 days from the date of your termination letter or 60 days from the decision of your review or conference. You must mail your request for a hearing to the following address:

Medicaid Agency – Central Office
Alabama Medicaid Agency
P.O. Box 5624
Montgomery, AL 36103-5624

Call Alabama Medicaid at 334-242-5741 for information on a fair hearing request.

Where to look for new coverage

Did you or someone you know lose health coverage due to the Medicaid unwinding? Other affordable coverage options may be available.

Contact Enroll Alabama for more information on enrolling in a plan through the Health Insurance Marketplace at healthcare.gov. Many Alabamians are eligible for Marketplace coverage at little or no cost thanks to subsidies under the Affordable Care Act.

How has the Medicaid unwinding affected you?

Alabama can protect families and make health coverage more affordable by expanding Medicaid to cover adults with low incomes. Your personal story can help influence legislators and inspire advocates to take action.

You’re not alone. Nearly 300,000 Alabamians who are uninsured or struggling to afford coverage would benefit from Medicaid expansion. When you share your story, you help make the issue real for people. And you help show what’s at stake if we don’t close Alabama’s health coverage gap.

Arise’s Cover Alabama storyteller Whit Sides is gathering and telling the stories of Alabamians living in the coverage gap. Click here to share your story.

A flyer introducing Arise's Cover Alabama storyteller Whit Sides. A picture of Whit is at the top right. She is a smiling white woman with blonde hair, wearing a blue blouse with white polka dots. Reach Whit at 205-329-1996 or whit@alarise.org.

Unwinding in the news

  • AL.com: Status of 129,000 Alabama Medicaid enrollees uncertain after post-pandemic emergency
  • Alabama Daily News: Alabama starts removing people off Medicaid, but won’t yet say how many
  • Alabama Reflector: Post COVID-emergency, Alabama not reporting how many people lost Medicaid coverage
  • CNN: Medicaid eligibility: More than a million people have lost their Medicaid coverage already. It’s far from over
  • Managed Healthcare Executive: Understanding the long-term implications of Medicaid unwinding
  • NPR: Texas Medicaid dropped more than 500,000 enrollees in one month
  • PBS NewsHour: Why some cancer patients will fall off a Medicaid coverage cliff this summer
  • Washington Post: Paperwork mistakes should not end a child’s health coverage
  • WBRC Fox 6, Birmingham: What to know if you’re losing your Medicaid coverage in Alabama

Additional resources

See the Gap: How Medicaid expansion would benefit stylists – and every Alabamian

By Whit Sides

Over the last year, Alabama Arise has collected the stories of some of the nearly 10,000 personal care workers who would benefit from Medicaid expansion in our state. We spent months getting to know folks in one of our state’s most vibrant industries. And we want to be sure you see the last few stories in this series.

You can find all of our See the Gap stories in one place here.

We kicked off our series with a personal story about how beauty professionals make sacrifices to support us, but often have no safety net of their own. That’s especially true when it comes to having access to affordable health care for themselves or their families.

Now, as we close the series, we’re lifting up even more stories that speak to a vital question: “How would life be better for so many people if Alabama expanded Medicaid?”

Stories from Alabama’s coverage gap

Like Kayla, a young stylist who is at the pinnacle of her career. Even so, she has reservations about becoming pregnant and having a child while she has no health insurance. There are some possibilities that she just can’t afford.

An image showing a hairstylist performing a color service on a client.
Kayla performs a color service on a client at her salon in downtown Birmingham. (Photo by Whit Sides)

Or Eryn Mullins, a new mom from Sumiton. She opened up to share her heart-wrenching story of navigating the mental health landscape in our state as a new stylist with no employer-provided health coverage. She needed help but couldn’t afford it.

The stories didn’t stop there. We highlighted the challenges facing many stylists seeking mental health care. We spoke to LGBTQ stylists about sacrifices they make both professionally and personally when it comes to finding care safely. And in our final piece in the See the Gap series, we talked to salon owners about what our state can and should do to improve lives and protect the health of those working in the beauty industry.

A path forward to close the coverage gap in Alabama

Hundreds of thousands of Alabamians are in the health coverage gap. Most of them are working at low-paid but essential jobs. They’re folks we see every day but may not realize are living without access to health care. Medicaid expansion would ensure they have the health coverage they need to survive and thrive.

With so many working folks in the gap, Medicaid expansion is an essential solution to save lives and make Alabama a healthier place. It would help real people across our state. And it would be an enormous financial boost for workers and businesses.

