An Analysis of the Successes, Challenges, and Opportunities for

Transcription

Alabama
State
Report
alabama
Successes,
Challenges, and Opportunities
for Improving Healthcare Access
An Analysis of the
H E A LT H L A W A N D P O L I C Y C L I N I C O F H A R VA R D L A W S C H O O L
A N D T H E T R E AT M E N T A C C E S S E X PA N S I O N P R O J E C T
Prepared by: Carmel Shachar, Robert Greenwald, and Amy Rosenberg
State Report | ALABAMA
contents
FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
PART I: INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
PART II: PROFILE OF ALABAMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.Overview of the HIV/AIDS Epidemic in Alabama . . . . . . . . . . . . . . . . . . . . . 10
Epidemiological information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Number of AIDS and HIV cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Reported exposure categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Geographic distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.State Economic Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.State Demographic Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
4.Government Structure and Constitution . . . . . . . . . . . . . . . . . . . . . . . . . 15
5.General Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Health insurance coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Death rates and causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Health status and behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Healthcare facilities and providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
HIV testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Substance abuse and mental health facilities . . . . . . . . . . . . . . . . . . . . . . . 19
6.Public Health Programs Serving HIV-positive Individuals . . . . . . . . . . . . . . . . 19
Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Funding, expenditures, enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Eligibility and programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Covered services and limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
State Children’s Health Insurance Program (SCHIP) . . . . . . . . . . . . . . . . . . . . 23
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Ryan White Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
AIDS Drug Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
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Successes, Challenges, and Opportunities for Healthcare Access
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7. Other HIV/AIDS-related Laws and Policies . . . . . . . . . . . . . . . . . . . . . . . 26
8.Other Programs Serving People With HIV/AIDS . . . . . . . . . . . . . . . . . . . . 26
PART III: SUCCESSES, CHALLENGES, AND OPPORTUNITIES . . . . . . . . . . . . . . . . . . . . 31
1.Medicaid in Alabama . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Raise Medicaid income standard/create“medically needy” eligibility category . . . . . 33
Raise Medicaid reimbursement rates . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Use presumptive eligibility/HIV waiver . . . . . . . . . . . . . . . . . . . . . . . . . 33
Improve Medicaid benefits package and make benefits easier to use . . . . . . . . . . 34
2.Provider Shortages in Alabama . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Raise Medicaid reimbursement rates . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Offer clinicians incentives for rural practice . . . . . . . . . . . . . . . . . . . . . . . 36
Expand the scope of practice for NPs and PAs . . . . . . . . . . . . . . . . . . . . . 37
Increase reimbursement rates for NP and PA services . . . . . . . . . . . . . . . . . 39
3.State Revenue and Spending Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
4.HIV and Segregation in Prisons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Past successes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Increase collaboration among state agencies and community organizations . . . . . . 45
Provide ADOC with more medical and public health information . . . . . . . . . . . . 46
Build broader coalitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Explore possibility of a lawsuit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
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5.Lack of Antidiscrimination Laws for People Living With HIV/AIDS . . . . . . . . . . 46
Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Educate providers and consumers about federal antidiscrimination law protections . . . 47
Explore filing state legislation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
6.ADAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Past successes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Raise income eligibility limit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Address Medicare Part D coverage gaps . . . . . . . . . . . . . . . . . . . . . . . . 49
7.State Health Officer Appointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
PART IV: CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
APPENDIX A: Alabama HIV/AIDS Epidemiological Information . . . . . . . . . . . . . . . . . . 52
APPENDIX B: Alabama HIV/AIDS Cases by Public Health Area and County . . . . . . . . . . . 56
APPENDIX C: Map of Alabama Counties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
APPENDIX D: Alabama Medicaid Covered/Noncovered Services . . . . . . . . . . . . . . . . . 63
APPENDIX E: 2009 Federal Poverty Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
NOTES AND REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
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foreword
It goes without saying that access to good quality, comprehensive healthcare
is critical for people living with HIV/AIDS. Advocating effectively for improved
healthcare access requires understanding the underlying legal and policy
landscape of a state, the state’s fiscal and cultural environment, and existing
barriers to healthcare access.
The State Healthcare Access Research Project (SHARP) is researching and
analyzing this information, and examining states’ capacities to meet the care
and treatment needs of people living with HIV/AIDS. Working together with
community partners in SHARP states, the project is identifying past successes,
current challenges, and future opportunities to improve access to care and
services for people living with HIV/AIDS.
Collaboration with community partners is integral to the SHARP process.
We have met in-state with people living with HIV/AIDS, community-based AIDS
services providers, healthcare providers, state and federal government officials,
and other researchers and advocates. These community partners have shared
their opinions and insights about the successes and challenges faced by people
living with HIV/AIDS as they seek care. They have also shared their perspectives
on the political, cultural, and fiscal factors unique to their state.
Our goal is for the SHARP reports to be informative and useful. It is our hope
and intention that they will become a framework for future efforts to expand
healthcare access— tools that can be used as part of a broader strategy to bring
healthcare to more people living with HIV/AIDS.
SHARP is being conducted by the Health Law Clinic of Harvard Law School and
the Treatment Access Expansion Project (TAEP) with support from Bristol-Myers
Squibb. The Health Law Clinic has provided legal services to low- and moderateincome people living with HIV/AIDS for 20 years, and actively participates in
HIV healthcare access advocacy efforts. TAEP is a national organization focused
exclusively on HIV healthcare access advocacy. The mission of both organizations
is to help bring good quality, comprehensive healthcare to more people living with
HIV/AIDS.
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acknowledgments
We gratefully acknowledge the contributions of the following individuals,
who shared their knowledge, experience, perspectives, and opinions with
us in the development of this report.
• Amy Bark, AIDS Alabama
• Frenshai Bonner, Peer Mentor
• Cynthia Boykin, Peer Mentor
• Bridget Byrd, Alabama Department of Public Health
• William Chastang, Franklin Primary Health Center
• Dayna Cook-Heard, UAB, The Family Clinic
• Richard Hailey, Peer Mentor
• Kathie Hiers, AIDS Alabama
• Marla Hinson, UAB, The Family Clinic
• Julie Hope, Health Services Center
• Catina James, Alabama Department of Public Health
• Vallarie Jones, Franklin Primary Health Center
• W. Randy Jones, Alabama Department of Public Health
• Sharon Jordan, Alabama Department of Public Health
• Kelli Lasseter, Health Services Center
• Gerald Lavender, AIDS Alabama
• Bill Manning, formerly Health Services Center
• Malcolm Marler, UAB, 1917 Clinic
• Mary Elizabeth Marr, AIDS Action Coalition
• Michael Mugavero, UAB, 1917 Clinic
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acknowledgments
• Mike Murphree, Montgomery AIDS Outreach
• Karen Musgrove, Birmingham AIDS Outreach
• Patrick Packer, Southern AIDS Coalition
• Elana Parker, Alabama Departments of Correction and Public Health
• DaNita Perry, Homeward Bound
• Karen Phillips, Health Services Center
• Mel Prince, Selma AIR
• James Raper, UAB, 1917 Clinic
• Delia Reynolds, Alabama Department of Public Health
• Martha Robinson, Peer Mentor
• Randy Russell, Healthcare Responses
• Michael Saag, UAB, 1917 Clinic
• Gloria Sims, Alabama Department of Public Health
• Marilyn Swyers, Unity Wellness Center/East Alabama Health Services
• Jackie Walker, American Civil Liberties Union National Prison Project
• Stephany Washington, Homeward Bound
and especially,
• the Alabama residents living with HIV/AIDS who met with us
and shared their experiences regarding healthcare access
• Rachel Frazier, Matthew Siegler, and Peter Chang of Harvard
Law School, for research and writing assistance
• Laurie Novoryta and Elise Procaccio, Discovery Chicago,
for help with logistics
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part I:
introduction
Alabama is a challenging state in which to live if you are a person with HIV/AIDS.
It is also a challenging state in which to provide services, medical treatment, and
advocacy for people living with HIV/AIDS. The South in general is at the epicenter of
the current HIV epidemic in the United States with the highest rates of new infections,
the most AIDS deaths, the greatest number of people living with HIV/AIDS, the largest
percentages of persons with HIV who are not in care, and the fewest resources.
Alabama is no exception. This report will describe some of the difficulties faced by
Alabamians living with HIV/AIDS and the people who work with them, particularly with
regard to accessing healthcare, as well as possible opportunities for improvement.
Alabama is a relatively poor state with a large rural population, characteristics shared
by many Alabamians living with HIV/AIDS. Lack of reliable, affordable transportation
options, combined with the worst shortage of medical providers in the nation, pose
significant obstacles to accessing both primary and HIV care. Alabama’s Medicaid
program has highly restrictive eligibility criteria and a limited benefits package for those
who are able to qualify. The state’s revenue and spending structure and practices mean
that few state dollars go to HIV/AIDS care and services. There are barriers to justice:
HIV-positive inmates live in segregated prison housing, and Alabama has no state
antidiscrimination laws to protect people living with HIV/AIDS (or any other Alabamians,
for that matter). The AIDS Drug Assistance Program (ADAP) has improved from years
past, but remains vulnerable, especially in a recessionary economic climate.
Alabama is also a politically and culturally conservative state. The mix of residents in
Alabama has shifted over the last 40 years from predominantly blue-collar workers,
such as steel-production laborers, to more of a white-collar workforce, such as
employees in the space industry (Huntsville) and university-centered positions. In the
late 1980s, the University of Alabama Birmingham became the largest employer in
Birmingham, Alabama’s largest city.
The migration to Alabama of highly-trained and skilled professionals has created
tension between the newer arrivals and long-time Alabama residents. People who have
relocated to Alabama within the last 25 years are less likely to vote in local elections for
a variety of reasons, leaving the electorate not truly representative of the current mix
of residents. Politicians still cater to the state’s voting population, which tends to be
long-term residents who are characterized by strong convictions to religion-based
politics. During the 2008 presidential election, Alabamians cast 35% of their votes for
President Obama, the second lowest national percentage (only Oklahoma had a lower
percentage of votes).
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part I:
introduction
Alabama’s cultural conservatism has implications for health education and public
health in the state. Health education is seen as a responsibility belonging to the family,
rather than the public schools, even though teenage pregnancy, chlamydia, gonorrhea,
and syphilis rates remain among the highest in the nation. There are no statewide
requirements for health education—Mobile, for example, has a separate board of
education governing curriculum and programs in its public education system.
Alabama’s state health officer position is the only one in the nation to be de facto
selected by the private state medical association. The state health officer is not included
in the governor-appointed cabinet. This separate role restricts the ability of the state’s
administration to streamline and implement public health interventions. These separate
and disconnected approaches to health and education represent the tension of a
deeply entrenched cultural belief that self-rule is better than seeking to accomplish
the good for all.
Stigma is a multifaceted and nuanced phenomenon, but stigma in Alabama is
certainly partly due to the association of HIV with behaviors that many consider
shameful, such as injection drug use and male-to-male sex. Many Alabamians hold
strong, traditional religious beliefs, and some churches have contributed to HIV-related
stigma by preaching that AIDS is a curse from God for sinful ways. Stigma also relates
to Alabama’s complex history of race relations, as HIV disproportionately impacts
Alabama’s African American residents. African Americans living with HIV in Alabama
may also experience discrimination from within their own communities (eg, churches)
and may be understandably hesitant to engage with a white-dominated healthcare
system in the long shadow of Tuskegee.
Notwithstanding the many social, cultural, political, and economic challenges,
there are some significant successes in Alabama HIV/AIDS care and services.
Alabama currently has more HIV housing than Georgia or Florida, 2 states with much
larger populations and more resources. The federal Housing Opportunities for Persons
with AIDS (HOPWA) program provided $1,679,000 in 2007 for Alabama projects,
including rental assistance and housing in all 67 counties. Recently the Department
of Housing and Urban Development awarded a Hobson City clinic nearly $1 million
for HIV housing.
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introduction
Alabama is one of only 11 states to have a targeted case management program for
people living with AIDS and is virtually unique in the fact that Medicaid funds the
program. Despite the limitations of Alabama’s Medicaid program, the state does have
a Medicaid waiver program to provide in-home care for people with AIDS who would
otherwise be institutionalized.
Advocates have made significant progress in recent years in improving conditions
for HIV-positive inmates, who are now allowed to participate in a greater range
of activities, including work-release programs (as of August 2009). There is some
collaboration among the Alabama Department of Corrections (ADOC), Department
of Public Health, and community-based organizations, providing a foundation on which
to build future efforts.
Perhaps the biggest success is the commitment, perseverance, and resourcefulness
of Alabama’s HIV/AIDS services providers and advocates. They are outstanding in
their dedication to their clients and their collaboration and cooperation with each
other. Although they have very limited means, everyone is determined to stretch
their capacities to the fullest. Providers work diligently and creatively to maximize the
benefits achieved for clients, and clients understand and appreciate their providers’
efforts. In this area, Alabama has lessons to offer to more well-resourced states.
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OVERVIEW OF THE HIV/AIDS EPIDEMIC IN ALABAMA
Epidemiological information
(see Appendix A for these data in table format)
Number of AIDS and HIV cases
Through 2007, Alabama reported 9,091 cumulative AIDS cases, which was 1% of the
total cumulative AIDS cases in the US.1 Alabama reported 6,430 cumulative cases of
HIV infection at the end of 2007, comprising 2% of the total cumulative reported
HIV cases in the US.2 There were 5,740 persons estimated to be living with HIV and
4,046 estimated to be living with AIDS in Alabama at the end of 2007.3 The estimated
rates, per 100,000 population, of persons living with HIV and AIDS in Alabama were
149.4 (HIV) and 105.4 (AIDS).4 In 2007, Alabama reported 391 AIDS cases and had an
annual AIDS case rate of 8.4 cases per 100,000 people, compared to 12.4 for the
US as a whole.5 Through 2007, there were 5,034 reported deaths among persons
with AIDS in Alabama.6
The Alabama Department of Public Health (ADPH) reports that there were 900 new
cases of HIV/AIDS in 2007 and 839 new HIV/AIDS cases in 2008. As of March 31,
2009, the cumulative HIV/AIDS case total was 16,377. These numbers will likely
change as reporting of 2008 data becomes more complete.7
Demographics8
The incidence of HIV/AIDS is not evenly distributed among different racial, ethnic,
or gender groups. According to ADPH, Blacks accounted for more than 70% of new
HIV/AIDS cases reported in 2008 (591 out of 839), and represent nearly 64% of the
cumulative HIV/AIDS cases through March 31, 2009 (10,413 out of 16,377). This rate
is significantly higher than that for Whites, which was 22.5% of new 2008 cases, and
33.4% of cumulative cases. Hispanics made up 3.6% of 2008 HIV/AIDS cases, and
1.7% of cumulative cases. Cumulatively, males make up 74.5% of total HIV/AIDS cases
and females comprise 25.5%. In 2008, however, males accounted for 71% of new HIV/
AIDS cases; females accounted for 29%, indicating that the epidemic is now increasing
faster among women.
The most common age at diagnosis of HIV or AIDS is 25-34 years, with nearly 35% of
cumulative cases in Alabama diagnosed when the patient was between those ages.
For 2008, 25-34-year-olds made up 26.6% of new cases. New cases appear to be
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increasing fastest among 13-24-year-olds, who accounted for 21% of new 2008 cases
(up from less than 17% of 2007 cases), while making up 13.5% of cumulative cases.
The 35-44-year-old group made up 24% of 2008 cases, and almost 31% of cumulative
cases. Older Alabama residents account for a larger percentage of recent HIV/AIDS
diagnoses. People aged 45-49 made up about 12% of 2008 cases vs 9% of cumulative
cases; people aged 50+ accounted for 16% of 2008 cases and 11% of cumulative
cases. Pediatric (age <13) HIV/AIDS cases comprised 0.4% of 2008 cases and
0.8% of cumulative cases.
Reported exposure categories9
The 2 largest exposure categories for newly-reported HIV/AIDS cases in Alabama
are men who have sex with men (MSM) and heterosexuals. In 2005, according to
ADPH, 37.6% of new cases of HIV or AIDS reported MSM as the primary risk factor.
In 2006, 34.8% of new cases were reported as MSM. In 2007, 38.6% of new cases
were reported as MSM. There have been 6,717 cumulative HIV/AIDS cases among
MSM in Alabama as of March 31, 2009, and MSMs make up 41.4% of cumulative
HIV/AIDS cases.
Exposure through heterosexual sex has been increasing as a percentage of new
HIV/AIDS cases. Heterosexuals made up 25.4% of new cases in 2005, 38.9% in 2006,
and 34.3% in 2007. Part of the large jump in cases between 2005 and 2006 is due to
the reclassification of women reported with no known risk factor to the “heterosexual
exposure” category. As of the end of March 2009, 4,626 heterosexual HIV/AIDS cases
had been reported, comprising 28.5% of cumulative cases.
Other exposure categories include injection drug use (IDU), MSM and IDU, and receipt
of blood products/transfusions. Through March 31, 2009, there were 1,805 cumulative
IDU cases reported (11.1% of total cases). MSM/IDU totaled 910 cases as of March
2009 (5.6% of cumulative cases). Transmission through blood products remained a
relatively low risk factor, with 0.75% of cumulative cases reported with this risk factor.
There are also cases with an exposure category of “risk not reported or identified/
other”—these cases totaled 2,050 and accounted for 12.6% of cumulative cases as
of the end of March 2009.
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Geographic distribution
Alabama is divided into 11 public health areas (PHAs). Almost one-third of HIV-positive
Alabamians live in Jefferson County, which includes much of the city of Birmingham.
A chart showing HIV/AIDS cases by PHA and county appears in Appendix B.
According to the Centers for Disease Control and Prevention (CDC), 20% of AIDS cases
first reported in Alabama in 2006 occurred among residents of rural areas (areas with
less than 50,000 people).10 This is a significantly higher percentage than for the United
States as a whole, where 7% of 2006 AIDS cases were rural, and also a higher rate
than the South as a region, where rural cases accounted for 10% of 2006 AIDS cases.
The CDC estimated that, at the end of 2006, 16% of Alabamians living with HIV (who
had not yet progressed to an AIDS diagnosis) were living in rural areas, and 19% of
Alabamians living with AIDS lived in rural areas.11 Having a relatively high proportion
of rural HIV/AIDS cases can present extra challenges in access to care and delivery of
services, as discussed further in Part III of this report.
