Author: ker2

Policy Watch: Evaluating the Impact of Medicare Negotiated Drug Prices in Alabama

By Kimberly Randall, Miriam Calleja, Kevin Joseph, Sean McMahon  

Introduction 

Prior to 2022, the federal government was legally unable to negotiate with pharmaceutical companies on the prices for prescription drugs for Medicare Part D. In recent communications discussing prescription drug prices, Senator Bernie Sanders of Vermont named pharmaceutical companies as whom to blame, stating, “big drug companies, through massive lobbying and campaign contributions, regulate Congress.” Many Medicare recipients often pay hundreds or thousands of dollars out of pocket for medications to treat prevalent conditions. If and how to address the financial burden related to prescriptions has been a political point of contention for some time. The Inflation Reduction Act (IRA) provided relief by giving Medicare the authority to negotiate prescription drug prices for select drugs, offering relief to vulnerable populations.  

Background 

Medicare is a government-sponsored health insurance program founded in 1965 available for individuals aged 65 and older and those with disabilities or specific medical conditions. The federal program provides standard coverage for hospital care (Part A) and outpatient services (Part B), and users can add additional prescription drug coverage (Part D) at their own expense.  

The process of including the ability to negotiate drug prices for Medicare recipients in the IRA began in early 2021, building on the momentum from the 2020 U.S. presidential race where the idea gained significant traction. With the Biden-Harris administration taking office, initial discussions emerged among legislators, advocacy groups, and policymakers to explore the potential of allowing Medicare to negotiate drug prices. During this period, various stakeholders, including healthcare experts, patient advocacy groups, and some members of Congress strongly advocated for this policy as a crucial component of broader healthcare reform.  

By mid-2021, congressional committees, including the Senate Finance Committee and the House Energy and Commerce Committee, were actively considering proposals to incorporate drug price negotiation into a larger legislative package. The committees conducted hearings, collected expert testimony, and engaged in talks with key stakeholders, including the pharmaceutical industry. A compromise was reached to limit the number of drugs eligible for negotiation to 10 in the first year and 15 for the following years to phase in the program over several years.  

In August 2022, President Biden signed the Inflation Reduction Act into law, including the Medicare drug price negotiation provision. This landmark legislation officially authorized the Secretary of Health and Human Services (HHS) to negotiate prices for certain high-cost drugs over the coming years. Following the signing of the Act, the Centers for Medicare & Medicaid Services (CMS), under HHS, initiated the implementation process, which involved developing specific rules, guidelines, and procedures for the negotiation framework. Throughout 2023 and 2024, CMS engaged in rulemaking, sought public comment, and held stakeholder meetings to finalize these rules. CMS was tasked with identifying the initial list of 10 drugs subject to negotiation, with the new negotiated prices set to take effect in 2026. An estimated 9 million seniors are expected to be affected by the first 10 negotiated drug prices. However, the pharmaceutical industry is pushing back with multiple lawsuits that may impact the implementation of the program.  

Policy  

The legislation establishes the negotiation process between CMS and drug manufacturers to determine the Maximum Fair Prices (MFPs), referring to the upper limit that Medicare will pay for certain prescription drugs, in order to make the high-cost drugs more affordable. The negotiations consider several factors, including the clinical benefit of the drug, its development and production costs, research and development expenses, and whether it represents a therapeutic advance over existing treatments. The goal is to arrive at a price that balances affordability for Medicare beneficiaries and provides a reasonable return for the manufacturer.  

To qualify for price negotiation with CMS, small molecule drugs need to have been on the market for 7 years and have no generic versions. For biologics, drugs made from living organisms instead of chemicals, they must be available for 11 years without any similar alternatives, known as biosimilars, on the market. Federal officials chose 10 drugs from the top 50 that Medicare Part D spends the most on and are widely used by its members following a public comment period.  

Impact 

Alabama is home to over a million Medicare beneficiaries, with about 650,000 enrolled in Medicare Part D prescription drug plans. Many of these residents face high out-of-pocket costs for medications, especially for managing prevalent chronic conditions such as cardiovascular disease, diabetes, and cancer, which are among the leading causes of death and disability in the state. Nearly 30% of Alabama’s Medicare beneficiaries have diabetes, compared to the national average of 26%, and around 40% have a history of cardiovascular disease, underscoring the critical importance of affordable medications for these conditions. 

In 2023, the total spending on prescription drugs for Medicare Part D beneficiaries was estimated to be around $216 billion. Of this amount, an estimated $48 billion (approximately 20%) was spent on the first 10 high-cost drugs targeted for negotiation under the Inflation Reduction Act. Alabama residents with Medicare Part D coverage faced an estimated $80 million in out-of-pocket costs for these specific medications, reflecting the state’s higher-than-average rates of chronic disease and medication use. 

If the negotiated prices agreed upon between CMS and participating drug companies had been in effect in 2023, the federal government would have saved an estimated $6 billion in net prescription drug costs after accounting for rebates, certain fees, and payments. This would have represented a 22% reduction in net spending for covered prescription drugs. Looking ahead to 2026, when the negotiated prices are set to take effect, Medicare beneficiaries are projected to save an estimated $1.5 billion under the standard benefit design. These projected savings from the Negotiation Program will be in addition to other cost-saving measures in the IRA, such as the first-ever cap on out-of-pocket drug costs for Medicare beneficiaries.   

Given that approximately 16% of Alabama’s population is aged 65 or older, and with 12% of these residents living below the federal poverty line, the impact of these cost reductions will be significant. It could allow more Medicare beneficiaries in Alabama to access essential medications without facing substantial financial hardship, contributing to better health outcomes and a reduction in overall healthcare spending in the state. 

