Alabama: No State for Children?

Yesterday, I made the six hour round trip to Alabama’s state capitol, Montgomery, to attend Pediatric Legislative day.  I’ve been many times—it was the largest turnout of docs I’ve seen yet.  This is my personal report, not in my capacity as a state AAP (American Academy of Pediatrics) board member.  In keeping with the several references to Titanic I heard, I am sorry to tell you that we have already hit the iceberg and our ship is in process of sinking.  I do not know if there are enough lifeboats.  Our legislators and Governor are tossing children overboard first.


Those of us who arrived early chatted while drinking coffee, before all the optimism got sucked out of us.  Last month, we got notice that Medicaid provider payments due March 16 were to be delayed and that “a payment date has not been established.”  Many friends in private practice, especially in rural areas where the great majority of their patients have Medicaid, have already forgone their own paychecks.  Many have had to let staff go (one lost 40% of her staff this week) AND take out emergency loans.  Some of the younger docs are already talking about leaving Alabama completely.


A friend in Mobile reported that because of these payment delays, not a single ENT (Ear-Nose-and Throat surgeon) in her county would accept a new child patient with Medicaid.  In Mobile, one of the largest cities in our state, doctors will have to send children out of town for care. Still, while we drank our coffee, we were smiling, hopeful that when our lawmakers heard about this, they would do something.


Once the speakers arrived, the news got worse.  First we heard from some of my personal heroes, those in our Medicaid agency.  These are the people who work day and night to find ways to stretch a dollar for the sake of children.  We heard that there was still no provider payment date set, and that Medicaid was waiting for the Finance office to release funds.  They are anticipating it may be a recurrent problem and are already making contingency plans for a rotating payment schedule.  Some doctors will get paid one month, some the next, etc.  We heard these grim words:  “You are going to see things you’ve never seen before.”


The Alabama House Budget is due in committee today.  We heard there is talk that the Medicaid Budget will be as low as 425 million.  I was told this is far less than the amount that even the corporate Third Party people would consider taking as a managed care contract.  That this would not fund adequate care for children.  That adult pharmacy benefits (serving the disabled poor, including those with serious mental illness like schizophrenia) would have to end.  There will most likely be a significant payment cut to All-Kids doctors (Alabama’s SCHIP program, for children in working families just above the poverty cutoff for Medicaid).


It was hard to watch my heroes try to smile and come up with something hopeful to say.  They looked so tired.


Next came the legislators.  They had big smiles!  Many of them said they personally “got it” and put the blame on Governor Bentley for his signed no new tax pledge, a bizarre Medes and Persians type oath that apparently means more than his oath of office to do his best for our state.  Senator Orr said the idea of having to override Bentley’s promised veto for a tax increase “gives us heartburn.” But the way they were smiling, I have my doubts about the “got it” part.  I sure didn’t see anything that made me want to dig in my purse for an antacid to share.


Speaker Mike Hubbard came in last, also smiling, at first.  He said his philosophy was “never let a good crisis go to waste” and that this was our chance to make Alabama’s government “leaner.”  He said “Medicaid is a black hole”.  I have added and deleted a sentence ten times about why he might have chosen those exact words, because I’m trying to be objective—you decide.  Don’t believe him, by the way—here’s a more accurate description of state spending.


The first question from the floor came from Dr. Marsha Raulerson, a nationally respected pediatrician who has served her poor rural community for decades—a woman who brings her beeper even on vacation and has somehow also managed to perform tremendous leadership and advocacy work.  She asked if Mr. Hubbard realized she was having to let staff go already and if he would consider a tobacco user fee, a $1 a pack fee on cigarettes that would bring us close to the average of other states, improve child health, and raise an estimated 200 million for the General Fund.  He gave the same heartburn sob story.


Around the room, other pediatricians spoke up.  We are usually a polite crowd, and we still were.  There was no name calling or personal criticism, but there was both passion and anguish.  I heard voices with barely held-back tears.  One friend told Hubbard he needed to understand children would die.  He listened to a few of these comments with visibly rising irritation and then said, curtly, “We appreciate your time”, turned on his heel, and walked out.  Dr. Raulerson tried to hand him an information sheet as he left, and he refused to take it.  It was a level of rudeness I have never encountered at our state house.


As we sat in shock, a legislator I didn’t recognize, stuffing his mouth with the lunch sponsored by Children’s Hospital of Alabama, said he had heard doctors were stealing from Medicaid left and right.  He also left.