Funding12
The total HIV/AIDS federal funding in fiscal year 2007 (FY07) for Alabama was
$33,896,136, which was about 1.2% of the $2,956,310,950 total FY07 federal HIV/AIDS
funding. Of Southern states (including Arkansas, Florida, Georgia, Louisiana, Mississippi,
North Carolina, and South Carolina), only Mississippi ($26.1M) and Arkansas ($13.1M)
received less federal HIV/AIDS funding in FY07.
The following table shows Alabama’s FY07 federal funding for HIV/AIDS:
Source
Amount (in millions)
Ryan White
$26.6
CDC
$3.8
(includes $2.1 for prevention)
Substance Abuse and
Mental Health Services Administration (SAMHSA)
$1.8
(all for substance abuse prevention
and treatment)
Housing Opportunities for Persons with AIDS
(HOPWA)
$1.7
The Office of Minority Health did not send funding to Alabama, despite disbursing
$11.3M nationally in FY07.
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STATE ECONOMIC PROFILE
Alabama has a gross domestic product (GDP) of $165,796 million (in 2007 dollars) as
of 2007. Alabama contributes 1.2% of total US GDP, a figure that has held steady from
2004 onward. The Southeast region overall contributes 22.5% of the US GDP.13 The
largest employer in Alabama is the University of Alabama Birmingham. As of 2006,
there were 423,550 goods-producing jobs, 160,720 government jobs, and 1,545,130
service jobs. The most common jobs in Alabama are registered nurses, team
assemblers, customer-service representatives, and elementary school teachers.14
Alabama has realized continual growth in its GDP, although this growth has slowed in
recent years, as in most other states. From 2006 to 2007, the GDP increased 1.8%.
This is a slight decline from 2005-2006, when the GDP grew 2.0%, and a continued
decrease from the growth in 2004-2005 (3.2%) and 2003-2004 (5.2%). Alabama is
ranked 27th for GDP growth among states in 2007. Retail trade, real estate rental
and leasing, and durable goods manufacturing contributed 0.48, 0.42, and 0.40
positive percent change to the GDP in 2006-2007. Construction, nondurable goods
manufacturing, and finance and insurance were the biggest drain on GDP growth,
contributing -0.49, -0.15, and -0.14% to change in GDP in 2006-2007.15
Alabama is one of the poorer states in the nation. It ranked 42nd in per capita personal
income in 2007 ($32,401, or 84% of the national average), although this was a 5%
increase from 2006.16 The percent of persons living below the poverty line was
16.1% in 2004 as compared with the national rate of 12.7%.17 In 2007, 4% of Alabama
residents (165,400 people) received Supplemental Security Income (SSI), a federal
income support program for low-income elderly, blind, and disabled individuals.
Nationally, 2% of the population got SSI in 2007. Alabama had a higher percentage of
individuals under age 65 receiving SSI (about 80% of SSI recipients, compared with
72% nationally), indicating that Alabama had more people determined to be disabled
than the national average.18
Alabama does fairly well with unemployment. In December 2007, the seasonally
adjusted unemployment rate was 3.7%, as compared with 5.0% for the nation.
Preliminary data for December 2008 show 6.7% unemployment in Alabama vs
7.2% nationally.19
Alabama’s agricultural exports were valued at $615.5M in 2007. Alabama is the third
largest state exporter of peanuts and products, with 2007 peanut exports valued at
$27.2M. Alabama is the fourth largest state exporter of poultry and products, with the
value of its poultry exports for 2007 estimated at $309.9M.20
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STATE DEMOGRAPHIC PROFILE21
According to the US Census Bureau, Alabama had an estimated total population of
4,661,900 as of July 1, 2008. The median age was 37.5 years, slightly above the national
median (36.8). Seventy-one percent of the population identified as White in 2008, and
26.4% as Black.22 Persons of Hispanic or Latino origin comprise 2.9% of the population,
Asians comprise 1%, and American Indian and Alaska Native persons make up 0.5%
(the numbers add up to more than 100% because a single person can be reported as
more than one race/ethnicity). This compares with the national average of 79.8% White,
15.4% Hispanic, and 12.8% Black. Thus, Alabama has a significantly higher percentage
of Blacks than most of the country, and fewer Hispanics. Alabama has fewer noncitizens
(3% of the population) than the national average (7%).23
According to the 2000 US Census, 55% of Alabama’s population live in urban areas,
with the remaining 45% living in rural locations. Nationally, only about 17% of the
population live in nonmetropolitan areas. Alabama’s poverty rate and unemployment
rate are higher in rural areas. The poverty rate of rural areas in Alabama is 18.8%, as
compared with the urban area’s rate of 15.8%.24 From 2006 to 2007, earnings per job
dropped 0.5% in rural areas and decreased 1.6% in urban areas.25 Both areas saw an
increase in per capita income from 2006 to 2007 (3.7% for rural areas and 4.3% for
urban areas).26 The unemployment rate in 2008 was 6% in rural areas and 4.7% in
urban areas.27
Part of the economic and employment disparity between urban and rural areas in
Alabama may be attributable to the difference in education levels. In 2000, 30.7%
of people in rural areas of Alabama did not complete high school, whereas 22.2% of
people in urban areas did not complete high school.28 In 2000, only 12.8% of people in
rural areas completed college vs 21.7% in urban areas.29 Alabama lagged behind
the national rates for education. In 2000, 75.3% of people in Alabama were high
school graduates as compared with the national rate of 80.4%. Nineteen percent of
people in Alabama had a bachelor’s degree or higher, as compared with 24.4%
of people nationwide.30
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GOVERNMENT STRUCTURE AND CONSTITUTION
Alabama’s executive branch consists of the following elected officials: governor,
lieutenant governor, attorney general, state auditor, secretary of state, state treasurer,
superintendent of education, commissioner of agriculture and industries, and a sheriff
for each county.31 Governor Bob Riley (R), who was elected in 2002 and reelected in
2006, has a 25-member cabinet.32 Of note, the chief public health officer for Alabama
is not part of the governor’s cabinet.
The Alabama legislature is composed of a 105-member House of Representatives and
a 35-member Senate. A regular legislative session is made up of 30 “legislative” or
“meeting” days that must be completed within 105 calendar days. There are usually
2 legislative days per week, with other days used for committee meetings and travel.
For 2009, the Alabama legislative session convened on February 3 and adjourned
on May 15.
Alabama currently operates under the Constitution of 1901, the sixth constitution in the
state’s history. Alabama’s constitution weighs in at 357,157 words (40 times longer than
the US Constitution) and is believed to be the longest active constitution in the world.
The Constitution of 1901 centralizes government power in the state legislature, rather
than delegating functions to local governmental authorities. In practice, this means
that local issues must be dealt with by state legislators, often through constitutional
amendments. Most of the Constitution of 1901’s length is due to its nearly 800
amendments, which often address issues in single counties (eg, mosquito control taxes,
bingo, dead farm animals) or are amendments of other amendments. Other criticisms of
the Constitution of 1901 are that it is racist, discriminatory, and outdated.33
There are efforts within Alabama to reform the state constitution, although there is
not necessarily agreement about the best way to accomplish this. Alabama Citizens
for Constitutional Reform (ACCR) is a grassroots, nonprofit group that supports
letting Alabamians vote on whether to call a constitutional convention to rewrite the
constitution. Joint resolutions filed in 2009 in both the House and Senate (HJR 91/SJR
20) that would have allowed such a vote did not pass.34 Some Alabama voters filed a
lawsuit in February 2009 against state officials, alleging that the 1901 constitution was
never legally ratified because of extensive voting fraud, and that officials violated voter
rights by failing to ensure that the constitution was valid. The plaintiffs are seeking either
a new vote on the 1901 constitution or a new constitutional convention.35
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GENERAL HEALTH
Health insurance coverage36
Eighty-six percent of people living in Alabama had health insurance in 2006-2007,
1% better than the national rate. In 2006-2007, 55% of people in Alabama got their
health insurance through their employer. Individual health insurance coverage accounted
for 4%. Medicaid enrollees comprised 13% of the population, while Medicare
beneficiaries made up 14%. Among poor adults (under 100% of the federal poverty
level [FPL]), 27% received Medicaid coverage in 2006-2007, but 44% were uninsured.
Eight percent of all Alabama children in 2007 were uninsured, better than the national
rate of 11%. However, for children living in poverty, 18% had no health insurance
(slightly less than the national rate of 20%).
There are several obstacles for people with HIV/AIDS seeking private insurance in
Alabama. Most Alabamians with private health insurance received coverage through an
employer group policy. But HIV-affected individuals have high rates of unemployment,
so this option may not be available to them. Individual market policies may also be
difficult to obtain—private insurers can turn anyone down for individual coverage
because there is no guaranteed issue in Alabama.37 Despite not being a mandated
benefit, private insurers generally do cover HIV/AIDS care in their policies.38 However, it
is unclear whether insurers are required to renew individual policies. If an HIV-affected
individual receives insurance through a large employer, the federal Health Insurance
Portability and Accountability Act (HIPAA) offers more protection. Under HIPAA, full
policy exclusions are disallowed and riders are limited to 12 months.
Death rates and causes
The death rate in Alabama was 952 deaths per 100,000 people in 2006, as compared
with the national rate of 776 deaths per 100,000 people. The death rate for Black people
was 1,132 deaths per 100,000 as compared with 935 deaths per 100,000 people for
White people in Alabama in 2005. Alabama’s birth rate was 14 births per 1,000 people
in 2006, the same as the national rate.39
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In 2007, the leading causes of death were, in ranked order:
1 Heart disease
2 Malignant neoplasms
3 Cerebrovascular disease
4 Chronic lower respiratory disease
5 Accidents
6 Alzheimer’s disease
7 Diabetes mellitus
8 Nephritis, nephrotic syndrome, or nephrosis
9 Influenza and pneumonia
10 Septicemia40
Although the incidence rate of cancer is lower in Alabama than nationwide (451 cases
per 100,000 in 2004 as compared with 458 per 100,000), the rate of cancer deaths is
higher in Alabama than it is nationally (202 deaths per 100,000 in 2005 compared with
184 deaths per 100,000). The diabetes death rate in Alabama in 2005 was 29 deaths
per 100,000 people; nationally it was 25 per 100,000 people. The number of deaths
due to heart disease in Alabama in 2006 was 253 deaths per 100,000, as compared
with the national rate of 200 deaths per 100,000.41
Health status and behaviors
In 2007, 22% of adults in Alabama smoked, compared with 19% nationally. Sixty-four
percent of adults in 2007 were overweight or obese, more than the 60% for the US
overall. In 2007, 33% of Alabama adults reported poor mental health, the same as those
numbers reported nationally. Alabama reported significantly higher rates of sexually
transmitted infections than US rates. In 2006, the rates of reported chlamydia cases
per 100,000 people were 503 for Alabama and 348 for the US. The rates of reported
gonorrhea cases were 234 for Alabama and 121 cases per 100,000 people for the US.
The number of reported syphilis cases per 100,000 in 2006 was 20 for Alabama and
13 for the US.42
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Healthcare facilities and providers
The number and geographic distribution of hospitals in Alabama is problematic.
According to the Alabama Department of Public Health, Alabama has 132 hospitals:
17 of those are in Jefferson County, 9 are in Mobile County, and Montgomery and
Tuscaloosa counties have 7 hospitals each. In contrast, 34 counties have only 1 hospital
and 2 counties have no hospitals. There are 130 community health centers, with the
majority of these located in Birmingham, Mobile, and Huntsville. Central and far northern
sections of Alabama tend to have stronger healthcare networks than the southeastern
section of the state.43
The Health Resources and Services Administration (HRSA) classified Jefferson,
Madison, Elmore, Escambia, Mobile, Autauga, Baldwin, and Barbour counties as having
health professional shortages. There are 11,352 doctors in Alabama as of 2007. Of the
88 infectious disease doctors in the state, the vast majority are in Birmingham and
Mobile. There were 41,560 registered nurses in 2008 (down from 42,180 in 2007),
or 891 nurses per 100,000 people, more than the national average of 836 nurses per
100,000 people.44 The projected number of physician assistants in clinical practice as of
the end of 2008 is 485, or 10 per 100,000 population (compared with 24 per 100,000
population nationally).45
All 67 counties have a health department. According to the Department of Public
Health, public health services in Alabama are primarily delivered through county health
departments. In addition, there are 64 rural health clinics. The Alabama Primary Health
Care Association has HIV/AIDS programs in DeKalb, Cherokee, Calhoun, Talladega,
Tallapoosa, and Cambers counties.46 There are no sterile syringe exchange programs
in Alabama.47
HIV testing
There are 106 HIV/AIDS testing sites in Alabama, with the testing being conducted
by the county health departments. Other testing sites run by hospitals, clinics, and
community-based organizations are located in Birmingham, Florence, Hobson City,
Tuscaloosa, Huntsville, Gadsden, Tuskegee, Montgomery, Evergreen, Mobile, Auburn,
Phenix City, and Selma.48 ADPH reports that 19,304 people were tested for HIV
between January and March 2005.49 In 2001, 47% of people in Alabama aged 18-64
reported ever having been tested for HIV, 1% higher than the national rate.
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The only option for HIV testing in Alabama is confidential, as anonymous testing is
not permitted. Name-based reporting has been required as of January 1988. There
are limited regulations in effect as to who can offer HIV testing and counseling. ADPH
has requirements, including licensure requirements, for providers participating in DPHfunded testing programs (those providers receiving test kits from ADPH).50 Alabama law
requires voluntary, signed, informed consent for HIV testing, although this consent can
be implied in certain circumstances, and a general consent form that mentions HIV may
be used.51 In line with CDC recommendations, Alabama has an opt-out policy for testing
pregnant women, meaning that pregnant women will be tested for HIV unless they
decline or are already known to be HIV-positive.52
Substance abuse and mental health facilities
There are 83 dedicated substance abuse facilities in Alabama. Forty-three cities have
facilities, with Birmingham, Mobile, and Montgomery having the greatest concentration
of facilities. Twenty hospitals have either an inpatient or outpatient substance abuse
program in 12 counties. There are 2 dedicated mental health centers and 12 facilities
providing combined mental health and substance abuse services.53
PUBLIC HEALTH PROGRAMS SERVING
HIV-POSITIVE INDIVIDUALS
There are a variety of ways that people with HIV/AIDS in Alabama can receive health
coverage and care, including Medicaid, SCHIP, Medicare, Ryan White programs,
and the AIDS Drug Assistance Program.
Medicaid
Funding, expenditures, enrollment
Alabama Medicaid is Alabama’s plan for medical assistance under Title XIX of the
Social Security Act. It is operated on the basis of nondiscrimination and provider
choice.54 Medicaid is funded by both federal and state contributions. The federal
medical assistance percentage (FMAP) is used to calculate the federal contribution to
state Medicaid programs. Alabama’s FMAP for FY10 is 68.01, meaning that for every
state dollar spent on Medicaid, the federal government contributes $1.68. In FY06, total
Medicaid spending in Alabama was $3,885,724,359. Seventy percent (about $2.7B)
came from federal funds and 30% (about $1.2B) came from the state. For the US as a
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whole in FY06, 57% of Medicaid spending was federal and 43% came from the states.
Fifty-five percent of FY06 Alabama Medicaid dollars were spent on acute care, 35%
on long-term care, and 11% on disproportionate share hospital payments. Twenty-one
percent of Alabama residents (947,900 people) were enrolled in Medicaid in FY05, just
above the national average of 20%.55
Eligibility and programs
Alabama Medicaid has several different programs to provide health coverage for
low-income citizens. For all programs, in order to be eligible, an individual must be
a US citizen or a qualified alien.56 Documentation of the requisite status is required.
An individual must be an Alabama resident unless a residency agreement applies.57
Medicaid providers of services to Medicaid-eligible hurricane evacuees need to enroll
as a Medicaid provider in the evacuees’ home states, such as Mississippi and Louisiana,
to be reimbursed.58 To qualify for Medicaid, individuals must fit an eligibility category
and must have countable income under a certain amount (the income limit is also called
the income standard).59 Medicaid also has asset limits, which vary by program.
Assets (also called resources) such as cars, life insurance, household goods, burial
funds, and a property used as a home are not counted toward the limit.60
Alabama Medicaid programs include, among others, SSI-related Medicaid, Pregnant
Women and Children (called SOBRA from the Sixth Omnibus Budget Reconciliation
Act), Medicaid for Low-Income Families (MLIF), Plan First, Nursing Home, Home and
Community-based Waivers, and Medicare Savings Programs, which are discussed in
the following Medicare section.61 Different agencies handle Medicaid applications for
the different programs. The US Social Security Administration (SSA) certifies SSI-related
individuals. The Alabama Department of Human Resources certifies applicants for foster
children and children who receive state or federal adoption assistance. The Alabama
Medicaid Agency handles applications for all other programs.
Alabama does not have a “medically needy” Medicaid program. A medically needy
program allows people who are categorically eligible for Medicaid (such as the disabled)
but slightly over the income limit to become eligible by “spending down” their excess
income until they meet the income requirements.
Most Alabama Medicaid beneficiaries are enrolled in Patient 1st, the primary care
case management program (PCCM).62 Patient 1st establishes a medical provider and a
medical home for enrollees. For Patient 1st participants, Medicaid will pay for medical
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care only if participants go through their primary care provider (PCP) first.63
For many Alabamians living with AIDS, Medicaid eligibility is associated with their
receipt of federal Supplemental Security Income (SSI) disability benefits. To qualify
for SSI, an individual must be over 65, blind, or disabled, and have very low income.
Alabama is a Section 163 state, meaning that the state accepts the SSA determination
of disability. SSA defines disability as “the inability to do any substantial gainful activity
by reason of any medically determinable physical or mental impairment which can
be expected to result in death or which has lasted or can be expected to last for
a continuous period of not less than 12 months”—in other words, severe medical
impairment(s) that prevent someone from working.64 For 2009, SSI-related Medicaid in
Alabama has a countable income limit of $694 per month for an individual and $1,031
for a couple; countable resources may not exceed $2,000 for an individual and $3,000
for a couple.
SOBRA Medicaid covers low-income pregnant women and children up to age 19.
