Rural Health – Lister Hill Center for Health Policy

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

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

Introduction

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

Trends Affecting Access to Dental Care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Facing the Facts, Addressing the Problem

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

Actions Taken

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

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

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

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

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

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

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

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

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

Policy Watch: Volunteer Licenses for Nonresident Dentists Practicing in Alabama

May 16, 2024 | Kimberly Randall

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

Background

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

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

Proposed Legislation

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

The bill goes into effect on October 1, 2024.

Potential Impact

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

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

Learn More

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

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

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

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

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

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

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

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

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

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

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

Learn More

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

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

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

March 14, 2023 | Kimberly Randall, LHC Staff

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

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

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

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

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

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

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

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

Other facts of note:

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

References

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

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

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

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

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

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

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

Policy Watch: The Impact of Eliminating Grocery Sales Tax

February 14, 2021 | Kimberly Randall, LHC Program Coordinator

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.

Holes in the safety net of healthcare

June 8, 2020, by Katherine Hymel Downs, RN, MPH

Many of us were forced to delay routine healthcare in one way or another due to COVID-19, whether a dental cleaning or counseling session. In fact, according to researchers at Harvard University, visits at ambulatory health clinics dropped by 60% by late April and were finally seeing a rebound as of mid-May. Now, we are left to investigate the continuing impact. Tangible metrics include the effects of economic loss incurred by the facilities themselves, including staffing furloughs and office closures. But how do we quantify losses in health of patients—losses from delay of care? What about those patients that now find themselves on the outskirts of our healthcare system due to unemployment and loss of benefits? For patients who rely on safety net clinics (rural health clinics, federally qualified health centers, free and charitable clinics), where can they turn when those already strained facilities are forced to close?

In early April, the Health Management Association predicted that Medicaid enrollment could increase from 71 million to the upwards of 94 million due to COVID-19 and related legislation. The process of Medicaid enrollment can be done by phone, without need of internet access. However, patients often require assistance selecting a plan accepted by their healthcare provider or gathering the necessary documentation. In the wake of social distancing measures where many public libraries and even social services buildings are closed to the public, where are people to turn? How many patients even realize they are now eligible to enroll, unless they were advised by a care coordination team at the end of a hospital stay? States are no longer held to the same timeliness standards amidst the pandemic, with limited staff and modified workflows.

Part of the Families First Coronavirus Response Act (FFCRA) did address this prediction of increased enrollment from a financial standpoint. States could benefit from a 6.2% increase in federal match rate (FMAP) (an estimated $36 billion) if they met certain criteria, including the assumption of cost for testing and treatment of the virus. But how exactly does this money reach an individual clinic that serves Medicaid patients—many of whom may not be coming in the door due to COVID-19? Clinics were forced to quickly adopt telehealth services, defined by Medicaid as including both a video and audio component for reimbursement. This presents the following barriers to patients: adequate technology, internet service, and digital literacy. Hybrid clinics that serve a variety of patients—Medicare, Medicaid and uninsured—rely on reimbursements to reserve other funding sources for uninsured patients and general overhead (payroll and benefits, PPE for staff, translation services). Now they are dependent on other relief measures such as the Paycheck Protection Program and outside grants to keep doors open and meet a growing need for care.

As a healthcare provider at a rural health clinic, I admit I do not have all the answers to policy changes. However, the following action items are worth investigating:

Medicaid expansion for states who have not already done so
Modify regulations to remove barriers from the Medicaid application process
Consistent and clear guidelines on reimbursement for telemedicine
Provision of cell phones with video technology by managed care organizations (MCOs) to ensure patients have access to telemedicine

Ag-Gag: Big Agriculture fighting back

October 11, 2019 by Sara Harper, LHC Student Intern

Three years ago, I got obsessed with where meat comes from. Kip Anderson’s exposé “Cowspiracy”had come out a few years prior and, while sensationalized, it gave me a passion for something that enveloped environment, policy, and justice. Since then, I’ve written several academic pieces on the factory farming industry and adjusted my purchasing habits away from supporting industrialized farms. Do I sound like PETA yet? Throughout my research I’ve consistently addressed the issue from a human and environmental health point of view, with animal rights being a positive outcome of the latter. My reasoning for this is to steer my point away from sensationalizing the animal cruelty involved, in favor of a health-based approach to this problematic industry.

Quick background: Factory farming, or intensive livestock farming, is a sector of the Agriculture industry that relies on overcrowding animals and assembly-line style production in order to maximize meat output. These facilities have large negative impacts on the surrounding environment including: Water source contamination, greenhouse gas production, and deforestation, and so many other issues.

