Policy Watch: Authorizing Health Benefit Plans from Agricultural Organizations in Alabama

May 20, 2025 | Kevin Joseph, LHC Student Assistant

Background

In the United States, health insurance is subject to regulations under the Affordable Care Act (ACA) signed by President Obama in 2010. The ACA puts certain rules on health services coverage labeled ‘insurance,’ particularly for group health insurance. Notably, these regulations include that insurance cannot deny (guaranteed issue), not renew (guaranteed renewability), or adjust premiums of an insurance policy based on a pre-existing or new condition of an enrollee. Additionally, insurance must cover a range of essential health benefits, including ambulatory and emergency services, mental health care, prescription drugs, and other benefits (Ortaliza & Cox, 2024). These regulations intend to protect consumers, but not all health coverage programs are required to be compliant with them if they are not considered insurance (Departments of the Treasury, Labor, and Health and Human Services, 2024).

For example, in more than 30 states, including Alabama, there are plans called short-term health insurance plans, which are meant to fill temporary gaps in coverage between employers without being considered health insurance under the Public Health Service Act (Healthinsurance.org, n.d.; Alabama Department of Insurance, n.d.). Accordingly, these ‘plans’ cannot provide coverage for more than 4 months under a 2024 HHS rule (Departments of the Treasury, Labor, and Health and Human Services, 2024). These plans also can deny consumers based on pre-existing conditions, new conditions, etc., and they do not have to cover all essential health benefits required under the ACA. These short-term plans are not allowed in 14 states and the District of Columbia (Healthinsurance.org, n.d.).

Similar to short-term health insurance plans but intended to provide longer-term coverage, farmer bureau ‘health plans’ are an option for health coverage to farmers allowed in several states, including Tennessee, Iowa, Kansas, South Dakota, Texas, and Indiana. If these plans are not considered comprehensive health insurance, they similarly do not necessarily have to meet the aforementioned ACA requirements (United States Government Accountability Office, 2023).

Proposed Legislation

HB477 of the 2025 Alabama Legislature Regular Session authorized nonprofit agricultural organizations and their affiliates to offer health ‘benefits.’ To be an eligible nonprofit agricultural organization, the group must collect annual dues, be exempt from federal income taxes, be based in Alabama, have existed before 1940, and have members residing in at least 98% of the state’s counties.

As passed, benefits authorized by HB477 must cover ambulatory services, hospitalization and emergency services, laboratory services, mental health and substance abuse disorder services, and prescription drugs. The plans cannot set an annual limit lower than 2 million dollars per year on the value of these covered benefits.

The organization providing the health benefits must provide a written notice to applying individuals that these benefits are not considered an insurance policy or part of insurance business in Alabama. However, the agricultural organization offering these health benefit plans must file with the Department of Insurance to confirm they meet certain actuarial standards. The benefits can only cover nonprofit agricultural organization members and their family members if that member does not have the option to participate in an employer-sponsored health plan that is less than 9% of their household income.

If health plan enrollees have complaints about the benefits, HB477 required that the selling organization establish an ombudsman to respond to complaints in a similar fashion to complaint procedures with the Department of Insurance. Despite not being ACA compliant-insurance, benefits must have in- and out-of-network providers with cost-sharing regulations for purchasers and the organizations themselves, like other insurances. Similarly, as enrolled, benefit plans authorized by HB477 will not be allowed to conduct medical underwriting after the contract starts and will not be able to cancel the contract, not renew the contract, modify the contract, or increase contract premiums due to a medical event once the benefits are established.

Premiums for the health benefits plans will be taxed at 1.3% annually for collection by the Department of Revenue.

HB477 had 40 sponsors, with Representative Faulkner (R-Jefferson County) serving as the title sponsor.

Impact

According to the American Community Survey 2023 estimates, about 8.5% of non-institutionalized civilian Alabamians, or about 426,000 people, are uninsured compared to 7.9% of people nationwide. Those who are in young and middle adulthood (ages 19-44), are racial minorities or ethnically Hispanic, are born outside the US, are less educated, are lower income, or are not employed full-time are more likely to be uninsured in Alabama (American Community Survey, 2023).

Currently, the Alabama Farmer’s Federation is a nonprofit agricultural organization that represents over 340,000 members, according to its website, which indicates up to hundreds of thousands of Alabamians may be eligible for such health plans (ALFA Farmers, n.d.). Although it is unclear how many people are covered by similar plans in other states that have authorized these benefits, a supporter in the hearing noted that Tennessee has had 138,000 people receive such coverage since 1947. Consequently, this bill and the consequently authorized plans may allow more Alabamian farmers to be covered under the bill, improving health outcomes due to increased care access. The Centers for Disease Prevention and Control report that agricultural workers face many occupational hazards that cause increased rates of injury and death, and the longitudinal Agricultural Health Study on farmers has shown that farmers may face unique exposures like pesticides that can increase the risk of certain health conditions (CDC, n.d.; National Institutes of Health, n.d.; UN Environment Programme, n.d.). Thus, healthcare coverage through health benefit plans for Alabamian farmers may be particularly needed.

HB477 proponents in an April 2^nd, 2025 House Health Committee hearing argued that the bill provides health plans as a less expensive alternative to existing healthcare coverage options that are more expensive. Specifically, they mentioned that ACA Marketplace individual plans may be unrealistic financially for farmers who do not qualify for income-based subsidies (i.e., make 400% or more of the federal poverty level). Since health plans will not necessarily have income stipulations and will also not be limited in time of year when you can enroll (like Marketplace plans are), Alabamian farmers may opt to get health coverage through these plans. However, it is unclear how many farmers will choose these plans over the two alternatives of paying for Marketplace plans or (employer-sponsored plans if they cost more than 9% of a family’s household income), which some claim are too expensive, or choosing not to be insured (since the individual mandate of the ACA was repealed).

