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 Review: Alabama’s Push Toward Electric Vehicles

March 1, 2022, | Anushree Gade, LHC Intern

As a state, Alabama has been making a more pronounced effort to adopt sustainability initiatives. This may result from people becoming more knowledgeable about climate change and how sustainability directly plays into it.

Electric vehicles have been receiving a lot of attention in the previous years. There are many more fully electric vehicles and hybrid cars on the road in the past year compared to five years ago. For example, we probably see numerous Teslas while driving around in Birmingham these days compared to how many we saw just two years ago. Why is this significant? It is important to note that transportation accounts for 70% of petroleum consumption in the United States. Hybrid vehicles consume less fuel than vehicles that are dependent entirely on gasoline. Electric vehicles rely solely on electricity as the source of energy. Electric and hybrid vehicles are better alternatives to conventional cars as it helps us decrease our fuel consumption and decrease our ecological footprint.

In this case, California serves as a model state for other states across the United States. California provides incentives to its residents to encourage them to purchase hybrid or electric vehicles. The state has a Clean Vehicle Rebate Program (CVRP) in which California residents who are buying hybrid or electric cars are given a rebate. This incentive encourages the residents to consider purchasing such vehicles to decrease the state’s contribution to air pollution and climate change. The state also provides grants to purchase electric buses to further their effort to increase the amount of zero-emission vehicles in the state. For more information on these incentives and other incentives for electric vehicles in California, visit this link.

The Alabama Department of Economic and Community Affairs has been attempting to encourage the public to learn about electric vehicles and their benefits through a marketing program called “Drive Electric Alabama.” This program aims to include TV, radio, and digital advertising to increase Alabama residents’ exposure to information about electric vehicles. They have also created a website where the public can learn more. Click this link to access the website! Furthermore, Alabama has an Electric Vehicle Supply Equipment (EVSE) Grant Program. This grant program provides funds to expand electric vehicle infrastructure. Alabama also offers grants to replace diesel vehicles with newer diesel vehicles or alternative fuel vehicles. Vehicles eligible for this include medium- and heavy-duty trucks, school buses, shuttle, transit buses, freight switchers, airport, and ground cargo handling equipment. The state has also been making an effort to increase the number of electric vehicle charging stations across the state. Lack of access to charging stations can serve as a con for those considering switching to electric cars. Increasing charging stations can further encourage residents to make the switch.

Despite the push towards electric vehicles being a success in California, such vehicles are relatively new and in the works for most states. Alabama has been making this transition, though it may take more time and effort to do this more effectively.

Furthermore, several different solar initiatives are in place for the residents of Alabama to encourage them to consider installing photovoltaic systems (solar panels) for the production of renewable energy. These initiatives include, but are not limited to:

Tax Credit: If you install solar panels, your tax credit is 26% of the cost of the entire solar panel system.
Property Tax Abatement: the Alabama Tax Code provides property tax abatement for qualifying facilities that use renewable energy.
Net Energy Metering helps people save some money on their electricity bills when they send electricity produced from their solar panels back to the grid.

Policy Review: Climate Change Initiatives in the Deep South

March 14, 2022 | Anushree Gade, LHC Intern

Chimneys smoking

White smoke is pouring out of the chimneys of the power plant.

BACKGROUND

Last year in late October and early November, we saw many news articles pertaining to the Glasgow Climate Change Conference. Counties across the world are collaborating with one another to address the international crisis of Climate Change. At the Glasgow Climate Change Summit, 151 countries submitted climate plans for emission reduction in order to maintain their goal of preventing temperatures from rising more than 1.5 degrees Celsius. Furthermore, there was also an agreement to significantly reduce coal consumption as it serves as a major source of CO2 emissions. It is important to note that developing countries lack funds to adopt sustainable practices. Developed countries have agreed to financially aid developing countries.

