Issue: Medicaid Expansion

How to advance our vision for Alabama’s next century

By Chris Sanders

What kind of future do we want for Alabama? It’s a question worth reflecting on as our state enters its third century this year. Are we all right with limiting power and prosperity to a select few? Or would we rather build a state where everyone has a voice and where people of all races, genders and incomes have a real chance to get ahead?

Alabama Arise believes in justice and opportunity for all, and our policy priori­ties flow from that vision. It’s why we support expanding Medicaid for Alabam­ians who can’t afford coverage. It’s why we want to rebalance an upside-down tax system that taxes struggling families deeper into poverty. And it’s why we urge stronger investments in education, housing, public transportation and other services that improve quality of life and promote economic opportunity.

We expect lots of infrastructure talk at the Legislature this year. The regular session starts Tuesday, but lawmak­ers may move quickly into a special session on the gas tax. Gov. Kay Ivey has asked legislators to increase the state’s 18-cent gas tax by 10 cents over three years. That money would fund road and bridge maintenance and oth­er infrastructure improvements.

Many of Alabama’s deteriorating roads are overdue for repair. But the defi­nition of “public infrastructure” goes far beyond tar and gravel. Education, health care and public transportation also help lay the foundation for shared prosperity. This session could bring chances to strengthen those invest­ments – and to make the tax system that funds them more progressive.

Hope on grocery tax, Medicaid expansion

One key breakthrough could be on a longtime Arise priority: ending the state grocery tax. We came heartbreaking­ly close in 2008, when a bill to untax groceries passed the House and fell one vote short in the Senate. But Arise members never gave up the advocacy fight. Now legislators face renewed pressure to end or cut the state’s 4 percent sales tax on groceries. (Some conservative lawmakers are urging a grocery tax reduction to accompany a gas tax increase.) Alabama is one of only three states with no tax break on groceries. It’s a highly regressive tax on a basic necessity, hitting hardest on people who struggle to make ends meet.

Pressure also is building for Alabama to expand Medicaid to cover more than 340,000 adults with low incomes. Medicaid expansion would save hun­dreds of lives annually and create a healthier, more productive workforce. It also would help save rural hospitals, support thousands of jobs and pump hundreds of millions of dollars into the economy.

Our work for a brighter, more inclu­sive future won’t end there. We’ll keep pushing for stronger consumer protec­tions against high-cost payday loans. We’ll make the case for the state to fund public transportation and remove barriers to voter registration. And we’ll continue seeking an end to injustices in Alabama’s civil asset forfeiture and death penalty systems. Visit our website and follow us on Facebook and Twitter for updates on these issues throughout the year.

Budget hearings show need for Alabama to expand Medicaid, boost public investments

By Chris Sanders

Alabama needs to expand Medicaid and invest more in education and other human services. Those were key takeaways from this week’s state budget hearings in Montgomery. The hearings highlighted a range of policy challenges and illustrated the connections between many of them.

We heard a lot of talk this week about the need to strengthen Alabama’s “infrastructure.” Many legislators say the state just doesn’t have enough money to make further investments in human infrastructure – the services like health care, child welfare and public safety that serve as a basic measure of what we value. But that’s incorrect.

Alabama’s lack of money for education, health care, child care and other services isn’t a natural force like the weather. It’s the result of decades of policy choices, as our Tax & Budget Handbook shows. And better choices can lead to better outcomes for Alabama.

Medicaid expansion could cut costs for corrections, DHR

Numerous agency leaders identified Alabama’s fraying rural health care system as a major concern. Rural hospital closures hurt communities and make it harder to get care. A lack of mental health care takes a toll on families, schools and workers. And both challenges increase financial strain on the corrections system.

The opioid epidemic is one problem that cuts across multiple areas: corrections, education, human resources, law enforcement, Medicaid, mental health and public health. Many parents fighting addiction lose child custody to the Department of Human Resources (DHR), which struggles to recruit foster parents for an average $16 daily allowance.

