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Update on “Medicaid”

Allen Farley



By Rep. Allan Farley

For several reasons, the Alabama Medicaid Agency has recently been the subject of many policy and budget-related conversations.  I want to use this newspaper column to share information I recently received from my friend Jason Isbell.  Jason is Legislative Counsel in the office of Alabama House Speaker Mike Hubbard.

The following document summarizes discussions regarding:

(1) The Supreme Court’s ruling on the Affordable Care Act; (2) the impact of the state’s decision on whether to expand its Medicaid program; and (3) the impact of the September 18th referendum on Medicaid’s budget.

Supreme Court Ruling: Mandatory Expansion and Optional Expansion

In their recent ruling on the Affordable Care Act, the Supreme Court upheld the constitutionality of (1) the provision known as “the individual mandate,” (2) the requirement that each state have its own Health Insurance Exchange, and (3) the requirement that state Medicaid programs include children less than age 19 whose income is less than or equal to 133% of the Federal Poverty Level.

On the other hand, the Court made a fourth provision – expanding Medicaid to include childless adults and parents less than age 65 whose income level is less than or equal to 133% of the Federal Poverty Level – optional rather than mandatory.  There is no deadline by which states must make the decision to exercise this option.  If a state chooses to expand its Medicaid program, the federal government will pay a large percentage of the additional expenses caused by the expansion.  This percentage, however, will decrease as time goes by.

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The Impact of the Expansion Decision

If Alabama chooses to expand its Medicaid program:

Expanding the Medicaid program will result in approximately 351,000 to 455,000 new enrollees being cumulatively added to the Medicaid program between FYs 2014 and 2019.


These new enrollees will, between FYs 2014 and 2019, cost the state an estimated cumulative total of between $470 million and $693 million in state dollars.

Over the same time frame, these new enrollees will also allow the state to receive an estimated cumulative total of between $10.3 billion and $11.4 billion in federal funds.

If Alabama chooses to not expand its Medicaid program:

Even if Medicaid is not expanded, it is estimated that approximately 200,000 new enrollees will be cumulatively added to the Medicaid program between FYs 2014 and 2019.  This estimate is based on the average annual growth rate in Medicaid enrollees over the last ten years (2.34% annually).

This estimate assumes no changes to Medicaid eligibility criteria or changes to Medicaid programs.  The estimate also predicts that the economic recession will not worsen.  Most importantly, however, this estimate does not include individuals already eligible for, but not enrolled in, Medicaid who will likely be routed to the program through a health insurance exchange.  With all of the news about health insurance mandates, many individuals will investigate whether they qualify for Medicaid.  Known as the “Woodwork Effect,” some experts predict that these individuals could increase total enrollment by as much as an additional 10%.

Under the Affordable Care Act, individuals with incomes of less than 100% of the Federal Poverty Level are not eligible to receive a premium subsidy through a health insurance exchange, while individuals with income of between 100% and 400% of the Federal Poverty Level are eligible to receive such a subsidy.

The reason for this disparity is because individuals with incomes of less than 100% of the Federal Poverty Level were to be covered under the Medicaid expansion (which, in the Act itself, is mandatory rather than optional).  This distinction is important because it effectively penalizes the working poor.

In short, a state that chooses not to expand its Medicaid program, a single individual making $15,000 annually, for example, will be ineligible for Medicaid and will not receive a premium subsidy, while a person making as much as much as $40,000 annually will receive a premium subsidy.

Regardless of whether Alabama chooses to expand its Medicaid program or not, and assuming the Affordable Care Act is not repealed or significantly altered:

Alabama will have its own Health Insurance Exchange, either because the state created the exchange itself or, alternatively, if the state refuses to create the exchange, because the federal government created an exchange on the state’s behalf.  If the state is going to create its own exchange, it must, by November 16, 2012, provide the federal government with general information about how the exchange will be governed.

Hospitals will receive fewer federal dollars – known as disproportionate share hospital (DSH) payments – which they can use to subsidize the cost of providing care to people who cannot afford to pay for it.

DSH payments, which currently total $11.3 billion annually nationwide and over $300 million annually in Alabama, will decrease by 61% between FYs 2014 and 2019.