See below for the full list of medications and their newly negotiated costs:  

Source: CMS

Policy Watch: Alabama Launches Childcare Tax Credit System for Workforce Development Initiative

May 31, 2024 | Kimberly Randall 

Background 

Childcare costs are one of the most widespread barriers to preventing parents from re-entering or staying in the workforce. According to the Economic Policy Institute, in Alabama, the average cost of childcare for a single child is over $6,000 per year, accounting for almost 12% of a median family’s income of $50,335. According to a study by Alabama State University, those numbers are unlikely to improve, as roughly 17% of childcare facilities surveyed said they increased prices due to the pandemic, and prices in those facilities went up by an average of 17%.

An estimated 13,000 parents who are work-eligible are currently unemployed due to childcare restrictions. As Alabama’s economic infrastructure continues to grow, offering affordable solutions for childcare in the state is necessary to access the workforce needed to sustain corporate development. While Alabama has a historically low unemployment rate of 2.2%, workforce participation is among the lowest in the country at just 57.1%, continuing a trend of being under the national average that goes back to the mid-1970s. 

Proposed legislation 

According to the bill text, HB358 “serves a public purpose by conferring a direct public benefit … through the promotion of public health, safety, morals, security, prosperity, contentment, and the general welfare of the community [by] increasing the quality of childcare to the general public, which has the effect of encouraging high-quality care and education for children and facilitating greater workforce participation throughout the state.” Through a series of tax credits to businesses, the legislation hopes to have more Alabamians enter the workforce and gain employment by improving the quality and availability of childcare options for working parents. 

At its core, the legislation offers an incentivized tax credit to employers who assist with the childcare needs of their employees. The tax credit is eligible for employers for: 

  1. The construction, renovation, expansion, or repair of a childcare facility, or for the purchase of equipment for such facility, or for the maintenance and operation thereof.
  2.  Payments made to childcare facilities or employees for the provision of childcare at childcare facilities for children of employees.
  3. Payments made to childcare facilities to reserve services for children of employees.

The bill specifically defines children as direct dependents under the age of 5 and restricts the tax credit to individuals who make less than $80,000 per year before overtime or bonuses. Additionally, the tax credit is tiered depending on the quality rating of the childcare providers, pressuring facilities to increase or maintain their ratings for increased funding opportunities. Each decreasing quality rating results in a decreased tax credit: 

  • (1) Five-star quality rating – two thousand dollars ($2,000) per eligible child.
  • (2) Four-star quality rating – one thousand seven hundred fifty dollars ($1,750) per eligible child.
  • (3) Three-star quality rating – one thousand five hundred dollars ($1,500) per eligible child.
  • (4) Two-star quality rating – one thousand two hundred fifty dollars ($1,250) per eligible child.
  • (5) One-star quality rating – one thousand dollars ($1,000) per eligible child.

Companies are eligible to apply for 75% of their expenses as a tax credit if a medium or large-sized organization, and 100% of their expenses in this area if they are small businesses. The bill provides special consideration of funding for small businesses, rural providers, and grants for non-profits. The total tax credits awarded shall not exceed $15,000,000 in its first year but have steady increases year over year until its sundown clause in 2027. 

Impact 

Many solutions for childcare accessibility have been suggested over the years, however, Alabama elected for an employer-first method rather than a direct-to-employee method, largely because of the vast number of Alabamians who file taxes using the standard deductions rather than itemized where the tax credit would appear. Because of this, a large portion of the intended population had the potential to not receive the benefits. Childcare has been highlighted as one of the key barriers in increasing Alabama’s workforce participation rate, alongside transportation and vocational training. 

Women are more dominantly affected by childcare limitations. A growing body of research shows that access to quality childcare in early development results in long-term health outcomes for children, such as improved cardiovascular and metabolic health, and reduced smoking in adulthood. Center-based care, specifically, shows an increase in kindergarten readiness and social skills, allowing for potential educational benefits of this program. 

At an economic level, the childcare tax credit is expected to offer a $1.3 billion of economic activity in the state. 

Next Steps 

HB358 was largely bipartisan, with public support from both the Speaker of the House and the Minority House Leader, who was also the champion, and passed on April 18 unanimously. It was signed into law by Governor Ivey on May 8th. 

The legislation will go into effect on January 1, 2025, and has a current sundown clause of December 31, 2027, if not renewed. The legislation text specifically states that a review of the data collected during this initiative must be analyzed and considered prior to any extensions. 

Policy Review: Workforce Shortage Trends in Dental Care in Rural Alabama

May 16, 2024 | Dr. Conan Davis, DMD; Dr. Stuart Lockwood, DMD; Dr. Carly McKenzie, PhD

Introduction 

Nationwide, populations in America are migrating away from rural areas to urban areas.  We continue to see this happen in Alabama as well.  Historically, younger generations returned to their hometowns after college, military service, or other training to work. However, trends in modern times show more and more people are moving away and choosing to stay in the urban centers where they were trained or have served.  This trend is particularly affecting the healthcare sector in rural areas, including dentistry.

Trends Affecting Access to Dental Care

Dr. Stuart Lockwood and Dr. Conan Davis wrote about how this trend and others were affecting the field of dentistry and impacting access to dental care in rural areas of Alabama in 2018, published by the Lister Hill Center for Health Policy in 2020. The publication was widely distributed and quoted widely in Alabama in news publications, civic and professional organization publications, and within the dental community. The data presented was used by several organizations, educational institutions, and even interested legislators to promote changes that will eventually impact and improve access to dental care in rural areas of Alabama.

This current paper is an attempt to report on some of the changes that have occurred in the state in the intervening years, update the current data, and propose additional measures to aid in the continuing efforts. Some of the changes we report in this paper will identify positive steps that have been taken by authorities within the state to attempt to rectify the problem of access to dental care. However, we will also describe where we are still observing a further decline in the number of state dentists and dental access in rural areas. We will demonstrate the need for further initiatives.

What has happened with the Alabama dental workforce from 2017 to 2024?