Expanding Medicaid would provide our state with more than $400 million a year to provide more than 280,000 people with health coverage. Click here to see the economic impact in our state, and click here to see it in your county.

Mert McNaughton smiles behind her desk in the Forecast Salon in Homewood. (Photo by Whit Sides)

Read the final story in our See the Gap series.

We encourage y’all to share these stories with state leaders in your district, as well as Gov. Kay Ivey. There’s never been a better time to, as Mert said herself, create more revenue for local businesses and put more money into workers’ pockets.

It’s been a privilege to collect these powerful stories and share them with the world. And we can’t wait to tell even more stories in the months to come. Thank you for your support of Arise and for being part of our work to make life better for all Alabamians.

See the Gap: ‘Medicaid expansion would end up creating more revenue for the business’

By Whit Sides

Just outside the Forecast Salon in Homewood is a gigantic mural painted along the wall. It features every color of the rainbow jumping out into the street. You’re up close with a 10-foot disco ball painted right beside a unicorn and two massive blue and purple manicured coifs.

Forecast’s owner Brittany McNaughton (friends call her Mert) chose the bright and welcoming mural as a manifestation of her personal philosophy.

“Big! Bold! Sunshine!” she says as we look at it. “The vibes are all there!”

The mural outside the Forecast Salon in Homewood, after its completion in February 2023. (Photo by Whit Sides)

Mert and Forecast’s co-owner, Mark Hyde, had a lot to look forward to in February 2020.

They had just reopened their salon in Homewood, just south of Birmingham, after an extensive expansion. Forecast had to shut its doors for three weeks. The renovations brought the space up to 16 chairs and almost doubled the original floorspace. The future looked bright.

Then the COVID-19 pandemic hit, and their world stopped.

“We’d been open for five years, but when 2020 happened, it felt like I had to go dark,” Mert said. “This massive adrenaline rush told me I had to stop expanding and keep my business afloat.”

Mert had just brought on some new stylists, and she said she probably could have hired even more. But soon she learned that the pandemic was shifting her focus from growth to her staff’s “mental capacity.”

Mert said that’s when she realized the shutdown would be longer than three weeks. And it wasn’t just about closing the physical doors to the shop.

“We went from managing everyone’s safety to all of a sudden seeing where our staff was just not doing so well,” she said.

More than just a paycheck

In a rare move in the salon industry, Forecast offers to pay for a portion of its stylists’ health insurance. After two years, they also contribute to employees’ 401(k) retirement accounts.

Another benefit that Mert said was useful during the pandemic was flexible scheduling. She said stylists are encouraged to take personal days off, especially for mental health.

“Whenever you have someone that’s not doing great personally or mentally outside of work, they bring that energy in with them into the workspace, and it can affect the people around you,” Mert said.

Mark Hyde serves a client at the Forecast Salon in Homewood. (Photo by Whit Sides)

Gov. Kay Ivey allowed barbershops and salons to reopen in May 2020 after the initial wave of pandemic shutdowns. It was a first step toward returning to business as usual. But for stylists, that meant getting up close and personal again – and many weren’t ready.

“We work in such an intimate space,” said Mark, Forecast’s co-owner. “We’re up close, touching our clients. It sometimes takes years for these young stylists to build up trust but also build up a shell that can protect them from negative energy or venting clients day in and day out.”

A focus on mental health

Mark and Mert decided to shore up the salon’s career development offerings beyond just continuing education on hair. They brought in local therapists, healers and self-help experts to discuss mental health. Their goal was to help teach stylists how not to take the stresses of personal care work home with them.

“Moving out of the pandemic, I saw a need to bring in programming focusing specifically on mental health and not just hair,” Mert said.

Mark and Mert agree that they can’t do it all. But they said they try their hardest to provide as much as they can for their staff.

“Nowhere is perfect,” Mert said. “I set standards for mental health here in the salon, but I’m not trained to treat anyone’s problems. I’m trained to do hair. That’s where therapists and doctors come in.”

More money in the pocket for both stylists and salon owners

Mert said she hopes that one day all salons will offer health insurance and other benefits. But she also said she knows that’s not a realistic option for all salons. And unfortunately, that means many stylists will have no affordable option for health coverage unless Alabama expands Medicaid.

