The Need for Medicaid Expansion Economic Instability in Barbour County Alabama

Policy Brief: Economic Instability in Barbour County, Alabama, and the Need for Medicaid Expansion

Executive Summary

The Center for Diseases Control and Prevention (CDC) defines social determinants of health (SDOH) as the conditions in which people are born, live, grow, work, and age (CDC, 2020). The SDOH selected for analysis in Barbour County, Alabama is economic stability, which focuses on the relationship between individuals’ financial resources and their health (CDC, 2020). Communities with affluent financial resources often report better health outcomes than those with inadequate resources. Data collected between 2014 and 2018, however, indicates that poverty is a significant social concern in Barbour, with 30.9 percent of the 24, 600 residents living in poverty (Census Data, 2019). The poverty rates in Barbour exceed the state average of 15.5 percent (Census Data, 2019). The median household income among Barbour residents in 2019 was $34,100, which is significantly lower than the state average of $48,500 (Census Data, 2019). Due to economic instability, a sizeable amount of the county’s residents – 13.5 percent – cannot afford health insurance (Census Data, 2019). This is worrying given the high burden of chronic illness. Alabama, for instance, has the third highest prevalence of diabetes in the US. This policy brief proposes an expansion of Medicaid coverage in the state under the Affordable Care Act (ACA) as a way to increase access to coverage for residents unable to afford private insurance due to low incomes. The proposed policy brings together the county mayor, state governor, and state legislators, who will be engaged mainly through open letters from residents. Through their vast membership, professional organizations such as the ANA could also be petitioned to engage in advocacy and push for such expansion.

Context and Scope

Social Determinant of Health (SDOH) in My Community

The SODH under analysis is economic instability. Poverty is a significant social concern in Barbour County. The rate of poverty in the state is above the state average and a significant proportion of the population lacks health insurance. Lack of health insurance is a worrying factor in Barbour given the high prevalence of chronic illness in Alabama.

Data to Support the SDOH

Data collected between 2018 and 19 shows that 30.9 percent of the 24, 600 residents of Barbour live in poverty (Census Data, 2019). The poverty rates in Barbour exceed the state average of 15.5 percent (Census Data, 2019). The median household income among Barbour residents in 2019 was $34,100, which is significantly lower than the state average of $48,500 (Census Data, 2019). The rate of housing instability in 2018-19 is significant, with 16 percent of residents having changed houses over the period (Census Data, 2019). Housing instability in the county is a result of poor housing quality and high housing costs given that the median gross rent is $590 (Census Data, 2019). Due to economic instability, a sizeable amount of the county’s residents – 13.5 percent – cannot afford health insurance (Census Data, 2019). This is worrying given the high burden of chronic illness. Alabama, for instance, has the third highest prevalence of diabetes in the US.

Three Characteristics of Target Population Affected by SDOH

i) The population in Barbour comprises mainly of whites and African-Americans, who make up 97 percent of the population

ii) 20 percent of the population is aged 18 and below, while 19.7 percent is aged 65 and over

iii) 27 percent of the population in Barbour did not complete high school, and only 12 percent have a Bachelor’s degree or higher

Identification of Appropriate Policy Maker(s) or Legislator(s)

Important policymakers in the implementation of the proposed policy include the Barbour County mayor, the Alabama state governor, and Democratic lawmakers who have made repeated attempts to have the state expand its Medicaid coverage. The proposed policy allows the state to expand Medicaid coverage, with the federal government covering at least 90 percent of the cost. To create and incentive for states such as Alabama to expand coverage, however, lawmakers at the federal level could allow states to access the temporary 100 percent federal math that was available during the first three years of Medicaid expansion under the ACA (2014 to 2016).

Why the SDOH Requires the Policy Maker’s Attention

The SDOH requires the policymaker’s attention because it will help ease the economic burden for chronically-ill patients. For instance, Alabama currently ranks third in the US in the prevalence of diabetes. Chronically-ill patients with insurance coverage have access to better care and medication than those without such coverage. Reducing the number of uninsured residents by expanding Medicaid coverage will help to ease the burden of chronic illness on patients and their families, and reduce the associated morbidity.

Current Policy or the Effect of Not Having a Current Policy

Currently, Alabama is considered one of the states with the most stringent Medicaid eligibility guidelines. Non-elderly, non-disabled adults are not eligible for Medicaid unless they have minor children. Even so, parents of minor children are only eligible if their income does not exceed 18 percent of the federal poverty level (approximately $325 per month). As such, a single mother earning a monthly income of $500 and raising two children will not be eligible for Medicaid in Alabama

Ethical Implications of Current Policy or Absence of Existing Policy

The current policy locks out hundreds of poor residents in Barbour and elsewhere across the state. This leaves such populations vulnerable and at higher risks of death when faced with illness, particularly chronic illnesses.

Demographics Table

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Statistics/facts

Summary of statistics/facts

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Demographic Information

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High poverty rates, above the national average

High rates of housing instability

30.9 percent of the 24, 600 residents of Barbour live in poverty (Census Data, 2019). The poverty rates in Barbour exceed the state average of 15.5 percent. The median household income among Barbour residents in 2019 was $34,100

16 percent of residents changed houses between 2018 and 19. Housing instability in the county is largely a result of poor housing quality and high housing costs given that the median gross rent is $590

Census Data (2020). Quick Facts: Barbour County, Alabama.

