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

April 30, 2024 | Miriam Calleja, Kimberly Randall 


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. 


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 

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


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


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 


HIV/AIDS, Viral Hepatitis, STI, TB $13,988,137 $11,776,613 


Emerging and Zoonotic Infections Disease $2,248,081 $2,096,864


Chronic Disease Prevention and Health Promotion  $13,587,018 $7,573,404


Birth Defects, Developmental Disabilities, Disability and Health  $6,557,429 $6,524,642


Environmental Health $404,616 $212,990


Injury Prevention Control $7,174,096 $6,882,110


Public Health Scientific Services $727,445 $630,986


Occupational Safety and Health  $1,949,377 $1,326,356


Public Health Preparedness Response $9,437,092 $7,664,806


Crosscutting Activities and Program Support $5,528,735 $1,764,219


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

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.

Policy Watch: Alabama Becomes First State to Enact Elder Abuse Registry

July 12, 2022 | Anantha Korrapati & Kimberly Randall, LHC Staff

Montgomery, USA State capitol building in Alabama during sunny day with old historic architecture of government and many row of flags by dome


Elder abuse is a prevalent issue in the United States and comes in various forms, such as physical harm, neglect or desertion, financial exploitation, and emotional abuse through verbal and non-verbal acts. According to the Alabama Department of Human Resources’ Adult Protective Services, over 9,000 reported adult abuse, neglect, and exploitation cases were reported in 2021.

Currently, the Alabama Code §13A, Chapter 6, Article 9 defines three degrees of elder abuse and elder financial exploitation:

The first degree of elder abuse and neglect occurs if someone intentionally abuses or neglects an elderly person resulting in serious physical injury, and the first degree of financial exploitation is if the value of the property taken from an elderly person exceeds $2,500. 

The second degree of elder abuse and neglect is defined by someone recklessly abusing or neglecting an elderly person resulting in serious physical injury, and the second degree of financial exploitation is if the value of the property is $500-$2,500. 

The third degree of elder abuse and neglect is defined by reckless neglect resulting in physical injury or emotional abuse, and third degree of financial exploitation is if the value of the property is up to $500.

Previous legislation, such as the APS Act of 1976, protected elderly and disabled adults by outlining the responsibilities of the Alabama Department of Human Resources, law enforcement authorities, agencies, caregivers, and individuals to report elder abuse cases, which has helped prevent over 1,700 cases in 2021.

In 2018, Shirley Holcombe was a victim of forgery by her caretaker, which inspired her daughter, Jo Holcombe, to campaign for the creation of a statewide elder abuse registry to improve protections for elders further and prevent future cases of abuse. 

Proposed Legislation

HB105, also known as “Shirley’s Law,” implemented the nation’s first elder abuse registry and was signed by Governor Kay Ivey on March 24, 2022, and became effective on June 1, 2022. 

Presented by Representive Victor Gaston and others, HB105 reads:

“To establish a registry for individuals convicted of certain crimes or found to have committed certain acts of abuse against certain individuals; to require certain care providers to query the registry for employees and prospective employees; to require the Department of Human Resources to adopt rules; to establish criminal penalties.”

In addition to requiring the Department of Human Resources to create a database, HB105 also requires all physicians, practitioners, and caregivers to file reports when they believe that any protected person has been subjected to physical abuse, neglect, exploitation, sexual abuse, or emotional abuse. Under HB105, oral reports are to be submitted immediately to the county Department of Human Resources with a supporting written report within seven days. If the report concerns a nursing home employee, it must be submitted to the Department of Public Health. HB105 establishes criminal penalties as well: “An individual required to make a report who knowingly fails to make a report shall be guilty of a Class C misdemeanor.”


According to a study recently published by the Division of Clinical Epidemiology and Evaluative Sciences Research, financial abuse of older adults is the most common form of abuse, but is the least studied. The study found that certain older adults were more likely to be economically, medically, and sociodemographically vulnerable, such as African Americans, adults living below the federal poverty line, and adults who do not live with a partner. The study also found that adults with impaired instrumental activities of daily living (such as using the phone, managing transportation, prepping meals, housekeeping, etc.) are more likely to be victims of elder abuse. 

