Background
Alabama is the thirtieth largest state and is sometimes called the Yellowhammer State, after the state bird. It is bordered by Tennessee to the north, Georgia to the east, Mississippi to the west, and Florida and the Gulf of Mexico in the south. Montgomery is the state capital and the location of the central office of ADPH. The largest urban areas in Alabama are the cities of Birmingham, Mobile, Montgomery, and Huntsville. Birmingham is the largest city in the state and the location of the University of Alabama at Birmingham which has one of the state’s level one trauma hospitals. Mobile is the state’s port city and the third largest metropolitan area. It considers itself the cultural center of the Gulf Coast and the birthplace of America's original Mardi Gras. Huntsville, the fourth largest city, has experienced exponential growth in the last 10 years because of its national defense installations and high-technology industries. Huntsville considers itself the star of Alabama. As such, it has become a star in the fight for better community health through the creation of Healthy Huntsville. This effort focuses on the core concepts of nutrition and exercise to encourage our residents to embrace healthy lifestyles.
The state of Alabama is divided into eight Public Health Districts and each Public Health District Office is overseen by a District Health Officer or District Administrator. District Offices manage county health departments in 66 of Alabama’s 67 counties. County health departments work to preserve, protect, and enhance the general health and environment of the community by:
- Providing health assessment information to the community.
- Providing leadership in public health policy.
- Assuring access to quality health services and information, preventing disease, and enforcing health regulations.
ADPH operates on a mission to promote, protect, and improve Alabama’s health with a focus on heathy people and healthy communities. In 2019, ADPH leadership released a 5-year strategic plan. The plan focuses on five main areas and goals, which are outlined below:
Health Outcome Improvement
Goal: Improve specific health outcomes or health disparities so that Alabama is a healthier place to live and work
Financial Sustainability
Goal: Increase available funds in order to continue to promote, protect, and improve the health of Alabamaians
Workforce Development
Goal: Strengthen the performance and capacity of the ADPH workforce so that the ability to serve our customers increases
Organizational Adaptability
Goal: Adapt to changes in the health care environment so that programs and processes are increasingly effective and efficient
Data Driven Decision Making
Goal: Become data-driven in analysis and decision making so that leaders and programs make informed decisions
An additional part of this plan was to assemble teams to concentrate on five special projects. For 2019 those projects were as follows:
1. Improve Pregnancy Outcomes
2. Increase Participation Rates in Obesity and Chronic Disease Prevention Programs
3. Increase Reimbursement for Services Provided in 2018 and 2019
4. Establish a More Unified Workforce
5. Increase the Number of Initiatives Reporting in InsightVision (ADPH's performance management dashboard)
The State of Alabama CSHCN Program is administered by CRS, a division of ADRS. CRS’ mission embodies the principles of comprehensive, community-based, and family-centered care. The mission of CRS is to enable children and youth with special health care needs and adults with hemophilia to achieve their maximum potential within a community-based, culturally competent, family-centered, comprehensive, coordinated system of services. Coordinated health services are delivered via 14 community- based clinics across eight service districts.
SELECTED CHANGES IN ALABAMA'S POPULATION /ECONOMIC ENVIRONMENT AND POVERTY LEVELS/TRENDS IN NUMBERS OF ALABAMA TITLE V-SERVED PERSONS
Total Population
Based upon the Annual Estimates of the Resident Population produced by the U.S. Census Bureau, the estimated population for the state, as of July 1, 2019, was 4,903,185 according to data retrieved on March 29, 2021. This figure exceeds the 2018 estimate, of 4,887,681, by 15,504 persons.
0-24 Year-Old Residents
Of the most current data available and retrieved on March 29, 2021, for the year 2019, there were 1,538,530 (or 31.4 percent) of the Alabama population, from the age of 0-24 according to the U.S. Census Bureau. The age group breakdown for this calculation was as follows: Under 5 years was approximately 6.0 percent (294,357); 5-9 years was approximately 6.1 percent (297,968); 10-14 years was approximately 6.3 percent (310,498); 15-19 years was approximately 6.4 percent (313,615); and 20-24 years was approximately 6.6 percent (322,092). Of the total population, approximately 4.6 percent of Alabama’s population was of Hispanic Origin and approximately 95.4 percent was Not of Hispanic Origin.