I looked around the room and saw pediatricians in all stages of grief except denial.  We can no longer deny that this is happening—that our state legislators and Governor will let this ship sink. If the budget is as bad as we are anticipating, we will not be able to fund care at the level required by federal rules.  I didn’t hear anyone mention it, but I was reminded of reports in the media in 2010 that Alabama might drop Medicaid entirely.  After seeing these people smile in the face of child death, I would not be surprised.  The story would be that Alabama tried but just couldn’t comply with “unfunded mandates”.


If nothing is done—and I mean immediately, not just for FY 2013—we will lose pediatricians very quickly.  No matter how much we love our patients, we will not be able to run offices without rent money, staffing or supplies.  Rural areas will go first.  Pediatric residents graduating in June will decide to take jobs elsewhere.  When they leave, they won’t come back.  We will lose the pediatric specialists who can’t pay staff and rent without Medicaid funding.   We will lose our Children’s Hospitals.  There won’t be special hospitals left for children of privately insured parents.  There will be nothing.  It will be like a bad movie called “Alabama: No State for Children.”


What is to be done?  I don’t know what to tell you.  It’s worth a try to make noise now, but it would take real noise, not just a friendly email or phone call.  Dr. Raulerson calls her legislators every day.  If you are a parent or a business owner who employs parents, and you don’t make or hear an uproar, I would be remiss if I didn’t advise you to start making evacuation plans soon.



Filed under Alabama legislative session 2012, Children's Issues

24 responses to “Alabama: No State for Children?

  1. Chuck

    “As we sat in shock, a legislator I didn’t recognize, stuffing his mouth with the lunch sponsored by Children’s Hospital of Alabama, said he had heard doctors were stealing from Medicaid left and right.”

    Sounds to me like legislators who sell out the citizens who pay their salaries are the ones doing the stealing.

  2. I believe the insensitivity and lack of responsibility of the legislature and governor rises to the level of evil.
    Bob Hurst

  3. I had so many opinions read this, but looking at this comment box I can’t even put what I’m really feeling into words.

    As a recovering Social Worker, I have worked with children & adults on disability in Alabama. Just the thought of what these changes will mean is overwhelming.

    I am currently living on SSD myself, following my last Social Work induced Bipolar melt down. Thankfully my career years left me over the income threshold for Medicaid, but I do get the SLMB assistance. I can’t claim to understand all the funding arrangements, but that seems to be an area that would be much easier to cut than those you’ve mentioned. Right now losing it would crush me financially, but it would be an easier blow than being a parent unable to get care for a sick child.

    These days I’m having to support my father as well, because the one place he worked his whole life shut down, his unemployment ran out, & no one seems to want to hire a man so close to Social Security age. Those Medicaid cuts will probably be bad news for the local clinic in our rural town where he gets his blood pressure medicine, since he doesn’t have any health insurance.

    If the yahoos in Montgomery actually had to live with the consequences of their decisions they wouldn’t have been smiling.

    Okay, maybe I did think of something to say. Sorry if it was a bit OT.

  4. CCR

    This is so heartbreaking! And yet, you still have faith that a government-run, single-payer system is what we need in this country? Imagine this situation with Medicaid expanded to the entire health care system. I lived it, when I was in Canada! You have far more (unjustified) faith in the politicians and bureaucrats than I, if you really think Medicare-for-All won’t turn into the same sort of catastrophe. At least private companies, for all their flaws, are subject to pressures from the market and from government regulation. The government, as you have seen, responds to nothing but its own greed and ineptitude.

    • Yes, as I’ve said previously– I don’t have faith at all in the politicians. Nor in private insurers. Private insurers are subject primarily to pressure from stockholders, not patients. It would be critical to build in safeguards, including first and foremost that we ALL have the same insurance, including these politicians– they and their children would have to live with what they do. 96% of Canadians prefer their healthcare system to ours. We would obviously need to learn from their errors and build something more similar to Taiwan’s.

  5. Does anyone have a report or other authority about the affect of the Medicaid funding problems on the nursing home program for the elderly? __Jim Zeigler, Elder care attorney

  6. I am saddened and overwhelmed by the lack of understanding by our legislators on the impact of budget cuts with no attempt to increase revenue–a lack of civic responsibility and lack of compassion for the 26% of children who live in poverty in Alabama. Marsha Raulerson

  7. Barbara Power

    Dear Pippa,

    I look forward to your postings, as heartbreaking as they are, and this description of what is playing out in Alabama is devastating. As mentioned in earlier replies to your blog posts, I see other states edging toward this very same model of throwing children overboard – first. Also as you stated, the next group to be thrown over are those with mental illness. The more severe the illness, the more quickly their options are cut. The top 5, 10, 12 list of The Most Vulnerable might as well have targets painted on their backs — all across the USA.