1. Alabama remained 51st in the country in dentists per 100,000 population. We currently have 4.1 dentists to every 10,000 people according to a ranking by the American Dental Association in (2024). The national average is 6.1 dentists per 10,000 people. Additionally, the federal government continues to identify a large number (50) of Alabama’s 67 counties as being federal dental professional shortage areas (see map). Several factors determined the designations.

2. The older dentists of 2017 (33% of all Alabama dentists were 60+ years of age in 2017) are retiring or have retired. In 2024 there were 162 fewer dentists aged 60+ than in 2017 and there were 78 fewer dentists in the 60-64 age category alone. Further, in 30 Alabama counties there were no dentists less than 40 years old, and seven counties had only a single dentist younger than 40 years of age (see map). 
3.  Many Alabama counties are losing dentists.  Overall from 2017 to 2024, there was a net loss of 2 dentists in the state, with 28 of 67 counties having fewer dentists in 2024 than in 2017. Further, 18 counties had no change in the number of dentists, and 21 counties had MORE dentists in 2024 than in 2017.  Among the smallest populated 25 counties, 11 of them lost dentists, 12 had no change and 2 counties gained dentists.  Among the 13 most urban counties, 7 counties gained dentists and 5 lost dentists.   

4. The gender effect is pronounced.  Between 2017 and 2024 there was a net loss of 190 male dentists and a net gain of 186 female dentists (28 were unknown).  There is a trend that female dentists are more likely to practice in rural Alabama.  Among the profoundly rural 41 Alabama counties, there was a net gain of 21 female dentists and a net loss of 9 male dentists.

5. Many dental graduates continue to stay in Jefferson County or leave Alabama entirely.  In 2017 there were 543 dentists in Jefferson County alone and 583 dentists in our 54 non-urban counties.  This changed very little in 2024, as there are 552 dentists in Jefferson County and 574 dentists in our 54 non-urban counties. In 2017, 156 of 543 (28.3%) dentists were female, and in 2024, 208 of 552 (37.7%) dentists were female.

A 2021 analysis indicated that for UAB School of Dentistry graduates and where they were living in 2021, only 37%, 49%, and 5% of UAB SOD graduates for the previous three years respectively were living in AL in 2021.

In sum, many Alabama counties are at risk of significant loss of dental services soon.  A crisis is here.  Specific workforce data by county further elucidates the situation:

Nine Alabama counties have either no dentists or only a single dentist in practice:

  • 3 counties (Clay, Greene, Wilcox) have no dentists.
  • 1 county (Coosa) has one dentist, who is 60 years of age and practices 2 days a week.
  • 1 county (Lowndes) has one dentist from a Federally Qualified Health Center in Montgomery who practices in the county 4 days per week. 
  • 4 counties (Conecuh, Fayette, Perry, Washington) have a single dentist.

In addition, many counties are at risk due to a retirement cliff.  For example, a majority of the dentists currently practicing in 15 Alabama counties are over 60 years of age 100% of dentists are 60+ years of age in 4 Alabama counties (Washington, Lawrence, Bullock, Monroe) 

  • 60-83% of dentists are 60+ years of age in 4 Alabama counties (Marengo, Franklin, Tallapoosa, Macon)
  • 50% of dentists are 60+ years of age in 7 Alabama counties (Jackson, Bibb, Butler, Clarke, Marion, Randolph, Sumter)

Therefore, Alabama has 23 counties where dental services are at significant risk in the near future.

 

Facing the Facts, Addressing the Problem

We speculated in 2018 that Alabama would be facing grave consequences in rural access to dental care in 10-15 years.  We proposed that unless significant changes were implemented to affect the current trends in dental practice location selection many areas of the state would be without any reasonably accessible dental services. So, what has transpired in the past 5-6 years since we made these predictions?

Actions Taken

First, a partnership was developed between the Alabama Dental Association (ALDA) leadership and leadership at The University of Alabama at Birmingham School of Dentistry (UAB SOD).  The support of these two entities was essential to accomplish everything necessary to make the legislative and policy changes needed. These organizations already had a close working relationship, but we knew greater cooperation was needed to address our issues of joint concern.

Secondly, we shared the data and our concerns about the future of dentistry in this state with news publications around the state, including AL.com, Yellowhammer News, and the publication of the League of Municipalities.  All provided news coverage for our concerns, thus helping to elevate the perceived importance and visibility of the issue.

We also published our findings in the Alabama Dental Alumni News and the ALDA newsletter.  We spoke at dental conferences and at an Alabama Rural Health Association conference to educate healthprofessionals about our findings.  Eventually, state legislators and the Governor were informed about these issues and the consequences of inaction.

Thirdly, we proposed making changes to the state Board of Dental Scholarships to be able to provide full-tuition scholarships to graduating dental students willing to serve in an approved rural practice setting for at least 4 years.  Many leaders in the dental community met with the Board and with legislators willing to propose legislation to make these changes.  After many rounds of discussion, legislation was passed and signed by the Governor in 2020.  The new legislation also provided funding of an additional $500,000 to the existing $220,000 currently in place.  Following these changes the focus transitioned from a scholarship award program with small loans to focus entirely on providing scholarships of $180,000 per graduating dental student willing to serve in designated rural areas of Alabama in need of dentists.  Currently, we have placed seven dentists in locations of dire need thus far.

Fourthly, the UAB School of Dentistry used data published in our last paper to make the case for Alabama’s need to train more dental students.  Previously, approximately 55 dentists graduated from UAB SOD each year for many years, though in recent years this number had been slowly rising.  A key component of this increase was an International Dentist Program that allowed UAB SOD to train an additional 12 future dentists per year.  However, these numbers were still not adequate to populate the state with the numbers of dentists we needed.  In response to the workforce shortage, UAB SOD increased total enrollment by 33 seats which raised the approximate number of yearly graduates to 108 students.  This lengthy process involved approvals from both CODA, the national accrediting body, and The University of Alabama System’s Board of Trustees.