Live Births
According to numbers, retrieved March 29, 2021, from the National Center for Health Statistics website, in 2019, there were a total of 58,615 live births to Alabama residents-a slight increase (approximately 1.5 percent) from the 57,761 live births in 2018 for the State. There were 4,910 (approximately 8.4 percent) live births to mothers of Hispanic origin in the same year. Of the mothers who were non-Hispanic, approximately 57.0 percent were white; 31.0 percent were black; 1.5 percent were Asian; approximately 0.3 percent were American Indian or Alaska Native and 0.06 percent were Native Hawaiian or Other Pacific Islander.
ECONOMIC ENVIRONMENT AND POVERTY LEVELS
Per the U.S. Census Bureau, 2019 American Community Survey Poverty Status In The Past 12 Months, for the year 2019, there were an estimated 739,108 or 15.5% of Alabamians below the poverty level.
TRENDS IN NUMBERS OF ALABAMA TITLE V-SERVED PERSONS
Per guidance on the completion of Forms 5a and 5b, the methods used for calculating the entries have changed; thus, data reported in this application/annual report will not be directly comparable to previous years.
For our annual report year 2019, there were 707 pregnant women and 31,621 infants less than one year of age served. There were 11,772 CSHCN and 71,402 “Others” served under Title V in our 2019 report.
CRS continually participates in community awareness and outreach activities in order to educate individuals about CRS services. The following figures represent CYSHCN and families who received services directly from CRS. Specifically, in FY 2017, CRS served 10,287 CYSHCN, an increase of 4.3 percent over FY 2016. In FY 2018, CRS served 10,784 CYSHCN, an increase of 4.8 percent over FY 2017. In FY 2019, CRS served 11,772 CYSHCN, an increase of 9.15 percent over FY 2018. The 2019 increase is attributed to expansion of Augmentative Communication Clinics to serve children with severe expressive language disorder, opening the Craniofacial Orthodontia Clinic to all payor sources, and additional hearing clinics.
In FY 2020, CRS served 12,091 CYSHCN, a slight increase of 2.17 percent over FY 2019. This number was the lowest increase over the past several years and is attributed to impacts surrounding the pandemic. In FY 2020, CRS provided information and referrals to 2,230 individuals. For FY 2020, CRS staff reached approximately 57,560 CYSHCN and their families via incoming toll-free calls, information and referrals, Parent and Youth Connection Facebook pages, ADRS/CRS website, outreach activities, health fairs, transition expositions, local hearing screenings, and Family Voices of Alabama (FVA) activities.
Issues important to understanding the health needs of the state's population include the health care environment, selected changes in the state’s population, the number of state Title V-served individuals, strategic and funding issues, and special challenges in delivery of services to CYSHCN. Also key to understanding the health needs of the state's Title V populations are salient findings from the current 5-Year Statewide Needs Assessment and priority MCH needs based on these findings which are discussed further in this MCH report/application.
The Health Care Environment
Changes that have occurred in Alabama's health care environment have caused a shift in the provision of direct medical services from CHDs to private providers. This shift has been especially evident with respect to the provision of services to pregnant women, children, and youth. Because the shift continues to affect ADPH's role in providing services, salient history concerning the health care environment is summarized here.
Medicaid Managed Care Programs
A discussion of previous and current Medicaid managed care programs, as well as case management or care coordination services provided through these programs, follows.
Medicaid Maternity Care Program
Under Medicaid's Maternity Waiver Program that was effective from 1988 through May 1999, ADPH had been the primary provider of prenatal care for 23 of the state's 67 counties and subcontractor for care in many other counties. The department's role in directly providing prenatal care markedly declined with Medicaid's State Plan for Maternity Care, which divided the state into 14 Medicaid maternity districts. With implementation of the plan, ADPH no longer provided maternity services via a direct contract with Medicaid. ADPH gradually withdrew from providing direct prenatal care and, by 2012, provided maternity care coordination in only two counties. Under this plan, the loss of federal matching funds and an increase in the number of eligibles have driven increased demand on the state General Fund.