While bare-bones health agencies tackle the epidemic’s medical consequences, Alabama’s corrections system has emerged as the largest provider of mental health services, with many of them linked to substance use disorders.

That’s true even as Alabama’s prison overcrowding remains staggeringly high. The state prison system once operated at nearly double its designed capacity. Recent sentencing reforms helped cut that rate to 163 percent, and Corrections Commissioner Jeff Dunn expects it to sink to 145 percent. But further reductions are unlikely without broader changes, Dunn said.

Rural hospital closures affect prison overcrowding, too. Sen. Cam Ward, R-Alabaster, said a private prison in Perry County is vacant despite an appropriation to buy it. The county has no hospital, which would make it hard to use the prison even if the state bought it, Ward said.

Medicaid expansion would cut costs and improve lives across all these areas of concern. It would stem the tide of rural hospital closures. It would expand access to mental health and substance use treatment. And that would save many Alabamians from going to jail or losing child custody. Arise members and other advocates must keep making the case for Medicaid expansion throughout 2019.

Decades of inadequate funding cause unmet needs, staff shortages

Our state’s upside-down tax system requires most Alabamians to pay twice the share of income in state and local taxes that the richest households pay on average. It also means Alabama struggles to raise enough money to fund health care, child welfare and other important services.

Staff shortages were a running theme at this year’s budget hearings. Alabama’s corrections and mental health commissioners both emphasized problems with hiring and keeping qualified employees. DHR cited high turnover in child welfare staff, who are first on the scene when children’s safety is at risk. And the Alabama Law Enforcement Agency (ALEA) needs more state troopers to ensure highway safety.

DHR Commissioner Nancy Buckner asked lawmakers for an additional $21 million for 2020. Buckner said DHR struggles to retain staff, especially in the stressful child welfare division, which has 36 percent turnover. “Anything you can see on TV, we probably have multiple cases,” Buckner said.

The new money would allow for salary increases, technology improvements, and higher payments for foster families, Buckner said. Foster parents are difficult to recruit, she said, and the opioid epidemic has left more children in foster care.

For corrections, Dunn asked for another $42 million to hire and retain 500 prison guards and improve mental health services. (Low unemployment makes it harder to retain officers, Dunn said, because they often can earn more at safer jobs.) A federal judge has ordered Alabama to address its guard shortage and inadequate health services in state prisons.

ALEA Secretary Hal Taylor requested another $8.7 million to provide raises and hire 50 new state troopers. Up to 200 troopers could retire soon, Taylor said, and ALEA must compete with other departments for officers.

K-12 schools seek to hire more teachers, expand mental health support

Alabama schools discussed their needs for 2020 as well. State school Superintendent Eric Mackey requested an additional $295 million from the Education Trust Fund. With that money, schools could hire more teachers in grades 4-6 and invest more in the Alabama Reading Initiative. They also could hire more school nurses and provide a $600 allowance per teacher for classroom supplies.

Mackey asked for an extra $270 per student to teach about 25,000 students for whom English is a second language. And he requested another $22 million for school safety improvements and school-based mental health services.

Mackey echoed other agency heads by raising concerns about future personnel shortages. A recent survey of high school seniors found only 4 percent want to become teachers, down from 12 percent in previous surveys, Mackey said.

Sen. Vivian Figures, D-Mobile, asked Mackey to address the state Department of Education’s listing of 76 schools as “failing.” Most of those schools are in low-income areas and serve mostly black students. Mackey said the Alabama Accountability Act requires him to designate the lowest performing 6 percent of schools as “failing,” no matter how well they may educate students. The Accountability Act, enacted mere hours after introduction in 2013, diverts tens of millions of dollars a year from public schools to private school scholarship funds.

ALL Kids, pre-K, SNAP offer models for success

The budget hearings painted a stark picture of Alabama’s challenges, but they brought good news, too. Lawmakers heard numerous examples of how investments in health care and education are paying off.