The UAB SOD also recognized that development and recruitment programs may help encourage and support promising students from rural and low-income areas of the state to pursue dentistry.  This required legislative action, collaborative partnerships, and funding.  These programs are designed to better equip students from low-income and rural communities to prepare for and navigate activities related to eventual success in dental education.  The basic framework for this program and some initial funding for it has been approved by the legislature but more is needed to accomplish it completely.  Some relevant UAB SOD initiatives are as follows:

• Rural Dental Scholar Program: This five-year pathway program models the Rural Medical Scholars Program framework, a very successful initiative developed by the UAB School of Medicine (SOM) in conjunction with the UA College of Community Health Sciences (CCHS). A key part is a 1-year Master’s program focused on Rural Health. Students engage in a biomedical science prep and study skills/test-taking development in addition to a clinical/practitioner mentor component and extensive education about rural healthcare. The first cohort of Rural Dental Scholars (4 students) received their offers in the 2022-2023 admissions cycle and matriculated at UA CCHS in Fall 2023 with UAB SOD matriculation in July 2024. During the 2023-2024 admissions cycle, five Rural Dental Scholars accepted offers to join the upcoming year’s cohort.
• Blazer to DMD:  This 5-year “red shirt” pathway program intends to develop promising applicants, with a special focus on applicants whose life experiences align with Alabama’s residents, including rural residents. Our initial cohort of 3 students completed a 1-year Master’s program at UAB in Spring 2023 and matriculated as D1’s at SOD in July 2023. Two Blaze to DMD students are expected to matriculate at UAB SOD in July 2024. Four applicants accepted offers to compose the next Blaze to DMD cohort.
• Virtual Education and Engagement Program (VEEP): This development and recruitment program is part of a Health Resources Services Administration (HRSA) grant led by the School of Dentistry faculty.  The UAB SOD Admissions team implemented the first program in Spring 2023 and executed the second in Spring 2024. This virtual seminar series is intended to develop, recruit, and engage future applicants from disadvantaged populations with Alabama residents as the primary target. Current plans include 10 scholars in each cohort and DAT Bootcamp access included, as funded by a 3-year HRSA grant. Seminar topics include preparing a competitive admissions portfolio, options for funding dental education, ways to use a DMD degree, and mock interviews with admissions committee members. Scholars also benefit from mentorship programs that connect them with both current dental students and practitioners.
• Board of Dental Scholarships: This initiative is facilitated and supported by UAB SOD although it’s a separate entity housed outside of UAB SOD. This group awards funds to practitioners agreeing to practice in an approved rural AL area for 4-5 years. Several of the pathway programs detailed above are intended to help increase future BDS awards.
• Rural Dental Health Scholar Program: This residential summer program targets rising high school seniors from rural communities in Alabama who express an interest in dentistry. UAB SOD and UA CCHS have partnered to expand the existing Rural Health Scholars summer cohort to target future dentists. The initial cohort of seven will participate in Summer 2024, courtesy of the Board of Dental Scholarships, who have graciously agreed to help fund scholarships for the Rural Dental Health Scholars to participate. The eventual goal is to have 10 high school students enrolled each summer as Rural Dental Health Scholars.

In summary, all the actions and efforts that many in Alabama have pursued over the last 5-6 years should be applauded.  Much has been accomplished.  We are pleased with the response of our state dentists, educators, and legislators in recognizing this potential crisis.  However, we have not yet seen the turn-around in access to dental care in rural Alabama that is so desperately needed.  Additionally, there are other issues that we believe affect the reluctance of new dental graduates to select a more rural area to practice.  In addition to the issues previously outlined, educational debt may be an increasingly weighty influence for recent dental graduates when selecting practice locations and environments.  The increasing presence of corporate dental practices in rural areas may also be influential.  Young dentists can begin working in these group practices and receive a healthy salary to help pay off debt while not incurring additional debt and overhead expenses, hence their popularity with graduates.

Many additional programs and activities will be required to close the gap in access to dental services, especially in Alabama’s rural areas. These are yet to be addressed or considered, but we remain optimistic that solutions can be developed.

Policy Watch: Volunteer Licenses for Nonresident Dentists Practicing in Alabama

May 16, 2024 | Kimberly Randall

As the 2024 legislative session comes to an end in Alabama, the Lister Hill Center is diving into the most influential bills passed with substantial public health impact. As a part-time legislature, the Alabama House of Representatives and Senate operate over a 100 calendar-day period, usually beginning on the second Tuesday of February. During the regular session, there are no restrictions on bills that can be brought to the floor. Unless a special session is called, where a single topic is the subject of all legislation being debated, the legislature will not reconvene until 2025. 

Background 

Alabama has a concerningly low number of counties that employ a full-time dentist. Approximately 80 percent of all dentists practicing in Alabama practice in the 13 most urban counties. The other 20 percent practice in the 54 non-urban counties of Alabama; many of these smaller counties only have one or two dentists, with one county (Greene) offering no permanent dental care at all for residents.

The federal government lists 65 of Alabama’s 67 counties as “dental professional shortage” areas. As such, many residents in rural communities are forced to travel far distances for dental care, putting an economic and logistical burden on patients. To combat this, several non-profits frequently bring in dentists and dental hygienists from other states to do low-cost or pro bono work in the state as volunteers. Currently, those dentists are required to obtain a full license in the state of Alabama, even if they only plan to practice for a short time as a volunteer. This often makes the volunteer service cost-prohibitive for those who would otherwise choose to come to Alabama.

Proposed Legislation 

Representative McCampbell proposed HB70 as a solution, offering a volunteer license for individuals doing this form of work. Individuals who have an active, full, unrestricted license in another state may submit an application to the Board of Dental Examiners of Alabama for a temporary license valid up to 15 calendar days within 30 days, which may be renewed at the discretion of the Board. Volunteer licenses will be available for $150 each for dentists and dental hygienists, which prior could have cost individuals thousands of dollars. 

The bill goes into effect on October 1, 2024.