Forms of financial abuse can include: stolen/misappropriated money and property, forced or misled into surrendering rights or property, impersonation to obtain property or services, and lack of necessary assistance for household expenses from loved ones. 

Financial abuse is most likely to occur among family members, with the highest report being adult children and other relatives. Other common perpetrators include friends, neighbors, or paid home-care aides. 

According to the Journal of the American Society on Aging, “the lack of visibility of elder abuse as a serious national problem has been a long-standing barrier to action.” As the creator of the nation’s first statewide elder abuse registry, Alabama is taking strides to bring awareness to this problem to prevent future incidents. 

Creating and implementing a comprehensive database protects elders by lessening situations in which they might be victims of exploitation. 

Next Steps

If you suspect elder abuse and want to report it to the Alabama Department of Human Resources, use these instructions to fill out a report or email to aps@dhr.alabama.gov. You can also call the hotline at 1-800-458-7214. 

Stay Informed

Policy Watch: The Impact of Eliminating Grocery Sales Tax

February 14, 2021 | Kimberly Randall, LHC Program Coordinator Grocery Tax

Photo Courtesy of Getty Images 


For almost two decades, Alabama policymakers have debated whether or not to remove the sales tax on groceries. Currently, sales tax on groceries accounts for nearly $500 million in state revenue from a 4% sales tax, earmarked for education spending. Additionally, in many cases, local taxes are added to the state tax, making the total grocery tax as high as 11% in some areas of the state. According to Alabama Arise, Alabama is one of three states in the nation with no tax breaks on groceries, and the 4% markup accounts for as much as two weeks’ worth of food for a family.

While Mississippi currently holds the highest grocery state sales tax rate in the nation, other surrounding states such as Georgia and Florida have eliminated sales tax on most groceries. Overall, 37 states have eliminated sales tax on groceries, while ten have a reduced sales tax. In addition to the sales tax rates, food costs are increasing overall. According to a report by KPMG, average consumers are seeing increases of up to 20% on prices at the grocery store, compared to 2019. 

Proposed Legislation 

Currently, two bills are being discussed to eliminate the state sales tax on groceries. House Bill 174, proposed by Representatives Holmes, Hanes, Meadows, Wadsworth, Fincher, Mooney, Wingo, Kitchens, Howard, Warren, Drummond, Paschal, Whorton, Sorrell, Wheeler, Brown (K) and Shaver, reads: 

“Under existing law, the state imposes sales or use taxes upon certain persons, firms, or corporations. Sales of certain items are taxed at a reduced rate. Sales of other items are exempt from the taxes. This bill would exempt sales of food from the sales and use taxes beginning September 1, 2022.” 

Meanwhile, House Bill 173, proposed by Representatives Holmes, Fincher, Wingo, Meadows, Paschal, and Mooney, also eliminates the sales tax on groceries but offers an alternative funding method by way of state income tax to make up the budget deficit earmarked for education. 

“This bill would exempt sales of food from state sales and use taxes beginning January 1, 2023. Under existing law, individual income taxpayers are allowed to deduct the amount of federal income taxes paid or accrued within the year. This bill would amend Amendment 225 to the Constitution of Alabama of 1901… [to] limit the amount of federal income taxes paid or accrued an individual income taxpayer can deduct to a maximum of $4,000 for individuals filing as single, head of household, and married filing separately and $8,000 for individuals filing as married filing jointly.” 


Reducing the amount of taxes for necessary purchases, such as groceries, has been shown to significantly impact the health of households falling below the poverty line. According to Zheng et al. (2021), states which impose income tax on groceries tend to see higher levels of food insecurity, which disproportionately affects lower-income households. In states with a sales tax rate of 4%, the probability of a household experiencing food insecurity rises 3% compared to states without a tax rate. 

