Reviewing Alabama’s Policy Efforts to Improve Mental Health

December 13, 2021 | Anushree Gade, LHC Intern

Mental Hospital

Closed mental health institution in Alabama | Photo courtesy of Getty Images

Mental health has been a growing concern in our state of Alabama over the past decade. However, despite its growing prevalence, mental health has been pushed aside due to funding issues that came with the Great Recession. This had caused three mental health institutions to be closed. Since 1990, at least 10 total mental health institutions have been closed and with the Great Recession, more were closed.

With mental health at the forefront of our concerns, Alabama’s legislature has been attempting to improve access to mental health care and services in order to support mental health in the state of Alabama. In February 2021, HB 284 was passed, which allows for law enforcement to take individuals into custody if that individual is capable of inflicting harm to themselves or others. Law enforcement will escort them to the care facilities and will have them in custody for 72 hours. There were concerns about the bill regarding the 72 hour hold as well as detaining children. As the bill progressed, changes were made to address these concerns and the bill would not apply to children under 14.

Additionally, another bill was passed where a mental health service coordinator was required for each school district. As of October 2020, 102 Alabama school districts had a mental health service coordinator. These coordinators ensure that students are receiving counseling and other mental health services they are in need of. There is an increasing number of students who are suffering from mental health problems and are in need of proper care. This bill aids, somewhat, with improving mental health for school children.

Another one of Alabama’s growing mental health concerns comes with the increased rates of incarcerated individuals developing mental health issues such as depression and anxiety. Incarcerated individuals are almost 6 times more likely to develop such conditions and jails spend a large sum of money to address this. Rep. Anthony Daniels has been encouraging Alabama counties to adopt the Stepping Up Initiative, which aims to reduce the prevalence of mental health in jails. Currently, 26 counties are involved in the Stepping Up Initiative, including Jefferson County, Mobile County, and Madison County.

As mentioned previously, several mental health institutions were shut down due to a lack of funding. Senator Garlan Gudger proposed a resolution for implementing crisis diversion centers in the state in order to provide facilities where people can go to seek mental health care. This was enacted in May 2020 as Act 2020-86. Medicaid expansion was also suggested as an option to address mental health in the state; however, Alabama is not anticipated to expand Medicaid under the Affordable Care Act. For more information on the impact of Medicaid Expansion on Mental Health, be sure to read this article.

Policy Watch: Top Public Health Issues in the 2022 Alabama Legislative Session

February 7, 2022 | Kimberly Randall, LHC Program Coordinator

Montgomery Capital Sign

Montgomery CapitalPhoto Courtesy of Getty Images

Legislatures have spoken about various agendas, and points of interest as the Alabama House of Representatives and Senate reconvene for the official 2022 session. The Alabama House Republican Caucus has dubbed its plan “Standing Tall for Alabama” and includes legislation banning Critical Race Theory, allowing concealed weapons to be carried without a permit, and increasing technology access to rural areas of the state. Meanwhile, state democratic lawmakers have declared that social issues such as ​​reducing or eliminating grocery sales tax, expanding Medicaid, and prison reform to be their top priorities. Here is a look at the leading public health issues expected to come up for debate over the next few months and the corresponding bills filed in the Alabama legislative directory. 


Infrastructure packages have been proposed at nearly every level of government over the last year. H.R.3684 – the Infrastructure Investment and Jobs Act passed through the US Congress in November, authorizing $65 billion to improve passenger railways, rebuild or repair roads and bridges, upgrade airports and improve public transportation in various metro areas across the country. Alabama seems to be following in the trend, as HB1 advocates the use of $225,000,000 to “improve access to clean water to the citizens of Alabama through investments in water and sewer infrastructure projects.”  

The bill allocates: 

  • Up to $120,000,000 in water and sewer systems grants for emergency or high need projects previously identified for participation in the Clean Water State Revolving Fund or the Drinking Water State Revolving Fund. 
  • Up to $100,000,000 in matching grants to public water and sewer systems for water or sewer infrastructure projects. 
  • Up to $5,000,000 provided as grants to install clustered decentralized wastewater system demonstrations utilizations utilizing a collection system known as Septic Tank Effluent Pump (STEP) or other demonstration systems in the Alabama Black Belt areas of low population density, rural poverty, and/or soils with poor perc characteristics, where there is a finding of discharge of raw sewage onto the ground due to the utilization of straight pipes, failing septic systems, or similar circumstances. 

