Alabama insured children
Alabama Arise Organizing Director Presdelane "Pres" Harris is seen with her nephews. They are among Alabama families who want better health insurance coverage for children. Photo courtesy of Alabama Arise

Equal Voice

In Alabama: The Work to Halt Falling Rates of Insured Children

January 14, 2020

By Katherine Webb-Hehn

A report found more than 10,000 children in Alabama lost health insurance in one year, part of a disturbing national trend. Community leaders and parents in the state are working to reverse that fact, given the importance of access to health care for families.

Having a sick or hurt child is one of life’s scariest moments.

When a little one has a stomach bug or a bump on the head, families call on primary care physicians for guidance. But without health insurance, families might not have relationships with doctors. They have to make tough decisions – including whether or not to rely on expensive emergency services – on their own. And those costly medical bills compound burdens for families who are often already struggling against poverty.

In Alabama, health care for children has been a priority for two decades.

Health care for children is “one of the few bragging points that we have in our health care system,” said Jim Carnes, policy director for Alabama Arise, a nonprofit and nonpartisan organization that promotes policies to improve the lives of low-income families in Alabama. “We were the first state in the country to put a state children’s health insurance program in place back in 1997, and ever since, we have been one of the national leaders.”

Public health experts said that ultimately, making sure every child is covered by health insurance is the first step in making Alabama a safer place for families.

Over the past decade, the uninsured rate in Alabama has been halved, coinciding with enrollment periods for the Affordable Care Act’s marketplace.

Since 2016 though, Carnes said the state is seeing a “downward turn” for the most vulnerable. The rates of uninsured children in Alabama are growing, according to a Georgetown University report, which found the number of uninsured children increased from 32,000 in 2016 to 41,000 in 2018.

The decline in coverage is part of an alarming national trend. Between 2016 and 2018, more than 400,000 children in the U.S. have lost insurance, according to the Georgetown report, despite economic growth that ought to lead to children gaining insurance.

The uninsured rate for Alabama children was 3.5 percent in 2018, which is below the national average and the lowest rate in the Southeast. But Alabama, which has an official poverty rate of nearly 17 percent, is one of 13 states seeing a significant decline in insured children.

Alabama Arise is working to make sure the state doesn’t enter what Carnes calls “the danger zone,” where more families lose coverage each year.

A Divide Over Medicaid

The danger of increased rates of uninsured children is more than a public health problem. It’s an economic problem.

“Poverty has long been the primary barrier to health insurance coverage in the U.S.,” said Dr. David Becker, associate professor of public health at the University of Alabama at Birmingham, where he teaches economics and policy. More than 25 percent of Alabama minors live in poverty and are eligible for public insurance coverage but are not enrolled, Becker said.

“Insurance coverage improves quality of care by reducing the risk that children will receive substandard care owing to their [family’s] inability to pay,” Becker said.

Alabama insured children
Families and advocates with Alabama Arise, a community organization based in Montgomery, say health insurance rates for children in the state need to improve. Photo courtesy of Alabama Arise

He added that beyond the health of the child, being uninsured puts a family’s well-being at greater risk overall. And one trip to the emergency room with a child could cost as much as a month’s rent, groceries or utilities.

Dr. Scott Harris, state health officer with the Alabama Department of Public Health, said the state is working to increase the number of children who are insured. The state health department administers the Children Health Insurance Program (CHIP), which once led the nation in coverage for minors.

“Alabama’s CHIP program scaled back outreach efforts several years ago, but is currently developing a new outreach plan,” Harris said.

Alabama Arise is advocating for Medicaid expansion. Currently, two-thirds of Medicaid recipients in the state are children. CHIP provides free coverage for children who qualify for Medicaid with a family income of 146 percent of the poverty level.

The number of families eligible for benefits would increase with Medicaid expansion, but Republicans have resisted, in part because the state would be responsible for 10 percent of the cost. Medicaid already accounts for a significant portion of Alabama’s general-fund expenditures. Recently, Alabama Medicaid requested $715 million for 2020, which is $40 million less than 2019’s budget.

In February, the University of Alabama at Birmingham released a study spearheaded by Becker that estimated Medicaid expansion would generate $2.7 billion annually in new economic activity in the state.

The divide over Medicaid expansion is “purely political,” Carnes said. State Democrats are widely in favor, while Republicans have opposed any expansion. Republican Gov. Kay Ivey has repeatedly said she won’t expand Medicaid but will look into other methods of improving health care access, carrying on a tradition from past administrations. In 2016, the previous governor opposed Medicaid expansion, calling it a “broken system,” despite the recommendation to expand by a task force he created.

But as neighboring states such as Georgia expand Medicaid coverage and “free health care for all” continues to dominate discussions for the 2020 election cycle, some Republican lawmakers are open to discussing expansion in Alabama.

Looking to Solutions

Public health experts said that ultimately, making sure every child is covered by health insurance is the first step in making Alabama a safer place for families.

“There is tremendous value provided by stable health insurance coverage over the life course,” Becker said. “However, insurance coverage alone does not ensure access to appropriate care, and clearly other issues must be addressed to improve child health.”

Alabama Arise is working to find a sponsor in the upcoming legislative session for their proposed policy that addresses more than health care access. The proposal would also eliminate Alabama’s income tax deduction for federal income taxes paid (or FIT), which the organization estimates will bring $800 million into state coffers.

“We believe this annual infusion of revenue would give the state the breathing room to address several major concerns,” Carnes said, “such as paying the 10 percent state share for Medicaid expansion, ending the state sales tax on groceries and strengthening our schools.”


Katherine Webb-Hehn is a freelance multimedia journalist in the South. Her work has appeared in The Bitter Southerner, The Nation, The Progressive, In These Times, The New York Times and Scalawag. She is a 2018 recipient of a Marguerite Casey Foundation Journalism Fellowship. Her work has been honored, awarded or selected by the Institute of Nonprofit News, The New York Times, The Atlantic, Longreads and others. Follow her at @KAWebb_. Equal Voice is Marguerite Casey Foundation’s publication featuring stories of America’s families creating social change. With Equal Voice, we challenge how people think and talk about poverty in America. All original Equal Voice content – articles, photos and videos – can be reproduced for free, as long as proper credit and a link to our homepage are included.

In Alabama: The Work to Halt Falling Rates of Insured Children