Practically speaking, if states choose not to expand Medicaid, there will still be a lot of uninsured folks utilizing uncompensated care, but non-expanding states would have to cover more of these costs (or the hospitals would lose those funds), since the users would not be on Medicaid (since the state did not expand) and since there would be less DSH dollars to otherwise cover costs.

Federal “Maintenance of Efforts” rules have been frozen in place.  Consequently, the state cannot adjust eligibility criteria for its Medicaid or ALL Kids programs in order to potentially save money.

The Impact of the September 18th Referendum

Current budget situation:

Several cost-cutting measures and some additional revenue realized from a legal settlement means Medicaid will likely make it – financially speaking – through FY 2012.  If, however, revenue fails to meet expenditures by even .5%, the program will need an additional $24 million, approximately $8 million of which will have to come from state sources.

Medicaid has contracted with a healthcare actuarial firm as well as an entity that will assist in identifying additional cost savings and needed system changes in hopes of lowering program expenditures.

If the Constitutional Amendment passes:

Medicaid will still need to save $20 to $40 million in additional state funds to balance the FY 2013 budget.

That estimate, according to the Medicaid agency, is currently being refined.

If the Constitutional Amendment fails to pass:

Medicaid would face an immediate FY 2013 shortfall of approximately $100 million.

Limited options would be available to close this funding gap, since nursing home and hospital rates are statutorily set, the FY 2013 primary physician rates are mandated by federal law, and the FY 2013 budget requires at least four brand-name drugs (unless $10 million of state savings are not identified).

Source(s): Information for this document was obtained from presentations made by Dr. Don Williamson, Chair of the Medicaid Transition Task Force, to the Permanent Joint Legislative Committee on Medicaid Policy, chaired by Rep. Greg Wren.  Some facts and figures used by Dr. Williamson were taken from the 2010 Kaiser Report, Medicaid Coverage and Spending in Health Reform.  Other data was compiled and calculated by the National Conference of State Legislatures, the Alabama Medicaid Agency, and the Legislative Fiscal Office.

2012 Federal Poverty Level

(% Gross Yearly Income)

(Family Size)                          (100%)                                  (133%)

1                                 $11,170.00                            $14,856.00

2                                 $15,130.00                            $20,123.00

3                                 $19,090.00                            $25,390.00

4                                 $23,050.00                            $30,657.00

5                                 $27,010.00                            $35,923.00

6                                 $30,970.00                            $41,190.00

7                                 $34,930.00                            $46,457.00

8                                 $38,890.00                            $51,724.00

*Chart taken from (Foundation for Health Coverage Education.)

Closing comments from State Representative Allen Farley:

The information concerning our current issues with Medicaid is overwhelming.  It’s easy to get consumed in all the numbers and percentages.  Of everything covered in this article I find one section most troubling, and convicting.  How can our great state have a group of “our people” continue to grow at an estimated rate of 2.34% annually?  (That’s approximately 200,000 people added to the Medicaid roles over the next 5 years).  How did we become so calloused that we can accept such data?

When I turned to my Bible for answers I found myself reading the 6th chapter of the book of Isaiah. (Beginning in the 8th verse):  Then I heard the voice of the Lord saying, “Whom shall I send? And who will go for us?”  And I said, “Here am I. Send me!” (9) He said, “Go and tell this people:  “Be ever hearing, but never understanding; be ever seeing, but never perceiving.  (10) Make the heart of this people calloused; make their ears dull and close their eyes. Otherwise they might see with their eyes, hear with their ears, understand with their hearts, and turn and be healed.”

My prayer is that “We the People” will turn and be healed.  God Bless America!!!



Faith in Action Alabama calls on law enforcement to protect voters from harassment

“In these harrowing days it is incumbent upon all of us as citizens and you and your colleagues as law enforcement professionals to do all we can to maintain this right secured by so much courage and sacrifice.”

Micah Danney




Nine clergy members from across the state have signed an open letter calling on local and state law enforcement to protect voters against intimidation and harassment at the polls.

The clergy are leaders in Faith in Action Alabama, a regional association of Christian congregations affiliated with the national group Faith in Action, the largest grassroots, faith-based organizing network in the country. It seeks to address a range of issues like gun violence, health care, immigration and voting rights.