For pregnant women and children under 6, the income standard is 133% of FPL. In
2009, that is $1,552 for a family of 2 and $2,350 for a family of 4. Children aged 6 to
19 must have countable family income of 100% or less of FPL—$1,167 for a family
of 2 and $1,767 for a family of 4.65
Medicaid for Low-income Families covers the parents or caretaker relatives of
children aged 6 to 19 in extremely low-income families. The 2009 income standards
for MLIF are $137 for a family of 2 and $194 for a family of 4 (about 11% of FPL).
People included in families must be blood related, related by marriage, or adopted.
For both SOBRA and MLIF Medicaid, certain deductions for working adults, child
support, and dependent care costs can be applied to gross income to determine the
net income amount.66
The Plan First Medicaid program provides family planning services to women aged
19 to 55, with income at or below 133% of FPL. Plan First participants receive family
planning services only—other medical services are not covered. Family planning
services include counseling, pregnancy tests, testing for HIV/AIDS and other STDs,
and pap smears.67 The Breast and Cervical Cancer Program provides coverage for
certain women under age 65 who have been screened through the CDC’s National
Breast and Cervical Cancer Early Detection Program.68
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Nursing home or institutionalized Medicaid provides coverage for long-term care for
certain low-income elderly or disabled beneficiaries. Alabama has several home and
community-based waiver programs, which provide health coverage at home and in
the community for individuals who would otherwise be eligible for institutional care.
One of these is the HIV/AIDS Waiver Program, which has a total of 200 slots. Care
under this program includes case management, homemaker services, personal care,
respite care, skilled nursing, and companion services. Hospice care is covered, though
people with HIV/AIDS have specific criteria with which to qualify.69
Covered services and limits
All medical services provided under Alabama’s Medicaid program must be medically
necessary and be coded, either under the Physician’s Procedural Terminology or
Healthcare Common Procedure Coding. Alabama Medicaid offers mandatory
(required by federal law) and optional services (see Appendix D for a list). Copayments
are required for certain services, including doctor visits, clinic visits, prescription drugs,
and inpatient hospital stays.70
Office visits are limited to 14 visits per year. Office visits include eye exams,
psychiatric care, prenatal care, postnatal care, second opinions, consultations, and
referrals. Exceptions to the 14-visit limit include emergencies, family planning, and
inpatient psychiatric care for enrollees over 65 years of age. According to the Alabama
Administrative Code, inpatient hospital visits are limited to 12 days per year,71 although
other Alabama Medicaid Agency materials state that Medicaid pays for 16 inpatient
hospital days per year.72 Exceptions to the inpatient limit include deliveries and awaiting
admission to nursing homes while in certain hospitals.
Alabama Medicaid does not cover preventive care, such as routine physical exams,
dental care, and hearing exams and aids, for enrollees over age 21. Enrollees under 21
years of age are entitled to well-child check-ups, dental services (not orthodontia), and
hearing screenings and aids. Enrollees under age 21 may also be covered for additional
inpatient hospital care.
Medicare
Medicare is a federal health insurance program for the elderly and disabled who have
worked long enough to qualify for coverage.73 As of January 2008, there were 804,351
Medicare beneficiaries in Alabama, or 17% of the population. Seventy-seven percent
of Medicare beneficiaries were aged (over 65) while 23% were disabled. Nationally,
84% of Medicare beneficiaries are aged and 16% are disabled.74
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Some low-income Medicare beneficiaries can receive assistance from Medicaid with
their Medicare premiums, deductibles, and coinsurance through Alabama Medicaid’s
Medicare Savings Programs (MSPs). MSPs only provide financial assistance and not
any additional medical services. Those eligible for MSPs include qualified Medicare
beneficiaries (QMBs), specified low-income Medicare beneficiaries (SLMBs), and
qualified individuals (QI-1s). QMBs have income below 100% of FPL and limited assets,
and are enrolled in Medicare Part A. Medicaid pays Medicare premiums, deductibles,
and coinsurance for QMBs and dual-eligibles (people eligible for both Medicaid and
Medicare).75 SLMBs have limited assets and income between 100% and 120% of FPL.
They can receive help paying Medicare Part B premiums only. QI-1s have limited assets
and income between 120% and 133% of FPL. They can receive Medicare expense
assistance when federal funds are available.76 Alabama Medicaid is not currently
accepting QI-1 applicants.77
State Children’s Health Insurance Program (SCHIP)
ALL Kids is the children’s health insurance program offered by ADPH for uninsured
children under age 19. Families who make too much money to qualify for Medicaid
but cannot afford private health insurance can get coverage through ALL Kids.78 To be
eligible, children must meet family income requirements, be Alabama residents, US
citizens or eligible immigrants, not covered by health insurance (with a 3-month waiting
period if previous health insurance is voluntarily dropped), and not eligible for Medicaid.
Income limits for ALL Kids range from 100% to 200% of FPL, depending on the age of
the children.79
Blue Cross Blue Shield of Alabama administers ALL Kids, with care provided through
a preferred provider network. Benefits include well-child check-ups and immunizations,
sick-child doctor visits, prescriptions, vision and dental care, hospitalization, mental
health, and substance-abuse services. Premiums range from $50 to $100 per year.
Copays may apply to nonpreventive services. As of the end of January 2009,
ALL Kids covered 70,770 children in Alabama.80
Another program that covers children is the Alabama Child Caring Program. It is
administered by a publicly-funded nonprofit foundation. This program covers children
under the age of 19 whose family gross income is under 235% of FPL. The child
must not be eligible for Medicaid or covered by private insurance. This program covers
periodic well-child physical examinations, physician office visits for illness or injury,
emergency care, routine immunizations, hospital outpatient care including surgery,
and diagnostic services and vision service.81
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Ryan White Program
In FY07, Alabama received $26,632,913 in Ryan White funding, 1.3% of the
approximately $2.1B national Ryan White appropriation. The following chart shows
the breakdown of Ryan White funding by part:
FY07 Alabama Ryan White Funding
Ryan White part
$ amount
% of total AL . Ryan White funding
Part B (total)*
$ 19,791,847
74%
Part C $ 5,645,891
21%
Part D $ 1,174,204
4%
Part F (dental reimbursement)
$ 20,971
<1%
TOTAL
$ 26,632,913
100%
†
‡
*Part B includes a base grant for a state, the ADAP award, ADAP supplemental grants, and grants to
states for emerging communities (communities reporting between 500 and 999 cumulative reported
AIDS cases over the most recent 5 years).
†Part C Early Intervention Services funds comprehensive primary healthcare in outpatient settings.
‡Part D funds family-centered services involving outpatient care for women, infants, children, youth,
and families.
In FY07, Alabama received no Part A funds, which are reserved for eligible metropolitan
areas and transitional grant areas. Alabama also received no funding for AIDS education
and training centers, special projects of national significance, or the community-based
dental partnership program.82
Ryan White funding is the main source of funding for HIV/AIDS programs in Alabama.
This is problematic because unlike entitlement programs such as Medicaid and
Medicare, Ryan White funds are subject to annual appropriations; the money can run
out, and even people who meet eligibility requirements may not be able to receive
services. In addition, Southern and rural states still receive disproportionately less
funding than more urban states, despite the reallocation in the 2006 Ryan White
HIV/AIDS Treatment Modernization Act.
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AIDS Drug Assistance Program
As of July 2009, the Alabama Department of Public Health reported 1,418 active
patients in AIDS Drug Assistance Program (ADAP) with open enrollment.83 Enrollees
must have a positive Western Blot test, be a resident of Alabama, have a total gross
income at or below 250% of FPL, and not be eligible for other medication programs.
ADAP provides medications during the Medicare Part D coverage gap (also called
the “donut hole”), with proof from clients’ insurers or pharmacies that they are in
the gap.84 It does not pay for Part D copayments for clients dually eligible for
Medicaid and Medicare.
For people who meet the ADAP categorical and income eligibility criteria, are enrolled in
Medicare Part D, and have been denied low-income subsidy assistance (“extra help”),
the Medicare Part D Client Assistance Plan (MEDCAP) will cover Part D premiums
and copays for the Medicare Part D Plan selected by ADPH.85 MEDCAP clients must
enroll in the Part D Plan chosen by ADPH; this plan can change from year to year.86
When MEDCAP participants reach the Part D donut hole, they are moved to ADAP for
medication coverage, although MEDCAP continues to pay the Part D premiums.87
As of July 2009, there were 7 MEDCAP participants.88
Alabama ADAP covers 58 HIV medications. According to the ADPH Web site, as of
September 2008, 45 “other medications” (including, among others, antidepressants;
antipsychotics; medications for high blood pressure, diabetes, and high cholesterol;
antibiotics; hepatitis B and C treatments; and vaccines for HPV and hepatitis A and
B) were included in the ADAP formulary, with the caveat that “medications in this
group may be removed from the formulary at any time to ensure that Alabama’s
ADAP continues to maintain adequate funding to provide anti-HIV medications for
enrollees.”89 Prior approval is needed for Fuzeon, Maraviroc, Procrit, and some hepatitis
C medications. A list of drugs covered by ADAP is posted on the ADPH Web site.90
The total ADAP budget in FY08 for Alabama was $16,313,574 with federal funding of
$11,238,171 (69%) and state contributions of $5,075,403 (31%).91 This was a 4% overall
decline from FY07 ADAP funding levels, but the state contribution to ADAP actually
increased 14% from FY07 to FY08 (comprising 31% of the FY08 budget vs 26% of the
FY07 budget).92 In June 2008, Alabama ADAP served 1,207 clients (94% of whom were
uninsured) and filled 3,219 prescriptions; the total drug expenditure for June 2008 was
$1,132,283, or an average of $938.10 per client.93
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OTHER HIV/AIDS-RELATED LAWS AND POLICIES
Under Alabama Code 22-11A-21, “Reporting Notifiable Diseases,” HIV transmission is a
Class C misdemeanor. The law states, “Any person afflicted with a sexually transmitted
disease who shall knowingly transmit, or assume the risk of transmitting, or do any act
which will probably or likely transmit such disease to another person shall be guilty of
a Class C misdemeanor.”94 Class C misdemeanors are punishable by fines of not more
than $500.95
Alabama has a quarantine law and regulation that allows public health officials to isolate
individuals with sexually transmitted diseases deemed to present a danger to the public
health.96 Alabama AIDS service providers note that a sheriff in Tuscaloosa has invoked
the quarantine law against a person living with HIV, and that there is always the threat
of the law being used.97
Alabama mandates education about HIV and sexually transmitted infections,
requiring that abstinence be stressed and contraception covered. Sex education
is not mandated—if it is taught, it also must cover contraception but stress
abstinence. Parents may opt their child out of sex or HIV education based on
religious or moral beliefs.98
OTHER PROGRAMS SERVING PEOPLE WITH HIV/AIDS
The Alabama HIV/AIDS Hotline (1-800-228-0469) is a toll-free source of information
and referrals. Advocacy groups serving people with HIV/AIDS include HIV prevention
community planning groups in every area of the state. There are also regional direct
care consortia for planning of services in all local areas.
Alabama Department of Public Health (ADPH) runs several HIV prevention programs.
They have a “get tested” campaign employing 5 tractor trailers to advertise the need
to get tested for HIV across the state. They have a brochure distribution program. They
also run the HIV prevention community planning groups. These groups bring together
health department employees, AIDS service and community-based organization staff,
and other interested partners to develop new, culturally-sensitive HIV prevention and
testing services. Each prevention network group is charged with 10 tasks, including
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fostering dialogue about HIV/AIDS, creating flyers and fact sheets, collaborating with
health, education, and social service professionals, conducting prevention activities, and
maintaining a calendar of events. The prevention network groups, corresponding to the
11 public health areas, are:
• Northwest Alabama HIV Prevention Network Group (PHA 1)
• Northeast Alabama HIV Prevention Network Group (PHA 2)
• West Alabama HIV Prevention Network Group (PHA 3)
• Jefferson County HIV/AIDS Prevention Network Group (PHA 4)
• HIV/AIDS Ongoing Prevention Education (HOPE) Network Group (PHA 5)
• Cheaha-Coosa Valley HIV Prevention Network Group (PHA 6)
• Black Belt HIV Prevention Network Group (PHA 7)
• East Central Alabama HIV Prevention Network Group (PHA 8)
• Southwest Alabama AIDS Prevention Coalition (PHA 9)
• Southeast Alabama HIV Prevention Network Group (PHA 10)
• Mobile County HIV Prevention Network Group (PHA 11)
There are a number of private programs serving people in Alabama with HIV/AIDS.
A nonexhaustive list includes:
• AIDS Alabama (Birmingham, www.aidsalabama.org ): AIDS Alabama operates
a statewide rental assistance program and provides transitional and permanent
housing, including substance abuse housing and rural housing, to people living
with HIV/AIDS. AIDS Alabama also offers mental health, substance abuse,
transportation, testing, and prevention education services for people with
HIV/AIDS, and researches access to rural care. AIDS Alabama provides annual
conferences and trainings for the state’s community-based organizations
and clinics on case management, post-test counseling, housing, and other
pertinent topics.
• AIDS Action Coalition (Huntsville, Florence, www.aidsactioncoalition.org/
welcome/index.html): AIDS Action Coalition runs the Davis Clinic, which
treats individuals with HIV/AIDS on a sliding scale basis. Confidential testing is
available along with support services, including social support, transportation
assistance, and medication assistance. AIDS Action Coalition also engages in
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community education and prevention.
• Alabama Disability Advocacy Program (www.adap.net/hiv.html):
The Alabama Disability Advocacy Program provides legal counsel for
individuals with HIV/AIDS. Cases include insurance, employment,
immigration, guardianships, and wills.
• Alabama Family Trust (www.alabamafamilytrust.com): Alabama Family
Trust assists with preparation of special needs trusts for people receiving
needs-based government benefits.
• Birmingham AIDS Outreach (Birmingham, www.birminghamaids
outreach.org/): Birmingham AIDS Outreach offers food, transportation,
help with medical costs, and a clothing closet for people dealing
with HIV/AIDS.
• Franklin Primary Health Center (Mobile, www.franklinprimary.org):
Franklin Primary is a nonprofit community health center, focusing on the
needs of the medically underserved, with 10 locations in Mobile, Baldwin,
and Choctaw counties. Among the health services provided are HIV care,
prevention, education, and testing services.
• Health Services Center, Inc. (Anniston, www.hscal.org): The Health
Services Center offers HIV medical care, education, and supportive services
to a 14-county area of East Alabama.
• H
omeward Bound (Phenix City, www.homewardboundinc.net):
Homeward Bound offers HIV education, testing, counseling, and prevention
programs. Prevention programs focus on reaching African Americans
and Latinos. Homeward Bound also provides a support group and local
transportation assistance.
• Jefferson
County AIDS in Minorities (AIM) (Birmingham,
205-781-1654): Jefferson County AIDS in Minorities provides culturally
sensitive services, including education, medical, mental health, family
therapy, and referral services, in the minority communities of the
greater Birmingham metropolitan area.
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• Montgomery AIDS Outreach (Montgomery, Dothan, www.maoi.org):
Montgomery AIDS Outreach provides medical care, social services, and
prevention education in Montgomery and 22 surrounding counties in Southeast
Alabama. MAO operates the Copeland Care Clinic in Montgomery, a clinic in
Dothan, and rural clinic sites in Auburn, Clayton, Greenville, Selma, and Troy.
• Selma AIR (AIDS Information and Referral) (Selma, www.selmaair.
bravehost.com): Selma AIR promotes community awareness of HIV/AIDS and
provides HIV/AIDS education and services in 8 counties within the Black Belt
area (Choctaw, Dallas, Hale, Lowndes, Marengo, Perry, Sumter, and Wilcox
counties). Services include certified HIV/AIDS educators, a speakers’ bureau,
counseling and testing, case management, a health monitoring clinic, and
support groups.
• South Alabama CARES (Community AIDS Resources, Education
& Support) (Mobile, www.southalabamacares.org): South Alabama CARES
provides support, assistance, education, and advocacy for people affected
by HIV/AIDS and provides HIV prevention education and awareness to the
community of Southwest Alabama. Client services include case management,
social and practical support services, and housing.
• Unity Wellness Center (UWC) (formerly AIDS Outreach) (Auburn,
www.aidsoutreacheamc.org ): UWC, in partnership with East Alabama
Medical Center, provides services to people living with HIV in a 5-county,
extremely rural area covering 3,000 square miles in east Alabama. UWC
services include access to medical care, medications, medical and nonmedical
case management, HIV counseling and testing and post-test education,
outreach, housing (rural housing campus), emergency financial assistance,
and transportation.
• UAB (University of Alabama Birmingham), 1917 Clinic (Birmingham,
www.1917clinic.org/): The 1917 Clinic at UAB has provided healthcare and a
wide range of supportive services to people living with HIV/AIDS and their
families for more than 21 years. The 1917 Clinic uses multidisciplinary teams
to engage and retain patients in medical care and social service support, and
provides a “one-stop shop” for HIV care. Project CONNECT facilitates prompt
access to care for new clinic patients. The clinic also conducts clinical trials to
find new HIV/AIDS treatments and educates other healthcare providers about
the care and management of HIV disease.
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• UAB (University of Alabama Birmingham), The Family Clinic (Birmingham,
Montgomery, www.uabhealth.org/12343/): Part of UAB’s Department of
Pediatrics, the Ryan White–funded Family Clinic provides comprehensive
medical care and supportive services to families infected and affected
by HIV/AIDS.
• West Alabama AIDS Outreach (Tuscaloosa, www.waao.info/en/):
West Alabama AIDS Outreach offers free confidential testing and education,
as well as case management and other support services for individuals
living with HIV/AIDS.
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MEDICAID IN ALABAMA
Challenges
Alabama residents seeking health coverage through Medicaid face challenges first in
getting access to the program, and if enrolled, face further challenges due to the limited
scope of services covered. Alabama’s Medicaid program has lower income eligibility
levels and is more restrictive than many other states’ programs.