INITIATIVES/POLICIES

It’s imperative to address climate change on an international level as it is a global crisis. However, what are we doing as a nation to be mindful of our contribution to this crisis? Recently, President Biden announced plans to reduce the United States’ greenhouse gas emissions by 50-52% by 2030. The United States is a major source of greenhouse gas emissions. In 2019, the United States emitted 6,558 million metric tons of greenhouse gases. Greenhouse gases contribute to global warming as they trap heat in the atmosphere and cause atmospheric temperatures to increase. Increasing greenhouse gas emissions has been a major cause of the observed global warming. Therefore, Biden’s plan to decrease greenhouse gas emissions comes with importance. Furthermore, the US has vehicle and aircraft emission standards set in order to ensure that greenhouse gas emissions are regulated. To learn more about these emission standards, click here. To learn more about greenhouse gases, click here.

Did you know?

Health effects of Climate Change include, but are not limited to:

Heat-related illness

Respiratory illness (i.e. asthma)

Water-borne diseases

Noncommunicable diseases

Malnutition

To learn more, visit this link.

You have probably heard about the Environmental Protection Agency’s (EPA) Clean Air Act. The Clean Air Act was first introduced in 1955, however, the act introduced in 1970 is the one that is most often referred to as the Clean Air Act and was one of the first policies that pertained to climate change. This act is one that “regulates air emissions from stationary and mobile sources.” The Act also sets deadlines for state and local governments to achieve the goals set forth by the Act. There are more components to the act that you can explore here.

We have discussed initiatives and policies targeted at climate change on the national level, but what are some ways climate change is being addressed at the local level? One way in which this is being done is that local and state governments are adopting standards in alliance with national standards to address local power plants and vehicle emissions. Additionally, there are various organizations that are aiming to address climate change from the local level. A primary example of such an organization is the Greater-Birmingham Alliance to Stop Pollution (GASP). They are an organization based in our city. GASP came about in the late 1960s when there was resistance to the ideals set forth by the Clean Air Act. This organization advocates for clean air policies right here, in Birmingham. GASP played a significant role in exercising the Act in Birmingham.

TAKING ACTION

The Lister Hill Center for Health Policy recently hosted a seminar with GASP discussing the Birmingham Green New Deal and how to get involved in local advocacy with climate change called Local Action: How the Urgency of Climate Change is Impacting Birmingham. GASP is a non-profit climate advocacy center dedicated to creating cleaner air for the city of Bimringham. A full recording of the event is available below.

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 Review: Medicaid Expansion’s Impact on Mental Health

November 15, 2021 – Anushree Gade, LHC Student Assistant

Background

Medicaid and Medicare are often used together, but the qualifications and operations for each are vastly different. Medicare is regulated by the federal government and is age-dependent (for people that are 65 years of age or older). Medicare is not income-based and functions as an insurance plan, providing coverage to seniors who no longer have access to private insurance through an employer. Medicaid, on the other hand, is managed at the state level, which independently creates its own qualification criteria. In Alabama, you must meet income qualifications and fall into one of these categories:

Pregnant
Blind
Have a disability or a family member in the household has a disability
Be responsible for someone 18 or younger
Be 65 years of age

The low-income designation is assigned depending on the annual household income and the number of people in the household. Medicaid Expansion under the Affordable Care Act (ACA) allowed for more people to be considered eligible for Medicaid. The expansion would ease some of the guidelines that would make Medicaid more inclusive and increase the number of people who qualify for Medicaid. However, Alabama remains one of twelve states who have yet to expand Medicaid even as most states in the northeast and west and adopted and implemented the expansion already.

In March of 2021, President Biden signed the American Rescue Plan into law which contained financial incentives for the remaining states to adopt Medicaid expansion. According to the Georgetown University Health Policy Institute, “the American Rescue Plan encourages states to finally take up the Medicaid expansion by offering even more favorable financial incentives than those already in place and allows states to provide longer postpartum health coverage for new mothers. Among its private insurance provisions, the American Rescue Plan provides full premium subsidies for COBRA coverage, substantially increases subsidies for the purchase of health plans offered through the Affordable Care Act’s marketplaces, and targets additional marketplace subsidies to those receiving unemployment benefits.”

