Category: Policy Watch

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

April 30, 2024 | Miriam Calleja, Kimberly Randall 

Background

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

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

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

Proposed Legislation 

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

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

Impact

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

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

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

Next Steps 

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

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

Learn More 

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

Kaiser Family Foundation State Report 

Rural Hospital Association 

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

Background 

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

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

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

Legislation 

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

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

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

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

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

Impact 

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

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

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

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

Next Steps 

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

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

Learn More 

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

Gifford Law Center to Prevent Gun Violence 

APHA Gun Violence Fact Sheet 

EFSGV Public Health Approach to Gun Violence 

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

Kimberly Randall | August 15, 2023

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

Background 

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

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

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

Proposed Legislation 

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

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

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

Impact 

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

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

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

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

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

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

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

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

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

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

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

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

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

(-68.09%)

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

Next Steps 

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

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

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

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

Stay Informed 

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

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

Policy Watch: Alabama Bill Looks to Decrease Correctional Incentive Time in State Prison System

March 6, 2023 | Kimberly Randall, LHC Staff

As the 2023 Alabama Legislative Session begins on March 6 with Governor Ivey’s State of the State Address, dozens of bills have been pre-filed over the last few weeks. This year starts the first of a four-year term with new committees, new legislators, and new leadership. As a part of a five-part series, the Lister Hill Center for Health Policy has identified five pre-filed bills that could have substantial health implications if passed in 2023.

Inmates sitting on bunks wearing white jumpsuits

SB1 – Deputy Brad Johnson Act

Sponsored by: Sen. April Weaver (R-Brierfield)

This bill has also been pre-filed in the House of Representatives as HB-9 by Rep. Russell Bedsole (R-Montevallo)

Background

Under current Alabama law, § Section 14-9-41, individuals incarcerated within the Alabama Department of Corrections had “good behavior time” calculated by a specific equation. Referred to as correctional incentive time, inmates can have time reduced off of their sentences for serving portions of their time in various amounts depending on their classification, a ranking system determined by the length of time spent incarcerated and the deemed trustworthiness of each individual.

Proposed Legislation

The legislation, SB 1, would decrease the correctional incentive time for each classification of inmates.

Class 1 inmates (considered trustworthy and able to work without supervision) are eligible for a maximum of 75 days to be removed from their sentence per 30 days served. SB 1 would reduce this amount to 30 days.

Class 2 inmates (able to work under supervision) are eligible for a maximum of 40 days of correctional incentive time per 30 days served, which would be reduced to 15 days.

Class 3 inmates (special assignments) are eligible for a maximum of 20 days of correctional incentive time, which would be reduced to 5 days.

Additionally, SB1 doubles the length of time that inmates must spend in each category before advancing to the next class.

Impact

Alabama has been scrutinized by the Department of Justice and legal advocacy organizations for being unsanitary, overcrowded, and dangerous. The state has one of the highest incarcerations in the country, with a mortality rate of more than twice the national average. Alabama is home to the most dangerous prison in the United States, as determined by the number of violent and often fatal incidents at St. Clair Correctional Facility. While funding was diverted from the American Rescue Plan in 2022 to build new facilities, the Alabama Department of Corrections Commissioner, John Hamm, has declared that the new buildings will not have a higher capacity than the existing ones.

SB1 would increase the number of incarcerated persons in the state at any given time. Under the existing guidelines, an incarcerated person who was given a five-year sentence could be released after 28 months if maxing out the correctional incentive time. Under the proposed changes, the same person would be released no earlier than 36 months. Without proper procedures to increase capacity, medical access, and staffing, this increase in prison populations could have significant adverse health implications for incarcerated persons and prison staff.