Nonelderly adults in Alabama generally get Medicaid coverage in one of 2 ways: by
being part of a low-income family with children, or by receiving Supplemental Security
Income disability benefits from the federal Social Security Administration.99 Medicaid
for Low-Income Families (MLIF) is a healthcare program that covers the parents or
caretaker relatives in very low-income families with children under 19. To be eligible for
MLIF in 2009, a family of 2 must have income of less than $137 per month, and a family
of 4 less than $194 per month. The Alabama Medicaid Agency itself notes that MLIF
meets federal income requirements, “but is well below the national average” and “
[c]overs only the poorest of the poor” at 11.5% of the Federal Poverty Level (FPL).100
In fact, Alabama’s income eligibility standard for families is the lowest in the nation.101
To get SSI benefits, claimants must be found disabled by the SSA, an arduous process
that often takes several years. In most states, including Alabama, simply being
HIV-positive and low-income is not enough to qualify for benefits. A person must also
have another medical condition severe enough to prevent him or her from working.102
To receive SSI-related Medicaid in Alabama, individuals must have income less than
$694 per month in 2009 (77% of FPL).
Unlike many other states, Alabama has no “medically needy” Medicaid eligibility
category. A medically needy category allows people who are categorically eligible for
Medicaid (such as the disabled) but slightly over the income limit to become eligible by
spending down their excess income until they meet the income requirements.
Medically needy eligibility recognizes that high healthcare costs can push near-poor
individuals into poverty.
Alabamians who do obtain Medicaid coverage receive a benefit package that is
among the most limited in the nation. Doctor’s visits are limited to 14 per year,
hospital days to 12 per year, and no preventive care is offered.103 Alabama Medicaid
covers 13 optional services (out of 27 listed), including prescription drugs, clinic
services, and hospice services,104 but this coverage is limited. Patients are generally
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allowed no more than 5 brand name prescriptions per month, but for antiretroviral
(and antipsychotic) medications, the limit is 10 brand name prescriptions per month.
Prior authorization is generally required for drugs not on the preferred drug list (but is
not required for HIV medications).105 The preferred drug list is posted on the Alabama
Medicaid Agency Web site.106
One optional service that Alabama Medicaid covers is transportation through the
nonemergency transportation (NET) program. NET requires prior authorization and
provides transportation only to appointments for Medicaid-covered services.107 Alabama
providers report that Medicaid paratransit is difficult to use. Clients themselves must
call to request the service (rather than having a social worker or case manager call),
and the organizations rarely get reimbursed. Clients state that Medicaid paratransit
does not transport clients across county lines, even if the closest medical provider is
in a neighboring county.108 This does not appear to be an official regulation or policy,
as neither the Alabama Medicaid Provider Manual nor materials provided for Medicaid
recipients refer to transportation across county lines.109
There are a few bright spots in the Alabama Medicaid program for people living
with HIV/AIDS. Alabama is one of only 11 states with a targeted case management
program for people with HIV. Even more unique is the fact that this program is funded
by Medicaid. Although there have been funding problems in the past, the Alabama
Medicaid Commissioner remains committed to reimbursing for these services. This
frees up Ryan White funds to provide services to people who would not otherwise get
assistance. One issue flagged by advocates as problematic with case management is
the policy that only one provider can get reimbursed for providing services to a client,
even if the client receives different services from more than one provider. For example,
if a client received housing-related services from one provider and transportation
services from another, only one of the providers could “claim” the client and receive
payment.110 This poses significant burdens for providers, especially when there are few
“one-stop shops” for clients to get all the services they need.
Alabama also has a Medicaid waiver to provide in-home care for people with HIV/AIDS
who would otherwise be in a nursing home. Eligibility for this program is less restrictive
than for regular Medicaid. The HIV home care waiver program has 200 spots, with
60 currently filled.
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Opportunities
Alabama’s Medicaid program can be improved both in access and coverage.
Raise Medicaid income standard/create “medically needy” eligibility category
Raising the Medicaid income standard and/or creating a medically needy spend-down
category of eligibility would allow more people affected by HIV/AIDS to access health
coverage. As part of the 2009 American Recovery and Reinvestment Act (ARRA, known
as the “stimulus act”), all states will receive a 6.2% increase in base federal medical
assistance percentage (FMAP). States with significant changes in unemployment
could get an additional FMAP increase. The Alabama Medicaid Agency has stated that
“every 1% increase in the FMAP provides $38M additional dollars to the state.”111 A
6.2% increase should bring an additional $235.6M to Alabama, which could be used to
expand Medicaid coverage. The US Government Accountability Office has estimated
that Alabama will receive an additional $850M from ARRA for Medicaid costs from
FY09-FY11.112
Raise Medicaid reimbursement rates
In addition to expanding coverage, the enhanced FMAP funding could also be applied
to improve Medicaid reimbursement rates. Low reimbursement rates put providers in
a position of not being able to afford to provide care to Medicaid beneficiaries, further
exacerbating already limited access to care (see section 2, “Provider Shortages in
Alabama”).
Use presumptive eligibility/HIV waiver
Other states have increased Medicaid access for people with HIV/AIDS by creating a
presumptive eligibility category and by using waivers to cover predisabled HIV-positive
individuals. Both Massachusetts and Maine have waivers allowing HIV-positive lowincome people to qualify for Medicaid. Earlier access to Medicaid can actually reduce
costs, as people with earlier access to care stay healthier longer, and can avoid more
expensive medical interventions.
The federal Early Treatment for HIV Act (ETHA), which is modeled on the Breast and
Cervical Cancer Prevention and Treatment Act of 2000, would expand on the Maine and
Massachusetts examples. ETHA would give all states the option of providing Medicaid
coverage to low-income, predisabled people living with HIV and would provide states
with enhanced FMAPs for the program. Advocates should ask Alabama’s members of
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Congress to cosponsor and actively support ETHA.
Improve Medicaid benefits package and make benefits easier to use
Advocates can also look at improving the Alabama Medicaid benefits package by
increasing the number of doctor and hospital visits covered, either generally or through
a “carve-out” for people living with AIDS. The NET program (transportation) could
also be modified to improve access to care. Two ways to do this would be (1) to allow
organizations to call Medicaid paratransit instead of the clients, to schedule trips that
could serve multiple patients; and (2) to end the restriction and practice prohibiting
crossing county lines for care. There should be a closer look at the existing home care
HIV waiver, to determine why only 60 of 200 slots are filled. Advocates suggest that
one possible reason is the procedural and paperwork burdens of the program, such as
the requirement that a doctor certify the cost-effectiveness of the home care.113 Ways
to streamline the home care waiver application process should be considered. Finally,
Alabama HIV/AIDS advocates should continue to work in collaboration with other
advocates in the state to improve Medicaid access and services.
PROVIDER SHORTAGES IN ALABAMA
Challenges
There are shortages of primary care providers (PCPs) across the nation, but the
situation in Alabama is particularly dire. About 20% of people nationally are medically
disenfranchised—that is, lack adequate access to a PCP due to a local shortage of
physicians.114 In Alabama, nearly 56% of residents were medically disenfranchised in
2005—more than twice the national average and the highest rate in the nation.115
More than 1 million Alabama residents lack access to a PCP.116
For people living with HIV/AIDS, finding good healthcare can be even more difficult,
both in Alabama and across the country. A recent survey by the American Academy
of HIV Medicine indicated that nearly one-third of surveyed HIV healthcare providers
(including physicians, physician assistants [PAs], and nurse practitioners [NPs]) intend
to stop practicing over the next 10 years.117 Alabama has relatively few doctors qualified
and willing to provide HIV care. Reasons for the shortage of HIV physicians include the
specialized training needed, the relatively low reimbursement rates (especially in the
Medicaid program), and the stigma associated with HIV-affected individuals.118
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The shortage of physicians in Alabama has dramatic effects, and can compromise
both individual and public health. One effect is the often long wait to get an
appointment. The lack of qualified providers in Auburn and Huntsville has at times
resulted in a 3-month wait to see an HIV-trained physician.119 It is difficult to attract
physicians to work in HIV clinics, as indicated by the difficulties that the 1917 Clinic
at the University of Alabama Birmingham has had in finding new providers.120 Staff at
another clinic in Florence noted that they have been searching for more than 8 months
for a physician to work only 1 afternoon a week—thus far, with no success.121
Along with protracted waits for appointments, the lack of physicians means that
patients must often travel long distances to see a doctor. Dr. John Wheat, professor
of community and rural medicine at the University of Alabama College of Community
Health Sciences and School of Medicine, states, “In the Black Belt, people have to drive
70 miles to get a doctor to care for them.”122 People who need to see a specialist may
have to travel even farther. Alabama AIDS services providers report that some clients
can spend 7 hours getting to and from medical appointments.123 Public transportation is
minimal and only exists in more urban areas.124 Volunteer organizations have attempted,
with some success, to meet clients’ transportation needs through creative solutions.
However, the costs of traveling long distances for medical care can often be prohibitively
expensive, both for individuals and for resource-strapped organizations that try to help
them. AIDS service providers report that it can cost up to $250 per trip per patient to
get clients to appointments.125
The long waits for appointments and long travel times caused by the shortage of
providers compromises standards of care for people living with HIV/AIDS, and can
negatively affect their health. Research has found that lack of a PCP (including an
NP or PA) leads to worse outcomes for HIV-positive patients.126
In addition to poor health outcomes for individuals, the lack of physicians can also lead
to damaging public health consequences. Individuals whose access to care is erratic
may be less likely to adhere to treatment regimens, leading to the development of
drug-resistant strains of HIV. Individuals who do not have consistent healthcare may be
more likely to engage in behaviors that can spread HIV.127 They may also have higher
viral loads, making them more likely to transmit HIV if they do engage in risky behaviors.
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Opportunities
There are several possible opportunities that could help address the problem of provider
shortages. Raising Medicaid reimbursement rates, creating more incentives for clinicians
to practice in underserved areas, and encouraging increased use of NPs and PAs are all
methods by which to attract additional providers and to encourage existing ones to treat
HIV-positive patients.
Raise Medicaid reimbursement rates
As discussed in section 1, “Medicaid in Alabama,” the rates of reimbursement through
Medicaid are often insufficient to cover the costs of providing HIV care. For example,
the 1917 Clinic loses around $1M a year because of poor reimbursement rates.128
HIV-positive patients often require more complex management and are more time
intensive, a problem when reimbursement rates for office visits can be as low as $17.129
Without an increase in reimbursement, it will be difficult to attract and retain healthcare
providers in Alabama and to get them to accept Medicaid patients.
Offer clinicians incentives for rural practice
Another way to attract medical talent to Alabama would be to create incentives for
clinicians to practice in underserved areas. Alabama has a state income tax credit for
physicians who practice and reside in rural communities.130 A bill introduced in the 2009
legislative session (HB 618) would have increased the amount of this tax credit and
extended the years for its allowance. Another bill (SB 21) would have increased the
amount of scholarships for medical students agreeing to practice in rural areas.
Neither bill passed.
Alabama could also consider the creation of loan forgiveness programs to attract new
providers to work in rural areas and with poorer populations. New Mexico Health
Resources operates a program in that state that matches individual practices and clinics
with new providers. It also coordinates with many federal and state loan repayment
programs. By careful outreach and placement, New Mexico Health Resources allows
students to pursue financial assistance in exchange for service in underserved areas.
Although these students often leave after the terms of the service are met, there is a
constant source of new providers through these programs.
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The federal National Health Service Corps (NHSC), part of Health Services Resource
Administration (HRSA), helps communities recruit and retain healthcare providers, and
provides loan forgiveness for clinicians who work in health professional shortage areas.
Alabama Department of Public Health has used this federal program in the past to find
doctors for underserved areas of the state.131 But the NHSC loan forgiveness program
applies only to PCPs, not to specialists.132 Many of the sites that qualify for NHSC
participation, such as federally qualified health centers or rural health centers, do not
have expertise in HIV treatment. Working with HRSA to create a federal requirement
that NHSC sites have HIV treatment expertise, or be able to link patients to a site that
does, would improve access to care for Alabamians living with HIV disease in medically
underserved areas. According to advocates, some of these conversations with HRSA
are already happening.133
Expand the scope of practice for nurse practitioners and physician assistants
Other states use NPs and PAs to address physician shortages. NPs are registered
nurses who have a master’s degree or other advanced training in nursing.134 Alabama’s
NPs must have a master’s degree or higher.135 NPs are required to be in a collaborative
relationship with a physician in order to practice, and the collaborating physician must
be on-site for at least 10% of the NP’s scheduled hours.136 PAs in Alabama must have
graduated from an approved program, be licensed and registered by the State Board of
Medical Examiners, and work under the supervision of a physician.137 A recent study in
the Annals of Internal Medicine found that the quality of care provided by NPs and PAs
was similar to or better than care provided by doctors in HIV clinics.138
Despite the severe shortage of healthcare providers, Alabama’s regulations significantly
limit the ability of NPs and PAs to practice. The “10% on-site” rule for NPs makes it
very onerous to sustain remote-practice sites in rural locations, where there are few
practicing physicians. The cumbersome administrative process and fees associated
with NP collaborative practice are also a disincentive. Alabama should simplify
the collaborative practice process and eliminate fees for collaborative practices in
underserved areas.139
Alabama also restricts the scope of practice for PAs and NPs more than other states.
The Alabama State Nurses Association (ASNA) notes that “Alabama is one of the most
restrictive states in the union in allowing NPs to do what they are trained and educated
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to do.”140 Alabama ranked last in the nation in a survey of NP practice regulation and
consumer healthcare choice.141 Alabama is one of very few states that still restrict
PAs and NPs to a specific list of allowed tasks. The American Academy of Physician
Assistants notes that
Many state legislatures or licensing boards created lists of items
that could be included in a PA’s scope of practice. However, states
soon determined that this approach was both impractical and
unnecessary…most state laws have abandoned the concept that
a medical board or other regulatory agency should micromanage
physician-PA teams.142
Most other states in the country use a standard that sets a PA’s scope of practice as
medical functions within the scope of practice of the supervising physician, as delegated
by the supervising physician.143
One specific example of restrictions on PA and NP practice pertains to prescribing
controlled substances. Controlled substances in Alabama include medications
considered to have a high potential for dependence or abuse, such as opiates,
stimulants, and depressants.144 According to the Alabama Society of Physician
Assistants, the inability to prescribe routine medications compromises the provision
of quality primary care, increases the number of visits to emergency rooms, and
forces patients to make return trips to the doctor’s office.145
Alabama is one of 3 states that do not allow NPs to prescribe controlled substances.146
Until 2009, Alabama was one of 4 states where PAs cannot prescribe controlled
substances.147 In the 2009 legislative session, Alabama lawmakers passed the PA
Controlled Substance Bill (HB 484/SB 359), which allows supervising physicians to
delegate authority to PAs to prescribe Schedules III through V controlled medications.148
Governor Riley signed the bill, which was supported by the Medical Association of the
State of Alabama (MASA), into law on May 13, 2009.149
Because PAs and NPs often help provide care to underserved populations, restrictions
on their practice can have a disproportionate negative effect on individuals who
already face significant barriers to care. Changing Alabama law to lessen restrictions
and broaden the scope of PA and NP practice could help improve healthcare access,
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particularly for marginalized populations. There are numerous ways to do this.
Passage of the PA Controlled Substance Bill is a start. Alabama should also consider
joining the majority of states by allowing PAs’ scope of practice to be determined by
the supervising physician, rather than by a specific list of activities.
Expanding NPs’ scope of practice is essential to improving healthcare access.
Currently, a Joint Committee of the Board of Nursing and the Board of Medical
Examiners oversees NP practice. One commentator has noted that letting the scope
of practice be determined by the Board of Medical Examiners may restrict access to
care, because the board of medicine often votes in the interest of cutting down on
competition with doctors.150
A bill in the 2009 legislative session would have remedied many of the limitations on
NP practice. Filed by Senate Health Committee chair Linda Coleman, SB 483 would
have given the Alabama Board of Nursing sole regulatory authority over NPs (retaining
physicians in an advisory capacity only), would have deleted the requirement for NPs
to have a written collaborative agreement with a physician, would have designated
NPs as PCPs, and would have allowed NPs to prescribe Schedules II-V controlled
drugs.151 While a public hearing was held on SB 483 in April 2009, the bill died in
the Senate Health Committee.
As with similar bills in the past, MASA strongly opposed SB 483. MASA believes
that patient quality of care would be compromised by NPs practicing independent of
physician oversight, and that the current law provides enough flexibility for NPs to see
patients without a physician present, while still providing patient safeguards.152 Of note
is the fact that the Executive Director of the Board of Medical Examiners is Alabama
Senator Larry Dixon, who sits on the Senate Health Committee. Senator Dixon has
opposed efforts to expand patient access to NPs and efforts to implement nationally
recognized standards for NP scope of practice.153
Also significant is the fact that under Alabama law, MASA’s Board of Censors (the
group that sets policy for MASA) is the Board of Medical Examiners.154 Thus, a group
that does not want expanded roles for NPs is the group regulating NP collaborative
practice agreements.
Increase reimbursement rates for NP and PA services
Another barrier to using NPs and PAs to expand access to care is insurance
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reimbursement of services. A report prepared at the request of Alabama Representative
(and physician) Robert Bentley found that the majority of NP practices in Alabama were
adversely affected by the lack of adequate third party reimbursement, and that the
majority of Alabama’s insured residents do not have NP coverage.155 Another report
observes that because the Alabama Nurse Practice Act156 defines NP practice as
“the performance of nursing skills” rather than the provision of healthcare, insurers
use this distinction to deny payment for services which, if performed by a physician,
would be paid in full.157
Blue Cross Blue Shield, Alabama’s largest private insurer, reimburses certified registered
NPs and certified nurse midwives in collaboration with a physician at 70% of the
physician rate.158 PAs are also reimbursed at 70% of the physician rate by Blue Cross
Blue Shield.159 Other private insurance companies either do not reimburse care provided
by NPs or reimburse at a greatly reduced rate. Amending the Nurse Practice Act to
designate NPs as PCPs could help, but advocates observe that MASA and Blue Cross
Blue Shield oppose this, since it would allow unfettered control of NP reimbursement
for both commercial insurers and Alabama Medicaid.160
Using nonphysician providers has economic consequences for healthcare facilities—
in fact, clinics operate at a loss when they use NPs on patients with private coverage.161
A clinic that is struggling financially will receive lower payments when NPs or PAs
provide the same services that doctors do. But the clinic may be using NPs or PAs
because it cannot find a doctor willing to work there. The current reimbursement
structure creates perverse economic incentives for clinics to turn patients away
at the door, rather than incur further financial losses by treating them. Increasing
reimbursement rates for NPs and PAs across the board would help correct this.