Additionally, sales taxes on groceries correlate to higher rates of obesity. A recent study published in the Health Economics Review found that “Counties with grocery taxes have increased prevalence of obesity and diabetes [and] estimate the economic burden of increased obesity and diabetes rates resulting from grocery taxes to be $5.9 billion.” 

The main difference between the two bills comes from funding. HB174 allows the state sales tax to expire without a plan to replace the lost revenue for the education system. However, lawmakers have stated that the Education Trust Fund has seen an increase in recent years, and the ability to cut taxes overall could be beneficial for the state as a whole. HB173 creates a limit on the amount of federal income tax that individuals can write off on their state income tax filing, ultimately only increasing taxes on individuals falling in the top 5%. 

According to an analysis from Alabama Arise, the income tax proposal would offer a tax cut to the majority of Alabamians. 

Next Steps  

The Alabama Legislative Session is currently underway and will continue for several months. Both bills are currently being discussed in committee and have not yet gone to a vote. 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. 

Stay Informed 

Want to know more? Alabama Arise, a statewide, member-led organization advancing public policies to improve the lives of Alabamians who are marginalized by poverty, has officially endorsed HB173 due to the impact of removing the sales tax without jeopardizing the state’s education budget. 


Policy Review: Birmingham Bus Rapid Transit System

May 16, 2022 | Anushree Gade, LHC Intern


        Public transit has emerged as a vital public service. Metropolitan cities across the world feature a multitude of rapid transit systems (subways, trams, buses, etc.). Such systems are also present in several cities across the United States including New York, Boston, Chicago, and Atlanta. Public transit is a means by which people are given access to various other services and facilities near where they live. The availability of public transit, such as the rapid transit systems, ensures that individuals in the community have the means by which they can obtain the services and experiences they need to improve their health and health outcomes. For many, public transit ensures access to education, employment, health care, and more.1 Therefore, an affordable and cost-effective form of public transportation is crucial for cities to consider.
While extensive light rail systems like those seen in Chicago and other large cities are too expensive for smaller cities, Bus Rapid Transit (BRT) offers such cities an opportunity to provide fast and reliable public transportation to their residents. BRT systems are defined as a “high-quality bus-based system that delivers fast, comfortable, cost-effective services at metro level capacities.”2 BRT systems have lanes of their own to ensure the performance and delivery of the service. They usually also have priority at signals and their own platforms.3 These components ensure that the system is an efficient and cost-effective method of transportation.
Several cities in the U.S. have their own Bus Rapid Transit systems, with Albuquerque’s BRT, seen as the gold standard.4 Albuquerque’s system was implemented to address connectivity and traffic congestion in the city. This system involves separate lanes just for the buses, which are centered in the middle of the road and are given priority at the signals. There are stations at the platform level throughout the city. The City of Albuquerque has implemented a pilot program that started in January 2022 and lasts until December 31, 2022, in which there are no fees associated with utilizing the Albuquerque Rapid Transit (ART) and ABQ RIDE, their original bus transit system.

Benefits and Costs of Public Transit

        With the population of cities growing, vehicle congestion and emissions are two severe consequences of personal transportation. There are increased numbers of cars on the road in metro areas, causing traffic congestion that delays travel times and greater fuel consumption as a result. These issues, in turn, contribute to the emission of greenhouse gasses into the atmosphere. With the implementation of public transit systems, either bus or rail, a decrease in congestion and improved air quality can be observed. Furthermore, public transit systems can provide disadvantaged populations such as the elderly, low-income, and disabled with a means of accessible transportation. This ensures that everyone has the opportunity to engage within the community.
Public transit provides several benefits for citizens; however, it is also important to consider the setbacks associated with it. One of the challenges that accompany the implementation of a public transit system is meeting optimal ridership. In order for public transit systems to operate effectively, there must be a sufficient reliance on them. Such systems can serve large capacities; however, the number of people that utilize the services is only a small fraction.6 As of 2018, the census indicated that only two thousand people depended on public transit in Birmingham.7 This represents about 1.0% of Birmingham’s total population. The COVID-19 pandemic has proven to be a challenge for public transit systems as well. Ridership decreased 73% across all public transit systems as a result of the pandemic.8 Public transit involves extensive human-human interactions and can contribute to the spread of infectious diseases, thus the pandemic negatively impacts ridership.