In addition to the improvements to water and sewer systems, the bill also allocates $85 million for statewide improvements to broadband internet access, particularly in rural communities. The Federal Communications Commission found that while broadband service is accessible to roughly 75% of the state’s population, some rural areas, such as Greene County, had fewer than 2% of residents subscribed to the service. According to, high-speed internet access in rural communities is vital to economic growth and development in these areas. Additionally, as more services such as telehealth and online pharmacies become more prevalent, broadband internet can impact the healthcare of rural citizens.

Gender-Affirming Medical Treatment 

In 2021, the Alabama Senate passed SB10, also called the Vulnerable Child Compassion and Protection Act, which made the administration of gender-affirming medical treatment a felony in Alabama. At the time, the Southern Poverty Law Center released a statement in opposition to the bill: 

“We are disappointed that, despite reservations expressed by committee members, House Bill 1 is moving forward, particularly after the heart-wrenching testimony during last week’s public hearing by Sgt. David Fuller. This legislation disregards the medical needs of transgender children and the hard choices that their families make in their best interest. It would criminalize the very doctors that so many families turn to in their times of need. The last place for governmental overreach is at the bridge of personal medical decisions and the advice of trained professionals.”

While SB10-2021 ultimately never went to a vote in the house, failing, similar legislation has been proposed this year as HB150 was filed by Representative Wes Allen and SB5 was filed by Senator Shelnutt. 

Did you know: The Lister Hill Center published a testimonial from a UAB student on SB10. Read it here

The bill works to “prohibit the performance of a medical procedure or the prescription or issuance of medication, upon or to a minor child, that is intended to alter the appearance of the minor child’s gender or delay puberty … [and] establish criminal penalties for violations.” 

Prison Reform

Following a special session in October 2021, critical pieces of legislation were passed to address prison reform. Overcrowding, a significant contributor to the spread of COVID-19 in prison systems, inspired a bill that funded the construction of new prison facilities. Additionally, legislation was passed that retroactively applied a mandated probationary period to individuals sentenced before 2015. However, in the 2022 general session, SB87 has been filed in the general session, which looks to roll back some of the granted probation initiatives. 

The legislation reads: “Under existing law, certain prisoners in the physical custody of the Department of Corrections are eligible for correctional incentive time. This bill would provide that any person who enters into a plea agreement would not be eligible for correctional incentive time.” 

The United States legal system has come underfire in recent years for a trend referred to as “coercive plea bargaining,” where prosecutors can use a wide variety of techniques to convince defendants to accept a guilty plea rather than going to trial. According to a report by the Pew Research Center, over 90% of convictions at the state level come from a plea rather than a jury, even though trial by jury is a constitutionally protected right. While it has not been passed, SB87 could remove the protections granted in the special session last year related to the mandated probationary period to those who plead guilty, a large percentage of current inmates in the Alabama Department of Corrections. 

HB28 looks to approach prison reform from a different angle. Pre-filed by Representatives Hollis and Hall, the bill offers protections for women who are pregnant or up to six weeks postpartum who are incarcerated. The legislation reads: 

“This bill would provide for prohibited practices relating to a pregnant female inmate or a female inmate who is in the immediate postpartum period. This bill would also specifically prohibit certain actions relating to strip searches, restraints, examinations, labor and delivery, solitary confinement, and transfer.” 

Specifically, the bill details specific instances in which pregnant or postpartum women would or would not be restrained through the use of wrist cuffs or placed in solitary confinement. The ACLU has declared that ending the shackling of pregnant inmates is a priority in the coming year. The United States is the only remaining industrialized nation to partake in this practice due to the abundance of evidence pointing to the mental and physical health implications to both the mother and child. 

Health Insurance Reform

Healthcare and insurance reform have been a growing state and national politics trend. The Department of Health and Human Services enacted new federal guidelines on “surprise” hospital bills effective January 1, 2022. The new rules work to shield Americans from unexpected bills from an out-of-network provider, out-of-network facility, or out-of-network air ambulance provider. However, legislation has been proposed at the state level to help patients receive the proper medical treatment approvals from their insurance providers. SB27, proposed by Senator Butler, enacts a timeline for insurance providers to approve or deny a request for prescription drug coverage. The legislation reads:

“This bill would require a health insurer to communicate to a physician or other health care professional with authority to prescribe drugs, within three business days of receiving a request for insurance coverage of a prescription drug benefit, that the request is approved, denied, or requires supplemental documentation. This bill would also require a health insurer to communicate to a physician or other health care professional with authority to prescribe drugs, regarding the approval or denial of the request, within three business days of receiving sufficient supplemental documentation.” 