At a minimum, facilities that can certify that they are unable to get a physician to
provide services should get increased reimbursement rates from insurers for NP
and PA services.
Alabama has within its power the ability to improve its medical provider shortage
problem. In particular, Alabama should increase incentives for clinicians to practice in
underserved areas, expand PA and NP scope of practice, raise reimbursement rates,
and require private insurance coverage of PA/NP services. Such measures would
enable more Alabamians to access care, improving health and quality of life. Expanding
healthcare access is also cost-effective, as a healthier population is better able to work
(and pay taxes) and less likely to need high-cost medical interventions.
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STATE REVENUE AND SPENDING ISSUES
Challenges
Alabama’s revenue and appropriations structures present significant challenges and
unique opportunities for HIV and AIDS-related programs in the state. Alabama’s
Department of Revenue collected approximately $8.7B in 2007, ranking 44th in the
nation in state government tax collected per person.162 For total state government
tax collected in 2008, Alabama ranked 26th out of all states.163 Alabama’s total
appropriations were $11.5B in FY09.164 Alabama appropriates more than it collects in tax
revenue because it gets additional revenue from fees and other “non-tax” assessments.
Despite these additional revenue streams, Alabama’s pool of funds is markedly limited
compared with other states around the nation.
These limited resources are largely due to low tax rates on property, low income
taxes, and a system of credits and deductions that is particularly generous to wealthy
economic actors.165 The state’s limited resources become even more pronounced for
HIV/AIDS-related programs because Alabama earmarks more than 80% of revenue
for programs outside the discretionary State General Fund, which funds much of the
state’s public health needs.166 These 2 areas—earmarking and tax policy—are significant
challenges to the current HIV/AIDS infrastructure in the state, but they also represent
areas where even small changes could have a significant positive impact on resources
for HIV/AIDS programs and Alabama’s public health in general.
Alabama’s largest overall sources of nonfederal revenue are income tax, sales tax, and
insurance premium taxes (in lieu of income taxes on insurance companies).167 However,
the distribution of those taxes across the economy and the population may not be as
efficient as they could be. A recent study found Alabama’s tax code to be the most
onerous in the nation for families living at the poverty line.168 Another analysis found
that families in the lowest 20% of incomes (less than $16,000 a year) pay more than
11% of their incomes in state and local taxes, while families in the top 1% of incomes
($316,000 a year and above) pay 4.3%.169 Alabama residential property taxes are the
second lowest in the nation (only Louisiana has lower taxes).170 In contrast, combined
state and local sales taxes are above the national average.171 Individual income taxes and
corporate taxes are some of the nation’s lowest, and deductions for wealthy individuals
and myriad corporate activities help keep state tax receipts at such a low level.172
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Recent efforts to reform the tax system in Alabama have not been successful. Bills filed
in the 2009 legislative session (HB 116 and SB 115) would have removed the 4% state
sales tax on groceries. Alabama is one of only 2 states, along with Mississippi, to fully
tax groceries.173 Alabama is one of only 3 states (Iowa, Louisiana) that allow taxpayers
to fully deduct federal income taxes when computing the amount of state income tax
owed.174 The grocery tax cut would have been paid for by capping, for the highestearning households, the amount of federal income tax allowed to be deducted when
determining state income taxes. HB 116 and SB 115 both failed to pass.
Alabama’s extensive earmarking of revenue exacerbates the challenges posed by these
limited resources. In 2008, just under 18% of Alabama’s annual revenue was directed
toward the general fund, while more than 80% was earmarked for other specific uses.
Many states earmark a significant amount of their revenue but Alabama does so more
than any other state.175 By far the largest recipient of state revenue is the education
trust fund, receiving approximately 70% of state tax revenue and more than 55% of
total appropriations in FY08.176 While a small portion of the education trust fund is
directed toward health-related programs, it amounts to less than 1% of state healthcare
appropriations.177 Half of the state’s Medicaid contribution and a third of all other public
health funds come from the general fund.178 Other funds earmarked for Medicaid and
public health come from earmarked funds like tobacco settlement monies and transfers
from numerous other state agency collections.179
Efforts to increase revenue or “unearmark” funds have been met with tremendous
political opposition in Alabama. Political leaders, HIV/AIDS service providers, and
numerous local commentators make clear that Alabamians are fervently antitax and
distrustful of legislative discretionary spending.180 This political reticence, coupled with
the limited flexibility imposed by the state’s earmarking policy, is a significant challenge
for parties aiming to increase state contributions to HIV/AIDS programs.
Opportunities
While Alabamians have been wary of legislative discretionary spending, they have also
shown a significant commitment to certain types of public spending and budgetary
discipline. The state’s rainy day fund, its substantial annual commitment to the education
trust fund, and its willingness to offer generous tax deductions for certain individual and
corporate groups demonstrate a commitment to steady and generous public investment
in targeted areas. Therefore, if specific earmarks for HIV/AIDS funding
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could be designed in politically palatable ways, if new tax credits could be offered for
private investment in the state’s public health infrastructure, or if the state could make
even small changes to the general fund’s revenue streams, the outlook for HIV/AIDS
funding in the state might significantly improve. Broader structural change may require
state constitutional reform. All efforts could be helped by better educating the public
about Alabama’s revenue and appropriation structure.
Finding a way to involve Alabama’s business community could also help with funding.
While Alabama businesses have been commendably involved with improving the
general perception of Alabama, they have shown relatively little interest in HIV/AIDS
issues. This perhaps relates to the stigma about HIV/AIDS still present in Alabama or the
perception that HIV/AIDS issues are not especially relevant to the business community.
Demonstrating that there are economic, as well as public relations, advantages
associated with HIV education, prevention, and treatment could increase support
from the business community.
HIV AND SEGREGATION IN PRISONS
As of 2006, Alabama had 297 inmates living with HIV within its prisons.181 Alabama is
one of only 3 states in the nation to maintain a policy of housing HIV-positive inmates
in quarters segregated from other prisoners.182 Before 2007, Alabama Department of
Corrections (ADOC) policy excluded HIV-positive prisoners in state-run prisons from
many programs and activities available to HIV-negative inmates. Inmates with HIV were
not allowed to eat with other prisoners, hold prison jobs, use family visiting rooms,
participate in work release programs, participate in sports or recreational opportunities,
or have regular access to religious services.183
Past successes
In 2007, pressure from state legislators, along with advocates from the American Civil
Liberties Union (ACLU) of Alabama and AIDS Alabama, prompted ADOC Commissioner
Richard F. Allen to implement a reform of prison policies and procedures. These reforms
integrated HIV-positive inmates with the general prison population for visitation,
substance abuse treatment, educational programs, and religious services.184 In addition,
the HIV-positive inmates at Tutwiler Prison for Women were allowed to eat in the dining
hall with the rest of the prison population.
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Inmates with HIV are also integrated into ADOC’s Pre Release and Reentry Program.
This program, which was announced in 2007, works with inmates who are near the
end of their sentences to prepare them for reentering their communities. Inmates learn
basic living and job search skills, and are linked with resources to help them transition
from prison successfully. Goals of the program include reducing recidivism, increasing
public safety, and decreasing public health and social disparities within the offender
population.185 The current Pre Release and Reentry program is based on the Alabama
Prison Initiative (API), a program that was originally only for inmates with HIV/AIDS.
API is a collaborative partnership between the Alabama Departments of Corrections and
Public Health. API is supported by statewide AIDS service organizations and communitybased organizations, which provide services to prisoners both pre- and post-release.186
In August 2009, after more than 20 years of advocacy by the ACLU and others, ADOC
changed its prison work-release policy to allow HIV-positive inmates to participate in
work-release programs.187 This is an important victory, and one that can significantly
improve the likelihood of successful reentry into community life for inmates living
with HIV.
Challenges
The recent ADOC policy changes have improved and will continue to improve life for
Alabama’s HIV-positive prisoners, but challenges remain. Male HIV-positive prisoners at
Limestone Correctional Facility are required to eat separately in their living area, because
of “logistical reasons and space limitations.”188 All HIV-positive inmates are still housed
separately from the general population in HIV-only dormitories.
ADOC’s policies continue to prevent HIV-positive prisoners from having access to the
full range of programs and services available to other inmates. In addition to program
access, segregation by HIV status raises issues of privacy because HIV-positive inmates
are easily identified by everyone else in the prison community. HIV-positive inmates lose
control over decisions about when and to whom to disclose their status. Segregation
policies also reveal HIV status to visiting family members.
Trying to change ADOC’s segregation policies through the courts has generally been
unsuccessful. In 1991, the 11th Circuit ruled that isolating HIV-positive inmates did not
violate any constitutionally protected privacy rights of inmates.189 Eight years later, the
11th Circuit found that participation in any prison program by HIV-positive inmates posed
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a significant risk of transmission and the state was not required to hire additional guards
to allow integrated programs.190 However, an Alabama state court ruled that sharing a
jail cell with an inmate dying of AIDS did not violate the eighth amendment.191 A 2002
federal lawsuit by HIV-positive inmates at Limestone (known as the Leatherwood case)
resulted in a settlement agreement with the state, but the agreement focused primarily
on improving dismal living conditions and medical care, rather than on desegregation
of programs.
While the courts have not been receptive to antisegregation arguments, there has been
some support from Alabama state government. In 2003, the Alabama governor’s HIV
Commission for Children, Youth and Adults found that, “evidence is overwhelming that
the exclusion of prisoners from educational, vocational, rehabilitative, or communitybased corrections programs, simply on the basis of HIV status, has no public health or
correctional justification.”192 The commission went on to recommend “that prisoners
with HIV/AIDS be allowed to participate in all in-prison and out-of-prison programs on
an equal basis with other prisoners.”193 As a result of the Commission’s report, in 2005
ADOC began allowing HIV-positive inmates at Tutwiler and Limestone to participate in
some vocational training programs alongside HIV-negative inmates. These integrated
training programs have worked well.194
Opportunities
ADOC’s changes in HIV-related policies over the past few years provide some
encouragement that more can be done to end prison segregation. Advocates can
build on recent successes in a number of ways.
Increase collaboration among state agencies and community organizations
Collaboration and “cross-fertilization” among ADOC, Alabama Department of Public
Health (ADPH) (which has done HIV education in prisons for years), and community
organizations, like that in the API, should be fostered and expanded. Information from
other states’ innovative programs, such as the BRIGHT Project in North Carolina, could
help demonstrate the effectiveness of such collaborative programs. The BRIGHT
(Bridges to Good Health and Treatment) Project is a partnership between the University
of North Carolina Chapel Hill and the North Carolina Department of Corrections. It uses
an intensive case management model, starting 3 months prior to release, that focuses
on inmates’ strengths and on actively connecting them to medical and social services in
the community. Preliminary data from BRIGHT suggest that the program’s intervention
reduces rearrest and the use of emergency medical services.195
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Provide ADOC with more medical and public health information
ADOC could be provided with more medical and public health evidence that punitive
segregation policies do not further public health goals, and may in fact undermine them.
The recent change in work-release program policies indicates that Commissioner Richard
Allen and other ADOC officials are willing to consider such evidence, and adjust policies
in response.
Build broader coalitions
Building on work already done, HIV/AIDS advocates can further develop coalitions
with other like-minded groups, such as the ACLU, to push for an end to segregation,
but should also think broadly and creatively about other possible allies, such as the
business community.
Explore possibility of a lawsuit
While Alabama courts have not been particularly receptive to antisegregation arguments
in the past, a lawsuit is one possible approach to seek an end to segregation in housing
and programs.
LACK OF ANTIDISCRIMINATION LAWS
FOR PEOPLE LIVING WITH HIV/AIDS
Challenges
Alabama offers relatively little by way of state antidiscrimination protection for any
Alabama residents, including people living with HIV/AIDS. There is no state
administrative agency that handles discrimination claims. According to the Alabama
Department of Labor, Alabama has no laws protecting people from losing their jobs—
Alabama residents must rely on the antidiscrimination provisions in federal law.196
Where Alabama law does discuss employment and HIV status, it is only to limit
HIV-positive healthcare workers’ participation in procedures with an increased chance
of transmitting HIV.197
Given the lack of state antidiscrimination law, Alabama residents must rely on federal
law to protect their rights. For people living with HIV/AIDS, the federal Americans with
Disabilities Act (ADA) may provide a legal remedy. The ADA prohibits discrimination
based on disability in public services and accommodations, and in employment
situations. The US Supreme Court has found that HIV/AIDS is a condition covered by
ADA protections.198
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Opportunities
Educate providers and consumers about federal
antidiscrimination law protections
Organizations such as the Alabama Disabilities Advocacy Program (www.adap.net)
have already produced helpful materials designed to advise Alabamians living with
HIV/AIDS about privacy, employment, insurance, and other issues. Advocates can
continue to educate both consumers and providers about the protections available
under federal antidiscrimination law, and can consider creative legal arguments for
using federal law to protect HIV-positive Alabama residents.
Explore filing state legislation
While previous efforts to pass state antidiscrimination laws, such as the Alabamians
with Disabilities Act, have been unsuccessful, it may be time to again consider drafting
and filing a state antidiscrimination bill. As part of this, advocates could mount a public
awareness campaign about the lack of protections for all residents (not just those living
with HIV/AIDS) under state law.
Such a campaign could include a broad coalition of interested groups, and could ask
why Alabama does not protect its citizens from discrimination based on disability, race,
ethnicity, gender, age, religion, sexual orientation, or national origin. Why are Alabama
residents forced to depend on federal law and courts to guard their rights, particularly
given the “states’ rights” political climate in Alabama? Why should Alabama’s residents
have fewer rights than residents of other states? In conjunction with a legislative and
public awareness strategy, a survey of other states’ antidiscrimination laws, and how
Alabama compares, would be informative.
One argument in favor of a state antidiscrimination law that covers people living with
HIV/AIDS is that studies have shown individuals are more likely to seek testing in states
with antidiscrimination laws.199 Antidiscrimination laws help reduce HIV stigma and
encourage testing. Having more people in Alabama become aware of their HIV status
would have both individual and public health benefits, as people who know their status
are less likely to engage in behaviors that can transmit HIV.
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ADAP
Past successes
For those unable to procure health insurance, medication help is available through ADAP.
As of May 2009, Alabama’s ADAP had no waiting list, after having had a list of up to 395
people in the past. Alabama ADAP also covers clients in the donut hole coverage gap of
Medicare Part D. A total of 45 non-HIV-specific medications (to treat conditions such as
diabetes, high blood pressure, asthma, and hepatitis) are part of the ADAP formulary as
of September 2008.
Challenges
Eligibility for Alabama’s ADAP is restricted to those below 250% of FPL, which equals
$27,075 for 1 person in 2009. Alabama is one of 8 states with gross income eligibility at
250% of FPL or lower; other states fall between 300% and 500% of FPL.200 According
to the 2009 National ADAP Monitoring Project Annual Report, only 3 states have fewer
drugs on their formularies than Alabama.201
ADAP is funded through discretionary federal Ryan White appropriations and state
contributions. Alabama ADAP has an erratic funding history. In June 2004, President
Bush announced the President’s ADAP Initiative (PAI), a release of $20M to address
ADAP waiting lists in 10 states, including Alabama. At the time, Alabama had 395
people on its ADAP waitlist, and had the oldest waitlist in the country (started
in FY99).202 Alabama froze enrollment in ADAP in 2004.203 Rather than use the
approximately $4M in federal money from PAI to expand coverage, the state chose to
cut its contribution for ADAP by 80%—from $2.86M to $560,000 from FY03 to FY04.204
In April 2005, ADAP needed an emergency $1M infusion by the state legislature to
prevent 200 patients from losing ADAP help.205 Since then, state funding for ADAP rose
from $3M in FY05 to $6M in FY06, before dropping 26% to $4.5M in FY07, then rising
14% to $5M in FY08.
Funding for ADAP and other AIDS services in the FY10 General Fund budget was
only $2.88M, approximately half of the $5.7M needed.206 Advocates contend that this
appropriation is not enough to meet federal “maintenance of effort” requirements
(risking loss of Ryan White funding), and that Alabama ADAP will have enrollment
caps and a waiting list within a year.207 Such a financial shortfall could also mean that
non-HIV-specific medications would no longer be included in the ADAP formulary.
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The up-and-down state contributions to ADAP pose a risk to individuals, who may lose
access to medications, and to the broader public health, as people whose treatment is
interrupted may develop drug-resistant strains of HIV.
Opportunities
There are several ways that Alabama ADAP could be improved, although FY10 funding
constraints present significant obstacles.
Raise income eligibility limit
One improvement would be to raise the income limit for ADAP eligibility above 250%
of FPL. This would bring Alabama more in line with the majority of other states.
Address Medicare Part D coverage gaps
ADAP in Alabama does not pay the Medicare Part D copays for people eligible for both
Medicare and Medicaid (dual eligibles). Changing this policy would improve access to
critically-needed medications for more people living with HIV/AIDS in Alabama.
Alabama could look into creating an HIV-specific state pharmacy assistance program
(SPAP) to help people in the donut hole obtain medications, as states like Illinois
and North Carolina have done. Because SPAP contributions count toward recipients’
“true out-of-pocket expenditures” (TrOOP) for Medicare Part D, more people would
be able to meet the TrOOP requirements, and thus reach the other side of the coverage
gap—the “catastrophic coverage” level where the federal government pays 95% of
prescription costs. This could potentially save the state money, as more participants
could be transitioned to federally-paid medications, rather than remaining stuck in
the donut hole where ADAP pays the entire cost of medications. Additionally, members
of Congress from Alabama should be encouraged to support the inclusion of
an “ADAP as TrOOP” provision in any federal health reform legislation. Such a
provision would allow ADAP contributions to count as recipients’ out-of-pocket costs,
and would enable more people to reach the other side of the coverage gap.