This is their letter:

Across our country and here in Alabama, it is being seen that citizens are turning out in record numbers to vote early and by absentee ballots. It is very heartening to see so many of our fellow citizens energized and committed to exercising that most fundamental and critical duty of citizenship, the use of their franchise.  As servant leaders of an ecumenical association of nearly 2,000 faith communities across our state we are certainly encouraging our congregants to fulfill this duty either through early, absentee or day of election voting. For us this is not only part of our civic duty, but as people of faith obligation as well.

Unfortunately, it it also largely known that there are forces in our country that are actively, publicly and fervently at work to suppress the votes of some of our fellow citizens. We write to implore you to use the full authority of your office and department to ensure that those who seek to vote, especially on November 3, 2020 are not assailed or intimidated by illegal harassment in their polling places. We believe these threats are pervasive enough and real enough that proactive measures should be in place as citizens come to vote throughout that day. The strong, visible presence of uniformed legitimate law officers will hopefully prevent any attempts at confrontation or intimidation and violence.

The history of our state is marked by the efforts of tens of thousands of Alabamians who marched, protested, brought legal actions, shed their blood and some even gave their lives that every citizen of this state might have full and free access to the ballot box. In these harrowing days it is incumbent upon all of us as citizens and you and your colleagues as law enforcement professionals to do all we can to maintain this right secured by so much courage and sacrifice.

Please be assured of our prayers for you and the men and women of your department who have the awesome responsibility of providing public safety and equal protection under the law for every Alabamian. If we, the members of Faith in Action Alabama’s Clergy Leadership Team, can be of assistance please do not hesitate to call upon us.


Rev. Jeremiah Chester, St. Mark Baptist Church, Huntsville

Rev. David Frazier, Sr., Revelation Missionary Baptist Church, Mobile, and Moderator, Mobile Baptist Sunlight Association

Bishop Teresa Jefferson-Snorton, Fifth Episcopal District of the Christian Methodist Episcopal Church

Bishop Russell Kendrick, Episcopal Diocese of the Central Gulf Coast

Bishop Seth O. Lartey, Alabama-Florida Episcopal District of the African Methodist Episcopal Zion Church

President Melvin Owens, Alabama State Missionary Baptist Convention

Bishop Harry L. Seawright, Ninth Episcopal District of the African Methodist Episcopal Church

Dr. A.B. Sutton, Jr., Living Stones Temple, Fultondale

Father Manuel Williams, C.R., Resurrection Catholic Missions of the South, Montgomery

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Report: Alabama’s Black Belt lags behind state in economic prospects

Black Belt counties lag behind others in economic prospects and investments in businesses.

Eddie Burkhalter




It took Marquis Forge five years and 18 banks before he and his partner were able to open their company, Eleven86 Water, in Autauga County, just north of the Black Belt, and a report released Tuesday shows how Black Belt counties lag behind others in economic prospects and investments in businesses. 

Forge, a former University of Alabama football player, told reporters during a briefing Monday that he considers Autauga County, which borders the Black Belt’s Lowndes County, part of the Black Belt, and said it shouldn’t have been so difficult to access the capital needed to start a business. 

The report released Tuesday by the University of Alabama’s Education Policy Center titled “Black Belt manufacturing and Economic Prospects” is the last in the center’s Black Belt 2020 series, and found that only four of the state’s 24 Black Belt counties, as defined by the center, are above the statewide average of 22.4 businesses per 1,000 residents, and just one, Montgomery County, was above the 2018 statewide average of personal income of $43,229. 

Researchers also found that just three Black Belt counties are above the state’s average in gross domestic product being produced by counties of $45,348. 

“To achieve Governor Ivey’s ambitious goal of 500,000 a million more Alabama workers with skills by 2025, all hands have to be ‘on deck.’ It will require higher labor force participation rates, particularly in the Black Belt, where the average is 20 points below the statewide average,” said Stephen Katsinas, director of the university’s Education Policy Center and one of the authors of the report. 

“Due to smaller economies of scale, our approaches to  education, workforce development, and community building will have to be different to reach Alabama’s Black Belt,” Katsinas continued. “In the longer term, we first must define the Black Belt, because you can’t measure what you can’t define. Then we must do what West Alabama Works is doing–go where the people are to bring hope by connecting them to a well-aligned lifelong learning system that makes work pay.”   