Prison systems are hot spots for disease transmission and often have understaffed medical facilities. The Alabama Department of Corrections utilizes a co-pay system for incarcerated persons to use healthcare resources which are often 5-10x their daily wages. Additionally, the cost of medical treatment within the prison system is significantly higher than for unincarcerated persons, resulting in a higher percentage of undiagnosed and untreated diseases. It is also important to note that some disease transmission, such as SARS-COV-2, can impact the prison staff and inmates.

Next Steps

The Alabama Legislative Session officially begins on Wednesday, March 7. SB1 has been scheduled for a first reading that day, which will be sent to the committee for deliberation. Should it pass in committee, a second reading on the Senate floor will place the bill on the official Senate calendar. Then, a third reading will occur where the entire chamber will debate the bill.

If you want to make your voice heard on this or future legislation, click here to identify your elected officials, and check out this guide from the ACLU on how to write a letter to your legislators.

Stay Informed

Want to learn more about this bill and other issues impacting the Alabama prison system? Join the Lister Hill Center for Health Policy, the UAB Institute for Human Rights, and the Southern Poverty Law Center on Wednesday, March 22, at 4 PM at University Hall, Room 1008, for a special discussion on Criminal Justice Reform & Human Rights in Alabama. Registration can be found here.

Additionally, we recommend the following organizations for more information on criminal justice reform:

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

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

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

Background

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

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

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

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

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

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

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

Proposed Legislation

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

Presented by Representive Victor Gaston and others, HB105 reads:

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

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

Impact 

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

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

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

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

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

Next Steps

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

Stay Informed

Policy Watch: Alabama legislature authorizes enhanced lead regulations

September 6, 2022 | Anantha Korrapati, LHC Intern

Lead is a natural chemical commonly used in various products such as household paint (before 1978), gasoline (before 1995), and plumbing pipes and fixtures. However, it is a potent neurotoxin that harms people, especially children, and pregnant women. 

According to the EPA, lead can be absorbed into the body through inhalation or ingesting lead dust from paint coatings or contaminated drinking water. It then travels through the bloodstream to accumulate in the bones. Depending on the level of exposure, lead can adversely affect the nervous system, kidney function, immune system, reproductive and developmental systems, and cardiovascular system. It has been shown to cause brain damage and cognitive deficits in children, even at low exposure levels. Lead exposure also affects the oxygen-carrying capacity of the blood. Levels should be checked through blood tests since there are no apparent symptoms of elevated blood lead levels (BLL). In Alabama, a BLL of five micrograms per deciliter (µg/dL) or higher is considered elevated.

Lead dust can be caused by air pollution near ore and metals processing centers and piston-engine aircraft operating on leaded aviation fuel. The highest lead particulate matter is found in soil near lead smelters at about 50-400 parts per million. 

According to the EPA, there are two extensive lead smelting facilities in Alabama that are superfund sites–nationally contaminated sites with improperly managed hazardous waste that are under the Comprehensive Environmental Response, Compensation and Liability Act (CERCLA), allowing the EPA to clean up contaminated sites and forces responsible parties to assist or reimburse them for cleanup services. 

The Interstate Lead Company, or ILCO, had a secondary lead smelter and lead battery recycling facility operating in Leeds, Alabama, from 1970 to 1992. It was named a superfund site in 1986 due to contaminated groundwater, sediment, soil, and surface water resulting from facility operations. The EPA, the Alabama Department of Environmental Management (ADEM), and the ILCO Site Remediation Group, the site’s potentially responsible parties (PRPs), have investigated site conditions. Site contamination does not currently threaten people living and working near the site. The other facility is the Sanders Lead Company in Troy, Alabama. The complete list of lead mines in Alabama can be found here.

Proposed Legislation

SB158, sponsored by Senator Bobby D. Singleton, is titled “Lead reduction, Alabama Lead Reduction Act, lead abatement and further regulation of lead hazard reductions” and aims to regulate lead hazard regulations further, revise the authority of the State Board of Health to conduct lead inspections, enforce the Alabama Lead Reduction Act of 1997, and provide criminal penalties for violation. 