Legislation passed in 2013 called for the state to be divided into regions and for a community-led network to coordinate the health care of Medicaid patients in each region, with networks ultimately bearing the risks of contracting with the state of Alabama to provide that care. In FY 2013, Medicaid began working towards the first milestone of establishing Medicaid districts with Regional Care Organization (RCO) provider networks in place. The RCO plan was unsuccessful and discussions began to replace it with the RCO Pivot Plan. The Pivot Plan continued to undergo redesign as Medicaid pursued better ways to transform its delivery system. Throughout the changes at Medicaid, ADPH continued to provide maternity care coordination in 15 of its 67 counties, receiving reimbursement for only about half of the services provided.
Patient 1st and Case Management/Care Coordination
The Patient 1st Program, a primary care case management program (PCCM), was fully implemented by Medicaid in November 1998. The Patient 1st model assigned all Medicaid recipients to a medical home that managed their health care needs, including referrals for specialty care and pre-authorization of specified Medicaid services. Under Patient 1st, the number of children seen in ADPH clinics declined markedly. PCCM and a prior increase in willingness of private providers to see Medicaid-enrolled patients were thought to be major factors in this decline. The Patient 1st Program originally affected the provision of case management or care coordination by ADPH.
As the provision of direct health care services to children and youth in the CHD setting diminished, the focus shifted from direct services provision to community-based services. This shift gave rise to increased emphasis on provision of care coordination. ADPH provided case management through the Medically at Risk (MAR) Case Management Program with most MAR referrals being for immunizations; dental care; appointments missed for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT); social systems issues; specialty referral coordination; and problems with a medical regimen. In early FY 2004 Patient 1st was discontinued, effective March 1, 2004, because of financial constraints and waiver expiration. When Patient 1st ended, Medicaid-enrolled patients could receive services from any physician who provided services under the Medicaid Program, but Medicaid no longer reimbursed for provision of care coordination for adults. Primary medical providers in the state petitioned Medicaid to restart the managed care program. A task force, which included persons from CRS and ADPH, was established to create a new waiver for a revised managed care program for Medicaid enrollees. The Patient 1st Program was redesigned in December 2004 and all counties were a part of Patient 1st by February 2005.
One change was that Medicaid no longer required a referral from the primary medical provider to provide care coordination. The removal of this barrier allowed ADPH care coordinators to receive referrals from a variety of sources and refer children with select conditions for care coordination by trained CHD staff. Also, CHD care coordinators could provide information and counseling on birth control methods and sexually transmitted diseases (STDs), including HIV infection, to Medicaid-enrolled teens who presented for family planning services. FHS implemented an electronic Care Coordination Referral System (CCRS) which is used for referrals received from the Children's Health Division for children with select conditions. The system is also used for infants referred by Medicaid for care coordination. In FY 2008, ADPH began providing chronic disease case management to asthma and diabetes patients under Medicaid's Together for Quality (TFQ) federal grant. The Patient 1st Care Coordination Program continued to grow; however, growth in the program had created financial concerns for ADPH in regard to the Medicaid match.