Impact on Mental Health

In a study conducted by researchers at Indiana University, it was identified that Medicaid expansion was responsible for increasing the use of preventative care visits, mental health services, and primary care. Furthermore, this study also observed that Medicaid expansion increased how people perceived their own health. There were lower rates of poor mental health days/psychological distress; moreover, there was increased reporting of better perceived physical health. Researchers suggested that the increase in better mental health perception could be an effect of increased access to medical services. The inability to access health care services could potentially place stress and impact the mental health of individuals. Medicaid expansion would allow more people to access health services; thereby, positively impacting mental health.

Medicaid expansion would allow for more people who are diagnosed with mental health illness to qualify for Medicaid. The expansion would allow for people, despite disability status, to qualify depending on their income level. This would increase the number of people that can access health care services and mental health care. Medicaid would allow for people with mental illness to access services such as psychotherapy, inpatient psychiatric treatment, and prescription medications.

If a patient makes an appointment with a primary care physician for a checkup, the physician would be able to refer the patient to mental health services covered under Medicaid. However, there are challenges that come with Medicaid referrals including delays associated with processing the referral request and the lack of cooperation between services. These challenges significantly impact one’s ability to get access to health services in a timely manner. Furthermore, there are also challenges associated with continuous access to mental health services. In order to provide continuous care, the social workers are required to justify why the recipient is still in need of mental health services and requires a diagnosis and formalized treatment plan.

Opposition

Medicaid expansion was initially suggested in 2015 by Governor Robert Bentley’s task force. These plans were put forth with intentions to transition to a managed care model. This type of insurance model would allow for contracts with medical professionals and facilities by which they would provide care at reduced costs for those who are covered by that health insurance (if implemented, it would be Alabama Medicaid). However, this would entail increased costs associated with financing it. Eventually, Gov. Bentley dropped the idea as it would promote strong opposition from the state legislature.

Policy Review: Should the current prison healthcare co-pay system be overturned?

October 19, 2021 | Kimberly Randall, LHC Program Coordinator

Handcuffed hands with inhaler

Photo Courtesy of Getty Images

Written in 2013, Administration Regulation Number (ARN) 703 dictates the current co-pay system that allows inmates in the Alabama Department of Correction (ADoC) facilities to seek medical care. Constitutionally, inmates have a right to medical care while incarcerated as the Supreme Court referenced the Eighth Amendment’s prohibition against cruel and unusual punishment as a precedent for providing healthcare access to inmates. ARN 703 states that “all inmates have access to healthcare regardless of their ability to pay. No inmate shall be denied care because of a record of non-payment or current inability to pay for health services.” However, the prison co-pay system establishes that ADoC is not responsible for providing care free of charge when an inmate has the means to pay the designated amount for health services.

According to the Prison Policy Initiative, a think tank dedicated to prison reform, the average inmate in an Alabama correctional facility makes between $0.25 and $0.75 per hour making license plates, building furniture, and creating chemicals for use in state agencies. At $4 per visit, it would take almost one weeks’ wage to see a medical professional.

ARN 703 and similar legislations state that utilizing a co-pay method for healthcare prevents inmates from misusing healthcare services as well as “instilling inmate responsibility by having them make resource allocation decisions.” Forty-two states, along with the Federal Bureau of Prisons, utilize a copay system. Some states operate on a method more closely associated with a deductible, such as the state of Texas which charges $100 per calendar year for unlimited visits with a medical provider.

Recent research completed by the John Howard Association, an independent prison monitoring association advocating for prison reform and improving conditions for incarcerated persons, found that prison co-pays were the top source of stress for inmates, and over half of all inmates stating that they avoid healthcare due to the cost of the co-pay. According to Fisher and Hatton (2012), “co-payments contributed to delays in treatment, avoidance of health care professionals, unnecessary suffering, and poor health outcomes. … [and] place an unfair burden on prisoners who are poor, limit access to health care, and contribute to needless suffering and potentially to preventable deaths.”

