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

May 31, 2024 | Kimberly Randall

Background

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

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

Proposed legislation

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

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

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

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

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

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

Impact

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

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

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

Next Steps

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

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

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

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

Introduction

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

Trends Affecting Access to Dental Care

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

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

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

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

2. The older dentists of 2017 (33% of all Alabama dentists were 60+ years of age in 2017) are retiring or have retired. In 2024 there were 162 fewer dentists aged 60+ than in 2017 and there were 78 fewer dentists in the 60-64 age category alone. Further, in 30 Alabama counties there were no dentists less than 40 years old, and seven counties had only a single dentist younger than 40 years of age (see map).

3.  Many Alabama counties are losing dentists.  Overall from 2017 to 2024, there was a net loss of 2 dentists in the state, with 28 of 67 counties having fewer dentists in 2024 than in 2017. Further, 18 counties had no change in the number of dentists, and 21 counties had MORE dentists in 2024 than in 2017.  Among the smallest populated 25 counties, 11 of them lost dentists, 12 had no change and 2 counties gained dentists.  Among the 13 most urban counties, 7 counties gained dentists and 5 lost dentists.  

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

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

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

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

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

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

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

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

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

Facing the Facts, Addressing the Problem

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

Actions Taken

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

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

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

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

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

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

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

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

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

Policy Watch: Volunteer Licenses for Nonresident Dentists Practicing in Alabama

May 16, 2024 | Kimberly Randall

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

Background

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

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

Proposed Legislation

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

The bill goes into effect on October 1, 2024.

Potential Impact

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

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

Learn More

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

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

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

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

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

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

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

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

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

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

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

Learn More

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

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

Policy Brief: Health implications of ARPA funding dedicated to on-site wastewater systems in the Black Belt area of Alabama

March 14, 2023 | Kimberly Randall, LHC Staff

A number of Alabama residents, particularly in the Black Belt area, are unable to connect to centralized water and sewage utilities and instead rely on on-site sanitation systems, or septic tanks. These systems are costly, particularly in comparison to the household income of the area, and often fail due to the unique geological structure of the region (He et al., 2011). Homeowners who are unable to afford a proper on-site sanitation system may resort to “straight piping” instead, dispensing raw sewage into nearby fields, ditches, or waterways (Loveless & Corcelli, 2015).

The Black Belt has a uniquely structured geologic profile that results in a rich, dark soil high in nitrates which gave the region its name. The unconfined aquifer, or layer of soil above the first layer of clay, is only a few feet deep and much more shallow than in other areas of the state. Traditional septic tanks are buried just below the ground level which results in the tanks potentially being buried in a layer of montmorillonite clay rather than soil.

This poses two issues. This type of clay is hydrophilic, meaning that any moisture leaving the system via drainage fields is not able to be naturally filtered the way soil composed of minerals and microorganisms is. Additionally, the clay expands and contracts in extreme temperatures found in Alabama which can cause the concrete septic tanks to crack and expose extreme amounts of waste into the groundwater, known as interaquifer leakage. Consequently, the area requires an engineered or “mounded” sanitation system that artificially creates a larger unconfined aquifer of sand and soil on a property, but the cost is upwards of 5x that of a traditional septic system.

Ineffective sanitation infrastructure poses a number of health and environmental risks. Common pathogens related to groundwater contamination include but are not limited to shigella, hepatitis A, norovirus, giardia, and salmonella (EPA, 2015). Additionally, parasites like hookworm have historically been present in the area due to poor sanitation (McKenna et al., 2017).

While many Alabama residents struggle to access adequate sanitation, the problem is especially severe in the Black Belt counties of Dallas, Perry, Sumter, and Wilcox. As some of the poorest areas in the state, the cost of an effective sanitation system is often unfeasible. However, under state law, it is the financial responsibility of the homeowner to install and maintain a state-permitted on-site sanitation system and risk fines, arrest, and a potential lien on their home for not doing so (Alabama Code § 11-68) It is estimated that tens of thousands of homes in the Black Belt area that have outdated, ineffective, or substandard on-site sanitation systems.

Currently, the Alabama Department of Environmental Management (ADEM) is the facilitator of all government funding for sanitation projects in the state. However, ADEM does not offer a mechanism to provide financial assistance for on-site systems to homeowners or non-municipal entities such as non-profit organizations.

On Tuesday, March 7th, Governor Ivey called for a special session of the Alabama legislature to distribute the remaining $1.06 billion in federal funding granted by the American Rescue Plan Act, a portion of which is expected to go toward sanitation infrastructure in the Black Belt. ARPA funds could be highlighted as a way to assist with on-site sanitation repairs via grants distributed through ADEM to begin tackling this problem.

To download this Policy Brief in PDF form, CLICK HERE.

Other facts of note:

According to one survey, 90% of land in the Black Belt is not suited for conventional on-site sanitation systems (He et al, 2011).
The average income in Wilcox county is $19,231 (US Census, 2021).
A survey conducted in Wilcox County showed that 90% of unsewered homes had an unpermitted sewage system, 60% of homes had a visible straight pipe, and 33% of homes had a buried straight pipe or other unpermitted sanitation systems (He et al, 2011).
Researchers estimate that upwards of 550,000 gallons of raw sewage are being put in the watershed each day due to inefficient sanitation (Walton, 2017).
One study estimated groundwater contamination from failing septic systems could affect up to 340,000 low-income people in rural Alabama, placing them at an elevated risk of disease (Wedgeworth & Brown, 2013).