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

Part of Forecast’s recent renovation was expanding to hire more younger stylists and apprentices into their already robust education program. Not everyone at Forecast would qualify for coverage under Medicaid expansion, but most newer stylists likely would, Mert said. 

Both owners agree that it would be nice to be able to pay stylists an extra $200 to $400 every month. That amount could help cover their groceries or a car payment.

“It’s expensive to provide insurance as a business. That’s why a lot of people don’t do it,” Mert said. “Medicaid expansion would end up creating more revenue for the business and put more money into that stylist’s pocket.”

Mert McNaughton smiles behind her desk in the Forecast Salon in Homewood. (Photo by Whit Sides)

The benefits for the local economy wouldn’t end there. Jefferson County could realize upwards of $298.6 million in additional economic impact in year one as a result of closing the health coverage gap. Medicaid expansion also would extend coverage to more than 22,500 county residents who didn’t have it before.

I asked Mert what Forecast Salon would do with the extra money when the day finally comes.

“As a business owner, I already know what I’m gonna do with that money,” she said. “Invest it right back into our people.”

ABOUT ALABAMA ARISE AND COVER ALABAMA

Whit Sides is the Cover Alabama storyteller for Alabama Arise, a statewide, member-led organization advancing public policies to improve the lives of Alabamians who are marginalized by poverty. Arise’s membership includes faith-based, community, nonprofit and civic groups, grassroots leaders and individuals from across Alabama. Email: whit@alarise.org.

Arise is a founding member of the Cover Alabama coalition. Cover Alabama is a nonpartisan alliance of advocacy groups, businesses, community organizations, consumer groups, health care providers and religious congregations advocating for Alabama to provide quality, affordable health coverage to its residents and implement a sustainable health care system.

See the Gap: ‘I needed help but couldn’t afford it’

By Whit Sides
A smiling husband and wife.
Eryn Mullins (left) smiles alongside her husband, Zach. Eryn is a hairstylist from Sumiton who struggled to afford mental health care after becoming uninsured at age 26. (Photo courtesy of Eryn Mullins)

Social media can be overwhelming. Like a lot of people, I’ve found myself stepping back from it lately. There is one thing I will never scroll past, though: baby pictures. (Well, that and jokes.)

And Eryn Mullins is good for both.

Eryn is a new mom and hairstylist from Sumiton, a small town in Walker County in northwest Alabama.

I spoke to her the week she returned to work after her maternity leave. Thanks to her husband’s insurance, she and her baby were well cared for during labor, delivery and the postpartum period.

The smiles in her family photos jump through the screen. It’s hard not to think she’s got it all together.

But Eryn will be the first to tell you that it wasn’t always this way. Things were much different for her just a few years ago.

‘A million things to worry about’

“Straight out of beauty school, there’s a million things to worry about,” Eryn said. “When I was 20, I suffered from extreme panic attacks, and I needed to be hospitalized. After that, it still took eight months and four or five different medications to get to a steady place.”

Eryn was diagnosed with a panic disorder that gave her “anxiety that you couldn’t just fix.” Her condition required regular doctor’s visits and consistent medication. Thanks to her dad’s insurance, she was able to keep everything under control.

Then Eryn turned 26. That’s the age when young adults are no longer eligible for their parents’ insurance under the Affordable Care Act. And things started to look very different.

“I was on my dad’s insurance, and then suddenly, I wasn’t. I was uninsured for three years after that,” Eryn said.

“I got a hospital bill for $2,500, and that’s when I decided I was going to try my hardest to not go to the doctor ever again.”

Cold turkey

One thing Eryn didn’t plan for was having to come off all her medications immediately. For her, “cold turkey” meant no prescription refills. It also meant no talk therapy and no visits with a psychiatrist to manage her mental health.

“I experienced so many adverse side effects that put me back in the hospital, suffering from withdrawal,” she said. “We all have brains; not all of them are healthy. Mine wasn’t.”

Any way Eryn looked at it, she was paying hundreds of dollars out of pocket every few months. Sometimes it was for a hospital stay. Once, she spent $400 for just one routine visit with a mental health provider.

“I worked in a high-stress environment my first year as a stylist,” she said. “It’s a vicious cycle. I needed mental help but couldn’t afford it.”

Being uninsured is expensive. And without consistent medical or mental health coverage, those expenses mount for many stylists. After facing a $2,500 medical bill while uninsured, Eryn told herself she would do whatever she could to avoid going to the doctor.