BRT in Birmingham, AL

        The city of Birmingham is one of the largest cities in the state with a population of 200,733 as of 2020.9 Birmingham spans 146.07 square miles in the center of Alabama. The Birmingham-Jefferson County Transit Authority (BJCTA) is the city’s publicly operated transit authority since 1972. The BJCTA organizes public transit services. Their main service, currently, is the MAX Transit services.
The MAX Direct is a feature of the MAX Transit services and is a micro-transit system that serves as the main form of public transportation in the city. As a micro-transit system, it is responsive to demand. The services are increased in areas with higher ridership density.10 The MAX Direct’s primary purpose is to provide transportation for commuters from the City of Mountain Brook and is an accessible transit option for people with disabilities. It travels around the city and provides transportation to the Birmingham Zoo, Bessemer, the Riverchase Galleria, and more significant Birmingham locations.11
The municipality has made plans for Birmingham’s own Bus Rapid Transit system, known as the Birmingham Xpress or BX. This new system will provide better transit options for the 25 neighborhoods along its route and replace some MAX routes between those neighborhoods. The construction for BX began in December of 2020. Similar to the Albuquerque BRT system, BX will have dedicated bus lanes and signal priority at intersections and connect citizens to several significant employers across Birmingham including the University of Alabama at Birmingham (UAB), Brookwood Princeton Medical Center, and Integrated Medical Systems. The signal priority and dedicated lane features are currently lacking in the MAX system; with BRT features in place, BX will run more efficiently than MAX, incentivizing increased ridership.12 Furthermore, Birmingham is hosting the 2022 World Games which will kick off on July 7th, 2022. This event has also seemed to have prompted the development of the BRT system.10 The construction of the BX is scheduled to be completed by July and before the World Games begin that same month.13
The existence of a transit system in Birmingham is integral to establishing and maintaining connectivity across the city and between neighborhoods. The Birmingham Xpress will enable residents to access healthcare, education, and employment. The transit system is expected to run through UAB, various health care facilities, and through the city itself where multiple large employers exist.
The Birmingham Xpress project was estimated to cost $58 million.14 The Birmingham City Council has had multiple items on its agenda relating to the BRT system. In March of 2021, the Council appropriated $9,037, 500 to the Birmingham Jefferson County Transit Authority (BJCTA) so that they can procure the buses for the BRT system.15 In August 2021, the Council provided the BJCTA with $5,000,000 for the BRT project. However, the exact reason for the funds was not mentioned.16 The Council also approved items involving the procurement of areas of land to build BRT platforms across the city.


        Public transit is a crucial element in large metropolitan areas as it provides communities and neighborhoods with opportunities to connect with one another. Once the Birmingham Xpress starts to run, citizens will be able to easily access services. The BX will also provide more efficient transportation during the World Games. As Rio was confirmed to host the Olympics in 2016, they began work for their own Bus Rapid Transit. The public transit systems constructed in Rio served 2.2 million passengers during the Olympics alone and left a long-lasting impact on the city.17 Their public transit systems provided organized and efficient transportation that was otherwise lacking before the games. With the World Games approaching in Birmingham, the city’s public transit systems will be expected to see a marked increase in ridership.
Furthermore, the BX may also contribute to a decrease in missed medical appointments.  A study that observed the effects of a new light rail line on the number of no-show appointments revealed that there is a correlation between public transit and the number of no-show appointments. Specifically, the analysis indicated that public transit systems contribute to a decrease in the number of missed medical appointments.18 As seen in this study, it can be expected that the BX will have a similar impact as it provides a connection to several medical facilities such as UAB and Brookwood Princeton Medical Center. Overall, the BX will play a vital role in improving Birmingham’s neighborhood connectivity and contributing to the city’s economic development. 