It was signed into law in April 2022 by Governor Kay Ivey. 

The act will establish a program to educate owners on renovation, risk assessments by health officers, a state-accredited program for lead hazard training, enforcement of the Alabama Lead Reduction Act of 1997, and fines for violations. 

Many homes and public buildings designed before 1978 may have lead-based paint on surfaces or fixtures, and this act establishes abatement and renovation accreditation programs for both individuals and firms under “Safe State,” the state accreditation agency for lead hazard training through the University of Alabama. These programs are in accordance with Title IV of the Federal Toxic Substances Control Act. 

Abatement is defined as the removal of lead-based paint or contaminated dust, replacement of lead-painted surfaces or fixtures, and the removal or covering of lead-contaminated soil. 

Renovation is defined as fixing painted components and removing building components with weatherization projects and any interim controls that disturb painted surfaces during the conversion of a building.

The legislation also establishes risk assessments where “the State Health Officer may conduct investigations of general lead contamination problems or conditions in public buildings and upon request of the building owner of commercial buildings, or the request of the owner or occupant of residential buildings.”

The Alabama Lead Contractor Certification Program established by the Alabama Lead Reduction Act of 1997 consists of Lead Hazard Reduction Contractor Certification (Abatement) and Alabama Lead Renovation Contractor Certification. This new legislation defers this training to the “Safe State” program.

Violations of this legislation depend on the number of incidences and can apply to individuals and firms. The fines are as follows:

  • First offense: $250
  • Second offense: $500
  • Third offense: $2500 – $5000

Impact

According to a study done in Kent County, Michigan (where over 50% of respondents live in homes built pre-1978), a lead safety course for parents was successful in promoting education and empowerment. However, the researchers stated that “longer-term solutions require advocacy at community and policy levels and cannot be prevented by individual behavior,” such as lead-safe mopping or collecting dust from window sills. Therefore, the legislation in Alabama will hopefully provide lasting changes through the renovation and abatement programs. 

This legislation will improve air quality, both primary and secondary air standards stated below:

National Ambient Air Quality Standards: 0.15 micrograms lead per cubic meter of air

  • Primary: publichealth protection, including protecting the health of “sensitive” populations such as asthmatics, children, and the elderly
  • Secondary: public welfare protection, including protection against decreased visibility and damage to animals, crops, vegetation, and buildings

According to a cost-benefit analysis from 2009, “Each dollar invested in lead paint hazard control results in a return of $17–$221”. This analysis compared the baseline cost of implementing lead hazard control programs to the health care costs and social behavioral costs incurred by lead poisoning, specifically in children. 

Specifically, in Alabama, ValueofLeadPrevention.org estimates $1 billion worth of lifetime economic burden of childhood lead exposure–including costs of “reduced lifetime productivity; increased health care, education, and social assistance spending; and premature mortality.”

Below is a map of the estimated percentage of children with elevated BLLs: 

Source

More economical costs and benefits of lead hazard training can be found here with research done by the National Institute of Environmental Health Sciences. 

Next Steps

The Alabama Department of Public Health and UA are managing this legislation. 

UA SafeState now manages registration for Individual Accreditation and Firm Certification. Register Here.

Firms that seek to be certified to perform renovations must have certification from the Alabama Department of Public Health and at least one individual accredited by UA’s Safe State program.

Here are a few EPA guidelines for individual actions to reduce lead exposure and poisoning. 

  • Eat healthy foods with calcium, iron, and vitamin C. These foods may help keep lead from being digested. 
  • Regularly wash hands, toys, and horizontal surfaces with soapy water and disposable cleaning materials. 
  • Vacuum with a High-Efficiency Particulate Air (HEPA) filtered vacuum
  • Take shoes off before entering the home or living areas
  • Cover lead-exposed soil with fruitless plant materials
  • Hire certified lead professionals to assist with home renovations in pre-1978 housing
    • Homes built before 1978 are more likely to have lead-based paint. Performing home renovations may disturb this paint and be a source of lead exposure. Using lead-safe work practices is critical when renovating. For guidance on lead-safe renovations, please visit the EPA or hire a certified lead professional to do the work for you.