Unfortunately, Eryn is not alone in receiving eye-popping medical bills while uninsured. Most of her coworkers are uninsured, she said, and seeing them navigate that is heartbreaking. More than 22% of people in Walker County are facing medical debt along with her right now.

In all, 6,108 people in Walker County do not have health coverage. That number would drop by more than half if Alabama expanded Medicaid to cover adults with low incomes.

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

‘Hanging up the apron’

Hairstylists often can set their own schedule, but that means income fluctuates. And especially in the beginning, they are paying for all their own supplies and losing a lot of money.

“Starting off as a new stylist is the hardest part,” Eryn said. “There’s no method to the madness.”

Eryn said it is becoming more common to see coworkers “hang up their apron.” That’s code for leaving the hair business altogether, often to train in another industry.

“It’s exhausting,” she said. “I feel like everyone I know is always putting money back, for every little (and big) thing. And you have to be really lucky to even have any left over for medical bills.”

Eryn said she loves what she does and doesn’t plan on quitting anytime soon, though she jokes about it sometimes.

“There are days where I debate working at Big Lots or Walmart. It’s steady, and they probably get insurance at full time,” she said.

A path forward

After seeing so many friends walk away from behind the chair, Eryn said she didn’t know how she would make it as a mom and a stylist.

“We were expecting our first baby soon, and I had no idea how I would handle maternity leave,” she said. “I was able to make a deal on my booth rental, but that’s it. If I didn’t have the support of my husband, I don’t know if I could even afford a child.”

A husband and wife with their newborn child.
Eryn Mullins (right) enjoys a moment with her husband, Zach, and their newborn child in March 2023. (Photo courtesy of Eryn Mullins)

Through it all, Eryn said she still would choose to become a stylist all over again.

“I’m glad I stuck with it,” she said. “It was a rough few years, but now I get to coordinate my life and schedule the way I want, which is much better for my mental health. I think that’s probably true of any career.”

Eryn said she hopes discussing her experiences can help improve life for hairstylists and other Alabamians living without health coverage.

“I wanted to share my story because it’s worth it to me if even one person feels less alone,” she said.

ABOUT ALABAMA ARISE AND COVER ALABAMA

Whit Sides is the Cover Alabama storyteller for Alabama Arise, a statewide, member-led organization advancing public policies to improve the lives of Alabamians who are marginalized by poverty. Arise’s membership includes faith-based, community, nonprofit and civic groups, grassroots leaders and individuals from across Alabama. Email: whit@alarise.org.

Arise is a founding member of the Cover Alabama coalition. Cover Alabama is a nonpartisan alliance of advocacy groups, businesses, community organizations, consumer groups, health care providers and religious congregations advocating for Alabama to provide quality, affordable health coverage to its residents and implement a sustainable health care system.

New report: Medicaid expansion would improve maternal health in Alabama

By Chris Sanders

Medicaid expansion would improve women’s health and expand access to maternal health care across Alabama, a new Georgetown University Center for Children and Families (CCF) report found. Expansion also would help reduce racial disparities, improve infants’ health and strengthen rural health care access, the report found.

Nearly one in six Alabama women (15.9%) of reproductive age (18-44) lack health insurance, CCF found. That rate is significantly higher than the national average (11.7%). And uninsured rates are sharply higher among Hispanic (41.5%) and Native American (46.7%) women in Alabama. Medicaid expansion would help by ensuring health coverage for tens of thousands of Alabama women who cannot afford it.

Alabama policymakers took an important step forward for women’s health last year by extending the Medicaid postpartum coverage period. That extension ensured coverage for a full year after childbirth, up from the previous cutoff of just 60 days afterward. But much work remains to protect women’s health in the state, Alabama Arise’s Cover Alabama campaign director Debbie Smith said.

Alabama Arise story collection coordinator Whit Sides speaks at a March 9, 2022, rally in Montgomery to support extending postpartum Medicaid coverage. Arise joined the American Heart Association and other Cover Alabama partners at the event.

“State leaders showed they’re willing to address Alabama’s maternal health crisis when they extended Medicaid postpartum coverage last year,” Smith said. “However, these findings show that this step alone is not enough to help mothers and families stay healthy. Alabama should take the next logical step to protect women’s health and expand Medicaid coverage for adults with low incomes. We urge Gov. Kay Ivey and legislators to make Alabama a better place for parents and babies by expanding Medicaid.”