Potential Impact 

Oral health is intricately linked to systemic health, and untreated dental issues can exacerbate or contribute to various chronic conditions. For instance, untreated gum disease has been associated with an increased risk of heart disease, stroke, and diabetes. According to a study published in the American Heart Association journal Circulation, individuals with severe gum disease have a 53% higher risk of developing heart disease compared to those with healthy gums (Lockhart et al., 2012). Moreover, chronic inflammation in the mouth due to untreated dental problems can trigger inflammatory responses throughout the body, potentially worsening conditions such as arthritis and respiratory diseases.

It is the hope that this license fee will entice more charitable work in the area of dental practice in areas that are facing higher levels of poverty. Routine dental hygiene is often a financial struggle for individuals living at or below the poverty line, particularly since Medicaid and other government assistance programs do not offer dental coverage for those over the age of 21, except for individuals who are pregnant or post-partum. 

Learn More 

Want to learn more about the impact of rural dentistry in the state of Alabama? Check out this guest publication from Drs. Davis and Lockwood breaking down the current state of dental infrastructure in the state. 

Community Partner Spotlight: Alabama Rivers Alliance Releases Water and Sanitation Infrastructure Resource Guide

May 15, 2024 | Victoria Miller (Alabama Rivers Alliance), Kimberly Randall (Lister Hill Center for Health Policy) 

Alabama has made headlines in recent years for the difficulties in maintaining and modernizing water infrastructure in the state, particularly through the rural Black Belt areas where poverty and distance between homes exasperate the issue. Researchers at The University of Alabama and UAB have collaborated on trying to understand the public health and engineering impacts and potential solutions, teaming up with a plethora of community partners to help address the issues. The Alabama Rivers Alliance, a Lister Hill Center community partner, is a statewide network of groups working to protect and restore all of Alabama’s water resources through building partnerships, empowering communities, and advocating for sound water policy and enforcement. 

One difficult aspect of addressing the water and sanitation crisis in Alabama is the lack of understanding about community and government resources available for residents who lack proper infrastructure. Most government resources have pooled in Lowndes County, Ala., bordering Montgomery, with other organizations reaching into other areas of the Black Belt like Wilox County. However, the complexity of finding and understanding those resources presents a barrier to the residents who most need them. 

The Alabama Rivers Alliance’s Wastewater Equity Fellowship has launched a new Alabama water infrastructure resource website, which will help communities address their wastewater needs. As concerns around water and wastewater infrastructure challenges grow in Alabama, and as funding deadlines approach, this new online resource hub is designed to empower citizens, advocates, and policymakers with knowledge and tools to address their community’s needs. This website serves as a vital starting point for communities looking to learn more about solving water-related issues with funding. The team unveiled their new website, and reported on their wastewater equity research, at Alabama Water Rally in March, the annual gathering of clean water advocates.

“This work is one of many in a larger, ongoing effort to strengthen collaborations between institutes of higher education and community-based partners to develop more effective water-related solutions for local communities.”  Dr. Jillian Maxcy-Brown, post-doctoral researcher at the University of Alabama who participated in the Alabama Rivers Alliance fellowship, said.  “We are also working on installing pilot-systems to test innovative low-cost water treatment technologies, conducting regional wastewater needs studies, and developing resource guides to holistically address historic infrastructure challenges in the Alabama Black Belt. We are planning to expand upon the work begun in this fellowship with more in-depth analyses of infrastructure funding mechanisms across the U.S.” 

The Alabama Water Hub website provides opportunities to learn about how water infrastructure is funded in Alabama. From the website, users can learn more about water infrastructure in general, see a list of funding options for water infrastructure projects, learn more about commonly used water funding terms, and find contacts for further assistance with water infrastructure funding.

Also featured on the website are the first maps of the applicants to the Alabama Department of Environmental Management’s (ADEM’s) State Revolving Fund (SRF). Mapping the SRF applicant information provided by ADEM highlights the primary mechanism being used to issue water funding to communities that need it. 

With the recent influx of federal water funding, communities are at a critical time to get informed about how drinking water and wastewater funding is allocated and how to access water funding when your town needs it. For communities that have long suffered with infrastructure issues such as crumbling/aging water pipes, overflowing sewers, contaminated drinking water, and/or degraded water quality, the funding availability is an opportunity to seek relief and get funding to address those issues. 

“Water infrastructure is a complex topic, but this website is a space where any Alabamian can learn more about the landscape in our state and find funding resources for water projects,” Madelyn Cantu, Alabama Rivers Alliance wastewater fellow, said. “Water is life, and we want this resource hub to help make water infrastructure more accessible.”

Learn More  

Visit the website today to access valuable resources and learn about water infrastructure funding in Alabama.

Want to get involved with environmental justice and policy work? The Lister Hill Center is hosting a Summer Advocacy Training Workshop with ARA on June 5th to give opportunities for individuals to learn more, increase their civics education, and learn how to get started. 

Policy Watch: The Economic and Health Impact of a Rural Hospital Investment Tax Credit Program

April 30, 2024 | Miriam Calleja, Kimberly Randall 

Background

Of the five million people residing in the state of Alabama, approximately 22% reside in rural areas. Many parts of the state lack adequate access to healthcare facilities, particularly specialty services like maternity care, neurology, and surgery centers, resulting in patients traveling to metropolitan areas such as Birmingham, Montgomery, or Huntsville for care. This poses a logistical, and often economic, strain on patients as they are forced to account for the mileage, transportation, and time necessary to drive sometimes several hours for treatment. Research suggests that this problem will only continue to worsen, as a concerning new report by The Center for Healthcare Quality and Payment Reform highlights that more than half of 52 rural hospitals in Alabama are at risk of closing, with 19 of these deemed to be at “immediate risk” of shutting doors. 

According to the USDA Economic Research Service, rural Alabamians make approximately 14% less in household income than their urbanite counterparts, with 19.7% of rural citizens falling below the poverty line. Additionally, over 17% of the rural population did not complete high school, resulting in lowered rates of health and economic literacy. 