In September 2008, Medicaid agreed to pay half of the federal match on any Medicaid-related expansion relative to FY 2007, after ADPH paid a $2.1 million match in a Medicaid-related expansion of the program. Despite the cost sharing and cost containment, in FY 2009 ADPH determined that it could not maintain the program as then funded and began negotiating with Medicaid for further help with the federal match. Being unsuccessful, ADPH's provision of care coordination under Medicaid's Patient 1st Program decreased. In FY 2010, the Medicaid match dropped but the Governor required that ADPH turn over any savings for distribution to other agencies. In FY 2012, Medicaid expected to be designated by the Centers for Medicare and Medicaid Services (CMS) for participation in Medicaid's "Health Home" option under the Affordable Care Act. Medicaid has since received the Health Home designation and is receiving the enhanced match rate. The number of full-time equivalents (FTEs) providing care coordination in the Patient 1st program has varied yearly. In January of 2019, the Request for Proposals (RFP) was released to transition Medicaid's Patient 1st program to the Alabama Coordinated Health Network (ACHN). This new Medicaid program moved all case management (maternity, Plan First, and Patient 1st) under one entity in seven regions throughout the state. Through negotiations with Medicaid, ADPH continued to only provide case management services to those infants that did not pass the Newborn Screenings at the hospital and those children with an elevated lead level. In FY 2020 ADPH provided case management services to those children that did not pass the Newborn Screening or Newborn Hearing Screening at birth and those children with an elevated lead level. FY 2020 ended with 7 FTEs providing services to the identified infants and children.
Collaboration between CRS and Medicaid
The Medicaid Commissioner has emphasized children's issues as an Agency priority and specific Medicaid staff members are assigned to work with CRS. Meetings between Medicaid and CRS are held quarterly to discuss any issues or concerns regarding providing services to Medicaid recipients with special health care needs. If issues arise outside the quarterly meetings, the CRS Medicaid liaison will contact Medicaid to discuss. In addition, CRS staff including the State Parent Consultant (SPC) participate on advisory committees and work groups associated with various Medicaid initiatives.
In order to ensure consistent quality, statewide standards of care, and access to community-based clinical services, Medicaid and CRS have negotiated a list of approved multidisciplinary clinics. CRS operates these clinics within Medicaid’s Children's Specialty Clinic Services program requirements, which includes the required practitioners credentialed in accordance with Medicaid Administrative Code. CRS clinics employ physicians, nurses, social workers, physical therapists, audiologists, nutritionists, occupational therapists, and speech language pathologists. CRS works with Medicaid to add new specialty clinics or modify existing clinics as needed.
Throughout the COVID pandemic, CRS worked closely with Alabama Medicaid to discuss the needs of therapists and Medicaid recipients, both in and out of ADRS, to maintain a continuum of service delivery for all recipients in the state. Medicaid communicated with CRS program specialists regarding therapeutic codes and service delivery options to ensure all Medicaid recipients could be served appropriately. Medicaid recognized the need for covering Speech Therapy, Occupational Therapy, and Physical Therapy via telemedicine visits which allowed CRS to continue providing services during the pandemic to families that would have otherwise been unable to receive needed services. Upon notification of coverage CRS began researching methods of delivery for telemedicine. This involved testing various methods and discussing options while considering efficacy of delivery, HIPAA, and service provision equivalents.
Alabama Medicaid communicates changes via Alerts. During COVID-19 CRS assisted with the distribution of these Alerts to many partners (Durable Medical Equipment (DME) companies, etc.) to ensure individuals were apprised of temporary changes to Medicaid policy in response to the pandemic. All forms of DME continued to be delivered to clients with training provided via tele-means, when needed, to prevent gaps in service.
CRS is a direct provider with Medicaid for audiological services, hearing aids, and related supplies, thereby providing better coordination of these services for Medicaid-eligible CRS clients. CRS reviews all statewide requests to Medicaid for augmentative communication devices (ACDs) and houses all Medicaid prior authorization requests for ACDs. During the COVID-19 shutdown, Prior Authorization requests for ACDs continued to be submitted and reviewed to prevent delay in receipt of equipment.
CRS is the only provider of medically necessary orthodontia for Medicaid recipients. CRS works closely with Medicaid’s Dental Director regarding coverage for medically necessary orthodontia services. During the pandemic CRS worked with orthodontists at UAB School of Dentistry to approve teledentistry codes to ensure clients in active orthodontia were still followed by their orthodontist for their plan of care to prevent patient abandonment.
CRS has an ongoing collaboration with Medicaid to meet Health Insurance Portability and Accountability Act (HIPAA) standards for privacy and billing. CRS staff have access to Medicaid eligibility data for confirming coverage as outlined in the Provider Agreement between Medicaid and ADRS.