This legislation will work to streamline the authorization process in Alabama, hopefully increasing the speed at which patients receive their medications. According to a report by HPI, 66% of first-time prescriptions are rejected at pharmacies due to required authorizations, causing a bureaucratic battle for patients who may be waiting for weeks. Only 29% of patients end up with their initially prescribed medication when authorizations are required. 

Policy Watch: Alabama Prison Expansion and the Subsequent Impact on Public Health

October 4, 2021, by Kimberly Tsoukalas, LHC Program Coordinator


The state of Alabama operates the most crowded prison system in the United States, with some facilities operating at 272% capacity. The state also ranks last nationally in the amount of funding allocated per prisoner and has the fifth-highest incarceration rate nationally per capita. The combination of these facts has resulted in several civil, humanitarian, and health crises and subsequent lawsuits against the state, including a class-action lawsuit alleging abuse and inhumane conditions toward female inmates at the Julia Tutwiler Prison for Women, which was later settled by the state. 

To read the investigation report from
the Department of Justice, click here.
In the last few years, the U.S. Department of Justice launched an investigation under the Civil Rights of Institutionalized Persons Act (CRIPA), 42 U.S.C. § 1997. The report determined Alabama prisons to “routinely violate the constitutional rights of prisoners” and failed to provide “adequate, humane conditions of confinement.” Additionally, a federal court ruled that the Alabama Department of Corrections failed to provide adequate mental health resources, suicide prevention, psychotherapy, programming, and out-of-cell time, resulting in a significantly higher rate of suicide and violence.

Former governor Robert Bentley proposed legislation in 2016 and 2017 to build new prison facilities; however, no bills were ultimately passed before Bentley left office. 

Proposed Legislation

Alabama House Bill 4, proposed by Rep. Steve Clouse, allows the Alabama Corrections Institution Finance Authority to issue bonds up to $785 million to “implement a prison modernization plan” that will construct two 4,000-bed men’s facilities and a 1,000-bed women’s facility while closing several smaller correctional facilities in the process. It also provides funding for the renovation and/or improvement of several remaining facilities across the state. Alabama House Bill 5, also proposed by Rep. Steve Clouse, authorizes the use of $400 million from the American Rescue Act (intended to be used for emergency assistance related to the COVID-19 pandemic) to assist in constructing these prisons. Lastly, Alabama House Bill 6 appropriates an additional $135 million from the State General Fund to assist prison construction projects. 


The construction of new prison facilities is expected to have significantly improved medical, mental health, and rehabilitation services. According to Fraser (2009), overcrowding in prisons results in lowered access to health care services, increased gang activity within prisons due to territorial disputes, an increase in individual mental health issues, an increase in violence and racism, higher spread of disease, and greater risk and stress to prison facility staff. 

The rise of the coronavirus pandemic brought about new issues related to overcrowding as COVID infections spread in prisons over three times the rate of the general population. As of October 1, 427,326 inmates across the nation had tested positive for the virus resulting in 2,603 inmate deaths, while 114,275 prison facility staff had tested positive, resulting in 218 staff deaths. While the state of Alabama prioritized inmates and prison staff during the vaccination rollout, only 43% of prisoners have received the vaccine, ranking last in the nation. Diseases like COVID-19 spread rapidly in congregate settings, and prison overcrowding is a serious risk to public health in incarcerated populations. 

Help We Matter

The main point of contention regarding HB4, HB5, and HB6 came from the allocation of funding provided by the American Rescue Act. Representative Terri Sewell (D-AL) released a statement through her office criticizing the allocation of COVID-19 resources.

“I am deeply disturbed to learn that the State of Alabama is considering a plan to use $400 million of COVID-19 aid from the American Rescue Plan to build prisons, especially as COVID-19 rages on in our state! Alabama currently has the highest COVID-19 death rate in the country. To be clear, the current state of the Alabama prison system is abhorrent, but the use of COVID-19 relief funds to pay for decades of our state’s neglect is simply unacceptable.

“COVID-19 relief money should be used for COVID-19 relief. Period.”

It is unclear how or if the appropriation of ARP funds for prisons will impact the state’s response to COVID in the future. 

