The Cover Alabama coalition held its first Lobby Day on March 21 on the steps of the State House in Montgomery. Faith leaders, community advocates and people living in Alabama’s health coverage gap spoke about the importance of Medicaid expansion for their families and communities. Advocates then met with lawmakers to urge them to save lives and create jobs by expanding Medicaid.
Issue: Health
PARCA presentation on Medicaid expansion in Brewton
Medicaid expansion would save lives, create jobs and strengthen the health care system across Alabama. Ryan Hankins, executive director of the Public Affairs Research Council of Alabama (PARCA), gave a presentation on Medicaid expansion’s benefits at a public event that Alabama Arise co-hosted on Feb. 27, 2023, at DW McMillan Memorial Hospital in Brewton.
Brewton community event on Medicaid expansion in Alabama
“Our rural hospital is the first line of care for the people in our community. If someone’s really sick, they need to be stabilized. They can be stabilized here quickly and efficiently. If our hospital closed … people will die.”
That was the blunt reality that Dr. Marsha Raulerson shared at a health care panel that Alabama Arise co-hosted Feb. 27 in Brewton. As we heard from her and many other people that night, Medicaid expansion is a crucial step to save lives and protect health care access in Escambia County and throughout Alabama.
Expand Medicaid and close Alabama’s health coverage gap
For years, Gov. Kay Ivey and legislators have said cost is the barrier to covering Alabamians with low incomes through Medicaid. However, thanks to new federal incentives for Medicaid expansion, any concerns about that barrier are gone. Now more than ever before, we have the opportunity to ensure no Alabamian has to choose between going to the doctor and putting food on the table.
More than 70% of Alabamians support Medicaid expansion, including 66% of Republican voters, according to a January 2022 poll, and opening up Medicaid coverage to adults with low incomes is the single biggest step Alabama can take to restore health, save our rural hospitals and boost our state’s economic recovery.
Who would gain coverage under Medicaid expansion?
Medicaid expansion would ensure coverage for nearly 300,000 Alabamians, including:
- People who work low-wage jobs and can’t afford private coverage
- Workers who are between jobs
- Adults who are caring for children or older family members at home
- People who have disabilities and are awaiting SSI determinations
- Adult college students
- Uninsured veterans
How would Medicaid expansion boost the economy?
Medicaid expansion would bring our federal tax dollars home to support:
- Healthier families, workers and communities
- Stronger rural hospitals and clinics
- Stronger community mental health and substance use disorder services
- A needed boost in jobs and revenue for state and local economies
How would Medicaid expansion keep people healthier?
Medicaid expansion would help Alabamians stay healthy by ensuring pathways to:
- Regular primary care and preventive checkups
- Earlier detection and treatment of serious health problems
- Regular OB/GYN visits without referral
- Less dependence on costly emergency care
- Better health and greater financial peace of mind
How would Medicaid expansion reduce health disparities?
Medicaid expansion would promote health equity in Alabama by:
- Reducing the racial/ethnic disparities in health coverage
- Lowering the high rate of Black infant deaths
- Lowering the high rate of Black maternal deaths
- Covering chronic health conditions that disproportionately affect people of color and make them more vulnerable to COVID-19 complications
Bottom line
Medicaid expansion would save lives, create jobs and strengthen Alabama’s health care system. Closing the health coverage gap is one of the biggest policy changes available to move our state forward. The governor and the Legislature should embrace this opportunity to build a brighter, healthier future for Alabama.
Join our Cover Alabama campaign!
An end to Alabama’s coverage gap is within reach. Through our Cover Alabama campaign, Alabama Arise is working to ensure that every Alabamian can afford to get the health care they need when they need it. Visit coveralabama.org to learn more and add your name to our ever-growing list of supporters.
Arise legislative update: March 6, 2023
Before the Alabama Legislature returns this week, Arise’s Akiesha Anderson welcomes everyone with an update on an upcoming special session on federal American Rescue Plan Act funds and an overview of Arise’s member-chosen policy priorities for 2023.
Fresh opportunities to push for a better Alabama
The Alabama Legislature will welcome 37 new lawmakers to its halls when its 2023 regular session begins March 7. Alabama Arise sees this as an opportunity to educate new legislators and identify new allies on issues of importance to our members. We urge folks to join us in calling for change, including at Arise Legislative Day on April 11.
Eliminate the state grocery tax
In early February, 11% of Alabama households said they sometimes or often didn’t have enough food to eat. And those hunger challenges are even more severe in communities of color. More than 23% of Black Alabamians and 13.6% of Hispanic Alabamians said they sometimes or often didn’t have enough food.