Medicaid Family Planning Waiver and Related Issues
The 1115(a) Family Planning Waiver Proposal, submitted by ADPH and Medicaid to the Health Care Financing Administration (HCFA) in FY 1999, was implemented in October 2000 (HCFA became CMS). This waiver, called "Plan First", expanded Medicaid eligibility for family planning services to 133 percent of Federal Poverty Level (FPL) for women aged 19-55 years of age. Family planning services for adolescents less than 19 years old were already covered by Alabama's State Children's Health Insurance Program (CHIP). Care coordination and outreach were key components of the Family Planning Waiver Proposal.
Effective January 1, 2010, women seeing private Plan First Providers were allowed to take contraceptive prescriptions to the pharmacy. Women receiving services through a CHD continued to obtain their contraceptives on site at the time of their visit, often receiving a 12-month supply. Also, effective January 1, 2010, women applying for Plan First no longer had to provide a birth certificate for proof of citizenship. Under the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009, states could now use a data match with the Social Security Administration (SSA) to verify citizenship. In FY 2014, CMS approved the addition of a smoking cessation initiative. This initiative allows waiver recipients to receive smoking cessation products and telephone behavioral counseling through the Alabama Tobacco Quit Line. The Plan First Family Planning Program includes coverage for women ages 19 to 55 up to 141 percent of FPL and coverage for men age 21 and older with incomes up to 141 percent of FPL for vasectomies only. A standard income disregard of 5 percent of the FPL is applied if the individual is not eligible for coverage due to excess income. In November 2016, Medicaid submitted a waiver amendment to add care coordination for males enrolled in Plan First to receive vasectomies and vasectomy-related services.
UAB evaluates the implementation of Plan First. The evaluation determines progress on six goals: enrolling 80 percent of eligible women under age 40, maintaining a high level of awareness of the Plan First program among enrollees, increasing utilization of Plan First services by enrollees to 70 percent, increasing the portion of Plan First enrollees who receive smoking cessation services to 85 percent, maintaining birth rates among Plan First participants, and making sterilization services available to income-eligible men over age 21. According to the Plan First Market Analysis report, the Alabama Family Planning Program provides services to approximately 33 percent of all Plan First enrollees statewide. The evaluation determined the program paid for itself by reducing costs associated with births and noted participants with the lowest birth rates are those who received risk assessments or care coordination and those who use Title X Family Planning services. The waiver has been extended through September 2022. Medicaid has consistently expanded services with each renewal, most recently adding care coordination services for males seeking sterilization services.
The State Children's Health Insurance Program
CHIP was added to SSA by the Balanced Budget Act of 1997. Alabama was the first state in the nation to have a federally approved CHIP plan. Alabama's CHIP program is the result of a partnership between ADPH, Medicaid, and the former Alabama Child Caring Foundation. Alabama’s CHIP is administered through ADPH's Bureau of Children's Health Insurance. CHIP provides comprehensive health coverage to eligible children through a separate program known as ALL Kids. As a result of provisions in the Affordable Care Act, in addition to the ALL Kids program, CHIP also funds two groups of Medicaid eligible children (MCHIP).
The Affordable Care Act of 2010 maintains the CHIP eligibility standards in place as of enactment through 2019. Three major activities concerning CHIPRA implementation include: 1) citizenship verification, 2) prospective payments for federally qualified health centers (FQHCs) and rural health centers, and 3) mental health parity. Verification of citizenship relies heavily on coordination with the federal SSA, follow up with parents, and internal tracking. ALL Kids became the sole component of Alabama's CHIP in FY 2004. Persons eligible for Medicaid are not eligible for ALL Kids. Medicaid and ALL Kids continue collaborating on the application process.
The bureau continues to work collaboratively with Medicaid to make enhancements to the dual eligibility enrollment system. This collaboration will ensure a streamlined application process that is easy for applicants to navigate. As of September 2019, there were 172,747 children enrolled in CHIP with 85,265 enrolled in ALL Kids and 87,482 enrolled in MCHIP. CHIP also developed the ALL Babies program, a pilot in Macon, Montgomery, and Russell counties. ALL Babies provides comprehensive health coverage and case management services for low-income pregnant women who are uninsured and do not qualify for Medicaid pregnancy coverage. The goal of this initiative is to positively impact pregnancy outcomes and reduce infant mortality.