Donny Jones, COO of Chamber of Commerce West Alabama and Executive Director of West AlabamaWorks, told reporters Monday that one of the keys to helping the Black Belt will  be helping state and Congressional legislators understand the nuances of rural Alabama. 

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Jones said the state should look at how colleges are graded, and that many smaller colleges don’t get credit for putting students through programs that get them short-term certificates that lead to jobs. 

“Those are some of the things on the statewide level that we can really start to work on,” Jones said, adding that they’ve already begun teaching modern manufacturing in Black Belt high schools that gives students college credits toward an associates degree while still in high school. 

“I think that’s very important for individuals to understand the impact that we can have in our higher ed and our K-12 system, really works hand in glove to move the needle for workforce development,” Jones said. 


Jim Purcell, State Higher Education executive officer of the Alabama Commission on Higher Education, told reporters that it’s also important to look at one’s own community and identifying what is “unique and special,” and said he was recently in Autauga County, where he is from, and bought two cases of Eleven86 Water because he remembered how good the water there was. 

“I think that’s what you’ve done, is you’ve taken the gift that Autauga’s environment has and enhanced it, so that the people can benefit from it,” Purcell said to Forge. “I think that’s the key.” 

Asked what he’d tell state legislators to spur them to make changes so that other entrepreneurs wouldn’t have to struggle as hard as he did to open a business, Forge said he would ask for a clearer path for assistance. 

“Instead of digging down through a tunnel with a spoon I would have someone outline the tracks on getting funds and assistance from local, state and the national level, because there are funds out there,” Forge said. 

After going to 18 banks to get the financing he needed, he still had to liquify all his assets to make it happen, Forge said. 

“How many people are going to do that?” he asked. “We shouldn’t have to do that.”

To read all of the Education Policy Center’s reports on Alabama’s Black Belt, visit here.

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Zeta is a hurricane again

Zeta currently has sustained winds of 85 mph. On its current course it will make landfall at Southeast Louisiana or the Mississippi Coast late this afternoon and move through Alabama tonight.

Brandon Moseley



A satellite image of Hurricane Zeta. (VIA NATIONAL WEATHER SERVICE)

Zeta is continuing its path toward the Gulf Coast, and it is strengthening. Zeta is now a hurricane again and is forecast to be a category two hurricane when it comes ashore this evening.

“As expected, #Zeta is strengthening as it moves across the Gulf of Mexico,” the Baldwin County Emergency Management Agency warned. “The windfield extends nearly 150 miles and we will begin to see impacts such as tropical winds, rain, rip currents and dangerous surf, as well as storm surge in Baldwin County.”

Zeta currently has sustained winds of 85 mph. On its current course, it will make landfall along southeastern Louisiana or the Mississippi coast late this afternoon. It should move through Alabama tonight.

A Hurricane Warning is in effect for Morgan City, Louisiana, to the Mississippi-Alabama state line including Lake Pontchartrain, Lake Maurepas and metropolitan New Orleans.

According to the NOAA, hurricane conditions are expected there this afternoon, with tropical storm conditions beginning later this morning.

Preparations to protect life and property should be rushed to completion. Damaging winds, especially in gusts, will spread well inland across portions of southeastern Mississippi and southern Alabama this evening and tonight.

A Storm Surge Warning is in effect from the mouth of the Atchafalaya River to Navarre Florida including Lake Borgne, Lake Pontchartrain, Pensacola Bay and Mobile Bay.

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“If you live in a low-lying area you should evacuate before dark on Wednesday evening to a safer place,” warned Congressman Bradley Byrne, addressing Mobile and Baldwin County residents. “If you live on higher ground in southwest Alabama please make your plans Wednesday to be wherever you plan to spend the night by dark Wednesday evening and do not leave until daylight Thursday as we will experience tropical storm force winds and 2-4 inches of rain which could cause flash flooding, downed trees or downed live power lines. This storm should pass through our area rapidly and be gone early Thursday. Let’s all pray that this is the last storm of this hurricane season.”