Okay now you’re caught up. These things are bad, right? So, who’s fighting the good fight? Well…

In the past two decades, “Big Ag” has proposed laws in states across the country that criminalize the efforts of whistleblowers in the industry. These laws have been coined “Ag-Gags” because, by nature, they silence those who intend to call out the harm done by intensive livestock farms. Alabama passed their own Ag-Gag bill in 2002, which makes it a felony offense to obtain access to a property “by false pretenses” and to possess records obtained by deception. This law was directly related to an increase in environmental advocates performing undercover investigations on factory farms under the pretense of employment.

So why is this important? The agricultural industry in America is a high grossing source of income and production but is, by all accounts, necessary. However, powerful, money intensive industries like factory farming have little government oversight when it comes to their environmental health impacts. These production facilities are known to under-report incidents like waste spills and romanticize the idea of their farms to consumers. In this industry, whistle blowers in the media and advocacy groups are the only people holding these companies accountable for their actions. Ag-Gag bills seek to make it virtually impossible to report on factory farms in order to reduce the amount of incriminating information leaking out of their facilities.

I know what you’re thinking… “What can I do?” As consumers, it’s up to us to consume responsibly. Using your purchasing power to opt for humanely farmed meat shows that you do not condone the actions of this negligent polluting industry. All in all, the future for defeating Ag-Gags looks bright. As of June 2019, 3 states have declared Ag-Gag policies unconstitutional, ruling that the laws infringe upon freedom of speech and freedom of the press. Seventeen other states have blocked such bills from ever being passed.

Are there Dental Access Issues in Alabama?

November 4, 2019 by Conan Davis, DMD MPH

Do we have any issues to be concerned about regarding access to dental care in Alabama? Everyone has a dentist who can see them on short notice if they need, right? Wrong.

If you live in Birmingham or in one of the larger cities in Alabama, you might not have a problem being seen on short notice – particularly if you have dental insurance or out of pocket cash for treatment, but if you live in smaller towns or rural areas in our state, you might not be so lucky.

Alabama currently has only one county without a dentist: Greene County. However, about 80 percent of all the 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 between one and three dentists. This translates to about one dentist for every 1800 people in the urban areas, versus one dentist for every 4100 people in the non-urban areas – a big difference.

This is the subject of a paper Dr. Stuart Lockwood and I are developing and hope to publish with the Lister Hill Center for al dentists.png Health Policy in the next few months. Dr. Lockwood and I are both former State Dental Directors with the Alabama Department of Public Health. We both have examined the teeth of thousands of children in Alabama to assess the state of dental decay and to make referrals to local dentists. We have seen many with excellent dental care and many without any need for treatment. However, we have also seen the evidence of neglected dental needs in many children. An even larger concern we have seen is the lack of access afforded to low-income adults with no dental insurance and no public dental coverage in Alabama. We will cover that connected subject perhaps in another post.

Dr. Lockwood and I have been engaged in studying the underlying issues for our widening gap between urban and non-urban areas concerning dental care access for many years. We developed a partnership between UAB School of Dentistry and the Alabama Dental Association to develop a strategy to correct the disparities we found in the more rural areas of the state.

Through this partnership, we wrote and were awarded a grant to do several things in this area. One was to take the available data on dental practices in Alabama and with the help of the UAB School of Public Health develop a GIS map detailing where all dentists’ practices are located in Alabama. The grant also allowed for rotation experiences in rural areas for dental students as a way to allow them to see dental practice life in these areas. We also provided significant financial awards to a few graduating dentists who agreed to practice in a rural area and also agreed to see a certain percentage of Medicaid patients for a specified number of years. Graduating dental students can have very significant school debt, and this was designed to assist them with that debt and help them establish a practice. The grants were planned to help “plant” dental offices in nine rural areas needing a dentist. Nine such practices came about through this grant program and they have successfully continued in those areas to this day.

I’ve worked with Dr. Lockwood and the state dental association on language presented to the state legislature and the Governor’s office for consideration of a similar state-based financial incentive program for new dentists willing to locate in a rural area. We hoped this would also encourage young dentists to choose a smaller town or rural area in which to practice. While all our legislators were favorable to the concept, funding has not been significant just yet. We continue pursuing this possibility.

Another issue regarding distribution of dentists involves the current ages of dentists in the rural areas. We will discuss these findings in some detail in our upcoming paper.

So – to answer the question, “Is it easy to find a dentist to see you on short notice anywhere in Alabama?” – no. However, many of us are engaged about this concern and working towards positive solutions for all Alabamians. We hope to be able to answer my question in the affirmative in the near future!

Conan Davis recently retired from his position as Assistant Dean for Community Collaborations and Public Health at the UAB School of Dentistry. He continues to research the inequities in access to dental care across Alabama.