MONTGOMERY — Alabama’s Black Belt counties have limited access to hospitals and clinics, and the state overall is suffering poor health outcomes, according to a report released this week by the University of Alabama’s Education Policy Center.

The policy center’s definition of the Black Belt includes 24 counties, and Monday’s report, “Health Care: A Key Challenge in Alabama’s Black Belt,” said 17 of them have fewer than the statewide average of 3.9 hospital beds per 1,000 people.

Four Black Belt counties — Lamar, Lowndes, Perry and Pickens — don’t have any hospitals.

“These data suggest that the Black Belt is largely underserved in terms of health care,” the report says. “Specifically, it indicates that Black Belt residents lack physical access to health care, i.e. the nearest hospital or clinic can be over an hour away.”

Seven rural county hospitals have closed in recent years.

The Education Policy Center’s Black Belt 2020 series concludes that the Black Belt’s population decline, school enrollment decline, persistent unemployment and lack of labor force participation all contribute to the closure of rural hospitals.

Former Gov. Robert Bentley declined to pursue Medicaid expansion under the Affordable Care Act, commonly referred to as Obamacare, when the federal government was using higher funding incentives to encourage states to opt in, saying the cash-strapped state couldn’t afford it. Stephen Katsinas, Education Policy Center (EPC) director, said that decision cost the state.

“Robert Bentley’s choice not to take the ACA funding in 2014 when the federal government was offering such generous matching inducements, is easily the single worst decision made by an Alabama governor since George Wallace’s infamous stand in the schoolhouse door barring African Americans from entering the University of Alabama in 1963,” Katsinas said.

Under the ACA, the federal government would have matched 100% of the state’s expenses for Medicaid expansion from 2014 to 2016, phasing down to 90% for 2020 and the years beyond that. The EPC estimates that would have amounted to $3.3 billion for the state.

Bentley was not alone in his decision not to expand Medicaid. Most Republican lawmakers, including state Sen. Arthur Orr, R-Decatur, stressed at the time that even the 100% match would have left administrative expenses for the state that had to be approved by the Legislature, and that long term — as the federal match decreased — the cost to the state would have been substantial.


State budget

But Katsinas said any financial cost to the state would have been outweighed by the benefits.

“The $3.3 billion in missing funds would have simultaneously stabilized Alabama’s volatile General Revenue Fund and thus protect education funding, while resulting in better health care outcomes statewide, for rural residents generally, and rural Black Belt residents specifically,” Katsinas said.

Some estimates show expanding the program to include 360,000 more residents would now cost the state about $170 million in the first year alone with increasing costs going forward, which state leaders say the budgets can’t afford.

U.S. Sen. Doug Jones spoke during a media briefing on the report this week, advocating for the expansion of Medicaid under the ACA. Jones has proposed federal legislation that would restore the 100% federal matching dollars for states like Alabama that did not initially expand Medicaid if they want to now opt in.

Rep. Kyle South, R-Fayette, participated in Monday’s press briefing and, while he didn’t address the state’s position on not expanding Medicaid, he did explain Alabama’s constitutional requirements that make such a move difficult.

The state covers Medicaid expenses through the general fund, but "most of the growth we would see, economic impact wise, would be in the way of sales and use taxes and income taxes, all of which are constitutionally bound to go to the Education Trust Fund,” said South, vice-chair of the House Ways and Means General Fund Committee. “So there are some hurdles that we would have to get beyond under our current constitutional restrictions.”


Doctor shortage

Other data analyzed by the EPC found that poor health outcomes are common across the state in both rural and urban counties.

The report shows that in 2014, the rate of preventable hospital admissions was evenly distributed across the Black Belt and non-Black Belt counties.

The Centers for Disease Control and Prevention defines preventable hospital admissions as “admissions to a hospital for certain acute illnesses … or worsening chronic conditions … that might not have required hospitalization had these conditions been managed successfully by primary care providers in outpatient settings.”

Alabamians overall lack the access to primary care physicians which causes chronic illnesses to go unaddressed and worsen, according to the report.

South said rural areas like the Black Belt don't just need more hospital beds, they need more primary care physicians.

“I think we have to continue to focus on incentivizing young people, young health care workers, professionals and doctors, to locate in rural areas of Alabama because we have almost a crisis point of recruiting those people back to the rural parts of the state,” South said.

The state’s share of CARES Act funding has helped during the ongoing coronavirus pandemic, including $191 million that went to 175 rural hospitals, clinics and community health centers.

The report says more needs to be done though as Congress lags in passing another coronavirus relief package.

The EPC encourages the state to participate in any new federal incentives for the ACA that are passed by Congress, like Jones’ proposed SAME Act restoring the 100% federal reimbursement for the first three years for states that expand Medicaid.

“At the end of the day we are still ranked low in health outcomes and poverty,” Jones said. “We’ve got to make sure that we can lift all folks and we need to get better health outcomes and I think if we can do that, we can get a better economy in all these rural areas. That’s how you get people and that’s how you keep kids staying in these rural areas.”

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