    I wonder if you would/could get this published on the PNHP site front page? I also suggest that if you have ~any~ national media contacts you get this story published.

    I live in a very small rural town. We, and the towns surrounding, once had to fight the DOE — they were going to flatten a few towns for a nuclear waste site. The site was going to require trucks to pass through the major cities of the northeast. By sheer luck one of our local citizens had a contact at the NYT and the story of our little town was published in the Sunday Edition of the Times. When this happened, the DOE backed down.

    As I wrote to NH governor and legislators, any eighth grader can cut a budget and that what I expected from them was real 21st century advanced thinking and enlightened solutions. NH has cut Medicaid too. They have especially hit the only children’s hospital unit in the state.

    Our legislators and governors and those in DC “ ARE “ devolving into monsters ready to let children and the vulnerable die.

    • I agree– I have contacted the national AAP office and heard back from them this morning. I am asking them to make the media contacts at the big level, because I think they’ll have a quicker connection that I would. I sent the post to PNHP, too, but we can’t afford to make this a “progressive” issue. Needs to be bipartisan (because it is!).

  8. None of this is as important as another abortion bill, however, because the right to life must be absolute — and must absolutely end at birth.

  9. laprofe63

    The dark ages are upon us with this. Only option is to make a lot of noise, get political and be activists. Or, of course, leave Alabama for more promising lands.

  10. tnlib

    This is utterly heartbreaking and absolutely infuriating. I smell the stench of the American Legislative Exchange Council behind this – a well funded organization that is writing so much of the draconian legislation in many states but mostly in the South. Imagine that. (I live above you in TN). Anyway, visit to learn more.

    I call these Neanderthals the pro-life-until-birth types and what you so poignantly describe is truly frightening. Of course, the obvious solution is to vote them out but with all the voter restrictions, fewer people are even registering. And I think it would be naive to expect honest elections. And, of course, there is the time factor in which thousands of children will not be able to receive health care of any kind. My heart breaks.

    This is such a stupendously revealing article and it certainly deserves more exposure. I very much would like your permission to publish it in full on my modest little blog – with full credit, of course. Please feel free to check it and me out at

  11. Pingback: Alabama Will See Things We’ve Never Seen Before | Osborne Ink

  12. tnlib

    I just posted your article:

    I applaud your activism and your courage. I have relatives in Huntsville. Nuff said.

  13. cyndi1983

    I’m reading The Hunger Games trilogy. Your experience reminds me very much of a district’s interaction with Panem’s Capitol. The image of heartless politicians snacking rather than having a discussion about a difficult topic is hard for me to hear about.

    There is more than one way to use a lottery to select which children will die. Alabama and its no new taxes for any reason seems to be choosing death of children over thoughtful consideration for “the least of these” and their fates.

  14. Dr. Abston,
    I am so sorry for the turmoil that you and your colleagues endured with the elected officials of Alabama. The poor, sick, young, disabled, weak and defenseless Alabamians are NOT important to our current elected officials. The Jesus Christ of my Holy Bible is surely in shock and shame for those Alabamians who call themselves His followers while ignoring apparent mistreatment of children.

  15. Billie Pugh


  16. Barbara Power

    As an advocate for those who need healthcare, and as one in favor of Single Payer, I hear these sorts of vitriolic comments a lot. I work in health care on the front lines and, unfortunately, I see the sort of issue Billie Pugh describes. It can be pretty hard… I do not know how to answer these concerns or comments (no matter from whom they come), because my sense is that the easy answer of “more oversight” is likely not a good answer — or it is a naive answer. It’s a long chain from those who abuse the system to those who allow abuse of the system and no one is able to work long enough or hard enough to connect the dots.

    This type of information / comment is enough to bring down an otherwise progressive discussion about Single Payer. Citizens assume the government will allow corruption at all levels. Again, I do not know the answer or where to find quality data on this issue.

    Perhaps other readers of this Blog can comment.

    • No matter what type of system we have, there will be cheaters. Seems like the trick is finding a balance between cheat detecting that eliminates enough abuse and spending excessive money on the remainder with diminishing returns. I anticipate fewer people applying for SSI if they can get national health insurance. I know many, including in my family, who only applied in order to get Medicaid because they were otherwise uninsurable.

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