Policy Watch: The Impact of Eliminating Grocery Sales Tax

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

Photo Courtesy of Getty Images 

Background 

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

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

Proposed Legislation 

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

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

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

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

Impact 

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

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

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

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

Next Steps  

The Alabama Legislative Session is currently underway and will continue for several months. Both bills are currently being discussed in committee and have not yet gone to a vote. If you want to make your voice heard on this or future legislation, click here to identify your elected officials. 

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

Stay Informed 

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

 

Policy Watch: Alabama Lawmakers Propose Mandated Mental Health Professionals in K-12 Schools

March 17, 2022 | Kimberly Randall, Lister Hill Center Program Coordinator 

Cutout of a head with puzzle pieces in brain

Image Courtesy of Getty Images

Background 

In 2009, the Institute of Medicine compiled a report that recommended local and state governments develop a system to increase access to resources for students for the prevention and treatment of mental, emotional, and behavioral disorders. A year later, the state of Alabama created the School-Based Mental Health Coalition, a subsidiary of the Alabama Department of Mental Health. The agency’s goal was to bridge the various government offices such as the Department of Education and Department of Public Health to ensure that students enrolled in public K-12 schooling had adequate access to adequate mental health intervention, treatment, and prevention services. 

Currently, there are 80 school systems statewide collaborating with just over a dozen mental health agencies to refer students for professional services. The program was expected to increase attendance, reduce the frequency of administrative corrections like suspensions, and integrate mental health practitioners into students’ lives. 

However, the program is not currently statewide, only accounting for 57% of school districts. While the state does offer some funding available for schools to partake in the program, often, the local districts are responsible for a portion of the cost, limiting the ability for poorer districts to join. 

Proposed Legislation 

Senate Bill 306, proposed by Sen. Rodger Smitherman (D-Birmingham), works to establish a minimum set of requirements for a certified mental health services coordinator and mandate that at least one position be required in all school districts within the state. The bill would go into effect with the 2023-2024 academic year. 

The coordinator must have one or more of the following qualifications: 

(1) Have a bachelor’s degree in social work. 

(2) Satisfy State Department of Education qualifications for a school counselor. 

(3) Satisfy State Department of Education qualifications for a school nurse. 

(4) Have professional mental health experience, or have been licensed in a mental health occupation including, but not limited to, licensure as a licensed professional counselor or marriage and family therapist.

(5) Other qualifications as determined by the Alabama Department of Mental Health and the State Department of Education.

Additionally, employees have one year after being hired to complete a certification program developed and implemented by the Alabama Department of Mental Health. 

The legislation also outlines an implementation plan to enact the bill, requiring each local board of education to complete a needs assessment report and a resource map for all public schools in their jurisdiction. These documents are intended to document the status of mental health for the entire school system and create a baseline on which to improve once the program is implemented. 

While the bill does not specify that school districts must join the School-Based Mental Health Coalition, there is substantial overlap between the legislation and the purpose of the SBMHC. 

Impact 

According to the World Health Organization, mental-health-related disabilities are a leading cause of mental health issues worldwide, with over ⅔ of patients receiving no or inadequate treatment for those conditions. Rates of depression have risen almost 50% in the last ten years, but access to mental health services has remained stagnant. Weare and Nind (2011) state that “childhood and adolescence provide key opportunities to develop the foundations for mental health and prevent mental health problems, and the school is a unique resource to help achieve this.” School-based services such as counselors and caseworkers have been shown to positively impact mental health prognosis in children and teens.