Concerns about the quality of coverage exist. As previously noted in a federal government’s Federal Register publication, some federal departments expressed concerns over plans that are not considered ‘comprehensive health insurance coverage’ subject to PHS, ACA, and other statutes’ regulations because potential enrollees may not understand that their plan is not considered comprehensive coverage (Departments of the Treasury, Labor, and Health and Human Services, 2024). Some essential health benefits required for ACA-compliant insurance like maternity and newborn care, certain preventive care services, pediatric dental and vision care, and rehabilitative and habilitative services, are not required to be covered in these plans per HB477.

Additionally, even if the bill’s writing does not allow for health plans to be terminated or non-renewed based on medical conditions, applicants still can be initially denied based on pre-existing conditions. Groups offering these health plans may opt not to cover certain individuals/families with high expected healthcare costs, which may leave such farmers and their families vulnerable. However, if these individuals/families are accepted and enrolled in the health plans, they may face higher out-of-pocket costs as opposed to traditional health insurance plans. Consequently, individuals with lower expected healthcare costs may preferentially opt to enroll in these health plans, which could destabilize existing insurances’ risk pools.

Next Steps

HB477 was passed by the Alabama State Legislature and signed by Governor Kay Ivey. 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.

References

Alabama Department of Insurance. (n.d.). Short-term health insurance plan. https://www.aldoi.gov/Consumers/ShortTermHealthIns.aspx

ALFA Farmer. (n.d.) History. https://alfafarmers.org/federation/history/

American Community Survey (2023). Selected Characteristics of Health Insurance Coverage in the United States, ACS 1-Year Estimates Subject Tables, Table S2701. [Data set]. U.S. Census Bureau, U.S. Department of Commerce. https://data.census.gov/table/ACSST1Y2023.S2701?q=S2701:+Selected+Characteristics+of+Health+Insurance+Coverage+in+the+United+States

Centers for Disease Control and Prevention (CDC). (n.d.). Agriculture Worker Safety and Health. https://www.cdc.gov/niosh/agriculture/about/index.html

Departments of the Treasury, Labor, and Health and Human Services. (2024). Short-Term, Limited-Duration Insurance and Independent, Noncoordinated Excepted Benefits Coverage. https://www.federalregister.gov/documents/2024/04/03/2024-06551/short-term-limited-duration-insurance-and-independent-noncoordinated-excepted-benefits-coverage

Healthinsurance. org. (n.d.). Short-term health insurance. https://www.healthinsurance.org/short-term-health-insurance/

UN Environment Programme. (n.d.). Highly Hazardous Pesticides (HHPs). https://www.unep.org/topics/chemicals-management/pollution-and-health/highly-hazardous-pesticides-hhps

National Institutes of Health. (n.d.). Study Updates. Agricultural Health Study https://aghealth.nih.gov/news/updates.html

Ortaliza, J. & Cox, C. (2024, July 29). The Affordable Care Act 101. KFF. https://www.kff.org/health-policy-101-the-affordable-care-act/?entry=table-of-contents-what-is-the-affordable-care-act

United States Government Accountability Office. (2023). Private health coverage: Information on farm bureau health plans, health care sharing ministries, and fixed indemnity plans. https://www.gao.gov/assets/gao-23-106034.pdf#page=13.19

Policy Watch: Alabama Medicaid coverage of noninvasive colorectal cancer screenings and colonoscopies

February 22, 2025 | Kevin Joseph, LHC Student Assistant

Background

Established to provide health care coverage to low-income people, Medicaid is a state-delivered health insurance program jointly financed by the states and federal government. Medicaid covers over 80 million people nationwide, accounting for approximately a fifth of all healthcare spending nationally. The structure of the Medicaid program allows for state Medicaid agencies to decide (with some parameters) what populations and services are covered (Kaiser Family Foundation, 2024).

For Medicaid enrollees in Alabama Medicaid, the Covered Services Handbook by the Alabama Medicaid Agency does not indicate that colorectal cancer screenings are covered for enrollees (Alabama Medicaid, n.d.). Colorectal cancer is currently the third most diagnosed cancer in the United States, with over 150,000 predicted diagnoses in 2025 (American Cancer Society, 2025). The most recent CDC data shows that 2,510 cases of colorectal cancer were reported in 2021 in Alabama, with a higher age-adjusted rate of 39.4 cases per 100,000 than the national metric of 36 cases per 100,000 people. Additionally, racial disparities in colorectal cancer exist in Alabama, with 43.5 cases of colorectal cancer per 100,000 among Black Alabamians as opposed to 39.4 cases per 100,000 overall (Centers for Disease Control and Prevention, n.d.).

A systematic review of colorectal cancer screening tests, of which there are multiple types, has indicated substantial existing evidence that various colorectal cancer screening types can reduce CRC mortality, with detection benefits generally outweighing procedure risks. Accordingly, the US Preventive Services Task Force concluded with high certainty that screening adults ages 45 to 75 has at least moderate net benefit, with high net benefit for ages 50 to 75 (Lin et al., 2021; US Preventive Services Task Force, 2021). Despite this recommendation, the American Cancer Society notes that state Medicaid Agencies differ in coverage of colorectal cancer screenings for enrollees (American Cancer Society, 2024).

Proposed Legislation

Introduced by Senator Larry Stutts (R-District 6), chair of the Senate Health Committee of the Alabama Legislature, SB27 of the 2025 Regular Session would require the Alabama Medicaid Agency to cover noninvasive colorectal cancer screening tests assigned grade A or B by the US Preventive Services Task Force, as well as any colonoscopy done due to a positive screening result, effective immediately. The covered screenings would include, at a minimum, the guaiac fecal occult blood test (gFOBT), fecal immunochemical test (FIT), and multi-target stool DNA test (sDNA-FIT).