References

EPA. (2015). Groundwater contamination Guide – US EPA. Retrieved March 10, 2023, from https://www.epa.gov/sites/default/files/2015-08/documents/mgwc-gwc1.pdf

He, J. et al., (2011). Assessing the Status of On-site Wastewater Treatment Systems in the Alabama Black Belt Soil Area. Environmental Engineering Sci, 28. 693-695.

Loveless, A., & Corcelli, L. (2015), Pipe Dreams: Advancing Sustainable Development in the United States, EPA BLOG, https://blog.epa.gov/blog/2015/03/pipe-dreams-advancing-sustainable-development-in-the-unitedstates/.

McKenna, M. L. et al., (2017). Human Intestinal Parasite Burden and Poor Sanitation in Rural Alabama. The American journal of tropical medicine and hygiene, 97(5), 1623–1628. https://doi.org/10.4269/ajtmh.17-0396

U.S. Census Bureau. (2022). Income and Poverty, July 1, 2022 (V2022) — Wilcox County, Alabama data table.

Walton, B. (2017). Diseases of poverty identified in Alabama County burdened by poor sanitation. Circle of Blue.

Wedgworth, J. C., & Brown, J., (2013). Limited Access to Safe Drinking Water and Sanitation in Alabama’s Black Belt: A Cross-Sectional Case Study. Water Quality, Exposure & Health, 5. 69-71.

Policy Review: Birmingham Bus Rapid Transit System

May 16, 2022 | Anushree Gade, LHC Intern

Introduction

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.⁵

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.

Conclusion

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.

References

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.
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/.
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.
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/.
City of Albuquerque. Zero fares pilot program. cabq.gov. Date Unkown. Accessed April 06, 2022. https://www.cabq.gov/transit/tickets-passes.
Gershon RRM. Public transportation: advantages and challenges. Journal of Urban Health. 2005; 82(1), 10.1093/jurban/jti003.
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/.
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.
United States Census Bureau. Quick facts Birmingham city, Alabama. census.gov. Date unknown. Accessed April 14, 2022. https://www.census.gov/quickfacts/birminghamcityalabama.
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/.
MAX Transit. Routes. maxtransit.org. Date unknown. Accessed April 13, 2022. https://maxtransit.org/routes/.
Birmingham City Council. Birmingham Xpress. birminghamal.gov. Date unknown. Accessed April 13, 2022. https://www.birminghamal.gov/brt.
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#.
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/.
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.
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.
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.
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.

Policy Works: US Launches At-Home Covid Testing Initiative

January 18, 2022 | Kimberly Randall, Lister Hill Center Program Coordinator

Photo Courtesy of Getty Images

Health policy can take many forms and impacts multiple parts of the public health sector. From housing reform to addressing nutrition in impoverished communities to climate change, legislation can have widespread impacts on the health of citizens.

Following rising cases of the Omicron variant of the novel coronavirus, President Biden announced a series of executive actions on December 21st to assist hospitals and public health agencies. In addition to mobilizing 1,000 troops with medical experience to be dispersed to hospitals overrun with COVID-19 cases and launching distribution systems for PPE to hospitals, clinics, and the general public, the White House also announced an initiative to provide free at-home antigen testing kits to be delivered through the United States Postal Service.

This initiative follows similar actions in the United Kingdom and Canada, where at-home test kits have been available to citizens free of charge for several months, either through mail delivery or at designated pharmacies. Tuesday, January 18th saw the launch of https://www.covidtests.gov/, the official website where US Citizens can request a set of four at-home test kits to be delivered via USPS. While the test kits are estimated to be delivered in late January, registration is open now. The federal government has purchased 1 billion test kits for this initiative, after doubling its original pledge of 500 million.

In addition to the at-home delivery service, President Biden announced that private insurance companies will be required to reimburse expenses for at-home test kits purchased at local pharmacies. According to the Centers for Medicare and Medicaid Services, private insurance companies are required to reimburse over-the-counter COVID-19 tests purchased on or after January 15, 2022 at a cost of up to $12 per test. Health insurance providers must reimburse the cost of up to 8 at-home test kits per month, per person enrolled. According to Blue Cross Blue Shield Alabama, the largest health insurance provider in the state, “members who purchase a test kit should file a claim to be reimbursed. Claims can be filed electronically by logging in to your account or by submitting a Medical Expense Claim Form along with the test kit receipt.” A full list of reimbursable kits can be found on the FDA’s website.

The Centers for Disease Control lists at-home testing as one of the key measures to reduce the spread of COVID-19. While at-home tests have a higher chance at a false-negative than a PCR test, it is suggested to utilize them prior to indoor social gatherings and other close-contact situations where the virus might be transmitted. According to the CDC, “a negative self-test result means that the test did not detect the virus and you may not have an infection, but it does not rule out infection. Repeating the test within a few days, with at least 24 hours between tests, will increase the confidence that you are not infected.”

Want to register for your at-home test kits? It’s a simple, two-step process.

Visit https://www.covidtests.gov

Select “Order Free At-Home Tests” which will direct you to the official page on the USPS website.

Fill in the information as needed. Tests are estimated to ship starting in late January.

Built Environment Symposium Re-Cap: Four Perspectives

November 21, 2019 by the LHC Team

Each Fall and Spring semester we focus in on a public health topic to encourage policy action among our stakeholders. We call this our Semester Spotlight program. This Fall was our first semester rolling out this program; we decided to start with the Built Environment. As our city continues to grow and re-develop, we hope to spark conversations about how the environment we build affects the public’s health.