Alabama’s rate of uninsured children is among the South’s best, and ALL Kids is a big reason why. The program provides health coverage for children whose low- and middle-income households don’t qualify for Medicaid. ALL Kids was the country’s first Children’s Health Insurance Program, and it remains a national performance leader in children’s health coverage.

The Program for All-Inclusive Care for the Elderly (PACE) provides an exemplary community-based long-term care option for residents of Mobile and Baldwin counties. The state’s commitment to pre-kindergarten has created a model for early childhood education. And aggressive workforce training programs in K-12 and two-year colleges are boosting Alabama’s economic potential.

Medicaid Commissioner Stephanie Azar highlighted investments in long-term care reform and primary care reform. The statewide Integrated Care Network (ICN) has already launched its case management system, designed to steer more long-term care patients into home- and community-based services. On the primary care side, Alabama Coordinated Health Networks (ACHNs) will launch in seven regions this fall. That move will bring Medicaid decision-making closer to communities and emphasize preventive and coordinated care.

Buckner thanked DHR’s Food Assistance Division for ensuring Alabamians received benefits under the Supplemental Nutrition Assistance Program (SNAP) during the recent federal government shutdown. Facing a Jan. 20 deadline to distribute February benefits, employees worked nights and weekends to approve 1,700 SNAP applications.

Buckner also praised the Food Assistance Division for earning federal bonuses of $2.4 million for timely processing of applications and low error rates in benefit calculations. Unfortunately for Alabama, which has a highly efficient and accurate SNAP program, Congress ended future bonuses in the 2018 Farm Bill.

It’s time to invest in a brighter future

Successful investments like these aren’t “one and done.” Alabama must resume providing some state money for ALL Kids next year as full federal funding ends. PACE seeks to expand, but its requests have been rejected so far. Only one-third of Alabama’s 4-year-olds are enrolled in pre-K. And gearing up for the 21st century will require even bolder workforce development.

Treading water is not enough. Education, Medicaid and other vital services need more funding so they can do more than the bare minimum. Smart investments in these services will pay off in a stronger, healthier future for all Alabamians.

Policy director Jim Carnes, policy analyst Carol Gundlach and communications director Chris Sanders contributed to this post.

Alabama should expand Medicaid to continue gains in children’s health coverage, new national report indicates

By Chris Sanders

Alabama still has one of the lowest rates of uninsured children in the country, but its progress on that measure stalled in 2017, according to a report released Thursday by Georgetown University’s Center for Children and Families (CCF).

The state’s uninsured rate for children (3.1 percent) remained below the national average (5 percent) in 2017. But after years of improvement, Alabama’s number of uninsured children under 19 ticked up from 32,000 in 2016 to 36,000 in 2017. While the increase was not statistically significant, it is a warning sign that Alabama could slip backward in children’s health care if policymakers do not protect and expand coverage, Alabama Arise policy director Jim Carnes said.

“Alabama’s rate of uninsured children has improved from 20 percent to just 3.1 percent in the last two decades, and CHIP and Medicaid have played big roles in that success,” Carnes said. “Our state should build on those gains by expanding Medicaid to cover uninsured adults. Medicaid expansion would boost financial security for struggling parents and increase the odds that their children get and stay insured. It would be a win for children, a win for families and a win for Alabama.”

Congress’ delay last year in renewing federal funding for the Children’s Health Insurance Program (CHIP) was a driver of the uptick in Alabama’s number of uninsured kids, the Georgetown CCF study says. CHIP covers about 171,000 Alabama children living in families with low or moderate incomes, including more than 84,000 on ALL Kids. Congressional efforts to cap and cut Medicaid and undermine the Affordable Care Act also likely contributed to the increase, the report finds.

High uninsured rates plague Alabama’s rural areas, show need to expand Medicaid

By Chris Sanders

Alabama’s small towns and rural areas have among the highest rates of uninsured low-income adult citizens in the country, and residents there are more likely to be uninsured than those in metro areas, according to a new report released Sept. 25, 2018, by Georgetown University’s Center for Children and Families (CCF) and the University of North Carolina’s NC Rural Health Research Program.