While legislation dictates that co-pays should be waived in cases of chronic illness or mandated care, a qualitative research study found that oftentimes those exceptions aren’t equally granted or sometimes ignored entirely. Even in specific scenarios where a medical condition is covered without a copay, such as MRSA, the Center for Disease Control and Prevention identified the perceived costs as one of the leading factors in infectious disease outbreaks within prison systems. According to the Marshall Project, “with prisoners living in close quarters, any policy that deters people from going to the doctor also increases the risk of contagion.”

Healthcare for inmates takes up approximately 20% of prison spending, a key point when arguing for co-pays in the Alabama prison system. However, research conducted in other states such as Illinois shows that the funds collected from the co-pay system in inmates don’t even cover the administrative costs associated with operating it. Additionally, since the state is required to cover the costs associated with chronic conditions, some health researchers state that it may be cost-defective to charge co-pays as minor, treatable conditions can blossom into extensive hospital stays when medical treatment is delayed.

According to the National Commission on Correctional Healthcare, the leading arguments for a co-pay system are:

The cost of medical care is an increasingly heavy burden on the financial resources of the facility, state, or county. The cost needs to be controlled legally without affecting needed care.
Sick call can be and is abused by some inmates. This abuse of sick call places a strain on available resources, making it more difficult to provide adequate care for inmates who really need the attention.
Inmates who can spend money on a candy bar or a bottle of shampoo should be able to pay for medical care with the same funds—it is a matter of priorities.
It will do away with frivolous requests for medical attention.
It cuts down on security problems in transporting inmates to and from sick call by reducing utilization.
It instills a sense of fiscal responsibility and forces the inmate to make mature choices on how to spend money.

Arguments against charging inmates a fee for health care services include the following:

Access is impeded. A fee-for-service program ignores the significance of full and unimpeded access to sick call and the importance of preventive care.
Inmates are almost always in an “indigent” mode. They seldom have outside resources and most have no source of income while incarcerated. They most often rely on a spouse, mother, or other family member to provide funds they can use for toiletries, over-the-counter medications like analgesics and antacids, telephone calls, writing paper and pens, sanitary napkins, candy, etc. These “extras” become extremely important to one who is locked up 24 hours per day. The inmate may well choose to forgo treatment of a medical problem in order to be able to buy the shampoo or toothpaste.
The program sets up two tiers of inmates: those who have funds to get medical care and commissary privileges, and those who have to choose between the two.
Avoiding medical care for “minor” situations can lead to serious consequences for the inmate or inmate population, since the minor situation can deteriorate to serious status or lead to the infection of others.
Crowded conditions increase the risk of spreading infections, and effective measures need to be taken to reduce this risk. Daily sick call should be encouraged rather than discouraged. Co-pay has been identified as a contributing factor for outbreaks of methicillin-resistant Staph aureus (Centers for Disease Control and Prevention, 2003).
A properly administered sick-call program keeps costs down through a good triage system, which has a lower level of qualified staff see the complaining inmate first, with referral to higher levels of staff only as medically indicated.
Charging health service fees as a management tool does not recoup costs; rather, when looking at the increased administrative work involved or the long-term effect of the program, charging health service fees can cost more to implement than what is recovered.
Inmates frequently have low health literacy and may not understand the difference between medically significant and medically insignificant symptoms nor when it is important to seek medical services. Thus, it may be ineffective to expect inmates to determine when to pay for medical services.

Several organizations, including the NCCHC, advocate for the removal of a co-pay system. During the pandemic, many states eliminated co-pays for inmates to reduce the impact of the virus on the prison system. Additionally, states like California have voted to eliminate co-pays entirely. Alabama recently passed two pieces of legislation related to prison reform – a bill allocating nearly $800 billion to construct two new prison facilities in the state and an amendment to a previous bill that mandates supervised probation for non-violent offenders. Should the prison co-pay system be examined or overturned as well?

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