ABC 33/40 television meteorologist James Spann said on social media, “We will deal with periods of rain today with temperatures in the 70s; the main wind and rain associated directly with Zeta will come tonight, and there is potential for a high impact wind event for much of the state.”

Storm surge predictions have risen since yesterday. Under current forecasts, Zeta is expected to bring a storm surge of six to nine feet for Dauphin Island. The storm surge will be four to six feet in Mobile Bay, and three to five feet for the Baldwin County shore towns of Fort Morgan, Gulf Shores and Orange Beach to the Florida line.


Wind gusts in Mobile and Baldwin counties could be as much as 70 miles per hour. Isolated tornadoes are a possibility as this powerful storm system moves through the state of Alabama.

Because the storm is moving so fast, it should not produce as much torrential rain as a slower moving storm, reducing the flooding risk; however, that fast speed means that it won’t lose a lot of strength as it moves through the state, thus tropical storm winds could be experienced well inland.

Most of Alabama should get 1 to 3 inches of rain. The combination of heavy winds and heavy rains could weaken the root systems of trees meaning there is a possibility of losing power tonight. Citizens should check their emergency kits and make sure that they have flashlights, batteries, radios and fully charged phones in case they are needed tonight.

The Mobile County Emergency Management Agency is asking that people who live on the coast or in flood-prone areas to evacuate before tonight. Shelters have been set up in Mobile County including a medical needs shelter.

The Alabama Department of Agriculture and Industries has set up a shelter for livestock evacuating the area at the Alabama A&M Agribition Center in Huntsville.

Sandbags are available at the Baldwin County Commission office in Robertsdale. There is a limit of 25 bags per person while supplies last.

Alabama Gov. Kay Ivey has declared a state of emergency.

Baldwin, Mobile and Escambia Counties were declared a natural disaster area after Hurricane Sally slammed into the state last month. Many areas are still in the process of cleaning up from that storm.

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Byrne introduces bill to protect underwater forest

This is the only known site where a coastal ice age forest this old has been preserved in place, with thousands of trees still rooted in the dirt they were growing millennia ago before being reclaimed by the Gulf of Mexico.

Brandon Moseley




Congressman Bradley Byrne, R-Alabama, has introduced the Alabama Underwater Forest National Marine Sanctuary and Protection Act, a bill that would designate the site of an ancient cypress forest found 60 feet underwater south of Gulf Shores as a National Marine Sanctuary.

“The underwater forest is another unique Alabama gem with global importance. As the only known site where a coastal ice age forest this old has been preserved in place, we must take action now to protect it,” Byrne said. “The Alabama Underwater Forest National Marine Sanctuary and Protection Act protects Alabamians ability to fish, dive, and recreate at the site while ensuring none of its invaluable artifacts can be removed or damaged. This designation will also open up further tourism opportunities along our Gulf Coast.”

“I would like to thank Ben Raines, whose work with me after his discovery of the site has been instrumental in crafting this bill,” Byrne said.

Some 60,000 years ago, the planet was cooler than it is now. This forest is a relic from an ice age before the last ice age 16,000 to 10,000 years ago. Tons of water were locked up vast glaciers that covered the globe from not just the Arctic but as far south as St. Louis.

Herds of wooly mammoths, giant bison, mastodons, wooly rhinos, horses and American camels were pursued by saber toothed cats, dire wolves, and the massive cave bear.

With so much water locked up in snow and ice, ocean levels were significantly lower than they are now. Gulf Shores, which is a barrier island town today, was not the Alabama coast then. The coast was much further south. The underwater forest is a remnant from that bygone age and appears to be a wholly unique relic of our planet’s past.

This is the only known site where a coastal ice age forest this old has been preserved in place, with thousands of trees still rooted in the dirt they were growing in millennia ago before being reclaimed by the Gulf of Mexico.

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For scientists, this a treasure trove of information about the types of plants that inhabited the Gulf Coast during the ice age and before humans. That world was impacted by a sudden sea rise.

The work of the team investigating the site is detailed in Ben Raines’s documentary, The Underwater Forest, co-produced by This is Alabama and the Alabama Coastal Foundation.

Byrne represents Alabama’s 1st Congressional District. He is not running for re-election.


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