Untaxing groceries would help families across Alabama keep food on the table. As we have for more than two decades, Arise once again will support bills this year to remove the state’s 4% sales tax on groceries. We also will support replacing the grocery tax revenue by limiting or ending a tax loophole for the wealthiest households. This legislation by Sen. Andrew Jones, R-Centre, and Rep. Penni McClammy, D-Montgomery, would empower Alabama to untax groceries while protecting funding for public schools.
Expand Medicaid to close the health coverage gap
For nearly a decade, Alabama has been outside looking in on a good deal. While hundreds of thousands of Alabamians continue to struggle without health insurance, state leaders have failed to expand Medicaid. Alabama is one of just 11 states that has yet to expand Medicaid. And that inaction has left more than 220,000 Alabamians in a health coverage gap.
Fifteen rural hospitals in Alabama are at imminent risk of closing this year if state leaders don’t act soon to protect health care access. Gov. Kay Ivey should act swiftly to expand Medicaid herself, but the Legislature’s support also will be vital. Arise will keep working to educate lawmakers and the public on the economic, budgetary and humanitarian benefits of Medicaid expansion.
Take bold steps to reform our criminal justice system
Legislators have an opportunity and an obligation to make strides in solving the many problems within Alabama’s criminal justice system. This issue has added urgency as Alabama faces a U.S. Department of Justice lawsuit alleging unconstitutional prison conditions.
Many avenues for progress exist. Arise will urge lawmakers to end the practice of suspending driver’s licenses for debt-based reasons. We will advocate for reform of the state “three-strikes” law, known as the Habitual Felony Offender Act. And we will support a bill to require the jury to be unanimous before imposing the death penalty.
Address housing and transportation needs
State House insiders expect the Legislature to go into a special session this spring to decide how to use remaining federal funds under the American Rescue Plan Act (ARPA). From the start, Arise has taken the position that Alabama should use some of its ARPA funds to jump-start public transportation and help thousands find an affordable place to call home.
During the probable special session, we will continue to uplift the need for these investments in the people of Alabama. Learn more at alarise.org/arpatoolkit.
Budget priorities for the people
Two weeks before the Alabama Legislature’s 2023 regular session, lawmakers, lobbyists and advocates packed into the State House in late February for the annual joint legislative budget hearings. One might call it the Super Bowl for budget nerds.
After years of scarcity, both Alabama budgets are starting out with a revenue surplus. There’s $351 million in “excess” revenue for the General Fund, and $2.7 billion for the Education Trust Fund. That’s not even counting the remaining $1.1 billion in American Rescue Plan Act (ARPA) funds still awaiting allocation.
What we heard at this year’s budget hearings was not surprising. Public services like education, health care, mental health and supportive services need more resources after years of underinvestment. State agencies are struggling with worker shortages and the consequences of underfunding – and understaffing – critical programs. It’s no surprise that lawmakers heard a long, detailed list of opportunities to meet these needs. Most agency heads were clear that new funding can’t fix all of the problems – but it’s a start.
Some lawmakers have floated the idea that this one-time surplus is a sign we need a tax rebate. If that proposal materializes, Arise will be front and center advocating for funds to go directly to low- and moderate-income households bearing the brunt of higher costs. But Arise’s proposal, which comes directly from listening to our members, is a longer-term solution to our upside-down tax code. Our bill to untax groceries would help families keep food on the table while also protecting funding for public schools. It’s a solution that goes beyond just one year to create more foundational and sustainable change.
One concern you may have heard is that nobody has enough workers. Too many Alabamians are still disconnected from the workforce due to missing critical infrastructure investments in child care, public transportation, health care and affordable housing. This year, we’ll be pushing for investments in these supports to help people get and keep work, and to build the healthy and educated workforce Alabama needs.
Our 2023 policy proposals provide that roadmap for change. Expand Medicaid to ensure nobody has to die for lack of preventive care or live in poverty because they have a chronic health condition. Invest in infrastructure to support workers, including child care, housing, public transportation and education. Stop funding public services with punitive fines and fees, and start ensuring the wealthiest Alabamians pay their fair share.
We look forward to seeing you all at our Legislative Day this April. If we continue to stand and work together, we will make significant progress for Alabama.
See The Gap: ‘Possibilities that we just can’t afford’
Kayla is a talented, young hairstylist who has built up a successful clientele in one of Birmingham’s hippest salons. She’s been a stylist for 12 years and said she loves the independence it gives her. She sees dozens of clients every week and takes great pride in her work.
“It’s a great industry, but it’s not taken as seriously as it needs to be,” Kayla said. “Especially relative to the number of people that come through our doors to get their hair done.”