Hospitals in rural areas are often underfunded, facing unique financial challenges such as increased labor costs and decreased numbers of private insurance payers. While rural hospitals reported increased profit margins during the COVID-19 pandemic due to the influx of government funding, that funding has largely dissipated, leaving many facilities in weakened financial standing. Currently, rural hospital margins are significantly worse in states that have not expanded Medicaid under the Affordable Care Act, including Alabama. 

Proposed Legislation 

In response to the looming rural health infrastructure crisis, Alabama lawmakers are calling on individuals and businesses to support rural health institutions through the Rural Hospital Investment Program. House Bill 310, championed by Representative Terri Collins, introduces an incentivizing tax credit solution aimed at stimulating financial contributions to rural hospitals. Under this initiative, taxpayers who donate to these hospitals can earn a dollar-for-dollar reduction on their state income tax, potentially reducing their liability by up to $15,000 annually for individuals. Married couples filing jointly can see this benefit doubled, while businesses could reduce their owed state income taxes by up to $500,000.

According to the bill, “qualifying hospitals would use the gifts to pay for their provision of acute care services to rural populations served by the hospitals. These funds may be used not only for direct care and operational expenses but may include expenditures to maintain or upgrade facilities.” Additionally, the legislation proposes a board within the Office of State Treasurer to determine the eligibility of qualifying rural hospitals and to operate the program as a whole. 

Impact

The Alabama Hospital Association says the need for additional funding opportunities in rural health infrastructure is immense and could make a significant difference. Currently, smaller hospitals don’t have the means to help every patient. This tax credit program encourages greater community and corporate involvement in the healthcare sector and represents a lifeline for these rural hospitals teetering on the brink of closure. 

A similar program was established in Georgia, which faces similar rural health challenges, which has seen remarkable success in the last year. Called the Georgia HEART Tax Credit Program (Helping Enhance Access to Rural Treatment), $367 million has been donated to eligible rural hospitals since 2017. 

In the Alabama legislation, the donations would be capped at $80 million a year. There is some concern over the economic impact of the state’s Education Trust Fund, which is the largest operating fund in Alabama used for the support, maintenance, and development of public education. This week, the Alabama Senate is debating the $9.3 billion budget plan passed by the House on April 17th, which runs from October 1, 2024 through September 30, 2025. 

Next Steps 

This is the second year that this legislation has been proposed. Currently, HB310 is awaiting a hearing in the Ways and Means Committee in the House of Representatives. If given a favorable report, the bill would then be scheduled for debate on the House floor later this week. 

The end date of the Alabama legislature is May 5, 2024. 

Learn More 

Want to know more about rural hospital infrastructure and how policy impacts health outcomes? Take a look at these resources: 

Kaiser Family Foundation State Report 

Rural Hospital Association 

Student Submission: The Education and Health Impact of Restricting Diversity, Education, and Inclusion Programming in Alabama

April 12, 2024
Raimi Liebel | UAB Graduate Student, Magic City Acceptance Center Intern

LHC is proud to feature student work on relevant policy issues such as this one. If you are a UAB student interested in contributing to Policy Watch publications, please email lhc@uab.edu.

The concept of DEI (diversity, equity, and inclusion) has become a political hot-button in recent years. DEI in higher education refers to programs, training, events, organizations, and spaces that are centered around historically marginalized identities. Higher education institutions have been incorporating DEI measures since the 1960s following the civil rights movement. DEI is not a new concept and has been integrated into universities and colleges across the country. Historic legislation such as Title IX, the Americans with Disabilities Act (ADA), and Deferred Action for Childhood Arrivals (DACA) have contributed to the increase in DEI offices, services, and organizations at higher education institutions across the US over the past 60 years.

Since 2022, more than 40 anti-DEI bills have been proposed in the US. Texas, Florida, North Dakota, South Dakota, Texas, Utah, and now Alabama have all signed bills into law limiting or banning DEI offices at higher education institutions. Representative Will Barefoot introduced SB 129 to the Alabama Senate on February 20th, which restricts state-funds from being used for DEI offices and sponsored DEI programming, potentially including student organizations such as USGA and SJAC. The University of Alabama at Birmingham alone has 12 DEI offices and more than 150 student organizations that could face state funding loss. SB 129 moved from its first reading to being passed in the Senate within three legislative days before was signed into law by Governor Kay Ivey on March 19th.

According to a 2023 mixed methods analysis, “Students of color thrive and achieve more at higher educational institutions where there are deliberate efforts made to provide diversity, equity, and inclusion activities.” The link between student success, belonging, and graduation rates and DEI programming has been demonstrated in several studies. Academic communities fear that legislation of this kind may prevent students from enrolling in higher education institutions where DEI restrictions are present. Reduced staff and student enrollment or retention can result in economic effects on institutions across the state, especially those that use diversity as an incentive to drive recruitment. DEI efforts at higher education institutions help facilitate students’ learning from a variety of thoughts and perspectives, which has proven to increase cognitive development and cross-cultural empathy.

DEI has been attributed to improved student enrollment, retention, and graduation rates. A 2023 mixed methods study identified significant positive correlations between perceived campus climate, diversity in staff/faculty, curricular diversity, and interactional diversity and college student re-enrollment. Also, explicit DEI policies in workplaces led to more diversity in employment, accounting for 46% of the variance reported in the study. Higher education institutions and workplaces benefit from recruiting and retaining diverse staff.

Attainment of a college degree is positively correlated with improved health outcomes and behaviors. Those who attain a bachelor’s degree or higher earn $1.2 million more than their high school-educated peers over their lifetime, and college degree holders are almost twice as likely to have employer-sponsored health insurance (ESI). ESI covers approximately 60.4% of the US population and is often the most affordable and comprehensive option for workers.