The Alabama Department of Early Childhood Education
DECE was created in 2015 to expand upon the duties of the former Department of Children's Affairs and to include the development of a cohesive and comprehensive system of high quality early learning and care experiences for Alabama's children from birth to eight years of age. DECE's mission is to provide state leadership that identifies, promotes, and coordinates services for children, their families, and communities.
DECE is the state designee for the federally mandated Early Childhood Advisory Council (designated as the Alabama Children's Policy Council in 2015), home of the Alabama Head Start Collaboration Office, coordinator of Alabama's state and local Children's Policy Councils, administrator of the Children First Trust Fund, lead agency for early learning and home visiting programs, and developer and operator of the nationally-recognized First Class Pre-K Program. DECE has also designed and coordinated the state plan for developing a continuum of home visiting services for children from prenatal to age five, including all relevant state agencies.
DECE receives and disperses any funds appropriated by state and federal sources for the establishment, operation, and administration of its programs. DECE is responsible for coordinating and organizing all efforts for the federal Preschool Development Grant and serves as its fiscal agent. DECE was awarded a $70 million ($17.5 million per year for four years) federal preschool development grant in 2014 to expand access to quality First Class Pre-K. In 2018 the Alabama Legislature approved an $18.5 million expansion for First Class Pre-K, increasing the FY 2019 program budget to $96 million. For the 2018-2019 school year, 18,720 children were enrolled in 1,040 classrooms in all 67 counties, serving 33 percent of the state's eligible 4-year-old population. Since 2012, investment in First Class Pre-K has grown from $19 to $100 million, more than 420 percent. There has been a 380 percent increase in additional classrooms and the number of students served during the same period.
Alabama is nationally recognized as a leader in quality early childhood education and care. DECE leadership and staff are regularly called upon to provide leadership and assistance to other states that look to Alabama as the national leader in quality early learning and care, regularly serving as a model and mentor to other states. The First Class Pre-K program maintains the program's nationally recognized quality standards. The National Institute for Early Education Research (NIEER) recognizes Alabama as one of only three states in the nation to have a state pre-kindergarten program that meets all of the quality standards benchmarks.
DECE is frequently invited to present on the national level and share Alabama’s successes in pre-k programs while maintaining high quality, developmentally appropriate programming.
CRS Services to Certain Medicare Enrollees
In FY 2020, CRS served 47 clients with Medicare benefits. All clients were adults with bleeding disorders. CRS assisted clients with Medicare coverage to select the health plan option that best addresses their needs and to help them locate Medicare pharmacies for factor treatment of bleeding disorders. In FY 2020, CRS paid insurance premiums for 16 clients with bleeding disorders.
Emergency Preparedness: ADPH and CRS
ADPH and CRS continue to be involved in emergency preparedness response. ADPH has a key role in promptly responding to potential man-made disasters and potential weather-related disasters during which the department's role is to coordinate the health and medical response during any emergency event.
Special Challenges in Delivery of Services to CYSHCN
In response to the Governor’s mandates, CRS operated most of the second quarter of FY 2020 with a hybrid of on-site service delivery, teleworking, and telemedicine. Even during the Stay at Home order, CRS staff continued activities to support the needs of children, youth, and families by paying copays, authorizing medications, providing needed services, and equipment. CRS staff worked diligently to contact families to assess needs and reassure them that CRS was continuing to serve them through innovative ways until it was again safe to reopen clinics. In the interim, several telemedicine clinics were provided including Seating, Cerebral Palsy/Neuromotor, Teen Transition, and Limb Deficiency.