Multi-tiered systems of support (MTSS) are integral to providing proper support to students utilizing a school counselor, social worker, or psychologist. MTTS methods often utilize universal intervention as the primary mechanism for identifying at-risk students, primarily through widespread behavioral testing across the student body. A second tier, narrowed intervention, focuses on a select, smaller unit of students who may be at risk or suspected of behavioral disorders and includes increased monitoring and small-group counseling sessions. Lastly, the final stage of MTSS is an individualized plan of action which may consist of: 

“(a) conducting a functional behavior assessment and developing an individualized behavior plan; (b) direct student-level mental health services provided by a counselor, school psychologist, or school social worker; (c) additional coordinated mental health services with community agencies; or (d) possible identification for special education.” 

However, there can be a substantial delay in getting students access to necessary psychiatric and behavioral resources, negatively impacting mental health outcomes. A study completed by Guerra et al. (2019) found that the presence of a mental health services coordinator was vital to creating an environment that supports mental student health and learning. While there is no accessible data in the state of Alabama correlating improved health outcomes with mental health service coordinators, broad-scale investigations have shown a substantial impact on overall mental health outcomes across districts. The legislation would ensure that coordinators employed in every school district help streamline the processes to get students the help they need. 

Next Steps 

The Alabama Legislative Session is currently underway and will continue for several months. SB306 is presently being discussed in committee and has not yet gone to a vote. If you want to make your voice heard on this or future legislation, click here to identify your elected officials. 

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

Stay Informed 

Want to learn more? Several state agencies are dedicated to mental health resources in the state, such as the Alabama Department of Mental Health and its subsidiaries, the National Alliance on Mental Health, and the Youth Services Institute. 

Additionally, check out these previous publications that the Lister Hill Center has released about mental health services in Alabama: 

Policy Review: Analyzing Alabama’s Efforts to Improve Mental Health

Policy Review: Medicaid Expansion’s Impact on Mental Health

Policy Review: Student Mental Health at UAB

Policy Watch: The Establishment of the Alabama Voluntary Firearm Do-Not-Sell Database

March 22, 2022 | Kimberly Randall, Lister Hill Center Program Coordinator

 

Background 

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

Alabama is one of the most lenient states in the country regarding gun laws. No additional background checks, evaluations, waiting periods, or training are required to purchase a firearm. While there are stricter measures for individuals applying for a concealed carry permit, where applicants may be denied a permit if they are a registered sex offender or have previously been declared mentally unstable in a court of law, these restrictions are generally at the discretion of the issuing county. 

Recent legislation (HB272) that was signed into law last month lifted additional restrictions for owning and carrying a firearm. Under the new legislation, a gun owner is able to have a weapon in a vehicle without a permit, and the bill revised the legal presumption that carrying a firearm is “prima facie” evidence or the intention to commit a crime of violence.

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

Legislation 

HB462, sponsored by Reps. Rafferty (D-Birmingham) and Farley (R-McCalla) is a bipartisan bill calling for the establishment of a database operated by the Alabama Department of Mental Health for individuals to volunteer their own names onto a Do-Not-Sell list. This would restrict an individual’s ability to purchase or possess a firearm once their name was added to the list and creates criminal penalties for violations. The bill also provides a pathway for individuals to remove their name once it has been added. The purpose of this list is to restrict access to firearms to individuals “when there is a fear that he or she may become a risk to himself or herself or others.”

With a start date of June 1, 2023, the ADMH is tasked with developing the searchable database, along with creating and distributing a registration form for applicants. Individuals wishing to add their names to their name to the Do-Not-Sell List may do so in the following ways: 

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

The bill also lays out additional actions to implement an online portal in 2024, with particular consideration to protecting the identity of applicants and preventing program misuse through fraudulent applications. 

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

Impact 

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

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

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

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

Next Steps 

Downtown Birmingham Want to know how gun violence is impacting Birmingham? Katie White, a former Lister Hill Center Intern, compiled research on the history, policy, and impact of firearms in the city.                                                                                                                   Read her full report here. 