The uninsured rate for Alabama adults with low incomes is 36 percent in rural communities and small towns, and 29 percent in metro areas. Both rates are much higher than the national averages of 26 percent for rural areas and 18 percent for metro areas. Even in states that have not expanded Medicaid to cover adults with low wages, those rates have declined on average over the last decade.

But that progress has not reached many parts of Alabama, where the uninsured rate for low-income adults in rural areas and small towns was virtually unchanged between 2008-09 and 2015-16, the report found. And the Medicaid “work requirement” plan that Alabama has submitted for federal approval would drive the uninsured rate even higher by stripping Medicaid coverage from thousands of parents in poverty. Virtually all of those parents would be left with no realistic alternative for affordable coverage.

“Not only has Alabama failed to move forward on health coverage, but now our state is seeking to move backward by leaving even more people uninsured,” Alabama Arise policy director Jim Carnes said. “Alabama should drop its cruel efforts to punish people living in poverty and focus instead on expanding Medicaid so all Alabamians can get the care they need to become and stay healthy. Medicaid expansion would save hundreds of lives, create thousands of jobs and keep rural hospitals and clinics open to serve residents across our state.”

States that expanded Medicaid saw more than three times as large a decline in the uninsured rates for low-income adults living in rural areas and small towns than non-expansion states experienced between 2008-09 and 2015-16, the report found. Nationally, the uninsured rate for low-income adults fell by more than half – from 35 percent to 16 percent – in rural areas and small towns in states that expanded Medicaid. For states that have not expanded, the decline was much smaller: from 38 percent to 32 percent.

“Medicaid expansion would reduce the uninsured rate for residents across the entire state; however, the most dramatic improvement likely would be felt in small towns and rural areas of Alabama,” Georgetown CCF executive director Joan Alker said. “Improved coverage rates typically translate to a more stable health care system and help rural areas and small towns maintain availability of health care providers in areas where shortages are all too common. Access to rural health providers is especially important to women of child-bearing age and those with chronic conditions like asthma.”

In Alabama and elsewhere, jobs tend to be scarcer in rural areas and small towns, meaning fewer people have health insurance through their employers. And many of the jobs available in these communities – like farming and small businesses – are less likely to come with health benefits. Ten of the 11 Alabama counties with the highest unemployment rates in July 2018 were rural counties.

Alabama’s persistently high rate of uninsured adults shows the need for Medicaid expansion

By Chris Sanders

New U.S. Census data show that the share of uninsured Alabamians increased between 2016 and 2017 and remained higher than the national average. Alabama Arise policy director Jim Carnes issued the following statement in response on Thursday, Sept. 13, 2018:

“The White House’s efforts to undermine the Affordable Care Act and Alabama’s refusal to expand Medicaid are making life worse for hundreds of thousands of people across our state. These bad policy choices are serving as barriers separating people from affordable health coverage.

“Alabama’s steady gains in health insurance coverage since 2013 took a turn for the worse last year, this week’s new Census data show. The share of Alabamians without health insurance coverage rose to 9.4 percent in 2017, up from 9.1 percent the previous year and above the national average of 8.8 percent. These are trends in the wrong direction, and they’re the result of intentional policy choices.

“The Trump administration eroded ACA coverage by slashing funding for federal outreach and advertising to promote open enrollment for Marketplace coverage. In Congress, repeated attempts to repeal the ACA created public confusion over the status of the law. And in Alabama, the state’s ongoing refusal to expand Medicaid has left about 300,000 people trapped in a coverage gap, making too much to qualify for Medicaid but too little to receive subsidies for Marketplace plans.

“It’s time to stop undermining health coverage and start investing in it. The White House should stop attacking the ACA. Congress should shore up funding for Marketplace outreach and enrollment assistance. And Gov. Kay Ivey should expand Medicaid to save our rural hospitals, create thousands of jobs and make Alabama healthier.”

