Category: Policy Watch

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

February 22, 2025 | Kevin Joseph, LHC Student Assistant

Background 

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

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

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

 

Proposed Legislation 

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

Impact 

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

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

Next Steps 

SB27 is currently pending in Senate Healthcare Committee in the 2025 Regular Session If you want to make your voice heard on this or future legislation, click here to identify your elected officials. 

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

 

References 

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

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

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

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

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

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

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

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

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

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

Policy Watch: Establishing a taxation system for heated tobacco sticks in Alabama

by Kevin Joseph, Lister Hill Center Intern

Background

Designed and sold by Philip Morris International (PMI), IQOS is a line of heated tobacco products currently sold in over 60 countries worldwide and a few states in the USA (Tobacco Prevention and Cessation). Per the name, these devices utilize a heated blade or induction system in order to heat tobacco sticks (sold separately from device) rather than burn and combust tobacco, as done in a regular cigarette. According to PMI, the produced aerosol is a healthier alternative to smoking that emits 95 percent less of harmful chemicals released in cigarette combustion; however, PMI reiterates that products are not risk-free or that the reduction in released aerosols corresponds to a 95 percent reduction in risk (Phillip Morris International).

According to data from the Behavioral Risk Factor Surveillance System (BRFSS), an estimated 15.6 percent of Alabamian adults are current smokers as of 2022 (CDC). Among those currently smoking, the American Lung Association notes that an estimated 63 percent have attempted to quit smoking as of 2022, emphasizing the prevalence of unsuccessful cessation attempts (American Lung Association). The American Lung Association notes that cigarette smoke contains over 60 carcinogenic chemicals that are related to lung cancer and subsequent mortality, as well as related chemicals that cause chronic obstructive pulmonary disease (COPD) (American Lung Association). Accordingly, PMI markets the IQOS products as a safer alternative to cigarette smoking (Philip Morris International).

Although the FDA officially voted to support PMI’s claim that IQOS products reduce exposure to harmful cigarette smoke chemicals in 2018, they did not agree to support claims that it was related to a reduction in disease or disease risk. Some critics claimed that studies that PMI had conducted do not sufficiency support the supposed reduced health impact of IQOS products compared to cigarettes; however, some support the IQOS product as a harm reduction device (NPR). However, although IQOS is most intended to be a product for current cigarette smokers, evidence shows that non-smokers in other countries have began to use IQOS products (Tobacco Prevention and Cessation).

The IQOS line was planned to have an expansion in the United States in 2024, which has been delayed (Tobacco Insider). Nonetheless, legislation has been proposed to implement a tax on these heated tobacco sticks, similarly to current taxes on cigarettes and other existing tobacco products.

 

Proposed Legislation

HB438 of 2024 was introduced by Representative Hollis (D-Birmingham) to amend Alabama tax code to implement a tax for heated tobacco products of 17 cents per single-use consumable unit (tobacco stick) from October 1st, 2024, to September 30th, 2027. For the following two years, the tax would be reduced to 8.5 cents, then to half a cent in 2029. The bill explicitly states that the tax is meant to serve as a tax to the consumer as an additional cost after the sale cost of the heated tobacco product itself. Furthermore, the bill establishes a county-level tax on the heat stick product that would equal half the state tax on cigarette at any given time, if the county already has an existing tax. If a municipality has an existing cigarette tax, the bill allows for the municipality to levy a tax on heated tobacco products of half the existing cigarette tax.

Compared to cigarettes, which have a tax of 3.375 cents per cigarette in Alabama, the initial proposed tax on heat sticks is higher. For one of the tobacco sticks made for an IQOS product, the California Department of Public Health has noted that PMI states that “the experience with IQOS is similar to the one of cigarettes” with a similar number of “puffs” per heat stick (California Department of Public Health). Thus, based on a “puffs per dollar” measure, the heat stick product is more expensive; furthermore, the IQOS device is a separate purchase of around $80-130 USD (Tobacco Prevention and Cessation).

 

Impact

Although this bill would not per se authorize IQOS and heated tobacco stick products to be sold in Alabama (a regulatory power which lies with the federal Food & Drug Administration), it may open the door to sales going forward.

Heated tobacco products are not prevalent in the United States but are more established in other countries, providing a potential comparison. In both Japan and South Korea, the American Lung Association notes with coauthoring organizations also in opposition to heated tobacco products that, rather than transitioning from cigarette use to heated tobacco product use, relatively more users are using both at the same time (American Lung Association). Considering this along with the FDA’s lack of approval for reduced risk claims, some have questioned PMI’s asserted population health benefits through harm reduction of heated tobacco products.

Concerns also have arisen regarding who the heated tobacco products will be marketed towards. The American Lung Association additionally noted that menthol flavoring utilized in IQOS products often is more palatable to youth who may have never smoked a cigarette before, increasing the risk of nicotine dependence even among non-smokers (American Lung Association).

 

Next Steps

HB438 was indefinitely postponed after review in the 2024 Regular Session by the Ways and Means General Fund House Committee. However, it is expected to be reintroduced in the 2025 Regular Session. If you want to make your voice heard on this or future legislation, click here to identify your elected officials.

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

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

May 31, 2024 | Kimberly Randall 

Background 

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

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

Proposed legislation 

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

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

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

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

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

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

Impact 

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

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

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

Next Steps 

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

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

Policy Watch: Volunteer Licenses for Nonresident Dentists Practicing in Alabama

May 16, 2024 | Kimberly Randall

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

Background 

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

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

Proposed Legislation 

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

The bill goes into effect on October 1, 2024.

Potential Impact 

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

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

Learn More 

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

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 2018 by Senator Pittman, and again in 2022 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, LHC Student Intern & Kimberly Randall, LHC Program Manager

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 Representative 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.