Degree attainment and long-term health are correlated, and historical trends showcase certain populations have lower enrollment and retention rates. The U.S. Department of Education notes that the “participation of underrepresented students of color remains a problem at multiple points across the higher education pipeline including at application, admission, enrollment, persistence, and completion.” DEI bans compounded with lower college enrollment could lead to increased health disparities for marginalized communities. Decreasing diversity in classrooms, workplaces, and communities decreases collaboration, cultural exposure, and productivity.

Other facts of note:

Click here to view this brief in PDF format.

Policy Watch: Creating a Voluntary Do-Not-Sell List in the National Instant Criminal Background Check System for Firearm Purchases

Background 

Currently, in the state of Alabama, the ability to buy a firearm is available to most adults over the age of 18, with certain weapons restricted to citizens over the age of 21. Individuals who have been convicted of certain violent or alcohol-related crimes are not able to legally purchase a firearm. Alabama follows federal regulations regarding background checks, where licensed gun dealers must process a potential buyer’s information through the National Instant Criminal Background Check System database, facilitated by the Federal Bureau of Investigation. 

Alabama is one of the most lenient states in the country regarding gun laws. No additional background checks, evaluations, waiting periods, or training are required to purchase a firearm. In 2022, the state enacted a permitless concealed carry law allowing anyone over the age of 18 to carry a handgun without a permit, background check, or mandated safety training.

Voluntary Do-Not-Sell lists have been proposed in several states since 2019. Sometimes called “Donna’s Law,” the legislation was first initiated after Donna Nathan admitted herself to a psychiatric facility and later took her own life by firearm upon release. 

Legislation 

Voluntary Do-Not-Sell legislation was first submitted in 2018 by Senator Pittman, and again in 2022 by Reps. Rafferty (D-Birmingham) and Farley (R-McCalla) as a bipartisan bill calling for the establishment of a database operated by the Alabama Department of Mental Health for individuals to volunteer their own names onto a Do-Not-Sell list. HB37, sponsored by Rep. Ensler, builds upon that legislation to be in compliance with constitutional requirements, and increases opportunities and access for individuals to utilize the service. 

HB37 would restrict an individual’s ability to purchase or possess a firearm once their name was added to the list and creates criminal penalties for violations. The bill also provides a pathway for individuals to remove their name once it has been added. The purpose of this list is to restrict access to firearms to individuals when there is a fear that he or she may become a risk to himself or herself or others.

With a start date of June 1, 2025, the ADMH is tasked with developing the searchable database, along with creating and distributing a registration form for applicants. Individuals wishing to add their names to their name to the Do-Not-Sell List may do so in the following ways: 

  1. Submitted in person at a circuit clerk’s office with government-issued photo identification. A county clerk shall immediately transmit any received registration form to the department.
  2. Mailed to the department with a copy of the registering individual’s government-issued photo identification.
  3. In person at a healthcare provider’s office with a government-issued photo identification. The healthcare provider should immediately transmit the forms to the department for processing. 
  4. Submitted electronically to the department by short message service or multimedia messaging service along with a copy of government-issued photo identification and a photographic portrait of the individual that contains exchangeable image file format data proving that the photographic portrait was taken within one hour before transmission to the department.

Individuals who request to be added to the Do-Not-Sell List must wait 21 days before requesting their names to be removed. Their application for removal will be administered by the district court, where the individual must provide evidence stating that they are not a harm to themselves or others. 

Impact 

Self-harm is the 10th leading cause of death in adults in the United States, and access to a firearm triples the risk of suicide. Recently, several states such as Virginia and Washington have enacted legislation establishing voluntary Do-Not-Sell Lists for firearms to restrict access to individuals experiencing a mental health crisis. According to the Centers for Disease Control and Prevention, half of all suicides are caused by a firearm and are, by far, the deadliest method with the highest chance of mortality per attempt. Delaying firearm purchases has been found to reduce the number of suicides without increasing the number of suicides by other means, showing that suicide attempts by different methods “is unlikely to undermine the lifesaving potential of these laws.”

There is empirical data to support the creation of a Do-Not-Sell list. A survey conducted in Alabama distributed to 200 patients receiving psychiatric care found that 46% of responses indicated they would register for such a database. Broader internet surveys found up to ⅓ of all participants would add their name to a Do-Not-Sell List. According to the New England Journal of Medicine, the vast majority of individuals experiencing suicidal ideation or thoughts will see a clinician within a year of their death, putting medical practitioners in a position to screen their patients for suicidal tendencies: 

“​​Clinicians routinely assess their patients’ risk of suicide, yet they are limited in terms of the practical interventions they can use for patients who are not actively suicidal but who fear they may become so. … [Voluntary Do-Not-Sell Lists] reduce suicide risk consensually and indefinitely in advance of a crisis. The majority of people who die by suicide see a primary care provider in the year before their death.” 

As a part of standard medical practice, clinicians can regularly encourage the use of advance directives such as determining a medical proxy, so this form of legislation offers patients an opportunity to create such a directive in reference to firearm-related decisions. Unlike other mental health interventions, voluntary registries develop opportunities to enhance patient autonomy and preserve their role in their healthcare decision-making processes. 

Next Steps 

HB37 is pending action in the Public Safety and Homeland Security Committee. If you want to make your voice heard on this or future legislation, click here to identify your elected officials. 

Don’t know what to say? Check out this guide from the American Civil Liberties Union on drafting a letter to your government officials. 

Learn More 

Want to know more about firearm legislation and how gun violence impacts mental health? Take a look at these resources: 

Gifford Law Center to Prevent Gun Violence 

APHA Gun Violence Fact Sheet 

EFSGV Public Health Approach to Gun Violence 

Policy Watch: US House of Representatives Proposes Significant Spending Cuts to CDC, Public Health Funding

Kimberly Randall | August 15, 2023

ATLANTA, GA – Exterior of the Center for Disease Control (CDC) headquarters

Background 

Each year, the House of Representatives and Senate pass a series of legislation that determine the funding for the federal agencies operating in the US government. Funding is broken down into two categories – mandatory (63%) and discretionary (30%) – determined by whether the funding is tied to specific laws. The remaining budget is dedicated to interest repayment on federal loans.