Medicaid expansion, end to grocery tax highlight Alabama Arise’s 2019 priorities

By Chris Sanders

Medicaid expansion and legislation to end the state sales tax on groceries are among the top goals on Alabama Arise’s 2019 legislative agenda. More than 200 Arise members picked the organization’s issue priorities at its annual meeting Saturday, Sept. 8, 2018, in Montgomery. The seven issues chosen were:

  • Tax reform, including untaxing groceries and closing corporate income tax loopholes.
  • Adequate funding for vital services like education, health care and child care, including approval of new tax revenue to protect and expand Medicaid.
  • State funding for the newly created Public Transportation Trust Fund.
  • Consumer protections to limit high-interest payday loans and auto title loans in Alabama.
  • Legislation to establish automatic universal voter registration in Alabama.
  • Reforms to Alabama’s criminal justice debt policies, including changes related to cash bail and civil asset forfeiture.
  • Reforms to Alabama’s death penalty system, including a moratorium on executions.

“Public policy barriers block the path to real opportunity and justice for far too many Alabamians,” Alabama Arise executive director Robyn Hyden said. “We’re excited to unveil our 2019 blueprint to build a more just, inclusive state and make it easier for all families to make ends meet.”

Alabama’s failure to expand Medicaid to cover adults with low wages has trapped about 300,000 people in a coverage gap, making too much to qualify for Medicaid but too little to receive subsidies for Marketplace coverage under the Affordable Care Act. Expanding Medicaid would save hundreds of lives, create thousands of jobs and pump hundreds of millions of dollars a year into Alabama’s economy. Expansion also would help keep rural hospitals and clinics open across the state.

The state grocery tax is another harmful policy choice that works against Alabamians’ efforts to get ahead. Alabama is one of only three states with no sales tax break on groceries. (Mississippi and South Dakota are the others.) The grocery tax essentially acts as a tax on survival, adding hundreds of dollars a year to the cost of a basic necessity of life. The tax also is a key driver of Alabama’s upside-down tax system, which on average forces families with low and moderate incomes to pay twice as much of what they make in state and local taxes as the richest Alabamians do.

Health security for Alabama’s working families

By Jim Carnes

Hundreds of thousands of uninsured Alabamians would qualify for Medicaid if Alabama expanded eligibility to adults with incomes up to 133 percent of the federal poverty level. (That’s about $15,000 a year for individuals and $31,000 a year for a family of four.) Many hard-working Alabamians have no health coverage because they earn too much to qualify for Medicaid and too little to afford private health insurance. This fact sheet examines what’s at stake for Alabama in deciding whether to expand Medicaid under the Affordable Care Act.

The State of Working Alabama 2014: Health coverage in Alabama: Where we’ve succeeded and where there’s work to do

By Carol Gundlach

Alabama has enjoyed great success in recent decades in ensuring that children and seniors have the health protection they need, according to a new Arise Citizens’ Policy Project report issued Tuesday as part of The State of Working Alabama 2014. But the state lags behind the nation when it comes to insuring young adults, nearly 30 percent of whom lack health coverage.

“Child care, construction and food service are essential jobs that are often low-paying, and the people who do that important work deserve the protection of health insurance,” ACPP policy director Jim Carnes said. “The Marketplace makes affordable coverage available for tens of thousands of Alabamians. Closing the coverage gap would insure hundreds of thousands more. It’s time for our state to take this important step toward a healthier, more secure Alabama for all.”

Legacies of recession, chronic shortfalls linger in Alabama’s budgets

By Chris Sanders

State support for education and other public services under the Education Trust Fund (ETF) and General Fund (GF) next year would not come close to its pre-recession level under the budgets that advanced in the Alabama Legislature on Wednesday. Both budgets are built on the assumption that the state will see no major revenue increases next year.