HB462 is currently in discussion in the Alabama House of Representatives, having been read on the floor and placed on the calendar for formal debate. If you want to make your voice heard on this or future legislation, click here to identify your elected officials. 

DDon’tknow what to say? Check out this guide from the American Civil Liberties Union on drafting a letter to your government officials. 

Learn More 

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

Gifford Law Center to Prevent Gun Violence 

APHA Gun Violence Fact Sheet 

EFSGV Public Health Approach to Gun Violence 

 

Policy Watch: Alabama Establishes Grant Program for Public Schools to Provide Feminine Hygeine Products to Students

April 6, 2022 | Kimberly Randall, Lister Hill Center Staff

Female student in bathroom

Background 

The purchase of menstruation products has historically caused financial hardship to a large percentage of the population, particularly individuals and families below the poverty line. In Alabama, feminine hygiene products are not eligible to be covered under SNAP or WIC. Last year, Illinois became the first state to lift this restriction to allow the purchase of tampons and menstrual pads using SNAP benefits; however, no such legislation has been proposed in Alabama. 

Currently, only five states require or provide funds for public schools to offer menstrual products at no cost to students, while 37 states have pending legislation to do so. Legislation in Alabama was proposed in 2020 to obtain funding for period products in schools that passed the House of Representatives but stalled in the Senate. 

Bill 

HB50, sponsored by Representative Rolanda Hollis (D-Birmingham), creates a grant program beginning in the 2022-23 school year for schools to apply for funding to purchase feminine hygiene products for students. Eligible schools must receive Title 1 funding and house students in grades 5-12. Funds will be reimbursed to schools that apply for the program and purchase supplies for students, who will be able to receive the products from a female counselor, teacher, or nurse in their schools. The bill has allocated $200,000 for the first year. The State Department of Education will administer the program.

Impact 

According to the Alliance for Period Supplies, a non-profit started by feminine hygiene brand Kotex, 1 in 5 women and girls between the ages of 11 and 44 live below the poverty line in Alabama. Along with 29 other states, Alabama taxes period products at a sales tax rate of up to 11%. According to a study completed at St. Louis University, two-thirds of women reported an inability to afford period products in the past year. At the same time, 21% of respondents stated that they faced financial hardship concerning period products every month. 

Lack of access to period products can impact the education of students. In a national survey, 1 in 4 students reported skipping class or leaving school early due to lack of access to period products, often due to financial difficulties. Individuals often resort to paper towels, toilet paper, or rags when proper menstruation products are unavailable. According to the University of Michigan, “when menstruators resort to unhygienic alternatives, they are vulnerable to harmful physical and mental outcomes [and are at a higher risk for] urogenital infections, such as urinary tract infections and bacterial vaginosis.” Additionally, the emotional toll caused by a lack of access to proper hygiene products can lead to depression, anxiety, and overall elevated distress. Providing menstrual products would help alleviate students’ mental and financial across the state. 

Next Steps 

HB50 passed unanimously in both the House of Representatives and the Senate on April 5, 2022, and now advances to Governor Kay Ivey’s desk to be signed into law. If you want to make your voice heard on this or future legislation, click here to identify your elected officials. 

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

Learn More 

Want to learn more on this issue? Women in Training is a non-profit organization located in Montgomery, Alabama, dedicated to providing menstruation education and period products to underserved women, girls, and nonbinary youth in packages coined WITKITS. Started in 2019 by twin sisters Brooke and Breanna Bennett, the organization also facilitates programs to help girls break the generational cycle of poverty, including:

  • WIT Leadership Development Circle to develop a select group of high school young women into compassionate and culturally aware global leaders
  • WIT Girls STEAM Initiative to expose girls to careers in Science, Technology, Engineering, Arts, and Mathematics
  • WIT Mentor Program to match high school girls with university students or professional women to guide them through the educational and early career stages