The budget discussions traditionally begin with the President’s Budget Request (PBR), a formalized plan from the executive branch outlining the President’s suggested funding and taxes for the following fiscal year. Then, respective House and Senate committees produce budget bills that will be discussed, reconciled, and voted on in committee before being sent to the chamber floor. According to the Congressional Budget Act of 1974, the budget is to be voted on by April 15th for the following fiscal year, which begins on October 1st. However, many times this process takes longer. 

For the fiscal year 2024 (FY24), President Biden officially requested $144 billion in discretionary spending, an 11.5% ($14.8 billion) increase from FY23, for Health and Human Services, through which the majority of public health funding is funneled. The official budget statement claims that the budget increase is expected to expand healthcare access, lower medical costs, increase funding for cancer research, increase access to behavioral health programs, support rural health programs, and improve nutrition and food safety. 

Proposed Legislation 

As Congress begins budget discussions for FY24, the House Appropriations Committee released the Fiscal Year 2024 bill for the Labor, Health and Human Services, Education, and Related Agencies Subcommittee. In the draft, several federal agencies are suggested to see a decrease in funding. The bill, named the Fiscal Year 2024 Labor, Health and Human Services, Education and Related Agencies Appropriations Bill, contains significant spending cuts to programs related to public health infrastructure and eliminates federal funding for family planning, HIV prevention, and gun violence research. 

According to the Appropriations Chair, Kay Granger (TX), the proposed budget legislation is intended to “restore fiscal responsibility and reduce the scope of social spending by $60.3 billion from the FY23 enacted level, eliminating 61 (support) programs” in addition to funding biomedical research on cancer, Althzeimers, opioid use, and other chronic and rare diseases. The legislation also looks to increase funding in rural health by way of telehealth programs, healthcare workforce recruitment programs, and specialized education funding. 

FY23 Enacted Budget (millions) FY24 Presidential Request (millions) FY24 Proposed Budget (millions)
Immunization and Respiratory Diseases $919 $1,256 $326
HIV/AIDS, Viral Hepatitis, STI, TB $1,391 $1,545 $1,171
Emerging and Zoonotic Infections Disease $751 $846 $708
Chronic Disease Prevention and Health Promotion  $1,430 $1,814 $797
Birth Defects, Developmental Disabilities, Disability and Health  $206 $223 $205
Environmental Health $247 $421 $130
Injury Prevention Control $761 $1,352 $730
Public Health Scientific Services $754 $962 $654
Occupational Safety and Health  $363 $363 $247
Global Health  $693 $765 $370
Public Health Preparedness Response $905 $943 $735
Crosscutting Activities and Program Support $724 $1,039 $231
Buildings and Facilities $40 $55 $40

Impact 

In the United States, most public health activities are carried out by state and local government agencies, and a large portion of the CDC’s annual budget is distributed via grants and cooperative agreements to these departments. In FY19, over 55% of the CDC’s annual budget was granted to state and local public health agencies and has significant influence on state and local budgets. 

In 2022, the Alabama Department of Public Health received $129,863,407 from CDC grants, with millions more going to The University of Alabama, The University of Alabama at Birmingham, Auburn University, and Tuskegee University for research in various areas. Reductions in the federal CDC budget will trickle down to impact local programs, including child vaccinations, staffing, and research. The table below represents a hypothetical look at the budget differences between funded programs in 2022 and a proportional budget in line with the FY24 proposed House budget. 

FY23 Grants Awarded (Alabama) Proportional Budget Estimate
Immunization and Respiratory Diseases $4,500,225 $1,597,580 

(-64.5%)
HIV/AIDS, Viral Hepatitis, STI, TB $13,988,137 $11,776,613 

(-15.81%)
Emerging and Zoonotic Infections Disease $2,248,081 $2,096,864

(-5.72%)
Chronic Disease Prevention and Health Promotion  $13,587,018 $7,573,404

(-44.26%)
Birth Defects, Developmental Disabilities, Disability and Health  $6,557,429 $6,524,642

(-0.5%)
Environmental Health $404,616 $212,990

(-47.36%)
Injury Prevention Control $7,174,096 $6,882,110

(-4.07%)
Public Health Scientific Services $727,445 $630,986

(-13.26%)
Occupational Safety and Health  $1,949,377 $1,326,356

(-31.96%)
Public Health Preparedness Response $9,437,092 $7,664,806

(-18.78)
Crosscutting Activities and Program Support $5,528,735 $1,764,219

(-68.09%)

The potential budget cuts come on the tails of a significant loss of funding following the Fiscal Responsibility Act of 2023, where an estimated $1.7 billion in secured funding was recessed. The CDC released a statement that multi-year funded projects would not receive the remainder of their grants: “We can confirm that the last two years of funding is no longer available to CDC for jurisdiction awards. Funds previously awarded are not impacted.” 

Next Steps 

The House of Representatives Appropriations Committee will continue to debate the contents of the bill, amending as necessary. Once the committee agrees on the House bill, party leaders will meet to reconcile it with the Senate bill. 

The Senate Appropriations Committee has already passed an appropriations bill for FY24 in a 26-2 vote, providing $117 billion in funding for the Department of Health and Human Services. The Senate released an official statement in late July regarding the sister legislation in the House: 

It is unclear how this legislation will proceed through the legislative process, given vastly different topline funding levels under consideration in the Senate and House, which has yet to advance its version of this legislation through the full House Appropriations Committee.

A full list of House Appropriations Committee members can be found here, two of which represent Alabama. 

Stay Informed 

Want to learn more about public health policy, funding, and advocacy? Check out the Advocacy Portal on the American Public Health Association’s website. 

Official updates from Congress can be found on the House of Representatives Appropriations Committee website.