Impact

If SB27 were to pass, Medicaid enrollees in Alabama may receive more colorectal cancer screenings from their providers, leading to earlier, more frequent detection of colorectal cancer. Data from Healthy People 2030 indicates that only 63.5% of people nationally receive colorectal cancer screenings based on recommended guidelines, with worse metrics among non-metropolitan areas and racial/ethnic minorities (Healthy People 2030, n.d.). Considering this current level of screening, along with existing findings on the benefits of colorectal cancer screening and that colorectal cancer is the second leading cancer killer in Alabama according to the Alabama Department of Public Health, coverage of screenings could consequently lead to a reduction in cancer mortality among Alabamians, particularly among Black Alabamians who face a higher prevalence of colorectal cancer (Lin et al., 2021; Alabama Department of Public Health, 2024).

As of February 19th, 2025, there is no fiscal note on SB27, but there would likely be an increased cost for Alabama Medicaid to cover these screenings and associated colonoscopies for positive screenings. However, a systematic review of colorectal cancer screenings indicated that most common colorectal cancer screening strategies, including gFOBT and FIT, are cost-effective and, in the US, even cost-saving compared to no receiving screenings due early detection of colorectal cancers (Ran et al., 2019). Further analysis would needed to understand the implementation costs and health/cost saving benefits in Alabama of enacting SB27.

Next Steps

SB27 is currently pending in Senate Healthcare Committee in the 2025 Regular Session 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.

References

Alabama Department of Public Health. (2024, September 5). Colorectal Cancer. https://www.alabamapublichealth.gov/colon/

Alabama Medicaid. (n.d.). Covered Services. https://medicaid.alabama.gov/content/4.0_Programs/4.1_Covered_Services.aspx

American Cancer Society. (2024, January 29). Insurance Coverage for Colorectal Cancer Screening. https://www.cancer.org/cancer/types/colon-rectal-cancer/detection-diagnosis-staging/screening-coverage-laws.html

American Cancer Society. (2025, January 16). Key Statistics for Colorectal Cancer. https://www.cancer.org/cancer/types/colon-rectal-cancer/about/key-statistics.html

Centers for Disease Control and Prevention (n.d.). Colorectal Cancer Statistics. https://www.cdc.gov/colorectal-cancer/statistics/index.html

Healthy People 2030. (n.d.). Increase the proportion of adults who get screened for colorectal cancer – C-07. Data. https://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/cancer/increase-proportion-adults-who-get-screened-colorectal-cancer-c-07/data?group=All%20groups&from=2023&to=2023&state=United%20States&populations=#edit-submit

Kaiser Family Foundation. (2024, May 28). Medicaid 101. https://www.kff.org/health-policy-101-medicaid/?entry=table-of-contents-introduction

Lin J.S., Perdue L.A., Henrikson N.B., Bean S.I., & Blasi P.R. (2021). Screening for Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA, 325(19),1978–1998. https://doi.org/10.1001/jama.2021.4417

Ran, T., Cheng, C., MIsselwitz, B., Brenner, H., Ubels, J., & Schlander, M. (2019). Cost-Effectiveness of Colorectal Cancer Screening Strategies – A Systematic Review. Clinical Gastroenterology and Hepatology, 17(10), 1969-1981. https://doi.org/10.1016/j.cgh.2019.01.014

US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA, 325(19), 1965-1977. https://doi.org/10.1001/jama.2021.6238

Student Reflection: Engagement Scholarship Consortium

January 6, 2025

Hailey Coyle, an MPH student and former Health Policy Ambassador, utilized LHC’s Health and Policy Conference Travel Scholarship in the fall of 2024. In this article, she reflects on her experience attending the annual conference of the Engagement Scholarship Consortium.

The Engagement Scholarship Consortium brings together university leaders who are focused on community-building. I was honored to present on the project I had worked on as a Health Policy Ambassador in the 2023-2024 academic year! My presentation, Cultivating Change: Broad Stakeholder Engagement to Move Municipal Policy, discussed efforts to incentivize the use of native plant species, discourage the use of invasive plant species, and encourage the development of green infrastructure through community engagement and municipal policy change.

I wanted to attend this conference to build my soft skills and to share the impact of collaborative work. Having never attended a national conference like this before, I was excited and grateful for the opportunity. I went into the conference with few expectations and was hoping to interact with other students interested in community engagement. With the wide variety of presentations, the only “plan” I had for myself was to attend any session I was interested in and to learn more about interdisciplinary partnerships. The symposium-style presentation Mobilizing Methods: Bridging Conservation and Art through Ecofeminism, presented by Liat Wilde, was one of my favorite presentations at the conference. Initially, I was interested based on the keywords from the presentation title. Wilde was a confident presenter who explained the community-engaged data collection tool used in Ecuador to advance conservation efforts and generate community knowledge. Foundationally, the program involves multiple long-term partnerships, and its success was insightful and inspiring.

Image of Hailey presenting at the ESC with Sean McMahon, Program Director for the LHC

With regard to my presentation, I received meaningful and encouraging feedback on our project. I was proud my presentation reflected the strong partnerships the Lister Hill Center has with both community-based organizations and students. Following the presentation, audience members were eager to learn more about the Center’s projects. Personally, I gained confidence in my presentation and communication skills. I met other students and made some meaningful connections.

I would strongly encourage other students to attend this conference in the future, especially if they are interested in community-based research, university-led partnerships, or the relationships between community members and institutions. I recommended preparing to socialize! Be present in the various meetings, take notes, and ask questions. Community is built by communicating and sharing knowledge.

Student Reflection: 2024 United to Beat Malaria Summit

Student Reflection: 2024 United to Beat Malaria Summit

Tayyaba Khan, an MPH student with an emphasis on global health, utilized LHC’s Health and Policy Conference Travel Scholarship in the spring semester. In this article, she reflects on her experience attending the United to Beat Summit.

Malaria is a life-threatening disease transmitted to humans through the bites of infected Anopheles mosquitoes. Despite being preventable and treatable, malaria remains a significant public health challenge. In 2022 alone, there were an estimated 249 million cases and 608,000 malaria-related deaths globally, with the vast majority occurring in sub-Saharan Africa. Tragically, a child dies from malaria every minute worldwide, highlighting the urgent need for effective interventions and increased funding.