  1. Wright L. Bus rapid transit. discovery.ucl.ac.uk. Published 2002. Accessed April 05, 2022. https://discovery.ucl.ac.uk/id/eprint/112/1/BRT_e-book.pdf. 
  2. Institute for Transportation and Development Policy. What is BRT?. itdp.org. Date unknown. Accessed April 05, 2022. https://www.itdp.org/library/standards-and-guides/the-bus-rapid-transit-standard/what-is-brt/. 
  3. Raleigh. What is bus rapid transit (BRT). Updated February 10, 2022. Accessed April 05, 2022. raleighnc.gov. https://raleighnc.gov/services/transit-streets-and-sidewalks/what-bus-rapid-transit-brt. 
  4. Institute for Transportation and Development Policy. Albuquerque, NM opens first USA gold standard BRT on historic route 66. itdp.org. Published November 27, 2017. Accessed April 6, 2022. https://www.itdp.org/2017/11/27/albuquerque-gold-standard-brt/. 
  5. City of Albuquerque. Zero fares pilot program. cabq.gov. Date Unkown. Accessed April 06, 2022. https://www.cabq.gov/transit/tickets-passes. 
  6. Gershon RRM. Public transportation: advantages and challenges. Journal of Urban Health. 2005; 82(1), 10.1093/jurban/jti003. 
  7. Liberation. Birmingham, AL: a victory for public transit. liberationnews.org. Published September 30, 2018. Accessed April 11, 2022. https://www.liberationnews.org/birmingham-al-a-victory-for-public-transit/. 
  8. Qi Y, Liu J, Tao T, Zhao Q. Impacts of COVID-19 on public transit ridership. International Journal of Transportation Science and Technology. 2021. https://doi.org/10.1016/j.ijtst.2021.11.003. Accessed April 13, 2022. 
  9. United States Census Bureau. Quick facts Birmingham city, Alabama. census.gov. Date unknown. Accessed April 14, 2022. https://www.census.gov/quickfacts/birminghamcityalabama. 
  10. Birmingham Times. MAX transit announces changes as the World Games 2022 nears. birminghamtimes.com. Published July 13, 2021. Accessed April 15, 2022. https://www.birminghamtimes.com/2021/07/max-transit-announces-changes-as-the-world-games-2022-nears/. 
  11. MAX Transit. Routes. maxtransit.org. Date unknown. Accessed April 13, 2022. https://maxtransit.org/routes/. 
  12. Birmingham City Council. Birmingham Xpress. birminghamal.gov. Date unknown. Accessed April 13, 2022. https://www.birminghamal.gov/brt. 
  13. WVTM 13. Birmingham Xpress construction almost complete. wvtm13.com. Date unknown. Accessed April 17, 2022. https://www.wvtm13.com/article/new-route-connects-five-points-west-with-woodlawn/39719728#. 
  14. Birmingham Times. MAX gets new leader as city council adds cash for bus rapid transit. Birminghamtimes.com. Published September 2, 2021. Accessed April 15, 2022. https://www.birminghamtimes.com/2021/09/max-gets-new-leader-as-city-council-adds-cash-for-bus-rapid-transit/. 
  15. Birmingham City Council. Summary of virtual pre-council meeting of the council of the city of Birmingham. Date unknown. Accessed April 6, 2022. https://docs.google.com/gview?url=https%3A%2F%2Fbhamal.granicus.com%2FDocumentViewer.php%3Ffile%3Dbhamal_32833bd813674f9eb079b619e2c6aaa4.pdf%26view%3D1&embedded=true. 
  16. Birmingham City Council. Regular meeting of the council. Date unknown. Accessed April 6, 2022. https://docs.google.com/gview?url=https%3A%2F%2Fbhamal.granicus.com%2FDocumentViewer.php%3Ffile%3Dbhamal_6d10040ec350872ae5d525f405389c3d.pdf%26view%3D1&embedded=true. 
  17. International Olympic Committee. Olympic games transport Rio to a new level. olympics.com. Published August 14, 2017. Accessed April 17, 2022. https://olympics.com/ioc/news/olympic-games-transport-rio-to-a-new-level. 
  18. Smith LB, Yang Z, Golberstein E, Huckfeldt P. The effect of a public transportation expansion on no-show appointments. Health Services Research. 2021. https://onlinelibrary.wiley.com/doi/10.1111/1475-6773.13899. Accessed April 17, 2022. 