Expanding access to medications benefits both individual health and public health, as
people with consistent access to antiretroviral medications are less likely to transmit
HIV and less likely to have drug-resistant HIV. As one Alabama newspaper has noted, it
makes sense from both a human and economic perspective to ensure that low-income
people with HIV/AIDS have access to life-saving medications.208
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STATE HEALTH OFFICER APPOINTMENT
Challenges
Under Alabama law, the Medical Association of the State of Alabama is the State Board
of Health (Board), which is charged with safeguarding the public health and acting as an
advisory board to the state on medical and public health matters.209 The Board functions
through the State Committee of Public Health (Committee), which is composed of 12
members of the MASA board of censors and the chairs of 4 health-related councils.210
The Alabama Department of Public Health is the administrative arm of the Board.211
The chief public health official for Alabama, known as the state health officer, must be
a physician and is elected by the Committee, which is dominated by physicians.212 This
structure creates a situation where the state health officer is not part of the governor’s
administration, and where other voices in the health communities, such as nurses,
PAs, social workers, and patients, have no say in who becomes the chief public health
official. There is little incentive to improve public health or to examine health outcomes
when there is no one to hold accountable, such as the governor. While the Board and
Committee are technically accountable to the legislature, Alabama’s public health is
essentially in the private hands of MASA.
According to the Association of State and Territorial Health Officials, only 3 other states
(Mississippi, Oklahoma, and South Carolina) have their boards of health choose the state
health officer.213 In those states, however, members of the board of health are appointed
by the governor, with Senate confirmation. Thus, Alabama is the only state to have its
chief public health official selected by the state medical association.
Individual physicians on the Board or Committee may have public health experience
and a commendable commitment to the field. But the governing structure of Alabama’s
public health organization concentrates power in an elite few, who do not have
to answer directly to Alabama voters. The current state health officer, Dr. Donald
Williamson, has served in that capacity for about 15 years. While he is knowledgeable
about HIV/AIDS, he has not been particularly helpful in securing funding—Governor
Riley zeroes out HIV budget line items every year.214
Opportunities
Amending Alabama law so that the governor appoints the state board of health and/or
the state health officer would bring more transparency and accountability and put public
health in the public domain. At a minimum, various health stakeholders should have a
role in public health governance and the election of the state health officer.
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conclusion
People living with HIV/AIDS in Alabama face a number of obstacles
to accessing affordable, quality, comprehensive healthcare. From a
restrictive Medicaid program to a severe shortage of medical providers
to an inhospitable state budget process, resources in Alabama are not
keeping pace with the growing need for HIV/AIDS care and services.
The difficult economic climate further compounds the problem by
creating more need at the same time that available funds are decreasing.
Despite the many challenges, there are specific, achievable opportunities
to improve access to care and services for Alabamians living with HIV/
AIDS. The additional federal Medicaid dollars coming to Alabama
through the American Recovery and Reinvestment Act of 2009 could be
used to expand access to Medicaid. Expanding Medicaid access could
free up some Ryan White ADAP funding, so that that program could
offer improved coverage. Some opportunities, such as creating a state
antidiscrimination law and expanding the roles of NPs and PAs, would not
necessarily cost much and might ultimately save the state money.
Alabamians living with HIV/AIDS and the providers who work with them
are practical and creative. They have an impressive ability to make the
most out of limited resources, which bodes well for enhancing healthcare
and treatment access in the future. The strong collaborative spirit and
tireless commitment of the AIDS services provider community are key
assets in any effort to improve access to care and services in Alabama.
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appendix A: Alabama HIV/AIDS epidemiological information
NUMBER OF AIDS AND HIV CASES IN ALABAMA*
Cumulative HIV cases reported through 2007
(and as a percentage of US total)
6,430 (2%)
Cumulative AIDS cases reported through 2007
(and as a percentage of US total)
9,091 (1%)
Persons living with HIV through end of 2007
5,740
Persons living with AIDS through end of 2007
4,046
Rate of persons living with HIV, per 100,000 people, 2007
149.4
Rate of persons living with AIDS, per 100,000 people, 2007
105.4
AIDS cases reported in 2007
391
HIV cases reported in 2007 (some diagnosed earlier)
529
HIV cases diagnosed in 2007
447
AIDS case rate, per 100,000 people (and national AIDS case rate)
Deaths reported among persons with AIDS through end of 2007
8.4 (12.4)
5,034
Sources: Centers for Disease Control and Prevention, Tables 11, 14, 16, 18. Cases of HIV Infections
and AIDS in the United States and Dependent Areas, 2007. HIV/AIDS Surveillance Report, Vol. 19,
2009. www.cdc.gov/hiv/topics/surveillance/resources/reports/2007report/default.htm; Kaiser Family
Foundation, State Health Facts, www.statehealthfacts.org/profileind.jsp?ind=525&cat=11&rgn=2.
New HIV/AIDS cases in 2007
900
New HIV/AIDS cases in 2008
839
Cumulative HIV/AIDS case total as of 3/31/09
16,377
Source: Alabama Department of Public Health. HIV and AIDS Cases by Demographic Group and
Exposure Category, Alabama (January-December 2008) and (January-March 2009). www.adph.org/
aids/assets/HIVandAIDSReport4thQuarter2008Demo.pdf and www.adph.org/aids/assets/HIV_
AIDSReport1stQuarter2009Demo.pdf.
*Some of these figures will likely change as the data are finalized.
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DEMOGRAPHICS (RACE/ETHNICITY, GENDER, AGE)
HIV/AIDS cases by race
Race
2008 cases
Cumulative cases
Black
70%
63.6%
White
22.5%
33.4%
Hispanic
3.6%
1.7%
2008 cases
Cumulative cases
HIV/AIDS cases by gender
Gender
Male
71%
74.5%
Female
29%
25.5%
HIV/AIDS cases by age
Age bracket
2008 cases
Cumulative cases
Pediatric (<13)
0.36%
0.8%
13-24
21%
13.5%
25-34
26.6%
34.7%
35-44
24%
30.7%
45-49
12%
9.2%
50+
16%
11%
Percentages may not add to 100% due to rounding.
Source: Alabama Department of Public Health. HIV and AIDS Cases by Demographic Group
and Exposure Category, Alabama (January-March 2009). www.adph.org/aids/assets/HIV
_AIDSReport1stQuarter2009Demo.pdf.
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PRIMARY EXPOSURE CATEGORY
New HIV/AIDS cases across time by primary exposure category
Year
New HIV/AIDS cases
reporting MSM as primary
exposure category
New HIV/AIDS cases
reporting heterosexual sex as
primary exposure category
2005
37.6%
25.4%
2006
34.8%
38.9%
2007
38.6%
34.3%
Cumulative HIV/AIDS cases by primary exposure category
HIV/AIDS cases by primary risk factor for
exposure (as of 3/31/09)
Cumulative
total
MSM
41.4%
Heterosexual sex 28.5%
IDU
11.1%
MSM and IDU
5.6%
Other
12.6%
MSM
41%
OTHER
13%
IDU
11%
MSM
& IDU
6%
HETEROSEXUAL
SEX
29%
Source: Primary exposure category statistics from the Alabama Department of Public Health.
HIV and AIDS Cases by Demographic Group and Exposure Category, Alabama (JanuaryDecember 2006), (January-December 2007), (January-December 2008) and (January-March
2009). www.adph.org/aids/assets/HIVandAIDSReport2006CompleteDemo.pdf, www.
adph.org/aids/assets/HIV_AIDSReportFourthQuarter2007Demo.pdf, www.adph.org/aids/
assets/HIVandAIDSReport4thQuarter2008Demo.pdf, and www.adph.org/aids/assets/HIV_
AIDSReport1stQuarter2009Demo.pdf.
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GEOGRAPHIC DISTRIBUTION
Geographic distribution
2006 AIDS cases occurring
among residents of rural areas
(<50,000 people)
Alabama
20%
Southern region
10%
United States
7%
Source: Centers for Disease Control and Prevention. Cases of HIV Infection and AIDS in Urban and
Rural Areas of the United States, 2006. HIV/AIDS Surveillance Supplemental Report, Vol. 13, No. 2.
www.cdc.gov/hiv/topics/surveillance/resources/reports/2008supp_vol13no2/default.htm.
Alabamians living with HIV in rural areas
16%
Alabamians living with AIDS in rural areas
19%
Alabamians living with HIV in Jefferson County
~33%
Source: Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report: Cases of HIV
Infection and AIDS in the United States and Dependent Areas, 2006. Vol. 18, Table 12.
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appendix B: Alabama HIV/AIDS cases by PHA and county
2008 INCIDENCE RATES OF HIV/AIDS IN THE PHAs
OF ALABAMA BY PHA
(Incident HIV and AIDS reflects cases whose first known HIV diagnosis or AIDS
diagnosis occurred during the specified time period.)
PHA
Counties included
Incidence (new cases
per 100,000 people per year)
I
Colbert
Franklin Lauderdale
Marion Walker Winston
4.36
II
Cullman
Jackson Lawrence Limestone
Madison Marshall Morgan
13.86
III
Bibb
Fayette
Greene
Lamar
Pickens
Tuscaloosa 15.39
IV
Jefferson 31.50
V
Blount
Cherokee
Dekalb
Etowah
Shelby St. Clair
6.47
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PHA
Counties included
VI
Calhoun
Chambers
Clay
Cleburne Coosa Randolph Talladega Tallapoosa 9.36
VII
Choctaw
Dallas Hale
Lowndes
Marengo
Perry
Sumter Wilcox
21.92
VIII
Autauga
Bullock
Chilton
Elmore
Lee
Montgomery Russell
32.08
IX
Baldwin Butler Clarke
Conecuh
Covington Escambia Monroe Washington
9.11
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PHA
Counties included
X
Barbour
Coffee
Crenshaw
Dale
Geneva Henry
Houston Pike
19.16
Mobile 24.16
XI
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2008 INCIDENCE RATES OF HIV IN THE PHAs
OF ALABAMA BY INCIDENCE LEVEL
PHA
Counties included
VIII
Autauga
Bullock
Chilton
Elmore
Lee
Montgomery Russell
32.08
IV
Jefferson 31.50
XI
Mobile 24.16
VII
Choctaw
Dallas Hale
Lowndes
Marengo
Perry
Sumter Wilcox
21.92
X
Barbour
Coffee
Crenshaw
Dale
Geneva Henry
Houston Pike
19.16
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PHA
Counties included
III
Bibb
Fayette
Greene
Lamar
Pickens
Tuscaloosa 15.39
II
Cullman
Jackson Lawrence Limestone
Madison Marshall Morgan
13.86
VI
Calhoun
Chambers
Clay
Cleburne Coosa Randolph Talladega Tallapoosa 9.36
IX
Baldwin Butler Clarke
Conecuh
Covington Escambia Monroe Washington
9.11
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PHA
Counties included
V
Blount
Cherokee
Dekalb
Etowah
Shelby St. Clair
6.47
I
Colbert
Franklin Lauderdale
Marion Walker Winston
4.36
Source: Alabama Department of Public Health. HIV and AIDS Cases by Public Health Area and County,
Alabama (January-March 2009). www.adph.org/aids/assets/HIV_AIDSReport1stQuarter2009PHA.pdf.
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appendix C: Map of Alabama counties
Lauderdale
Limestone
Jackson
Madison
Colbert
Lawrence
Franklin
De Kalb
Morgan
Marshall
Marion
Cherokee
Cullman
Winston
Etowah
Blount
Walker
Fayette
Lamar
Calhoun
St. Clair
Cleburne
Jefferson
Talladega
Shelby
Tuscaloosa
Pickens
Randolph
Clay
ALABAMA
Bibb
Coosa
Greene
Hale
Perry
Elmore
Autauga
Sumter
Marengo
Lee
Macon
Dallas
Choctaw
Chambers
Tallapoosa
Chilton
Montgomery
Russell
Lowndes
Bullock
Wilcox
Pike
Butler
Clarke
Barbour
Crenshaw
Monroe
Henry
Conecuh
Washington
Coffee
Dale
Covington
Escambia
Geneva
Houston
Mobile
Baldwin
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appendix D: Alabama Medicaid covered/noncovered services
COVERED SERVICES
Service
Coverage details
Ambulance servicesMedicaid pays for ambulance services only when
medically necessary.
Dental services
(for children under
21 years of age)
Medicaid pays for a check-up and teeth cleaning every
6 months. Medicaid pays for some crowns, extractions (pulling teeth), fillings, root canals, TMJ surgery, and x-rays. Some services must be approved by Medicaid ahead of time.
Doctor servicesMedicaid pays for 14 doctor visits per calendar year. These
include visits to the doctor’s office, emergency room (unless
it is a certified emergency), healthcare clinics, and centers.
Medicaid also pays for 16 days of doctor’s care when a
patient is in a hospital.
Eye care services
(for adults)
Medicaid pays for eye exams and eyeglasses once every
2 calendar years for recipients 21 years of age or older. Contact lenses may be provided only under certain
conditions and when approved ahead of time.
Eye care services
(for children under
21 years of age)
Medicaid pays for eye exams and glasses once every calendar year. Additional covered services may be available
if medically necessary.
Family planning servicesFamily planning services are available to women of
childbearing age and men of any age. Birth control methods
covered by Medicaid include birth control pills, IUDs,
diaphragms, shots, and implants.
Medicaid pays for women 21 years of age and older to have
their tubes tied and vasectomies for men 21 years of age and
older. Consent forms must be signed at least 30 days before
the surgery.
NOTE: Family planning services do not count against regular
doctor’s office visits.
Preventive health
education services
Medicaid pays for classes on preparing for childbirth and
preventing teenage pregnancy. Hospitals, county health
departments, and other groups offer these classes.
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Hearing services
(for children under
21 years of age)
Medicaid pays for one hearing screening every calendar
year beginning at 5 years of age and for hearing aids. Additional covered services may be available if
medically necessary.
Home health servicesMedicaid provides for certain medical services at home
if the patient has an illness, disability, or injury that keeps
him/her from leaving home without special equipment or
the help of another person. Services can be part-time or
off and on during a certain span of time.
Certain medical supplies, equipment, and appliances that
can be used in the home are also covered with some limits.
Hospice servicesMedicaid pays for hospice care for terminally ill persons.
There is no limit on hospice days. Covered hospice services
include nursing care, medical social services, doctors’
services, short-term inpatient hospital care, medical
appliances and supplies, medicines, home health aide and
homemaker services, therapies, counseling services, and
nursing home room and board.
Hospital services1. In-patient hospital care–Medicaid pays for 16 in-patient
hospital days per calendar year. Coverage is for a semiprivate
room (2 or more beds in a room). In certain hospitals, nursing
home care services are provided to Medicaid patients who
are waiting to go into a nursing home.
2. Outpatient care–Medicaid pays for 3 nonemergency
outpatient hospital visits per calendar year. Examples of
nonemergencies include upset stomach, sore throat, mild
cough, rash, and low-grade fever.
There are no limits on outpatient hospital visits if a patient
goes in for laboratory work, x-ray services, radiation
treatment, or chemotherapy only.
Medicaid pays for 3 outpatient surgical procedures per
calendar year if the surgeries are done in an ambulatory
surgical center.
alabama
An Analysis of the
64
ospital services
H
(cont’d)
Medicaid also pays for emergency outpatient services
when there is a certified emergency.
OTE: A noncertified outpatient emergency room visit counts
N
as 1 doctor visit and 1 outpatient visit.
. Psychiatric hospital services–Medicaid pays for
3
medically necessary services in a psychiatric hospital for
children under 21 years of age if approved by Medicaid
ahead of time.
Laboratory and
x-ray services
Medicaid pays for laboratory and x-ray services when
they are medically necessary.
Maternity servicesMedicaid pays for prenatal (before the baby is born) care,
delivery, and postpartum (after the baby is born) care.
Medicaid also pays for prenatal vitamins.
Mental health servicesMedicaid pays for treatment of people diagnosed with
mental illness or substance abuse.
The treatment is provided through community mental
health centers for eligible children and adults, and through
the Department of Human Resources (DHR) and the
Department of Youth Services (DYS) for children under
21 years of age being served by DHR and DYS.
NOTE: The services received from a mental health center
do not count against regular doctor’s office visits or other
Medicaid covered services.
Nurse midwife servicesMedicaid covers nurse midwife services for maternity
care, delivery, routine gynecology services, and family
planning services.
Nursing home care
services
Medicaid pays for nursing home room and board,
prescribed medicines, and 14 doctor’s visits per calendar
year while the beneficiary is in a nursing home.
In certain hospitals, nursing home care services are provided
to Medicaid patients who are waiting to go into a nursing
home, if they meet the guidelines for nursing home care.
Medicaid also pays for long-term care for mentally
retarded persons.
alabama
An Analysis of the
65
Out-of-state servicesServices that Medicaid covers in Alabama may be covered
out-of-state if:
• the patient has a certified emergency,
• it would be hazardous to have to travel back to Alabama
for treatment,
• the medical services needed are more readily available
in the other state, or
• an out-of-state medical provider has a contract with
Medicaid in Alabama.
NOTE: The medical provider must agree to enroll as a
provider with the Alabama Medicaid Agency. Some services
must be approved before the service can be given by an
out-of-state provider.
Prescription drugsMedicaid pays for most medicines ordered by the patient’s
doctor. Many over-the-counter drugs are also covered.
There are some drugs that must be approved by Medicaid
ahead of time. For most recipients, Medicaid only pays for
4 brand-name drugs each month. Generic and covered
drugs are not limited.
Renal dialysis servicesMedicaid pays for 156 outpatient dialysis treatments per
calendar year for recipients with kidney failure. Medicaid
also pays for certain drugs and supplies.
Transplant servicesMedicaid pays for some organ transplants. If a transplant
is needed, the recipient’s doctor will work directly with
Medicaid to arrange for the transplant.
Home and community- based waivers
Medicaid pays for services for certain disabled clients
who prefer to stay in their home rather than be admitted
to a nursing home.
Transportation
. Ambulance services–Medicaid pays for ambulance
1
services only when medically necessary.
Medicaid will not pay for an ambulance service if another
means of transportation can be used without harming the
health of the patient.
alabama
An Analysis of the
66
Transportation (cont’d)2. Nonemergency services–The Medicaid NET Program is
set up to help cover the cost of transportation to and from
medically necessary appointments if Medicaid recipients have
no other way to get to their appointments without obvious
hardship. Medicaid issues vouchers for these medically
necessary appointments. These vouchers should be
approved by Medicaid ahead of time.
NONCOVERED SERVICES
Below is a partial listing of some goods and services that are not covered by Medicaid in Alabama.