Medicaid expansion would save lives, protect rural health care access

The consequences of being unable to afford timely medical care can be deadly. Alabama had the nation’s third-worst maternal mortality rate between 2018 and 2020, the report found. The state’s rate (36.2 maternal deaths per 100,000 live births) was significantly higher than the national average (20.4 per 100,000) in those years.

Alabama’s infant mortality rate (7.2 infant deaths per 1,000 live births) also was much higher than the national average (5.4 per 1,000) in 2020. Black babies died at an even higher rate in Alabama that year (11.1 per 1,000 live births).

A decades-long decline in access to maternity and obstetric care in rural Alabama is compounding these terrible statistics. Twenty-nine of Alabama’s 54 rural counties lost hospital obstetric care providers between 1980 and 2019, CCF found. These closures required women in these counties to travel farther to providers elsewhere. That, in turn, can reduce the timeliness of care and increase barriers for women with limited transportation options.

Medicaid expansion is associated with lower maternal and infant mortality rates, with the greatest benefits for Black women and infants. Expansion also promotes health improvements throughout pregnancy and into children’s early years, CCF found. In addition, Medicaid expansion would decrease the costs of uncompensated care significantly, allowing more rural hospitals and providers to remain open to continue treating pregnant Alabamians.

“Research shows that stable health coverage for women before, during and after pregnancy can save moms and babies’ lives,” said Joan Alker, executive director of the Georgetown University Center for Children and Families. “Medicaid expansion is an essential investment in the health of Alabamians and builds a solid foundation for the state’s future.”

Read the full report here.

Alabama lawmakers allocated the state’s final $1 billion of ARPA funds. What comes next?

By Dev Wakeley

As the Alabama Legislature begins to craft the 2024 General Fund budget, decisions made during last month’s special session should provide lawmakers with more flexibility to meet ongoing needs for our state. With additional near-term funding already in place for key priorities, legislators should seize the opportunity to improve the quality of life for every Alabamian. Investments that would further this goal include providing funds for public infrastructure like Medicaid expansion and public transportation.

On March 16, Gov. Kay Ivey signed HB 1 to end the special session she called to distribute the remaining federal funds that Alabama received under the American Rescue Plan Act (ARPA). This act provided states with federal funding to help cover losses and expenses incurred because of the COVID-19 pandemic. Lawmakers previously distributed the majority of the funds, leaving $1.06 billion to be allocated in this year’s special session.

Arise priorities eligible for funding

The Department of Finance received $55 million in ARPA funding for direct services for people likely to face economic hardship. These categories include older Alabamians and victims of domestic violence. Service providers will receive this money through departmental grants.

Further available categories for this funding include food banks, long-term housing security and mental health care. Summer education programs for schoolchildren and services to families involved in child welfare also are eligible for this funding.

Arise has advocated for using a portion of Alabama’s ARPA aid for affordable housing. While the ideal path would have been a specific allocation to housing, this funding pool provides a path for that important investment. Direct food assistance is likewise a vital public good. And increased mental health funding could help improve the well-being of Alabamians of all demographics.

Health care receives significant funding

Lawmakers allocated $339 million for direct health care expenses and related services. The largest portion will be used for hospital and nursing home reimbursements at $100 million each. Increased expenses for state employees’ health insurance will account for $80 million of the remaining $139 million.

The remaining $59 million will go toward several programs to expand health care availability and efficacy for Alabamians. These funds include:

  • $9 million for telemedicine infrastructure expansion, particularly focused on specialist coverage for Alabamians in rural communities.
  • $20 million for research into increasing access to personalized health care.
  • $175,000 in cost reimbursement for COVID-19 vaccinations provided to college and university students.

Also notable is a $25 million line item for mental health care investment. This expenditure can help bring state programs up to the requisite standard of care. This amount is in addition to the permissible use of a portion of the Finance Department’s $55 million in funding.

Infrastructure improvements receive lion’s share of ARPA aid

Lawmakers allocated the largest share of this round of funds, $660 million, to infrastructure improvements in water and sewer systems. Of that amount, $260 million will go toward broadband internet access.

This decision is consistent with the state’s emphasis on increasing internet connectivity during recent legislative sessions. These funds are also available for use by state agencies to modernize and improve access to state computer infrastructure. This has been another recent priority for the Legislature.

The remaining $400 million in this category will go toward water and sewer infrastructure improvements. This includes $195 million for high-need water and sewer projects. A further $100 million will be available for water projects in growing communities. And an additional $100 million will be designated for grants that require 35% funding matches by local governments.