Kayla grew up in a small town in Walker County but started her career in an “Over the Mountain” suburb south of Birmingham. The salon served a wealthier clientele, but it didn’t offer many benefits to stylists. Among the benefits she didn’t have: employer-provided health insurance.
Kayla said lack of access to care is the norm in an industry where health coverage is often an afterthought.
“People love to say that college is too expensive now, so you should go into a trade,” she said. “Maybe the more dangerous trades offer benefits, but when you go into something like hair, we’re kind of left behind.”
Kayla said not many of her clients know she is working full-time while uninsured. And most don’t know how it affects her future in more ways than just going to the doctor.
“No one is talking about why we don’t have health coverage. They don’t usually even care if we have it in the first place,” she said. “No one has ever asked me. You’re the first one.”
When the cost is simply too high
During the COVID-19 pandemic, Kayla decided she needed a change and moved to a new salon. She was thrilled to learn that it offers health insurance to its stylists.
But when she and her husband ran the numbers, it just didn’t work for them. The cost was simply too high. She couldn’t justify the risk of adding such high expenses to her already stretched budget.
Kayla said she still considers herself lucky, though.
“I know I can’t afford it, but at least they offer it. Most places don’t,” she said. “None of the salons back in my rural hometown offered insurance. I don’t imagine that’s changed much since when I started in the industry.”
Kayla explored other options, but nothing panned out.
“The last time I looked at buying a plan online, I put in what I earned and it was still $600 a month,” she said. “I’m not rich. I can’t afford that.”
‘A pragmatic decision’
Kayla is one of more than 220,000 people in Alabama’s Medicaid coverage gap. She is ineligible for Alabama Medicaid or subsidized Marketplace coverage under the Affordable Care Act. And she is also unable to afford premiums for private insurance.
Kayla said she often gets anxious when she thinks about what would happen in an emergency. She said she researches what people do when they need emergency care or surgery and don’t have insurance.
Those long nights researching and worrying about costs led Kayla and her husband to the choice not to have children.
“We’re not going to have children,” she said. “I don’t even know how I’d do it, especially in Alabama.”
The budget is tight for Kayla and her husband. She said she feels it’s not fair to bring a child into the world without the resources to support one.
“Babies are just so expensive. I made a pragmatic decision to not have kids,” she said. “I’m uninsured, and these are all possibilities that we just can’t afford.”
Coverage gaps for prospective new mothers in Alabama
Kayla said she’s heard it’s easier in other states for newer moms. She’s right.
Women in Medicaid expansion states are more than twice as likely to already have coverage prior to becoming pregnant compared to women in non-expansion states, according to the Kaiser Family Foundation. Being enrolled in Medicaid throughout pregnancy means more consistent prenatal care. That leads to healthier pregnancies and reduced risk of complications or death.
An added risk in Alabama is that prospective mothers generally can’t qualify for Medicaid until they’ve confirmed they are pregnant. That means they are unable to access valuable prenatal care until later in the pregnancy.
In Alabama, Medicaid only covers pregnant people with an income up to 146% of the federal poverty level, or around $1,300 monthly for a couple. Working-age adults with no children and no disability do not qualify for Alabama Medicaid, no matter how little they make. This leaves Kayla and 50,000 other uninsured Alabama working women without any options for affordable health coverage.
Some good news for those in Kayla’s situation is that even though our state has some of the most restrictive income eligibility limits for adults, most children in Alabama are eligible for ALL Kids coverage. ALL Kids insures tens of thousands of Alabama children whose low- and middle-income households do not qualify for Medicaid.
Gov. Kay Ivey and lawmakers also recently extended postpartum Medicaid coverage for up to one year after childbirth. This would be great news for Kayla, if workers like her were eligible for ongoing Medicaid coverage. But without employer-sponsored health insurance or Medicaid expansion, Kayla said she and her husband can’t afford the high costs of prenatal care and childbirth.
‘I don’t know what I’m gonna do’
For now, Kayla said she is focusing on taking care of herself. She’s been healthy so far, but she wants to work on a plan for when she might not be
“I bought dental and vision insurance recently,” she said. “I can afford the small stuff, not the big stuff, you know?”
Kayla also sought out a clinic north of town that will work with her on copays for when she needs care for the occasional cold or injury.
“I can do $70 at a time, even though that’s kind of a lot,” she said. “That’s my only real plan. Otherwise, I don’t know what I’m gonna do.”
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.
How Alabama can protect health coverage during the Medicaid ‘unwinding’ period
In 2020, we watched as the COVID-19 pandemic changed the world. Many of us searched for toilet paper, stocked up on groceries and spent a lot of quality time in our homes as we sheltered in place. But the world did not change only in our daily lives. This public health emergency (PHE) also led Medicaid officials to take additional steps to ensure people could afford to get medical care when they needed it.