• Cosmetic surgery or procedures
• Dental services for adults (age 21 and older)
• Dental services for pregnant women who are eligible for pregnancy-related services only
• Dental services, such as routine orthodontic care (braces), routine partials, dentures or
bridgework, gold caps or crowns, or periodontal or gum surgery
• Hearing services for adults (age 21 and older)
• Hospital meal trays or cots for guests
• T V rentals and VCRs in hospital rooms
• Infertility services or treatment
• Recreational therapy or experimental treatments, supplies, equipment, or drugs
• Respiratory therapy, speech therapy, and occupational therapy (age 21 and older)
• Services or treatment if a person is not eligible for Medicaid
• Services to persons who are in jail or in prison
• Sitter services
• Any service not covered under the State Plan for Medical Assistance
Source: Alabama Medicaid Agency. Your Guide to Alabama Medicaid. www.medicaid.state.al.us/documents/
Resources/4-G_Publications/4G-1_YourGuideToMedicaid.11-08.pdf.
alabama
An Analysis of the
67
appendix E: 2009 Federal Poverty Guidelines
THE 2009 POVERTY GUIDELINES
FOR THE 48 CONTIGUOUS STATES
AND THE DISTRICT OF COLUMBIA
Persons in family
Poverty guideline
1
$10,830
2
$14,570
3
$18,310
4
$22,050
5
$25,790
6
$29,530
7
$33,270
8
$37,010
or families with more than 8 persons, add $3,740
F
for each additional person.
Source: United States Department of Health and Human Services,
http://aspe.hhs.gov/POVERTY/09poverty.shtml.
alabama
An Analysis of the
68
notes and references
1.Information obtained from: Centers for Disease Control and Prevention, Cases of HIV Infections and AIDS in the
United States and Dependent Areas, 2007, Table 16, HIV/AIDS Surveillance Report, vol. 19, 2009, http://www.cdc.
gov/hiv/topics/surveillance/resources/reports/2007report/default.htm.
2.Id., Table 18.
3.Id., Table 14.
4.Id., Table 11.
5.Id., Table 16.
6.The Kaiser Family Foundation, statehealthfacts.org. Data Source: Centers for Disease Control and Prevention,
Division of HIV/AIDS Prevention-Surveillance and Epidemiology, Special Data Request, February 2009,
http://www.statehealthfacts.org/profileind.jsp?ind=525&cat=11&rgn=2.
7.Information obtained from: Alabama Department of Public Health, Alabama HIV and AIDS Quarterly Statistics,
“HIV and AIDS Cases by Demographic Group and Exposure Category, Alabama (January-December 2008) and
(January-March 2009),” http://www.adph.org/aids/assets/HIVandAIDSReport4thQuarter2008Demo.pdf and
http://www.adph.org/aids/assets/HIV_AIDSReport1stQuarter2009Demo.pdf.
8.Demographic statistics from the Alabama Department of Public Health, Alabama HIV and AIDS Quarterly
Statistics, “HIV and AIDS Cases by Demographic Group and Exposure Category, Alabama (January-March 2009),”
http://www.adph.org/aids/assets/HIV_AIDSReport1stQuarter2009Demo.pdf.
9.Exposure category statistics from the Alabama Department of Public Health, Alabama HIV and AIDS Quarterly
Statistics, “HIV and AIDS Cases by Demographic Group and Exposure Category, Alabama (January-December
2006, 2007, 2008) and (January-March 2009),” http://www.adph.org/aids.
10.Information obtained from: Centers for Disease Control and Prevention, HIV/AIDS Surveillance Supplemental
Report, Volume 13, Number 2, Cases of HIV Infection and AIDS in Urban and Rural Areas of the United States,
2006, released December 2008, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2008supp_
vol13no2/default.htm.
11.Information obtained from: Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report: Cases of
HIV Infection and AIDS in the United States and Dependent Areas, 2006, Volume 18, Table 12, http://www.cdc.
gov/hiv/topics/surveillance/resources/reports/2006report/default.htm.
12.Funding statistics from The Kaiser Family Foundation, statehealthfacts.org. Data Source: National Alliance of State
and Territorial AIDS Directors (NASTAD) at http://www.nastad.org, Special Data Request, 2008, http://www.
statehealthfacts.org/profileind.jsp?ind=528&cat=11&rgn=2.
13.Information obtained from: US Department of Commerce, Bureau of Economic Analysis.
14.Information obtained from: Alabama Department of Industrial Relations, Occupation and Industry Projections,
http://www2.dir.state.al.us/Projections/.
15.Information obtained from: US Department of Commerce, Bureau of Economic Analysis.
16.Information obtained from: US Department of Commerce, Bureau of Economic Analysis, State BEARFACTS 1
997-2007, http://www.bea.gov/regional/bearfacts/stateaction.cfm.
17.Information obtained from: United States Census Bureau, State and County QuickFacts, http://quickfacts.
census.gov.
18.The Kaiser Family Foundation, statehealthfacts.org. Data Source: Table 1, Annual Statistical Report on the Social
Security Disability Insurance Program, 2007, Social Security Administration, Office of Policy, SSI Recipients by
State and County, 2007, http://www.statehealthfacts.org/profileind.jsp?ind=255&cat=4&rgn=2.
19.Information obtained from: Alabama Department of Industrial Relations, Labor Market Information Division,
http://dir.alabama.gov; http://www2.dir.state.al.us/; US Department of Labor, Bureau of Labor Statistics,
http://data.bls.gov/.
alabama
An Analysis of the
69
20.Information obtained from: Economic Research Service, US Department of Agriculture, State Fact Sheets,
http://www.ers.usda.gov/StateFacts/AL.htm.
21.Data from US Census Bureau, American FactFinder and Census QuickFacts, http://factfinder.census.gov and
http://quickfacts.census.gov/qfd/states/01000.html.
22.We capitalize the names of racial and ethnic groups here because that is the convention used by the US
Census Bureau.
23.The Kaiser Family Foundation, statehealthfacts.org. Data Source: Urban Institute and Kaiser Commission
on Medicaid and the Uninsured estimates based on the Census Bureau’s March 2007 and 2008 Current
Population Survey (CPS: Annual Social and Economic Supplements), http://www.statehealthfacts.org/profileind.
jsp?ind=3&cat=1&rgn=2.
24.Information obtained from: US Department of Agriculture, Economic Research Service, State Fact Sheets,
http://www.ers.usda.gov/StateFacts/AL.htm.
25.Id.
26.Id.
27.Id.
28.Id.
29.Id.
30.Information obtained from: US Census Bureau, State & County QuickFacts, http://quickfacts.census.gov/qfd/
states/01000.html.
31.Alabama Constitution of 1901, Article V, section 112.
32.Information obtained from: Office of Governor Bob Riley Web site, http://governor.alabama.gov/cabinet.aspx,
accessed May 18, 2009.
33.Information obtained from the Alabama Legislature Web site, http://www.legislature.state.al.us, and Wikipedia,
“Constitution of Alabama,” http://en.wikipedia.org/wiki/Alabama_Constitution, accessed May 18, 2009.
34.Blalock B. Alabamians should show outrage over Legislature refusing to let voters decide on convention of citizens
to write new constitution. The Birmingham News. May 10, 2009. http://blog.al.com/bblalock/2009/05/alabamians_
should_show_outrage.html.
35.See, eg, “Lawsuit questions validity of Alabama Constitution,” The Birmingham News, February 13, 2009,
http://blog.al.com/bn/2009/02/constitution_challenge.html, “Lawsuit Alleges Alabama Constitution Racist,
Invalid,” American Constitutional Society, ACSblog, February 16, 2009, http://www.acslaw.org/node/12934.
36.Health insurance statistics from The Kaiser Family Foundation, statehealthfacts.org. Data Source: Urban Institute
and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau’s March 2007 and
2008 Current Population Survey (CPS: Annual Social and Economic Supplements), http://www.statehealthfacts.
org/profileind.jsp?ind=125&cat=3&rgn=2.
37.Information obtained from: The Kaiser Family Foundation, statehealthfacts.org. Data as of December 2008,
compiled through review of state laws and regulations and interviews with state health insurance regulatory staff,
http://www.statehealthfacts.org/profileind.jsp?rgn=2&cat=7&ind=353.
38.Information obtained from: phone calls to Alfa Blue Cross and Assurant Health, 12/11/08.
39.Death and birth rate statistics from The Kaiser Family Foundation, statehealthfacts.org.
40.Information obtained from: Alabama Department of Public Health, Center for Health Statistics, Division of
Statistical Analysis, Alabama Vital Statistics 2007, http://www.adph.org/healthstats/.
41.The Kaiser Family Foundation, statehealthfacts.org. Data Source: The Centers for Disease Control and Prevention
(CDC), National Center for Health Statistics, Division of Vital Statistics, National Vital Statistics Report, Volume 57,
Number 14, April 2009, Table 29, http://www.statehealthfacts.org/profileind.jsp?ind=77&cat=2&rgn=2.
alabama
An Analysis of the
70
42.Id.
43.Information obtained from: Alabama Department of Public Health, Healthcare Facilities Directory. http://ph.state.al.us/
facilitiesdirectory/.
44.The Kaiser Family Foundation, statehealthfacts.org. Data Sources: Bureau of Labor Statistics, State Occupational
Employment and Wage Estimates, May 2008, http://www.statehealthfacts.org/profileind.jsp?ind=438&cat=8&rgn=2;
and calculations based on the Bureau of Labor Statistics, State Occupational Employment and Wage Estimates,
May 2008, and the Annual Population Estimates by State, July 1, 2008 Population, US Census Bureau, http://www.
statehealthfacts.org/profileind.jsp?ind=439&cat=8&rgn=2.
45.Id.
46.Information obtained from: Alabama Primary Health Care Association Web site, http://www.alphca.com/dirservice.
aspx?id=468.
47.The Kaiser Family Foundation, statehealthfacts.org. Data Sources: Centers for Disease Control and Prevention.
Update: Syringe Exchange Programs-United States, 2005. MMWR. 2007;56(44):1164-1167; and Burris S, et al.
The Legality of Selling or Giving Syringes to Injection Drug Users. J Am Pharm Assoc. 2002;42(6), Supp.2: S13-18.
Accessed August 2005, http://www.statehealthfacts.org/profileind.jsp?ind=566&cat=11&rgn=2.
48.Information obtained from: Centers for Disease Control and Prevention, www.hivtest.org.
49.Information obtained from: Alabama Department of Public Health Web site, http://www.adph.org/aids/.
50.Information obtained from: SHARP Community Partners Meeting, April 9, 2009, Birmingham.
51.Ala. Code §§22-11A-51 and 22-11A-52, and Ala. Admin. Code Chapter 420-4-1-.06. Circumstances under
which consent shall be implied include when an individual, based upon reasonable medical judgment, is at high
risk for HIV, when medical care may be modified depending on HIV status, and when there is an immediate
danger of communication of HIV to attending medical personnel.
52.Ala. Admin. Code Chapter 420-4-1-.14.
53.Information obtained from: Alabama Department of Mental Health and Mental Retardation Web site, http://www.
mh.alabama.gov/SA/FindServices.aspx.
54.Ala. Admin. Code r. 560-X-1.
55.The Kaiser Family Foundation, statehealthfacts.org. Data Source: Calculations based on the Urban Institute and Kaiser
Commission on Medicaid and the Uninsured estimates based on data from Medicaid Statistical Information System
(MSIS) reports from the Centers for Medicare and Medicaid Services (CMS), 2009, http://www.statehealthfacts.org/
profileind.jsp?ind=199&cat=4&rgn=2. This number is different from the percentage cited on page 13 because the
percentage on page 13 is derived from the Census Bureau’s Current Population Survey, and reflects a specific
“point-in-time” number, while the percentage cited here comes from the Centers for Medicare and Medicaid
Services’ Medicaid Statistical Information System, and reflects persons enrolled at any point in the year (including
those, such as children, who often cycle on and off Medicaid coverage). Telephone conversation with Lindsay
Donaldson, Kaiser Family Foundation, June 5, 2009.
56.However, emergency services are covered for illegal aliens who would be eligible for Medicaid except for the
alienage requirement.
57.Ala. Admin. Code 560-X-25.
58.Information obtained from: Alabama Medicaid Agency Web site, http://www.medicaid.state.al.us.
59.“Countable income” is the amount left after taking into account all applicable deductions.
60.Ala. Admin. Code 560-X-25.
61.A complete list of Alabama Medicaid programs is available on the department’s Web site, http://www.medicaid.
alabama.gov/programs/index_programs.aspx?tab=4.
alabama
62.Some exceptions are dual-eligibles, foster children, and institutionalized beneficiaries.
63.Information obtained from: Alabama Medicaid Agency Web site, http://www.medicaid.alabama.gov/programs/
patient1st/index_patient1st.aspx?tab=4.
An Analysis of the
71
64.20 CFR 416.905.
65.Information obtained from: Alabama Medicaid Agency Web site, http://www.medicaid.alabama.gov/apply/apply_
information.aspx?tab=3.
66.Id.
67.Information obtained from: Alabama Medicaid Agency Web site, http://www.medicaid.alabama.gov/programs/family_
planning/plan_first.aspx?tab=4.
68.Information obtained from: Alabama Medicaid Agency Web site, http://www.medicaid.alabama.gov/apply/apply_
information.aspx?tab=3 with link to Alabama Department of Public Health Web site at http://adph.org/earlydetection/
Default.asp?id=546.
69.Information obtained from: Alabama Medicaid Agency Web site, http://www.medicaid.alabama.gov/.
70.Information obtained from: Alabama Medicaid Agency, “Co-Payments for Medicaid Services,” http://www.medicaid.
alabama.gov/programs/program_resources/program_resources.aspx?tab=4 (accessed 3/2/09).
71.Ala. Admin. Code r. 560-X-7-.03.
72.Information obtained from: Alabama Medicaid Agency, “Your Guide to Alabama Medicaid” and “Alabama Medicaid
Covered Services and Co-payments,” http://www.medicaid.alabama.gov/programs/program_resources/program_
resources.aspx?tab=4 (accessed 3/2/09).
73.Medicare also covers people who have Lou Gehrig’s disease or end-stage renal disease.
74.The Kaiser Family Foundation, statehealthfacts.org. Data Source: CMS Statistics: Medicare State Enrollment, Centers
for Medicare and Medicaid Services, http://www.statehealthfacts.org/profileind.jsp?ind=293&cat=6&rgn=2.
75.Ala. Admin. Code r. 560-X-1-.14 (2000).
76.Ala. Admin. Code r. 560-X-1, 25.
77.Information obtained from: Alabama Medicaid Agency Web site, http://www.medicaid.alabama.gov/.
78.Information obtained from: Health Insurance Alabama Web site, http://healthinsurance.alabama.gov/unins_children.
htm (accessed 3/2/09).
79.Information obtained from: Alabama Department of Public Health Web site, http://www.adph.org/allkids/ (accessed
3/2/09).
80.Information obtained from: Alabama Department of Public Health Web site, ALL Kids Enrollment Data, http://www.
adph.org/allkids/Default.asp?id=580 (accessed 3/2/09).
81.Information obtained from: The Alabama Child Caring Foundation, http://www.accf.net/.
82.The Kaiser Family Foundation, statehealthfacts.org. Data Source: National Alliance of State and Territorial AIDS
Directors (NASTAD) at http://www.nastad.org, Special Data Request, 2008, http://www.statehealthfacts.org/
profileind.jsp?ind=535&cat=11&rgn=2.
83.Information obtained from: Alabama Department of Public Health Web site, http://www.adph.org/aids/index.
asp?id=995 (accessed 8/26/09).
84.Information obtained from: telephone conversation with Gloria Sims, Alabama Department of Public Health ADAP
Coordinator, August 26, 2009.
85.Information obtained from: Alabama Department of Public Health Web site, http://www.adph.org/aids/assets/
MEDCAPGuidance2009.pdf (accessed 8/26/09).
86.Information obtained from: telephone conversation with Gloria Sims, Alabama Department of Public Health ADAP
Coordinator, August 26, 2009.
87.Information obtained from: electronic mail correspondence with Gloria Sims, Alabama Department of Public Health
ADAP Coordinator, August 26, 2009.
alabama
An Analysis of the
72
88.Id. and Alabama Department of Public Health Web site, http://www.adph.org/aids/index.asp?id=995,
(accessed 8/2609).
89.Information obtained from: Alabama Department of Public Health Web site, http://www.adph.org/aids/assets/
ADAPFormularyRevised11-08.pdf (accessed 8/26/09).
90.Id.
91.Information obtained from: National ADAP Monitoring Project Annual Report, April 2009, http://www.kff.org/hivaids/
upload/7861.pdf. Note that the ADAP fiscal year runs from April 1 to March 31 of the following year (so FY08 is April
1, 2008-March 31, 2009), unlike the general federal fiscal year, which runs from October 1 to September 30 of the
following year.
92.Id.
93.Id.
94.Information obtained from: http://www.legislature.state.al.us/CodeofAlabama/1975/coatoc.htm.
95.Alabama Code 13A-5-12, http://www.legislature.state.al.us/CodeofAlabama/1975/coatoc.htm.
96.Ala. Code §22-11A-18 and Ala. Admin. Code Ch. 420-4-1-.05.
98.Information obtained from: Guttmacher Institute, State Policies in Brief: Sex and STI/HIV Education, http://www.
guttmacher.org/statecenter/spibs/spib_SE.pdf.
99.Ala. Admin. Code r. 560-X-1-.04 (1993); Ala. Admin. Code r. 560-X-25-.03(1)(h) (2004).
100.Information obtained from: Alabama Medicaid Agency, A Medicaid Primer, February 2009, p. 7, http://www.
medicaid.alabama.gov/documents/apply/2A-General/2A-4_What_is_Medicaid_2-13-09.pdf.
101.The Kaiser Family Foundation, statehealthfacts.org. Data Sources: Challenges of Providing Health Coverage for
Children and Parents in a Recession: A 50 State Update on Eligibility Rules, Enrollment and Renewal Procedures,
and Cost-Sharing Practices in Medicaid and SCHIP in 2009. Data based on a national survey conducted by the
Center on Budget and Policy Priorities for the Kaiser Commission on Medicaid and the Uninsured, January 2009,
http://www.statehealthfacts.org/comparetable.jsp?ind=205&cat=4.
102.Information obtained from: SSA Web site, http://www.ssa.gov/disability/professionals/bluebook/14.00Immune-Adult.htm#14_08.