I was honored to receive an invitation to the 2024 United to Beat Malaria Summit to advocate for increased funding for critical malaria intervention programs, such as the U.S. President’s Malaria Initiative; CDC’s Division of Parasitic Diseases and Malaria; the Global Fund to Fight AIDS, TB and Malaria; Gavi, the Vaccine Alliance; and UNICEF. Having experienced malaria three times during my childhood in Pakistan, I strongly believe in the lifesaving impact of these programs and the importance of advocating for global health initiatives that not only save lives but also strengthen public health infrastructure in resource-limited settings both domestically and internationally. This was the first time Alabama had representation at this platform, providing a vital opportunity to raise awareness and engage with state representatives who may not have previously heard from constituents on this issue, which strengthened my passion and purpose to attend even more.

Though I have attended national conferences before, this was my first time attending a UN-organized gathering. I expected to hear from experts in the field, network with like-minded individuals, and identify additional resources to advocate for the fight against malaria. The Summit truly exceeded my expectations on content, speakers, and activities we participated in. Moreover, I must commend the conference organizers for their accommodations, support, and understanding as observing Ramadan impacted some attendees’ ability – including my own – to fully engage with conference activities.

Tayyaba and colleagues in a meeting with a Congressional staffer Hill Day was my favorite experience in attending the Summit. This was my first time meeting members of Congress at the Capitol to advocate for a cause that I firmly believe in. It was a very empowering experience to see democracy in action and recognize the power our voices have. After a day and a half of insightful sessions, presentations, panels, and preparation, the opportunity to visit Capitol Hill and meet with our Congressional representatives and their staff was truly impactful. What I particularly liked about this experience was the genuine interest shown by our elected officials in hearing directly from their constituents. They welcomed our perspectives and were receptive to our advocacy efforts. We had the chance to engage in meaningful conversations, answer their questions, and present our specific asks, which centered on maintaining current funding levels for critical malaria intervention programs without any anticipated cuts. This was especially timely given the ongoing budget discussions for the next fiscal year. It was truly inspiring to directly contribute to the dialogue and advocate for sustained support for malaria initiatives at such a critical time.

The Hill Day experience not only strengthened my understanding of the policymaking process but also highlighted the importance of grassroots advocacy in influencing decision-makers and driving impactful change in global public health. The Summit helped me develop skills for effectively engaging with members of Congress, including how to communicate clearly, stay focused, and express our requests concisely within a limited timeframe during our interactions on Capitol Hill. I also learned more about the implications of malaria on health outcomes and economy, both locally and globally, which deepened my understanding and passion for the fight against malaria. I was also able to network with other like-minded individuals, especially from Alabama and Mississippi, as we were in the same group. Additionally, representing Alabama on a national platform renewed the sense of commitment in me to work for this cause at UAB and across the state.

Tayyaba Khan, MPH student I would recommend this event to anyone who is passionate about the fight against malaria and is looking for a platform and resources to make a difference in this area. These programs have saved over 11 million lives in the past two decades. In addition, they help build more stable and resilient economies and workforces, they lead to fewer missed school and workdays, and they empower local health systems to respond to infectious disease outbreaks. Coming together to support this cause, raise our voices, and advocate for increased support is not only empowering but also incredibly impactful. To prepare for this event, I recommend submitting the application on time and planning travel well in advance to avoid availability issues and price hikes. Additionally, conducting research on your members of Congress will allow you to tailor your conversations accordingly and prepare specific talking points ahead of time. Approach these discussions with confidence, respect, clarity about your requests, and authenticity. Bringing business cards is also beneficial, as you’ll have the opportunity to network with inspiring individuals throughout the summit. Overall, be prepared to engage, connect, and advocate passionately for this important cause—it’s an experience that will leave a lasting impact on both you and the fight against malaria.

Overcoming Needle Fear: Strategies to Minimize Vaccination Pain

April 1, 2024 | Miriam Calleja, LHC Staff

Needle phobia is more than just a minor concern; it’s a legitimate issue that can lead to avoidance of essential medical care, including vaccination. For parents and healthcare professionals, understanding how to alleviate this fear is pivotal to ensuring that children and adults receive necessary immunizations and other interventions that involve the poke of a needle. Industry experts can help decrease the pain and anxiety associated with vaccinations.

The Painful Truth Behind Needle Phobia

Needle phobia can strike at any age, but it often takes root in childhood. The sheer sight of a needle can trigger fear, escalating into an aversion that persists into adulthood. This dread isn’t just psychological; the anticipation of pain plays a significant role. The snowball effect distresses the individual and complicates the job of healthcare providers. The fear can be associated with the pain of the needle piercing the skin, but it can be more complex, such as associating the pain of a needle with an operation that occurred soon after.

It is estimated that around 25% of adults have a fear of needles, known as trypanophobia, with most fears developing during childhood. The implications are widespread, as needle fear has been known to lead to the postponement or outright refusal of vaccinations. This can have dire consequences on public health, herd immunity, and individual well-being.

The problem isn’t confined to immunization either. Children who require surgery such as a bone marrow transplant or heart surgery due to serious illness can become highly distressed and agitated due to their fear of needles. “This is so bad that many children and many parents decide not to continue the treatment,” says Dr. Stefan Friedrichsdorf, a specialist at the University of California San Francisco’s Stad Center for Pediatric Pain, Palliative and Integrative Medicine, speaking at the End Well conference in Los Angeles last November.

The distress experienced by those with needle phobia is not just psychological. Physical effects such as difficulty breathing, increased heart rate and blood pressure, trembling, and chest tightness have been reported. Patients have been known to faint at the sight of a needle.

Although several studies have investigated the issue, the avoidance of pain in children remains underrecognized. Of the top pain-causing procedures in hospitalized children, needle pokes remain the top quoted one, coming in at approximately 40% of pain experienced. Addressing the problem requires a compassionate, multi-faceted approach.

