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 countys 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 countys 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 Bachelors 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 Makers Attention

The SDOH requires the policymakers 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...

…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 epansion 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.

Potential Results of Inaction

Inaction could have several potential consequences. Poor households will continue to live without insurance coverage, which affects their ability to obtain proper healthcare, particularly when faced with chronic illness. Consequently, the high prevalence of chronic illness in the state will persist as will the associated morbidity rates.

Reflection

Change Agent Description

To steer a successful campaign for a policy change, the change agent needs to develop a diversified knowledge base. From this project, one can deduce that it is important for the change agent to conduct research effectively to justify that a public health problem requiring a policy change indeed exists. There is also a need to accurately identify the most relevant policymakers around the proposed policy change and devise ways to effectively engage them. Finally, the change agent can do very little on their own. Collaboration is crucial when an agent is seeking to drive a policy change. There is a need to empower members of the local community and also engage professionals in different capacities in research and planning for advocacy.

Knowledge and Skills to Develop

From the description above, one can deduce that an agent requires certain knowledge and skills to steer a successful policy change campaign. First, there is a need to develop ones research skills. Research, specifically data collection, is the basis for identifying whether a policy problem exists and, hence, whether a change may thus be necessary. Secondly, there is a need for the agent to develop their communication skills to be in a good position to engage policymakers and members of the local community to support their change idea. Further, there is…