One-time teacher bonus, Alabama State funding cut in Senate committee’s ETF budget

Alabama would allocate $113.9 million, or 1.9 percent, less from the ETF next year under the $5.9 billion budget that won approval Wednesday in the Senate’s ETF budget committee. (By contrast, K-12 and higher education officials had requested $474 million more support next year.) If the budget becomes law, ETF funding in 2015 would be 18.5 percent less than it was in 2008, adjusted for inflation. The full Senate could consider the plan as soon as Thursday.

K-12 teachers would receive a one-time 1 percent bonus next year under the committee’s budget. Gov. Robert Bentley had recommended a 2 percent pay raise, but committee chairman Sen. Trip Pittman, R-Montrose, said he isn’t sure revenues will grow enough to sustain that pay increase. “You can’t spend optimism,” Pittman said. The committee rejected an attempt by Sen. Hank Sanders, D-Selma, to provide a 6 percent teacher raise.

K-12 schools and two-year colleges would receive slightly more ETF money next year under the committee’s budget, while universities would receive slightly less. The budget would include money to hire more middle school teachers and increase support for the Alabama Math, Science and Technology Initiative (AMSTI). Funding for the Alabama Reading Initiative would be flat.

Alabama State University (ASU) would lose about one-fourth, or $10.8 million, of its ETF support next year under the budget, accounting for almost the entire overall funding cut to universities. The budget would include $10 million for ASU as a “first-priority conditional,” meaning Bentley could release the money to the university if ETF revenue collections exceed budgeted spending next year.

Flat funding abounds for General Fund services

The House voted 80-20 Wednesday night to approve a GF budget that would be about the same size it was last year and is little different than the one that cleared a House committee last week. The $1.8 billion budget now goes to the Senate.

Medicaid, prisons, mental health care and other public services could struggle to maintain current services at the funding levels in the House’s GF budget. Overall GF support for those and other non-education services would be 8.3 percent lower next year than it was in 2008, adjusted for inflation, despite higher costs and population growth since then.

The House budget would cut GF support for Alabama’s prison system, which operates at nearly twice its designed capacity. Rep. Steve Clouse, R-Ozark, who chairs the House’s GF budget committee, said last week that he wants to work with House and Senate leaders to find more money for corrections.

Medicaid would see an 11.4 percent GF increase, though that amount still would fall short of what State Health Officer Don Williamson said the agency needs from the GF. Williamson said Medicaid could survive next year at the House’s proposed funding level by looking for more ways to trim costs in the prescription drug program and other areas.

Mental health services would receive the same amount of GF money next year, despite the increased demand for community-based mental health services following the closure of several state mental health hospitals. State courts, which have cut hundreds of jobs in recent years, would receive far less GF funding than they requested.

ALL Kids, which insures Alabama children whose low- and middle-income families do not qualify for Medicaid, would receive 28.3 percent more from the GF to help cover higher enrollment. A $13.9 million ETF boost for the Department of Human Resources (DHR) would help the agency offset an $11.8 million GF reduction. DHR provides child welfare, child support collection and elder abuse services. The agency also administers the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) program in Alabama.

Rep. Chris England, D-Tuscaloosa, said lawmakers have missed several opportunities to ease the burden on state budgets in recent years. Instead, England said, the Legislature has declined to increase the state cigarette tax, reform the state’s criminal sentencing system, or expand Medicaid eligibility under the Affordable Care Act.

The GF draws its revenues from a variety of sources that do not grow quickly enough to keep pace with cost increases. That leaves the budget with a structural deficit, meaning it often is strapped for cash even when the economy is doing well.

Rep. John Knight, D-Montgomery, said lawmakers eventually must solve Alabama’s perennial GF shortfalls. “At some point, we’re going to have to figure out how to say, ‘We’re going to do better,’” Knight said. “We can’t take care of the basic things we’re supposed to do.”

Time is getting shorter for the Legislature to finalize the budgets. Lawmakers will return Thursday for the 19th of 30 allowable meeting days during the 2014 regular session, which is expected to last until early April.

By Chris Sanders, communications director. Posted Feb. 26, 2014.