A Case Study in Comfort

Physicians used to be taught almost to ignore vaccination pain and see it as a necessary evil. The approach is different nowadays, and this new philosophy could be a game-changer in avoiding needle phobia. Now, pain and fear associated with needles were deemed to be significant enough barriers to vaccination in children to warrant attention.

Reducing the stress around vaccination is particularly important with neurodiverse patients who tend to have lower childhood immunization rates than their peers, leaving them vulnerable to vaccine-preventable diseases.

Friedrichsdorf spoke to NPR about what he is calling “Ouchless Jab Challenge.” He has worked with these practices at Children’s Minnesota and is now leading the rollout of new protocols for all children at UCSF Benioff Children’s Hospitals in San Francisco and Oakland. The Children’s Hospital of Philadelphia has also led similar campaigns, highlighting various methods to alleviate the anxiety and discomfort associated with shots. These approaches aim to provide a less daunting experience for both patients and caregivers.

Distraction Techniques – One of the simplest but most effective tactics is distraction. Engaging children in conversation, playing music or videos, or allowing them to play with toys during the injection can significantly defuse tension. For teenagers and adults, deep breathing or focusing on a picture or an object in the room might serve the same purpose.

Topical Anesthetics – A more direct way to minimize vaccine discomfort is by applying topical anesthetics to numb the skin before injection. Products like lidocaine creams or patches can be placed on the injection site about 30 to 60 minutes before the vaccination, reducing the pain sensation.

Cognitive Behavioral Strategies – Cognitive behavioral techniques also play a role in managing needle fears. By educating patients on what to expect using vocabulary they understand and teaching them coping strategies, healthcare providers can help transform a scary experience into a manageable one.

The Role of Technology – The advancement of technology paves the way for innovative solutions such as the Buzzy Bee device, which employs a combination of cold and vibration to confuse the body’s pain nerves, making the injection less painful. These types of solutions can be valuable tools in a healthcare provider’s repertoire.

Adapt the position – No child should be pinned down by the healthcare professional. Instead, the caregiver should hold the child in a comfortable position. Patients known to feel faint or experience a drop in blood pressure should be vaccinated lying down.

Guidance for Parents and Caregivers

Parents can prepare their children by talking to them honestly about vaccinations calmly and reassuringly. Practicing with a toy doctor’s kit can demystify the process for young children. It’s also helpful to plan a fun activity after the appointment, giving the child a positive event to look forward to.

For older children and teenagers, involving them in the discussion about their health and the importance of vaccines can make them feel more in control of the situation. Validating their feelings while offering encouragement and support can also ease apprehension.

Adaptation and Empathy

A study conducted on 194 children and their parents in 2018, after initiating the new pain-reducing protocol, showed its effectiveness compared to the same survey conducted two years earlier. Both meaurements resulted from a single-day, hospital-wide survey of children’s pain and its treatment. A higher percentage of children reported no pain (33% vs 24%), and fewer children experienced severe pain (a score of ≥ 7 out of 10) after the protocol was put into effect. While needles remained the highest reported cause of pain of the experience overall, fewer children identified needle pain as the cause of the worst pain (21% vs 30%).

Acknowledging and understanding the individual’s fear can help with decision-making. Does the patient prefer to look at the injection site to know that the needle didn’t get stuck inside the arm? Do they prefer to look away and avoid the sight of blood?

Healthcare professionals can tailor their approach based on age groups and individual needs. For instance, adolescents might appreciate a quick, matter-of-fact process, while younger children may need more time to be comforted. Maintaining a gentle, empathetic bedside manner is crucial throughout.

Overcoming the fear of needles to ensure timely vaccinations is a collaborative effort. It combines clinical interventions with psychological support from healthcare professionals and parents. By incorporating these research-backed methods, we can transform the narrative around vaccinations from fear to empowerment. Through understanding, innovation, and empathy, everyone plays a role in making the vaccination process more comfortable—and therefore more effective—for those with needle phobia.

Sources:

Free Program for Needle Anxiety. “Symptoms of Needle Phobia.” Accessed February 29, 2024. https://www.idontlikeneedles.com/symptoms-of-needle-phobia.

Taddio, Anna, Christine T. Chambers, Scott A. Halperin, Moshe Ipp, Donna Lockett, Michael J. Rieder, and Vibhuti Shah. “Inadequate Pain Management during Routine Childhood Immunizations: The Nerve of It.” Clinical Therapeutics 31 Suppl 2 (2009): S152-167. https://doi.org/10.1016/j.clinthera.2009.07.022.

Friedrichsdorf, Stefan J., Andrea Postier, Donna Eull, Christian Weidner, Laurie Foster, Michele Gilbert, and Fiona Campbell. “Pain Outcomes in a US Children’s Hospital: A Prospective Cross-Sectional Survey.” Hospital Pediatrics 5, no. 1 (January 2015): 18–26. https://doi.org/10.1542/hpeds.2014-0084.

Hamilton, J. G. “Needle Phobia: A Neglected Diagnosis.” The Journal of Family Practice 41, no. 2 (August 1995): 169–75.

Postier, A. C., Eull, D., Schulz, C., Fitzgerald, M., Symalla, B., Watson, D., Goertzen, L., & Friedrichsdorf, S. J. (2018). Pain Experience in a US Children’s Hospital: A Point Prevalence Survey Undertaken After the Implementation of a System-Wide Protocol to Eliminate or Decrease Pain Caused by Needles. Hospital Pediatrics, 8(9), 515–523. https://doi.org/10.1542/hpeds.2018-0039

Boldly Opening Doors to Better Chances and Improved Healthcare

A BOLD grant was awarded to a program by MedsPLUS in collaboration with the Lister Hill Center for Health Policy and Jenkins Public Health Consulting.