Local Initiatives to Reduce Food Insecurity in Birmingham Communities

November 22, 2021 | Kimberly Randall, LHC Program Coordinator


Food bank
Photo Courtesy of Getty Images | 2020

2021 marked the 80th anniversary of President Franklin D. Roosevelt’s Four Freedoms: Religion, speech, want, and fear. While religion and speech are constitutionally protected, many families in the Birmingham metropolitan area regularly suffer from food insecurity and are unable to provide for themselves and their families. The pandemic has worsened food insecurity nationwide, with food banks reporting 55% more people going to food banks, according to Feeding America. The US Department of Agriculture officially defines food insecurity as “a lack of consistent access to enough food for an active, healthy life” and affects an average of 1 in 8 Americans.

With Thanksgiving approaching, many families will turn to non-profit and charity organizations to access a holiday meal and offers an opportunity to evaluate the causes, effects, and resources related to food insecurity. 

What causes food insecurity? 

Food insecurity is differentiated by low and very-low access to nutritious food on a stable basis. 2008 saw a substantial jump in the number of families experiencing food insecurity with approximately 22% of children claiming food insecurity of some kind. While there are several nuances in terms of how families can become food insecure, the root of all food insecurity comes from financial instability. Geographical regions, such as the rural south, see higher numbers of impoverished families and, correspondingly, a higher number of families and individuals applying for food assistance. 

However, wages alone aren’t the only deciding factor. One major issue with food insecure individuals comes with the lack of nutrition available in affordable food options. According to the USDA, fresh foods have seen an exponentially higher increase in cost compared to less nutritious alternatives. Between 1985 and 2000 a study found that “the retail price of carbonated soft drinks rose by 20%, the prices of fats and oils by 35%, and those of sugars and sweets by 46%, as compared with a 118% increase in the retail price of fresh fruits and vegetables.” Consequently, households often choose to purchase higher calorie, less nutritionally dense foods that are highly processed. 

Additionally, a policy research report commissioned by The Future of Children determined that non-income factors can influence food insecurity, such as a caretaker’s poor mental and physical health. The report states that “children living with a disabled adult are three times as likely to experience very-low food insecurity” compared to children with similar income levels who are not living with a disabled adult. 

What are the long-term impacts of food insecurity? 

According to Feeding America, hunger and health are very closely related. A 20140 study found that food insecurity can increase the likelihood of chronic conditions such as diabetes, hypertension, and obesity (Seligman and Schillinger, 2010), ultimately leading to a cycle of higher healthcare expenditures and reducing income even further. It is estimated that food-insecure households account for nearly $60 billion in healthcare costs annually. Additionally, many families have to choose between many other necessities such as utilities in order to provide food. 

In addition to the health disadvantages of food insecurity, food-insecure children and teens see a direct impact on their education. Research shows that food insecurity prevents youth from fully participating in social and school settings and have difficulty engaging in daily activities, assignments, and social interactions during school while also having greater difficulty in creating peer relationships. According to No Kid Hungry, by the time most food-insecure children reach high school, they are twice as likely to have been diagnosed with a mental health problem such as depression, anxiety, and behavioral problems by a psychologist and are significantly more likely to have been suspended from school. With all other factors accounted for, food insecurity also decreases a child’s chances of graduating from high school, ultimately affecting their income-earning ability later in life and continuing the poverty cycle. 

What can be done about food insecurity? 

Solving or mediating food insecurity has been a priority for many organizations and policymakers for years. The child tax credit, a part of the American Rescue Plan, was partially intended to reduce food insecurity by providing extra income to families. According to the Household Pulse Survey, an experimental tool utilized by the US Census Bureau to evaluate the economic and social impacts of the pandemic, there was a 3-point drop in the number of households with children reporting food insecurity from 11% to 8.4%. 