Next Steps

While the Alabama House of Representatives and Senate have passed the bill, it will now go to Governor Kay Ivey to be signed into law. Ivey has been a strong supporter of the bill and is expected to sign with no objections. If you want to make your voice heard on this or future legislation, click here to identify your elected officials

Stay Informed

Want to learn more about Alabama prison reform? We recommend following these organizations: 

Equal Justice Initiative 

Covid Prison Project 

Prison Policy Initiative 


Policy Watch: Alabama Prison Sentencing Reform – How does long-term incarceration impact health outcomes? 

October 11, 2021 | Kimberly Randall, LHC Program Coordinator

Man behind jail bars

BackgroundAlabama’s Department of Corrections operates the prison system for one of the highest rates of incarceration per capita in the United States, with 938 per 100,000 residents residing in jails, prisons, or other correctional facilities. Additionally, the United States, and subsequently Alabama, use the prison system as a default response to criminal activity with upwards of 70% of convictions resulting in incarceration, many of which are for non-violent offenses. 

The massive number of incarcerated persons has led to overcrowded and underequipped facilities. Last month, the Alabama Legislature passed HB4, HB5, and HB6 which would allocate funds for the construction of new, state-of-the-art prison systems in the state. However, it fails to address the root of the problem of overpopulation – over sentencing. 

In 2015, Alabama signed Code 15-22-26.2 into law, which mandated supervised probation for non-violent offenders: 

Department of Justice Complaint to Gov. Ivey RE: Prison ConditionsTo read HB2 in full, click here.

(1) If the defendant is sentenced to a period of five years or less, he or she shall be released to supervision by the Board of Pardons and Paroles no less than three months and no more than five months prior to the defendant’s release date;

(2) If the defendant is sentenced to a period of more than five years but less than 10 years, he or she shall be released to supervision by the Board of Pardons and Paroles no less than six months and no more than nine months prior to the defendant’s release date; or

(3) If the defendant is sentenced to a period of 10 years or more, he or she shall be released to supervision by the Board of Pardons and Paroles no less than 12 months and no more than 24 months prior to the defendant’s release date.

However, this legislation only applied to individuals who are sentenced after the law went into effect. 

Proposed Legislation

Proposed by Rep. Jim Hill, R-Moody, HB2 retroactively applies the mandated probationary period to individuals who were sentenced before 2015. It maintained the same probationary structure and restrictions, such as not being applicable to child sex offenders. The bill was one of two proposed pieces of legislation from Governor Kay Ivey focusing on prison sentencing reform. 


While this legislation is intended to impact the overcrowding and limited resources of the Alabama prison system, it will have long-term health impacts for inmates, prison staff, and the community. According to researchers at Brown University, prisoner health is a volatile public health issue as correctional facilities often lack the resources to provide adequate healthcare. The majority of inmates will eventually return to their communities, bringing their health conditions with them. 

The longer an inmate spends incarcerated, the greater their chances of disease, mental health issues, and chronic illness. The National Institute of Health lists having poor ventilation, limited opportunities for exercise, high levels of stress, poor sanitation, infestations with bugs and vermin, poor nutrition, tension, noise, lack of privacy, and lack of family support as contributing factors in poor inmate health. 

Additionally, while HB2 works to get inmates out of prison facilities faster, increasing the number of prisoners granted mandated probationary periods decreases recidivism by as much as 30% when compared to end-of-sentence release, or fulfilling the entirety of their sentence in a correctional facility.  According to the Equal Justice Initiative, “thoughtful and expanded parole remains the most effective mechanism for reducing the prison population without undermining public safety.” 

In addition to the retroactive sentencing guidelines, the bill also ensures that inmates will be given a state-issued photo identification card, social security card, and birth certificate upon their release, a key hurdle in obtaining employment for many inmates, along with appropriate clothing and public transportation. 

Many organizations have advocated for prison reforms, including the EJI, over the last decade; however, the bill has received criticism within the state, particularly from Alabama Attorney General Steve Marshall, who stated that law will only affect a few hundred inmates and doesn’t work to address the overall issue of overcrowding. 

Next Steps

Governor Kay Ivey has already signed the legislation into law. It will go into effect on January 31, 2023. If you want to make your voice heard on this or future legislation, click here to identify your elected officials

Stay Informed

Want to learn more about Alabama prison reform? We recommend following these organizations: 

Equal Justice Initiative 

Covid Prison Project