On May 1, 2020, CRS District Office and State Office staff returned to on site work. On May 4, 2020, CRS clinics resumed operations per guidance provided through the CRS Re-Open Task Force and CDC. Safety practices included wearing Personal Protective Equipment (PPE), utilizing screening procedures (questions and temperature), managing waiting areas, reducing clinic numbers, and holding telemedicine clinics when appropriate. Of course, all staff maintained recommended social distancing, wearing face coverings, and diligently washing their hands.
CRS has utilized CMS/Medicaid's lessened restrictions on telemedicine visits during the pandemic. Several CRS Evaluation clinics began to meet as telemedicine clinics over secure Zoom accounts even before offices reopened to staff. Clients were provided the multidisciplinary team evaluation they were accustomed to receiving even though the visit occurred via telemedicine. Offices reopened on May 4, 2020, and additional Evaluation and Medical clinics were developed to deliver multidisciplinary clinical services via telemedicine. These include Adult Hemophilia, Augmentative Communication & Technology, Cystic Fibrosis, Feeding, Neurology, Pediatric Hemophilia Seizure, and Seating/Positioning/Mobility Clinic. During the COVID-19 crisis, CRS audiologists continued to serve clients by providing curbside assistance when possible for hearing aid troubleshooting, providing batteries, and providing audiological counseling and education.
CRS staff members continue to ensure CYSHCN and their families receive high quality services in their local communities while identifying resources for families to address issues created by the impacts of COVID-19. Our mission has always been to provide quality clinical services to CYSHCN and their families and we were able to continue meeting their needs even during a time of extreme limitations.
In addition to the COVID-19 crisis, CRS faced continued challenges in rural areas. The state is largely rural, with greater population concentrations surrounding three larger urban areas (Mobile, Birmingham, and Huntsville). In rural areas, more risk factors exist that could potentially increase the percentage of CYSHCN in the general child population, such as higher poverty levels and lower education levels. According to the USDA Economic Research Service the poverty rate in rural Alabama is 18.5 percent compared with 14.8 percent in urban areas of the state and 18.8 percent of the rural population has not completed high school.
Comprehensively meeting the needs of CYSHCN in rural areas is even more difficult due to transportation barriers and limited access to providers with specialized experience in treating complicated health issues. Specialists and allied health professionals with pediatric experience are mainly located in the larger urban areas, necessitating travel to access them. In general, the state has poor public transportation systems. Though private programs exist in some areas and reimbursement for transportation is provided through various sources (including Medicaid and CRS), the state lacks the infrastructure to meet transportation needs in all locations. Thus, CRS continues to have an integral direct service role in the state's system of care for CYSHCN through its 14 community-based offices. Via the provision of multidisciplinary medical specialty and evaluation clinics, care coordination, and family support throughout the state, more CYSHCN have access to care in their home communities. Public/private partnerships, including agreements with the state's two tertiary-level pediatric hospitals, enable CRS to bridge gaps in the system of care, thereby increasing the state's capacity to address the health, social, and educational needs of Alabama's CYSHCN.
The State’s Fiscal Situation
The COVID-19 pandemic stalled the economy putting more than 400,000 Alabamians out of work. Despite the massive economic shutdown that crippled the state economy and thousands of businesses, there will not be any need to prorate either the general fund or the education trust fund budgets in 2022. The General Fund provides funding for most non-education programs in the state. The $2.4 billion General Fund budget which was approved will increase spending 3.6% over the current year 2021 by $90.6 million.
The General Fund got a break this year as federal matching dollars for the state Medicaid program and the Children’s Health Insurance (CHIP) were higher than usual. That means, while actual funding won’t increase, the state will spend $51 million less on Medicaid and $12 million less on CHIP. Medicaid’s state funding will fall from $820 million to $769 million, however, carryover funds combined with and increased federal match will make up the difference. Most agencies would receive about the same amount as the current year. These three agencies would receive budget increases: Alabama Pardons and Paroles, Alabama Department of Corrections and Alabama Department of Mental Health. Public Health would receive departmental funding of $47.7 million, a $1.9 million increase over FY 2021.
In FY 2020, Alabama’s Title V MCH Program received $11,482,727 and will be budgeted at this level for the FY 2022 application.
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