Future policy changes are possible as well. Lawmakers have declared their intention to make the child tax credit a permanent fixture in the Internal Revenue Code, as well as expanding SNAP (Supplemental Nutrition Assistance Program) benefits by 15%. However, community organizations are often the first point of contact for individuals experiencing food insecurity.

Currently, there are eight food banks in the state of Alabama with one, the Community Food Bank of West Alabama, serving the Birmingham Metro. Operating primarily as a food distribution center, the Food Bank purchases food through industry connections and distributes it to a series of community agencies, over 250 of them, to be administered to local individuals and families in need. Information regarding food distribution events can be found on the Community Food Bank of West Alabama’s website. Information regarding volunteer opportunities, events, and a donation page can be found here

Recently re-opened Blazer Kitchen, operated on UAB’s campus, provides resources for students experiencing food insecurity. In order to abide by COVID-19 regulations, the center is offering online appointment timesfor students and employees to collect pre-packaged parcels of food. Blazer Kitchen operates out of the Hill Student Center and the 1613 Building. A donation portal, volunteer opportunities, and more information can be found on the official Blazer Kitchen website. 

Food banks and local pantries are integral toward mitigating food insecurity in communities and are considered the first line of defense in the fight against hunger. According to the University of Vermont, 85% of food pantry users reported a good or very good experience with them. While some individuals surveyed complained of the long lines and limited selection, the overwhelming majority stated that they were positively impacted by food banks. Food banks are vital to improving food security in communities. 

An Introduction to Redistricting and its Effects on Healthcare

August 13, 2021 by Kimberly Tsoukalas, LHC Program Coordinator

Following the 2020 census, the national and state legislatures are set to redefine the boundaries for congressional elections and representative districts. These districts determine the geographical areas for state and national elected officials including Representatives, State Senators, and Board of Education members. Due to the coronavirus pandemic, the process is running behind schedule but government officials are still working diligently to redraw new district lines in time for the 2022 election cycle. Below, we’ve broken down where the state of Alabama is in the redistricting process, what citizens can expect during the process, and how it can impact healthcare policy in our communities.

Redistricting Timeline

Steps to Delivering Census Redistricting Data. Visit “Timeline for Releasing Redistricting Data” on the Census Bureau website for more information!April 26, 2021
The United States Census released the apportionment counts to the public showcasing the general state population changes in the country. Some states gained seats in the House of Representatives while others lost seats. Alabama’s population increased to just over 5 million and will retain the same number of representatives (7) for the next redistricting cycle.

August 12, 2021
The US Census released the P.L. 94-171 Redistricting Data Summary Files, which includes information about housing occupancy status, population counts by race and ethnicity for the total population and voting-age population, and by group quarters type for the group quarters population. This information will be released on the Census Bureau’s FTP website using the same file format provided to state governments and requires additional software to extract the data. This information distribution is intended for experienced data users and will be re-released to the general public at a later date in a more digestible format.

Proposed – September 30, 2021
The Census Bureau will release the same data from August 12th in an easier format that allows the public to search for and understand local redistricting data, accessible at https://data.census/gov. Additionally, it will be delivered to the Reapportionment Committee in an interactive toolkit on a flash drive for further publication and reference.

Did you know? The term “gerrymandering” was first used in 1810 after the redistricting of Massachusetts. Elbridge Gerry, a prominent political figure of the time, drew district lines to facilitate political gain in a shape that was thought to look like a salamander. Hence, (Elbridge)Gerry(sala)mander. Today, the term is used to describe disproportionate district lines that give an unfair advantage for a political party or group. See below for a quick graphic on how this looks in a population of 60% blue squares and 40% yellow squares.

Redistricting Gerrymandering Explained

Proposed – January 28, 2022

While not an official Census deadline, January 28th is the official filing date for House of Representatives candidates. Redistricting borders are presumed to have been drawn by this point, though there may be delays this year due to the pandemic. Official verification comes by legislative vote which should occur later in the spring.