103.Ala. Admin. Code r. 560-X-6-.14(1) (2005); Ala. Admin. Code r. 560-X-7-.01 (2004); Ala. Admin. Code r.
560-X-6-.13(13)(a) (2005).
104.Information obtained from: Alabama Medicaid Agency, A Medicaid Primer, February 2009, p. 7, http://www.
medicaid.alabama.gov/documents/apply/2A-General/2A-4_What_is_Medicaid_2-13-09.pdf.
105.Information obtained from: SHARP Community Partners Meeting, Provider session, November 17, 2008,
Birmingham.
106.Information obtained from: Alabama Medicaid Agency Web site, http://www.medicaid.alabama.gov/programs/
pharmacy_svcs/pref_drug_list.aspx.
107.Information obtained from: Alabama Medicaid Agency, Medicaid Provider Manual, Appendix G, http://www.medicaid.
alabama.gov/documents/Billing/5-G_Manuals/5G-2_Provider.Manual_Jan.2009/Jan09_G.pdf.
108.Information obtained from: SHARP Community Partners Meeting, Consumer session, November 17, 2008,
Birmingham.
109.Information obtained from: Alabama Medicaid Agency Web site, http://www.medicaid.alabama.gov/billing/provider_
manual.10-08.aspx?tab=6 and http://www.medicaid.alabama.gov/documents/3L-3-d-Questions.Answer.Recipients.
pdf (accessed 2/27/09).
alabama
110.Information obtained from: SHARP Community Partners Meeting, April 9, 2009, Birmingham. Community partners
also noted that a similar “one provider only” policy has been adopted within the Ryan White Part B program in
Alabama, and that this policy creates significant administrative burdens for service providers.
An Analysis of the
73
111.Information obtained from: Alabama Medicaid Agency, “FMAP increase, Health IT funds on stimulus wish list,”
http://www.medicaid.alabama.gov/documents/News/Federal_Stimulus.pdf.
112.The Kaiser Family Foundation, statehealthfacts.org. Data Sources: The United States Government Accountability
Office and Center on Budget and Policy Priorities (for Territory estimates), February 19, 2009, http://www.
statehealthfacts.org/comparemaptable.jsp?cat=4&ind=664&typ=4&gsa=1.
113.Information obtained from: SHARP Community Partners Meeting, April 9, 2009, Birmingham. Another reason
given by SHARP partners is that the Elderly/Disabled Medicaid home care waiver used to offer better coverage than
the HIV waiver, so participants opted to enroll in the Elderly/Disabled program. The HIV/AIDS waiver now offers the
same benefits.
114.Medical disenfranchisement can be calculated by considering the number of people who live in Health Professional
Shortage Areas and Medically Underserved Areas, as designated by the federal Health Resources and Services
Administration. The National Association of Community Health Centers and The Robert Graham Center, Access
Denied: A Look at America’s Medically Disenfranchised, pp. 2, 3 and Appendix F (2007).
115. Id., pp. 3 and Appendix A.
116.Information obtained from: Ann DeBellis. A Physician Shortage – The Looming Crisis. Birmingham Medical News,
June 2008, at 4, http://birmingham.medicalnewsinc.com/mod/secfile/viewed.php?file_id=31.
117.Information obtained from: http://aahivm.org/index.php?option=com_content&task=view&id=736&Itemid=144.
Birmingham.
119.Id.
120.Id.
121.Id.
122.Information obtained from: Ann DeBellis. A Physician Shortage – The Rural Crisis. Birmingham Medical News,
August 2008, at 6, http://birmingham.medicalnewsinc.com/mod/secfile/viewed.php?file_id=33.
Birmingham.
124.Id.
125.Information obtained from: SHARP Community Partners Meeting, Provider session, November 2008, Birmingham.
126.See, eg, Ding L. et al. The Quality of Care Received by HIV Patients Without a Primary Provider, 20 AIDS Care 1,
35-42 (2008).
127.See, eg, Fisher JD et al. Clinician-delivered intervention during routine clinical care reduces unprotected sexual
behavior among HIV-infected patients. J Acquir Immune Defic Syndr. 2006, Jan, 41(1):44-52; and Richardson JL et
al. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: a multi-clinic assessment,
AIDS. 2004 May, 18(8):1179-86.
Birmingham.
129.Information obtained from: AAP Medicaid Reimbursement Survey 2007/2008,
http://74.125.47.132/search?q=cache:AOApcJ0hvB8J:www.aap.org/research/medreimpdf0708/
al.pdf+medicaid+reimbursement+alabama&hl=en&ct=clnk&cd=3&gl=us&client=firefox-a.
130.Ala. Code of 1975 §40-18-132.
132.Information obtained from: National Health Service Corps Web site, http://nhsc.hrsa.gov/join_us/lrp.asp.
alabama
An Analysis of the
74
134.Information obtained from: Sharon Christian et al. Overview of Nurse Practitioner Scope of Practice in the United
States – Discussion, The Center for the Health Professions 6 (2007), http://futurehealth.ucsf.edu/pdf_files/NP
percent20Scopes percent20discussion percent20Fall percent202007 percent20121807.pdf.
135.Ala. Admin. Code r. 610-X-5.02(c), http://www.abn.state.al.us/main/downloads/admin-code/Chapter
percent20610-X-5.pdf.
136.Ala. Admin. Code r. 610-X-5.08, http://www.abn.state.al.us/main/downloads/admin-code/Chapter
percent20610-X-5.pdf.
137.Rules of the Alabama Board of Medical Examiners, Chapter 540-X-7-.01.
138.Summaries for Patients: Quality of Health Care Provided by Nurse Practitioners, Physician Assistants, and Doctors.
143 Annals of Internal Med. 10, I72 (2005). Ira B. Wilson et al. Quality of HIV Care Provided by Nurse Practitioners,
Physician Assistants, and Physicians. 143 Annals of Internal Med. 10, 729-36 (2005).
139.According to the Board of Medical Examiners, “there are several initiatives with the Board of Nursing to streamline
the [collaborative practice] process and make it more user friendly.” Alabama BME Newsletter and Report, JanuaryMarch 2009, Vol. 24, No. 1, http://www.albme.org/Documents/Newsletters/BME2009-01.PDF.
140.Information obtained from: Alabama State Nurses Association, ASNA Legislative Update 09-2, February 2009,
http://www.alabamanurses.org/associations/9886/files/LEGISLATIVEUPDATE09-2.pdf (accessed 2/25/09).
141.Lugo N et al. Ranking State NP Regulation: Practice Environment and Consumer Healthcare Choice, Am J Nurse Pract.
April 2007, Vol. 11 No. 4.
142.American Academy of Physician Assistants, Issue Brief: Physician Assistant Scope of Practice, http://www.aapa.org/
gandp/issuebrief/pascope.pdf (accessed 2/25/09).
143.American Academy of Physician Assistants, Summary of State Laws for Physician Assistants: Abridged Version,
http://www.aapa.org/gandp/statelaw.html (accessed 2/25/09).
144.Ala. Admin. Code r. 20-2-1 et. seq.
145.Information obtained from: Alabama Society of Physician Assistants Web site, Legislative News, http://www.myaspa.
org/legislativenews.php (accessed 2/25/09).
146.Sharon Christian et al. Overview of Nurse Practitioner Scope of Practice in the United States – Discussion, The Center
for the Health Professions 11 (2007), http://futurehealth.ucsf.edu/pdf_files/NP percent20Scopes percent20discussion
percent20Fall percent202007 percent20121807.pdf.
147.Information obtained from: Alabama Society of Physician Assistants Web site, http://www.myaspa.org/
legislativenews.php (accessed 2/25/09).
148.Information obtained from: Alabama Society of Physician Assistants Web site, http://www.myaspa.org/ (accessed
May 20, 2009).
149.Information obtained from: MASA Web site, http://www.masalink.org/alapac/news.aspx?id=2090 (accessed
May 20, 2009).
150.Sharon Christian et al. Overview of Nurse Practitioner Scope of Practice in the United States – Discussion, The
Center for the Health Professions 12 26 (2007). http://futurehealth.ucsf.edu/pdf_files/NP percent20Scopes
percent20discussion percent20Fall percent202007 percent20121807.pdf.
151.Information obtained from: Alabama State Nurses Association, ASNA Legislative Update 09-2, February 2009,
http://www.alabamanurses.org/associations/9886/files/LEGISLATIVEUPDATE09-2.pdf (accessed 2/25/09).
152.Information obtained from: Alabama Medical PAC Web site, “Nurse Practitioners to Seek Medical Independence,”
January 21, 2008, http://www.masalink.org/alapac/news.aspx?id=1002.
154.Ala. Code of 1975 §34-24-53.
alabama
An Analysis of the
75
155.Information obtained from: “A Proposal to Increase the Utilization of Nurse Practitioners in Underserved Alabama,”
prepared by the Nurse Practitioner Taskforce at the Request of Dr. Robert Bentley, House of Representatives,
District 63, April 7, 2007, http://www.arhaonline.org/PDF%20Files/NPTFreport.pdf.
156.Ala. Code of 1975, §34-21-81.
157.Information obtained from: K. Heins and A. Heins, “Plan to Improve the Health and Health Care of the People of
Alabama at Lower Cost,” http://www.npalliancealabama.org/.
158.Information obtained from: Susanne J. Phillips, 18th Annual Legislative Update, 32 The Nurse Practitioner 1 (2006).
159.Information obtained from: Blue Cross Blue Shield of Alabama Web site, https://www.bcbsal.org/providers/
publications/specialBulletins/archiveSpecial/2004-21.pdf.
Birmingham.
162.Information obtained from: Alabama Department of Revenue, Annual Report 2007, 3. http://www.ador.state.al.us/,
hereinafter ADR Annual Report; State Tax Collections per capita, 2007, http://www.taxfoundation.org/research/
show/289.html.
163.The Kaiser Family Foundation, statehealthfacts.org. Data Source: State Government Tax Collections: 2008, US Bureau
of the Census, http://www.statehealthfacts.org/comparemaptable.jsp?ind=762&cat=1.
164.Information obtained from: Alabama Legislative Fiscal Office, Presentation to the Legislature for Budget Hearings,
Jan. 12, 2009 (hereinafter LFO Presentation).
165.See The Tax Foundation, The Facts on Alabama’s Tax Climate, http://www.taxfoundation.org/research/topic/10.html;
and Center on Budget and Policy Priorities, The Impact of State Income Taxes on Low-income Families in 2007,
Oct. 29, 2008.
166.Information obtained from: LFO Presentation; Alabama Legislative Fiscal Office, State General Fund Comparison
Sheet.
167.Information obtained from: LFO Presentation.
168.Information obtained from: Center on Budget and Policy Priorities, The Impact of State Income Taxes on Low-income
Families in 2007, Oct. 29, 2008.
169.“Another study (yawn) shows that Alabama has a low tax burden.” The Birmingham News. August 15, 2008.
Citing Institute for Tax and Economic Policy Report.
170.Information obtained from: N. Siniavskaia, “Residential Real Estate Tax Rates in the American Community Survey,”
HousingEconomics.com, National Association of Home Builders, May 22, 2007, http://www.nahb.org/fileUpload_
details.aspx?contentTypeID=3&contentID=76984&subContentID=105281.
171.Information obtained from: The Tax Foundation, The Facts on Alabama’s Tax Climate, http://www.taxfoundation.org/
research/topic/10.html.
172.See, among others, General Summary of State Taxes, Alabama Department of Revenue; and Alabama Taxes and
Incentives, Birmingham Chamber of Commerce, www.birminghamchamber.com/busdata/incentives.pdf.
173.Information obtained from: Arise Citizens’ Policy Project, “The 2009 Tax Fairness Amendment: Answers to
Some Common Questions,” March 31, 2009, http://www.alarise.org/Taxes%20Reform/Tax%20Fairness%20
Amendment%20Q&A.pdf.
174.Id.
175.“Alabama Earmarks More of its Taxes than Any Other State.” Birmingham News. December 1, 2008 (citing NCSL
study of FY05 spending).
176.Information obtained from: Alabama State Treasurer, State of Alabama Comprehensive Annual Financial Report FY07,
Table II. LFO Presentation, Exhibit 1; The discrepancy between revenue and appropriations is due to the $3 billion in
other state funds not collected through the Alabama Department of Revenue.
alabama
An Analysis of the
76
177.Information obtained from: LFO Presentation, Exhibit 1.
178.Id.
179.See LFO Presentation; State of Alabama, Executive Budget, 2009-2010, pp xxi, http://budget.alabama.gov/pages/
buddoc.aspx.
180.See, among many others, “Alabama Earmarks More of its Taxes than Any Other State.” Birmingham News.
December 1, 2008.
181.Information obtained from: US Department of Justice, Bureau of Justice Statistics, Table 1, HIV in Prisons, 2006.
182.South Carolina also houses HIV-positive prisoners separately, and Mississippi segregates male (but not female)
HIV-positive inmates. Telephone conversation with Jackie Walker, HIV/AIDS/Hepatitis Information Coordinator,
American Civil Liberties Union National Prison Project, August 25, 2009.
183.Information obtained from: letter to ADOC Commissioner Richard Allen from state legislators, ACLU of Alabama, and
AIDS Alabama, September 28, 2007, http://www.aclu.org/hiv/discrim/tutwilerprison.html.
184.Information obtained from: ACLU of Alabama, HIV Positive Prisoners Receive More Equal Treatment in Alabama After
ACLU’s Efforts, November 1, 2007, http://www.aclualabama.org/News/PressReleases/Highlights/110107.html.
185.See ADOC Web site, http://www.doc.state.al.us/reentry.asp.
186.Information obtained from: electronic mail correspondence with Elana M. Parker, Reentry Coordinator and Public
Health Liaison, Alabama Department of Corrections and Alabama Department of Public Health, February 20, 2009.
187.Information obtained from: American Civil Liberties Union, Alabama Department of Corrections Ends Ban of Prisoners
with HIV from Work Release Programs, August 13, 2009, http://www.aclu.org/hiv/discrim/40734prs20090813.html.
188.Information obtained from: letter to ACLU of Alabama from ADOC Commissioner Richard Allen, October 24, 2007,
http://www.aclu.org/prison/restrict/32493res20070928.html.
189.Harris v. Thigpen. 941 F.2d 1495 (Ala. 1991).
190.Onishea v. Hopper. 171 F.3d 1298 (Ala. 1999).
191.Johnson v. U.S. 816 F.Supp. 1519 (N.D.Ala. 1993).
192.Information obtained from: Report on Program Access for Prisoners Living with HIV/AIDS, 2003.
193.Id.
194.Information obtained from: letter to ADOC Commissioner Richard Allen from state legislators, ACLU of Alabama, and
AIDS Alabama, September 28, 2007, http://www.aclu.org/hiv/discrim/tutwilerprison.html.
195.See BRIGHT Project Web site, http://brightproject.org/history.php; telephone interview with Michele Bailey, BRIGHT
Program Coordinator, December 15, 2008.
196.Information obtained from: Alabama Department of Labor Web site, http://alalabor.alabama.gov/job_termination_
laws.htm.
197.AL ST §22-11A-60 et. seq.
198.Bragdon v. Abbott, 524 U.S. 624 (1998).
199.See, eg, Center for AIDS Prevention Studies, University of California, San Francisco, Anti-discrimination policies in the
US increase use of HIV testing, International Conference on AIDS, July 1992.
200.Information obtained from: National ADAP Monitoring Project Annual Report, April 2009, http://www.kff.org/hivaids/
upload/7861.pdf.
201.Id. The 3 states are Idaho, Texas, and Utah.
202.Information obtained from: National Alliance of State and Territorial AIDS Directors (NASTAD), ADAP Watch, June
2004, http://www.nastad.org/Docs/Public/Publication/2006226_2004-JUNE.pdf (accessed 2/26/09).
alabama
An Analysis of the
77
203.Information obtained from: “Alabama to Remove 200 Patients from ADAP Unless State Approves $1M in Funding,
Health Department Says,” Kaiser Daily HIV/AIDS Report, 13 April 2005, http://www.kaisernetwork.org/daily_
reports/rep_index.cfm?hint=1&DR_ID=29319.
204.Information obtained from: National ADAP Monitoring Project Annual Report, April 2005, and SHARP Community
Partners Meeting, Provider session, November 17, 2008, Birmingham. Note that the ADAP fiscal year runs from
April 1 to March 31 of the following year, unlike the general federal fiscal year, which runs from October 1 to
September 30 of the following year.
205.Information obtained from: “Alabama to Remove 200 Patients from ADAP Unless State Approves $1M in Funding,
Health Department Says,” Kaiser Daily HIV/AIDS Report, 13 April 2005, http://www.kaisernetwork.org/daily_
reports/rep_index.cfm?hint=1&DR_ID=29319.
206.Information obtained from: K. Hiers. MY VIEW: Cutting AIDS funding in Alabama will hurt. The Birmingham News.
May 17, 2009, http://blog.al.com/birmingham-news-commentary/2009/05/my_view_cutting_aids_funding_i.html,
(accessed May 18, 2009).
207.Id.
208.Information obtained from: “Alabama Should Fully Fund State ADAP to Remove Patients from Waiting List,
Editorial Says,” Kaiser Daily HIV/AIDS Report, December 21, 2004, citing Birmingham News editorial of December
20, 2004.
209.Ala. Code 1975 §22-2-1.
210.Ala. Code 1975 §§22-2-4 and 22-2-9, and Ala. Admin. Code 420-1-5-.02. The four councils are the Council on
Dental Health; the Council on Animal and Environmental Health; the Council on the Prevention of Disease and
Medical Care; and the Council on Health Costs, Administration and Organization.
211.Ala. Admin. Code 420-1-5-.02.
212.Ala. Code 1975 § 22-2-8.
213.Information obtained from: telephone conversation with Jason Hohl, ASTHO Member Services, May 20, 2009.
alabama
An Analysis of the
78
alabama
An Analysis of the
Successes, Challenges, and Opportunities for Improving Healthcare Access
Prepared by the Health Law and Policy Clinic of Harvard Law School
and the Treatment Access Expansion Project.
Funded by Bristol-Myers Squibb, with no editorial review or discretion.

An Analysis of the Successes, Challenges, and Opportunities for

Transcription

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