Census Data (2020). Quick Facts: Barbour County, Alabama.

A sizeable amount of the population lacks a high school education

27 percent of the population did not compete high school, and only 12 percent hold a Bachelor’s degree or higher

Census Data (2020). Quick Facts: Barbour County, Alabama.

Risk Factors

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A sizeable amount of the population is at a high risk of chronic illness

19.7 percent of the population is aged 65 and over and predisposed to chronic illness. Alabama has the third highest prevalence of chronic illness in the US

Census Data (2020). Quick Facts: Barbour County, Alabama.

A sizeable amount of the population, particularly in rural areas cannot afford health coverage

13.5 percent – cannot afford health insurance, which is worrying given the high burden of chronic illness in the state.

Census Data (2020). Quick Facts: Barbour County, Alabama.

Trends in SDOH Over Recent Year(s)

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Poverty levels among residents have fallen consistently, as evidenced by the increasing levels of household median income in the county

The median income among Barbour residents in 2000 was $26,600 as compared to $34,100 in 2019, representing an improvement of 21 percent. Despite the improvement, poverty levels in Barbour are still above the state and national average

Census Data (2020). Quick Facts: Barbour County, Alabama.

Federal Reserve Bank of St. Louis (2019). Estimate of Median Household Income for Barbour County.

The number of residents with a Bachelor’s degree and above has been on a declining trend

In 2012, 14.5 percent of the population had a Bachelor’s degree or higher, as compared to 13.4 percent in 2013, and 12 in 2019. The decline could be attributed to the fact that most graduates opt to move out of the rural county to pursue job opportunities in more urban counties within the state.

Federal Reserve Bank of St. Louis (2019). Bachelor’s degree or higher in Barbour County, AL.

Policy Proposal and Implementation Plan

Two Policy Alternatives to Address the SDOH

i) Expand Medicaid coverage in the state to aid more of those unable to avoid private insurance in Barbour County. Medicaid expansion is provided under the ACA and is aimed at increasing access to government insurance for the most vulnerable.

ii) Improve the affordability of marketplace coverage. This could take several forms including addressing enrolment barriers, and increasing subsidies thus reducing the share of income that individuals have to pay for marketplace coverage

Preferred Policy

The preferred policy is to expand Medicaid coverage in the state. The ripple effect will be a reduction in the number of the uninsured poor in the counties, including Barbour.

How the Desired Results of the New Policy will Optimize Health in Community

Estimates from Health Insurance.org indicate that in its current form, Alabama Medicaid covers 899,824 residents of the state, and that an additional 314,000 would be covered if the state accepted expansion (Health Insurance, 2020). Assuming that the uninsured are equally distributed across the 67 counties in the State, then approximately 4,600 vulnerable poor residents in Barbour County would obtain coverage. This would reduce the problem of lack of insurance coverage among poor residents in the county, making it easier for them to enhance their own health outcomes and those of their dependent children.

Financial Costs and Benefits of Proposed Policy Alternative

A report by the University of Alabama estimated that the state’s portion of the Medicaid expansion costs would be approximately $222 million a year, as states cover 10 percent of the cost (Health Insurance, 2020). On the other hand, over 300,000 poor people within the state, (including 4,600 in Barbour County) would be able to obtain coverage, which would enhance their quality of life.

Two Ethical Implications of Proposed Policy Alternative

Medicaid expansion may improve access to healthcare for the poor residents of Barbour who cannot afford private coverage. However, Medicaid participants are required to obtain coverage within their state of residence, and the amount of coverage varies significantly when one obtains healthcare services outside their state (Riley & Moy, 2012). The ethical implication is that the financial pressure to refer patients to their home states places an undue geographical burden on patients and could lead to suboptimal care (Riley & Moy, 2012). This is particularly the case if one requires specialized care, for instance, cancer care in a specialized program outside the state. The second ethical implication is that unscrupulous residents in the high and middle income categories may take advantage of Medicaid expansion to drop their private insurance plans and take up Medicaid, which is more cost-friendly.

Barriers to Implementation of Proposed Policy Alternative

Geographical limitations to coverage – generally, Medicaid coverage is restricted to healthcare organizations within one’s state of residence (Riley & Moy, 2012). This could be limiting, especially when one requires specialty care outside their state. The second barrier is that Medicaid expansion is, to a large extent, driven by the politics of the day. For instance, Democrat lawmakers have demonstrated more support for such expansion while Republicans have been more reserved, yet Alabama is a Republican state.

Communication Methods used to Introduce the Proposed Policy

Several communication methods will be used to introduce the proposed policy. First, presentations supporting the same could be made in conferences organized by professional organization such as the American Nurses Association. Such groups could then engage in advocacy to encourage the state governor and lawmakers in the state to approve the Medicaid expansion plans. Additionally, with the relatively high literacy rates, uninsured residents could be encouraged to send open letters to the governor and state legislators to push them to consider Medicaid expansion.