Proposed – May 2022
Based on previous years, we can expect the Alabama House of Representatives and Senate to approve the newly redrawn districts in May. However, prior to 2020 Census data was available in March, rather than August, allowing for a longer deliberation period. It is unclear how this approval will be affected by the pandemic. Once the lines are approved by the House and Senate, they are passed on to the Governor who has the ability to veto the districts, sending it back to the Alabama Permanent Legislative Committee on Reapportionment (APLCR) for redrawing.

Proposed – October 2022
The final stage in the redistricting process is called preclearance, a term you probably haven’t heard since your AP Government class in high school. The Voting Rights Act of 1965 provided additional protections against discrimination in the elections processes. Section 5 of the Act requires that the United States Department of Justice or a three-judge panel of the United States District Court for the District of Columbia approve any attempt to change any voting practices, including redistricting.

What happens next?

The data released on August 12 will allow the APLCR to begin redrawing districts. However, the committee must abide by certain rules and regulations to ensure the proposed districts are fair.

In addition to keeping each district relatively proportional to each other in terms of population, there are four main criteria for redistricting: Contiguity, Compactness, Community Interest and Political Boundaries. Contiguity simply means that all portions of the district must be geographically adjacent. Similarly, all portions of the district should live as near to one another as is practical to represent the collective interests of a portion of the state. Lastly, political boundaries references the geographical borders of county lines and city limits, allowing for proper representation for those citizens.

Did you know? Any citizen or group can submit a proposed redistricting map during public input meetings occurring through the month of September. Click here to try your hand at drawing your own redistricting lines. Full list of times and locations for public meetings is available here, along with Zoom links for individuals choosing to attend virtually.

The Reapportionment Committee will need to balance these needs when redrawing state lines to account for the population changes within the state. Additionally, they will need to abide by the guidelines enacted by the Voting Rights Act of 1965 to ensure that the districts are not disproportionate to certain populations based on race or other demographic factors.

What does this mean for health policy?

The process of redistricting will impact healthcare more than you might realize. In addition to national issues like universal healthcare or insurance reform which elected representatives could sponsor or support legislation for, redistricting and census data have local implications as well. Hospitals, health care clinics, and health care programs such as Medicaid and Medicare are among the many public health services included in annual budget proposals to be approved by Congress. Additionally, state and federally-funded community health centers are heavily impacted by the annual budget, which can determine where to build new hospitals and clinics or expand existing ones.

Access to rural healthcare continues to decline. The healthcare analytics firm Chartis Group recently released a report that 12 of Alabama’s 45 rural hospitals are considered “most vulnerable” to closing partly because the state has not expanded Medicaid. As quoted in an article by AL.com, Danne Howard, chief policy officer for the Alabama Hospital Association, stated “when a rural hospital has to cut services or close, residents have to travel and overload the urban facilities. It’s a domino effect when a rural hospital closes. It becomes an urban hospital issue. It becomes a health access issue.”

Redistricting is a critical part of our electoral process, paving the way for representation at the state and national level. Redistricting, as we’ve seen in the past, can potentially determine the outcome of major legislation. If we consider health as a human right and strive to improve population health through the enactment and enforcement of evidence-based public policy, it is imperative that we nominate leaders who prioritize healthcare access and affordability.

Census 2020: How and Why

March 26, 2020, by Ariann Nassel, LHC Director of Geospatial Data Visualization


census graphicThe first wave of letters containing Census forms were mailed out to approximately 140 million households two weeks ago and last week those letters were followed up with reminder letters for households that had not already responded. If you’ve been busy and haven’t gone through the pile of mail on your kitchen counter, stop everything, find the letter, and fill out the form either online (https://my2020census.gov/) or over the phone (https://2020census.gov/en/ways-to-respond/responding-by-phone.html). If neither of those options works for you, a form will be mailed to you later in the month.

I received my letter on March 12th at 5:52 pm. Including the time it took to open the letter, sit down on the sofa, and log on to the internet, I had completed it by 6pm. That’s, right it only took me 8 minutes.

But, there might be a few other things going on right now that have your attention. You might be wondering, “Why bother with the Census?”