By Miriam Calleja

The Building Opportunities for Lasting Development (BOLD) grant awarded by The City of Birmingham’s Department of Innovation and Economic Opportunity (IEO) accepts proposals from organizations, businesses, and public or private entities to provide programs or services to promote economic development to Birmingham residents. IEO aims to foster an ecosystem that thrives on innovation and opportunity. They provide resources to nurture talent, establish infrastructure to support the growth of women, minorities, and disadvantaged businesses, and focus on developing small businesses. Now in its sixth year, the BOLD funding program aims to create partnerships with community organizations that share IEO’s vision of making Birmingham a model of an inclusive and resilient economy.

BOLD’s objectives include overcoming barriers in development and prioritizing certain geographic areas that are deemed disadvantaged and that may often be overlooked. Working with data-driven and innovative approaches, they aim to provide funds for sustainable development.

One of the grants this year was awarded to MedsPLUS Consulting, an independent pharmacy and healthcare consulting firm that has a history of serving minority communities in Birmingham, particularly those who feel they have been mistreated and marginalized by mainstream healthcare and government systems.

The BOLD grant will provide finances for a two-pronged approach.

Three individuals will be trained to become community health workers, and a diabetes education service will be set up for sixty Birmingham residents. The project aims to overcome various barriers to employment opportunities by training workers to become pharmacy technicians who specialize in diabetes management while also setting them up for employment, which includes instruction such as resume writing and LinkedIn profile setup. It also targets the education of diabetes patients themselves.

The collaborators in this project are Dr. Dashauna Ballard, a Postdoctoral Fellow at the Lister Hill Center for Health Policy at the University of Alabama at Birmingham (UAB) who did her Ph.D. in Health Education and Health Promotion, MedsPLUS Consulting, and Jenkins Public Health Consulting (JPHC).

Dr. Dashauna met Dr. Pauline Long and Dr. Jennifer Campbell from MedsPLUS Consulting by chance over a year and a half ago at a Birmingham city meeting. Since then, they’ve collaborated and applied for a few grants together. They were able to prepare two scientific presentations when Dr. Pauline and Dr. Jennifer had the idea of a pilot program to offer a culturally-tailored diabetes self-management, education, and support services to the public. According to the American Diabetes Association, diabetes is a significant problem in Alabama, including Birmingham. Around 15% of Alabamians have diabetes, and less than 7% of people with diabetes have any formal diabetes education.

Overcoming Barriers

Dr. Dashauna set out to investigate the barriers that patients with diabetes face when taking care of their disease. She was able to boil it down to three main barriers. Even though diabetes education is available at health centers, hospitals, and doctors’ offices, many patients are not taking advantage of what is available. For many patients, the biggest hurdle was physically getting to the appointments, especially if they lived in the suburbs or couldn’t get into the city to be present for their appointments. Parking and transportation were the second type of issue they faced. Thirdly, there was a lack of knowledge on the accessibility of diabetes education. It became clear that diabetes education needed to be available closer to home. And so, for example, the service could be accessed from libraries within the community if these were found to be active sites in the chosen neighborhoods.

This is when their third collaborator, Jenkins Public Health Consulting, will come in. Brittaney Jenkins, CEO at JPHC, is a Certified Health Education Specialist and Public Health Practitioner who will engage and communicate with the specific community. This is a crucial step in detecting where help is needed most. They will assist in recruiting individuals for the health worker program and engage the community to recruit participants for the diabetes education sessions.

To conduct this pilot study, MedsPLUS culturally tailored a standardized program by the Association of Diabetes Care Education Specialists (ADCES). As part of the norms for the project, Drs. Jennifer, Pauline, and Dashauna agreed to have participants address them by their first name as a means of building rapport and trust in the communities for which they will be working. Dr. Dashauna and the Lister Hill Center for Health Policy then translated their pilot program work into research presented at scientific conferences. Dr. Dashauna completed the background research and processed the literature review so that the information obtained through the program could be published.

The project aims to get several research publications that will establish evidence-based benefits from their pilot program and then scale it up to help more people across the state of Alabama. The background research found evidence to justify the project’s structure and methodology. When the program launches this January 2024, Dr. Dashauna will oversee the data management, the quality of data collected, and how that data is reported. Her role is to ensure success, i.e., that the project achieves what it sets out to do so that more patients with diabetes can be educated and empowered, and more health workers can be set up to work in the field.

Better Opportunities

The three community health workers will be chosen from the Birmingham area. They will benefit from a twelve-month apprenticeship to get health worker training and become licensed pharmacy technicians by the end of the program. MedsPLUS will then either employ the workers or set them up for meaningful employment elsewhere in the same field. While no healthcare background will be required since MedsPLUS will be conducting the training, the individuals will be chosen on criteria that assess their soft skills, an essential and sometimes overlooked aspect of healthcare.

“This type of apprenticeship will allow them to see the community health worker side and the pharmacy technician side and to get professional development so that they can go on to do what they would like to do,” said Dr. Pauline, referring to the case study they made for their grant, of a young recently-graduated high schooler from one of these geographical areas, who is not sure what to do next in career terms.

The training will be conducted by Connection Health, a non-profit organization that recruits, trains, and deploys community health workers. When the individuals have completed 120 hours of training and become entry-level health workers, they will start their diabetes training through the Association of Diabetes Care and Education Specialists (ADCES). These two phases will prepare them to go into communities and assist pharmacists or diabetes educators with facilitating their courses. In the fourth quarter of 2024, they will undergo professional development training to get their pharmacy technician license.

A Promising Future

This project is an excellent example of how community engagement can help change different populations’ health prospects. By coming together, the Lister Hill Center for Health Policy at UAB, MedsPLUS Consulting, and Jenkins Public Health Consulting have employed their specific skills to improve countless people’s lives through skilled outreach. This robust program is a promising start that will elevate the quality of life of many. And this is just the beginning. Once the research shows improvement, the three players can scale their program to help more individuals across Birmingham obtain health worker training and control their diabetes for improved health.