The Alabama Department of Public Health has designated $5 million to conduct wastewater system improvements in areas with high poverty rates, low populations and difficult soil conditions for septic systems. This expenditure aims to improve longstanding sewage disposal issues in the Black Belt.

In several Black Belt counties, recent major sewage problems due to inadequate investment in public sewage disposal have drawn international condemnation. This ARPA allocation will help mitigate the problems, though further investment will be necessary to fix them fully.

Final thoughts

Overall, state lawmakers used this final round of ARPA funds as generally intended: to improve Alabamians’ lives and mitigate shortfalls due to the COVID-19 pandemic. The relative flexibility of the appropriations bill still leaves open the possibility that some funds could be used in counterproductive ways. But the Legislature performed much better in allocating ARPA funds equitably this session than with the first round, when they devoted $400 million of relief funding to prison construction.

Thankfully, this special session created numerous pathways to help Alabamians by directly providing important public goods. The opportunity to make significant improvements in vital areas includes funding adequate housing and providing food for people who need it. It includes investments in mental health care and improvements in state agency reliability. And it includes mitigation of some harms resulting from decades of state disinvestment in Black Belt communities with mostly Black populations.

Make no mistake: Many urgent and vital needs remain unmet after the special session. But ARPA funding nonetheless will provide a generational opportunity to make substantial improvements to the lives of all Alabamians. Lawmakers should build on that momentum by expanding Medicaid, funding public transportation and making other investments in a brighter, more inclusive future for Alabama.

Walker County Medicaid town hall 2023

By Alabama Arise

Alabama Arise and Cover Alabama co-hosted a Medicaid town hall in Jasper on April 10, 2023. Speakers discussed the importance of Medicaid expansion and how our state can afford it, as well as the cruelty of the Medicaid coverage gap. To learn more and join our movement to expand Medicaid in Alabama, visit coveralabama.org.

Alabama Arise Action Legislative Day 2023

By Alabama Arise

Arise held our 2023 Legislative Day on Tuesday, April 11. More than 100 supporters joined us in Montgomery to hear updates on our policy priorities and urge their lawmakers to untax groceries, expand Medicaid and end debt-based driver’s license suspensions. Thank you to everyone who spoke out for a better Alabama for all!

It’s time to expand Medicaid and close Alabama’s coverage gap

By Alabama Arise

Here are five reasons it’s time to expand Medicaid and close Alabama’s coverage gap:

  1. Nearly 300,000 Alabamians with low incomes would benefit from Medicaid expansion.

    • People in the coverage gap earn too much to qualify for Medicaid, but not enough for an affordable private health insurance plan on the Marketplace. This leaves them in the health coverage gap.
    • The vast majority of people who would gain coverage through Medicaid expansion are working. More than 100,000 Alabamians in the coverage gap hold jobs that are important but pay low wages. Thousands more are self-employed, serve as caregivers or attend school.
    • People who work low-wage jobs and can’t afford private coverage are among the Alabamians who would benefit from closing the coverage gap. So are workers who are between jobs, uninsured veterans, adults who are caring for children or older family members and people who are awaiting SSI determinations.

  2. We can afford it now. Medicaid expansion comes with a $619 million signing bonus.

    • States that close their coverage gap will receive a 5-percentage-point increase in the federal match rate for Medicaid for two years. This is thanks to an incentive in the American Rescue Plan Act.
    • An increased federal match rate would bring $619 million to Alabama over the next two years.
    • The state’s cost to close the gap in the first two years would be roughly $423 million. That means nearly $200 million in additional federal funding would come to our state above and beyond the cost to extend Medicaid coverage up to hard-working Alabamians. And that doesn’t even count other budgetary savings for the state and the revenue generated by thousands of new jobs across Alabama.

  3. Closing the coverage gap helps workers stay employed.

    • States that have closed the coverage gap have seen a greater increase in labor force participation among people with low incomes than in non-expansion states. One in three Alabama adults have a disability.
    • Injuries or manageable illnesses like diabetes can get so severe for those without health coverage that they prevent people from working or leading healthy lives. 
    • People with disabilities are more likely to be employed in states that have expanded Medicaid than in states that haven’t.