As the PHE’s end approaches, though, tens of thousands of Alabamians will start paying more for critical medical care – or simply be unable to afford it – unless our state lawmakers take action. About 61,000 Alabamians are expected to lose Medicaid coverage by June 2024 due to this change, according to a report by the Robert Wood Johnson Foundation and Urban Institute.
These coverage losses and higher health care costs would come during a pandemic that is still ongoing. And they would leave many Alabamians with no realistic option for affordable coverage because our state still has not expanded Medicaid to cover adults with low incomes.
Medicaid expansion is the single best step Alabama could take to preserve health coverage and reduce costs for people who cannot afford a private plan and otherwise would be uninsured. In the meantime, state officials should be proactive in communicating with enrollees and facilitating transitions to Marketplace coverage where possible.
Continuous coverage eligibility kept many Alabamians insured
When federal officials declared the official public health emergency (PHE) in 2020, they activated measures to ensure that millions of Americans maintained access to health coverage. Medicaid, the health insurance program funded by federal and state governments and administered by states, was essential to these efforts.
Medicaid received additional federal funding to keep current and new enrollees eligible until the PHE’s end. Under this maintenance of effort (MOE) requirement, traditional eligibility criteria were relaxed.
The relaxed criteria led to continuous coverage eligibility. That meant Medicaid enrollees would not lose eligibility unless they requested in writing to be removed, moved out of state or died. Continuous coverage eligibility also meant changes in income or family size no longer caused removal from Medicaid during the PHE.
The MOE requirement increased the Alabama Medicaid rolls by approximately 50%. The additional federal funding, through an increased Federal Medical Assistance Percentage (FMAP), was necessary to help ensure everyone had access to health care services. But now that the MOE has been separated from the PHE, so too is continuous coverage eligibility. Alabama Medicaid will begin reviewing people for eligibility again starting April 1, 2023.
What is Medicaid unwinding, and how might it affect you?
The end of continuous coverage eligibility means states may return to traditional eligibility rules to determine continued Medicaid coverage. This return to normal rules is called “unwinding.” Alabama Medicaid will begin the unwinding process on April 1.
On that date, Alabama Medicaid will resume its traditional process for verification of eligibility. Alabama Medicaid officials say they will take one year to complete the unwinding process.
Current Medicaid enrollees will receive a mailing to their home addresses from Alabama Medicaid discussing these changes. Current enrollees should ensure their most current and up-to-date information is on file by visiting the recipient portal here.
Take action to maintain coverage
The stakes of unwinding are high. Approximately 61,000 Alabamians may lose their Medicaid coverage during the unwinding period. This could result in a 16% increase in the number of uninsured Alabamians.
The Alabama Unwinding Task Force, which Alabama Arise chairs, is working with Alabama Medicaid to support outreach and communication efforts. This task force is ensuring that support is available for current eligible Medicaid enrollees to maintain their coverage. It also is working to ensure that people who no longer meet Alabama Medicaid’s eligibility criteria know their available options for continued coverage. To get involved with the Unwinding Task Force, email Arise’s Jennifer Harris at jennifer@alarise.org.
Individuals who remain eligible for Medicaid could be at risk of losing coverage during unwinding due to administrative barriers. To ensure they maintain coverage, eligible enrollees first should verify their current contact information. Next, they can elect to receive text messages from Medicaid with vital information by signing up here. And finally, enrollees should respond promptly to Alabama Medicaid’s requests for information to determine eligibility.
If an enrollee is no longer eligible for coverage through Alabama Medicaid, they should contact Enroll Alabama to discuss health insurance options that may be available to them on the Health Insurance Marketplace. They also can dial 211 to connect with an Enroll Alabama navigator who can assist in finding coverage.
Ultimately, state lawmakers should step up to ensure every Alabamian can afford the health care they need to thrive. Thirty-nine states and the District of Columbia have invested in their people’s health and well-being by expanding Medicaid. Alabama can and should do the same.
See the Gap: ‘A bigger problem in our industry’
Barbers and stylists in Alabama often work for themselves, and that comes with a cost. One Birmingham barber in the state’s health coverage gap said he decided against getting health insurance because premiums were close to $1,000 monthly.
In his own words: “Me personally? I don’t go to the doctor. I think it’s part of a bigger problem in our industry. We all just accept that care is too expensive, so we put it off. As a small business owner, that’s scary, especially with a family.”
Medicaid expansion would help this barber – and more than 220,000 other uninsured Alabamians – get the health care they need to survive and thrive. Read more stories of people living in Alabama’s coverage gap here.