Student Reflection: SOPHE 2023 Advocacy Summit

In October, I attended Society for Public Health Education’s 2023 Advocacy Summit to present on my experience as a Health Policy Ambassador. Together with other Ambassadors from the 2022-2023 cohort, I developed a poster and discussed the structure of the program, our projects, and some of the benefits and challenges of this unique, community-engaged program. I decided to attend not only showcase the HPA program in the poster presentation portion, but to learn more about advocacy in health policy, including approaches to stakeholder engagement, policy development, and community engagement.

This was the first national conference I have ever attended. With that, I was a bit nervous and unsure what to expect, especially since I wanted to make the most of my time there. However, I was definitely expecting the Summit to be very busy with presentations by public health practitioners working in health policy, along with interesting keynotes related to this year’s theme of voting. I was also very excited for special events related to being in Washington, D.C., such as being on the Hill.

I benefitted from the conference in many ways. First, I got some interesting ideas of how to tackle issues related to some of our projects with Health Policy Ambassadors, particularly about assessing stakeholder engagements. My poster presentation was very well received, and many attendees were interested in establishing similar programs at their institutions. Personally, I enjoyed traveling to Washington, D.C., and I learned a bit more about navigating professional spheres. Additionally, this was the first time I did legislative visits, and I visited the offices of Senators Tommy Tuberville and Katie Britt as well as Representative Terri Sewell. It was fascinating but challenging to work in the Capitol environment, and I think I can bring that to potentially working with policymakers at the state/local level.

One of my favorite presentations that I attended featured Lieutenant Janesia Robbs in the U.S. Public Health Service. She spoke to the audience about stakeholder engagement. She went very in depth about what stakeholder engagement is and is not, including how to work with key stakeholders who may have missions that go against yours. Though I’ve had some basic experience with this concept, this presentation was very enlightening for me. The presentation touched on general principles of stakeholder engagement, as well as many of the smaller details that she believes needs to be done before, during, and after stakeholder engagement. Stakeholders may or may not hold the same mission or vision as your group, so sharing your general goals may help focus your meeting to get the most out of your time and narrow down your scope. I found this very helpful for our work with Health Policy Ambassadors, as we sometimes have limited time to get extremely important information from or share an ask with a government official, community member, and so on.

If you are interested in advocacy and health policy, I would recommend SOPHE’s Advocacy Summit – especially if it is your first national conference. To prepare, I would plan to network, and I would also reflect on your own experiences with health policy and think about what you would like to gain from the conference, particularly in terms of policy advocacy. I would also think about what to do in exciting cities like Washington, D.C.! I was shocked by both the beauty of D.C. as well as the amount of action in the city, especially when I walked down one street and saw the White House, visited a Smithsonian Museum, saw the US Department of Justice, US Environmental Protection Agency, and the US Capitol. I also got to kayak on the Wharf and eat at some local restaurants. Overall, it was a great trip, both professionally and personally!

Kevin Joseph participated in the HPA program in the 2022-2023 academic year, and is currently participating again. Co-authors on his presentation include his fellow Erik Angus, Ritika Samant, Mikayla Rigsby, and the program’s director, Sean McMahon. Kevin utilized the LHC’s Health and Policy Conference Travel Scholarship to attend the SOPHE Advocacy Summit.

Cool Green: Together, we gather strength

Together, we gather strength.

A partnership of teams brings fantastic news for the livability and health of Birmingham!

By Miriam Calleja

When we think about our health, we often focus on factors such as diet, exercise, sleep, stress reduction, and medication. While these things are undoubtedly important, we often overlook our natural environment’s impact on our well-being. Trees provide critical benefits to human health, including cleaner air, reduced stress, and protection from the sun’s heat. Often, areas that are less dense in trees coincide with areas of race or ethnicity-based discrimination.

In a recent development, three organizations in Birmingham, Alabama, have joined forces in a project that positively impacts public health and the environment. The Jefferson County Department of Health, the University of Alabama at Birmingham’s Lister Hill Center for Health Policy, and the program Cool Green Trees, which functions under CAWACO RC&D Council, a non-governmental organization (NGO) and local non-profit, have come together to improve the well-being of Birmingham residents and mitigate the potential damage caused by storms in one fell swoop. This is how it happened.

What can one woman with conviction and a vital purpose do? She can do a lot. But with some help, she can do much more.

Meet Francesca Gross, a natural scientist who has been working in nonprofits for the past 25 years and the Program Manager at Cool Green Trees. For several years, Francesca has had a specific purpose: to bring together urban conservation and the world of human health. This purpose took a significant turn when she met Ariann Nassel, a scientist and geospatial data specialist from the Lister Hill Center for Health Policy at the University of Alabama, Birmingham.

Ariann and Francesca, using their particular expertise, could take the project to its next goal post by making a visual science-based narrative using data on the EnviroAtlas boundary for the Birmingham area obtained through the Environmental Protection Agency (EPA). The StoryMap helped them (and us) visualize air quality, flooding issues, and summer urban heat island effects on a map of the Birmingham area.

This academic-nonprofit collaboration also caught everyone’s attention. For the first time, residents, the city council, the neighborhood presidents, and, as it turns out, funders were listening and understanding the impact trees had on their city… and their health.

The first financial aid came in thanks to Francesca and her liaison with Mark Wilson, former Jefferson County Department of Health director. This was precisely what the department wanted: an insight into how natural systems directly affect human health. This funding meant that Cool Green Trees was now not only a dream but a viable program.

Three didn’t make a crowd in this collaboration. This trio could move the project even further. Most recently, Cool Green’s StoryMap was used to get a substantial amount of money from the US Forest Service Urban and Community Forestry grant, which was specifically looking at urban forests. The partners for this grant include Ruffner Mountain Nature Coalition, Jefferson County Department of Health, and the City of Birmingham. The data on human health by the US Forest Service tallied with that of EnviroAtlas obtained through the EPA, so there was a solid launchpad to start with.

On top of that, the health department offered a startup sum and an unprecedented five years of funding. This will ensure that the Cool Green – Lister Hill Center for Health Policy UAB – Jefferson County Department of Health partnership can continue improving community livability and health for Birmingham’s residents for years to come.