  4. Sixteen rural hospitals are at immediate risk of closing. Medicaid expansion can keep them operating.

    • Expanding Medicaid will help more rural residents afford health care services and reduce the financial losses experienced at hospitals from serving uninsured patients or providing uncompensated care.
    • Research shows that a rural hospital being located in a Medicaid expansion state decreases the likelihood it will close by an average of 62%.
    • Rural hospitals in states that have expanded Medicaid coverage have more sustainable median operating margins compared with rural hospitals in non-expansion states.

  5. Medicaid expansion can help strengthen mental health care services in Alabama.

    • We need more coverage and better care for Alabamians with mental health conditions. Medicaid expansion would allow more people with these conditions to access the vital care they need.
    • Alabama’s mental health care and substance use treatment providers deliver nearly $50 million worth of uncompensated services each year. Closing the coverage gap could drastically reduce this amount and allow more mental health services to be provided to people in need.

It’s time to expand Medicaid and close Alabama’s coverage gap

  • Nearly 300,000 Alabamians would benefit from Medicaid expansion.
  • We can afford it now. Medicaid expansion now comes with a $619 million signing bonus.
  • Closing the coverage gap helps workers stay employed.
  • Sixteen rural hospitals are at immediate risk of closing. Medicaid expansion can keep them operating.
  • Medicaid expansion can help strengthen mental health care services in Alabama.

Advocates visit Alabama lawmakers to urge support for Medicaid expansion

By Chris Sanders
Kenneth King speaks from behind a lectern outside the Alabama State House in Montgomery. He is a Black man wearing a gray suit, a gray toboggan cap and a scarf that is white and black. Standing behind him are numerous supporters of Medicaid expansion, including a white man wearing a black jacket and glasses who holds a sign reading "Save Our Rural Hospitals," and a white woman with red hair and glasses who holds a sign reading "Help the Working Poor: Expand Medicaid."
Alabama Arise board member Kenneth King speaks at Cover Alabama’s advocacy event outside the State House in Montgomery on March 21, 2023. King shared his story of living in Alabama’s health coverage gap and urged lawmakers to support Medicaid expansion.

More than 80 Alabamians gathered outside the State House in Montgomery on Tuesday to urge state lawmakers to expand Medicaid to cover adults with low incomes. The Cover Alabama coalition sponsored the event as part of its advocacy day for Medicaid expansion. Alabama Arise is a founding member of Cover Alabama.

Some advocates shared stories of how Medicaid expansion would help their families and communities. Others highlighted how expansion would benefit Alabama’s economy and health care system. All sought to show the human faces of the state’s health coverage gap and the suffering it causes.

Video footage from the event is available here. Photos from the events are available here.

“I lost my job because of a chronic health condition. I’m the primary provider for my family, but I could not stay well enough to do my job,” said Jesse Odland, a Huntsville line cook. “Now, I worry my medical debt will affect how my family can thrive. The working class drives our economy, and we’re hit the hardest by the coverage gap.”

Closing the coverage gap would help nearly 300,000 Alabamians access potentially life-saving care. It also would create thousands of new jobs and invigorate the state’s economy, research shows. Medicaid expansion could create more than 20,000 new jobs and save the state almost $400 million each year for the next six years, according to a recent report by the Public Affairs Research Council of Alabama. And in rural areas, expansion would have the added benefit of reinforcing rural hospitals.

“Alabama’s rural hospitals are in trouble. More than a dozen are at immediate risk of closing this year,” said Dr. Marsha Raulerson, who has been a pediatrician in Brewton for more than 40 years. “When a rural hospital closes, that community loses not only their access to health care but also a primary economic engine and the jobs that come with that. Medicaid expansion is a win-win for patients and providers alike.”

Rev. Carolyn Foster, the faith in community coordinator at Greater Birmingham Ministries, argued that expanding Medicaid is just the right thing to do.

“No matter our creed, we can all agree that we are called to love our neighbors as ourselves,” Foster said. “So long as we allow our neighbors to fall into the health care coverage gap, we are failing to answer that calling. It is an affront to people of faith and people of good will.”

Thirty-nine states and the District of Columbia have expanded Medicaid, and North Carolina likely will join that list next week. Debbie Smith, Alabama Arise’s Cover Alabama campaign director, said advocates hope this is the year Alabama will expand, too.

“Research shows Medicaid expansion is favorable on both sides of the political aisle,” Smith said. “We are hopeful Alabama lawmakers will do the smart, compassionate and fiscally responsible thing and expand Medicaid now. How can our state not afford to save money?”

Click here for video from the event. And click here for photos from the event.