As Helen Keller said, “Alone we can do so little; together we can do so much.”

Student Submission: Ocular Trauma and Nonpowder Firearms

August 11, 2023 | Ayaka Fujihashi, Medical Student

Amidst the political climate on gun control and gun safety, there is another aspect of public safety that is often overlooked: nonpowder guns. Firearms such as BB guns, airsoft guns, and paintball guns. These guns differ from their powdered counterparts in their mechanisms. Nonpowder firearms use plastic or pellet bullets, and, instead of relying on the high pressures created from chemical reactions using powder, nonpowder guns utilize springs, compressed air, or CO2 to send their projectiles flying. Nonpowder firearms are often seen as toys, with marketing campaigns specifically targeting male children. Yet, these devices are deceptively dangerous.

Between 1990 and 2016, roughly 360,000 cases of nonpowder firearm related injuries were treated in emergency departments, which equates to about 13,500 cases annually.¹ Most injuries occur in children between 6 and 12 years old, and 87% occur in boys. The majority of the injuries occur in the head and neck region, and many injuries specifically involve the eye. Of the total, 16% suffered an open injury to the eye. 3.5% were left with legal blindness—defined as visual acuity of 20/200 or less in the better eye with correction—and 11.1% were left with visual defects.²

While accidents do happen, 98% of these ocular injuries occur without eye protection and could have been prevented.¹ Currently, there are no federal law regulations on the use, possession, or transfer of nonpowder firearms. Because these forms of firearms are considered a consumer product, the regulating body would be the Consumer Product Safety Commission (CPSC), but it has not adopted any specific regulations. Some states have laws limiting the possession, use, or sales to minors, but there are no laws at any government level mandating the use of eyewear protection.

The American Academy of Pediatrics and American Academy of Ophthalmology issued a joint statement recommending the use of protective eyewear for all participants in sports in which there is a risk of eye injury. Nonpowder firearms were categorized in the “high risk” category, meaning an increased risk of the eye being impacted with sufficient energy to cause injury.³

However, statements of recommendation with no actionable authority can only go so far. In order to help reduce needless injuries, legislation on the state/federal level is necessary. While these laws may be difficult to enforce, especially considering that many of these injuries occur in private homes, laws could provide a motivator for proper safety. The implementation of such a change can bring about awareness on the importance of eye protection, be the instigator of changes in social norms, and create a culture of social responsibility.

Ocular trauma is the leading cause of monocular blindness in the United States. But it doesn’t have to be. Well written legislation addressing this could be the difference between full, binocular vision or a life of permanent disability.

References:

Lee R, Fredrick D. Pediatric eye injuries due to nonpowder guns in the United States, 2002-2012. J Am Assoc Pediatr Ophthalmol Strabismus. 2015;19(2):163-168.e1. doi:10.1016/j.jaapos.2015.01.010
Jones M, Kistamgari S, Smith GA. Nonpowder Firearm Injuries to Children Treated in Emergency Departments. Pediatrics. 2019;144(6):e20192739. doi:10.1542/peds.2019-2739
Protective eye wear for young athletes. A joint statement of the American Academy of Pediatrics and the American Academy of Ophthalmology. Ophthalmology. 1996;103(8):1325-1328.

Student Submission: Throwing Away Free Money

August 11, 2023 | Akshay Aluri, Medical Student

Do you like free money?

Everyone seems to except Alabama state legislators. In 2010, the Affordable Care Act expanded Medicaid to cover nearly all adults up to 138% of the Federal Poverty Line. As of today, Alabama remains one of only ten states that has refused to expand Medicaid to provide, per the Kaiser Family Foundation, 350,000 citizens access to healthcare. Recently, the Republican-led North Carolina state legislature came to an agreement with the governor to expand Medicaid by levying a small tax on big hospitals. One of the reasons behind North Carolina’s tentative Medicaid expansion was the dismal state of its rural hospitals and the extra financial incentive from the federal government.

The situation of rural hospitals in Alabama is, if anything, a great deal worse than the one that North Carolina is dealing with. The Alabama Hospital Association has reported that a dozen rural hospitals in our state are on the verge of immediate shutdown. While these hospitals have faced issues for years, the pandemic resulted in record losses of $1.5 billion since 2020–greater than any other state in the country–and their closure would have a deleterious impact on the health of our rural population by forcing them to drive farther to see a doctor. In addition to meeting the healthcare needs of 250,000 Alabamans, the expansion of Medicaid would provide much-needed relief to prevent these hospitals from shutting down. Furthermore, The Kaiser Family Foundation found that Medicaid expansion, in addition to bolstering rural hospitals, would decrease the share of our uninsured populations and, from a physician’s point of view, ensure a decline in uncompensated care.

While the prospect of our rural hospitals shutting down may seem terrifying to ordinary Alabamans, our state legislators and governor continue to insist that Alabama lacks the money to expand Medicaid. It is time to dispel this myth. If our state chooses to expand Medicaid, according to the ACA, the federal government would cover 90% of the costs for the expanded Medicaid coverage. But the incentive to expand Medicaid increased substantially in 2021 when President Biden signed The American Rescue Plan. The ARP offers every state willing to expand Medicaid a “signing bonus” and the additional funds–amounting to nearly a billion dollars per Jane Adams, the former Executive Director of Cover Alabama, a coalition of organizations supporting Medicaid Expansion–would pay for the cost of the expansion for nearly the first five years. Currently, 10% of Alabama’s population is uninsured and the Medicaid expansion would reduce that number substantially. It would allow for patients to get screened for heart disease, cancer, and diabetes early and get treatment for their chronic medical conditions. According to a study from University of California-Davis, the states that expanded Medicaid saw a decline in annual mortality among their most vulnerable populations.

For all the reasons listed above, it is high time that the politicians in Montgomery do right by our poorest citizens and expand Medicaid. It makes economic and moral sense to do so.