The 2020 Census: What’s at Stake for the State of Alabama

Alabama is at risk of losing federal funding, a congressional seat, and an Electoral College vote. These outcomes are based on projected results of the 2020 Census.

The 22nd decennial census, mandated by the U.S. Constitution, begins on April 1, 2020. The census counts every person living in the United States. Business, industry, nonprofits, researchers, and governments use this information to understand and serve the public. The Constitution requires the census. Federal law requires all people living in the U.S. to respond.

The census is always a challenging project, but there are additional complications in 2020.

• The 2020 Census will be the first census administered primarily online.

• Proposals to add a citizenship question have created confusion in many communities.

• Trust of government is at near historic lows.

• The Census Bureau has reported to be behind in hiring field staff.

Regardless, the census results will have a profound impact on every community in America. While ultimately the responsibility of the federal government, the census is important to the states, and most invest substantial resources to promote the census.

As of this writing, Alabama has created the Alabama Counts! taskforce to promote the census and has committed $1.24 million, or $0.25 per capita, to the effort, compared to an average of $1.37 across the country, based on data reported by the National Council of State Legislators.

The stated goal of Alabama Counts! is to increase Alabama’s initial participation rate beyond the 72 percent reported in 2010. This figure represents the number of households that returned a census form by mail. Those who did return a form by mail received a visit from a census worker.

While increasing Alabama’s initial participation rate is a worthy goal, it is worth remembering that the national initial participation rate in 2010 was only 74 percent. A significant increase in the initial participation rate will be difficult and will require concerted effort from local officials in Alabama’s 67 counties and the 460 towns and cities recognized by the Census Bureau.

Even if the efforts of Alabama Counts! are exceedingly successful, Alabama may well lose a congressional seat. Census workers simply cannot count people who are not here. And Alabama is simply not growing as fast as other states.

But how does Alabama compare? What options do we have? Find out the answers to these questions and more in the full report.

Read PARCA’s full report here.


First Class Pre-K lowers discipline rates for students middle and high school years

Children who have participated in Alabama’s First Class Pre-K program, a voluntary, public early education program are about half as likely to be involved in disciplinary problems throughout their school careers than students who didn’t participate in First Class Pre-K, and the most pronounced differences between the two groups is evident in the students’ middle and high school years, according to new analysis of discipline data.

The analysis was conducted by the First Class Pre-K Research Evaluation Team, a multi-disciplinary group of researchers that includes faculty and staff from the UAB School of Public Health, UAB School of Education, and PARCA. The Alabama Department of Early Childhood Education provides grant funding for the research in order to provide ongoing, rigorous assessment of the First Class Pre-K’s effectiveness.

The research team analyzed data provided by the Alabama State Department of Education which included disciplinary records of over 530,000 infractions for three academic years 2014-2015, 2015-2016, and 2016-2017. Data were matched with the records for all individual public school students who were enrolled over the time period. The analysis found that from the time they entered first grade, former First Class Pre-K students were less likely to be involved in the serious disciplinary violations tracked by the state records. The difference in the discipline rates of the First Class Pre-K students compared to other students actually widened in the upper grades. These results were consistent across all three years examined. For a more detailed description of the research, click here.


The Lasting Effect of Alabama First Class Pre-K

Students who attended the First Class Pre-K program in Alabama are more likely to be proficient in reading and math compared to other students — and this academic advantage persists over time.

This is the key finding of an ongoing study of Alabama First Class Pre-K conducted by researchers from the Public Affairs Research Council of Alabama, the UAB School of Public Health, and the UAB School of Education. This research was funded by the Alabama Department of Early Childhood Education.

Key Findings

These findings add to previous findings that showed students receiving Alabama First Class Pre-K:

  • demonstrate higher readiness for kindergarten;
  • are less likely to be chronically absent;
  • are less likely to be held back a grade; and
  • are less likely to need special education services in K – 12

All of these measures produce savings to the education system that recur year after year as students progress through school.

Why is Pre-K Important?

The early years of school through the 3rd grade are a critical time in a child’s brain development. These early years provide a window for developing a foundation for sustained success. Problems that emerge during the early years are more difficult to address later on. High-quality pre-k programs provide opportunities to address gaps in early child development and to improve school readiness.

UAB-PARCA Research

The effectiveness of quality pre-k in preparing students for kindergarten has been well

documented. However, recent studies in other states have suggested the impact of pre-k programs fade away once students are in school, especially in the later grades. In response our UAB-PARCA research team, as part of its on-going assessment, specifically examined whether or not this happens with the Alabama First Class Pre-K program.

We studied three years (2014-15, 2015-16, and 2016-17) of student scores on state reading and math assessments, comparing students who received First Class Pre-K with those who did not receive First Class Pre-K.

We also compared the percent of students who were proficient in reading and math to identify differences between pre-k and non-pre-k students over time. We wanted to know if — after allowing for differences in poverty, race, gender, school attended, and general statewide trends — the academic benefit for students who received First Class Pre-K persisted as the students aged.

Study Findings

The UAB-PARCA team found that students who received First Class Pre-K were more likely to be proficient in reading and math compared to students who did not receive First Class Pre-K, and the benefit of First Class Pre-K persisted over time and did not fade out.

Specifically…

  • The percent of students earning a proficient score in reading were 1.6 percentage points higher for students receiving First Class Pre-K than for students who did not receive First Class Pre-K, all else equal, and this difference persisted at least through the middle school years.
  • The percent of students earning a proficient score in math were 3.2 percentage points higher for students receiving First Class Pre-K than for students who did not receive First Class Pre-K, all else equal, and this difference persisted at least through the middle school years.

Conclusion

Studies in other states have suggested the academic effects of pre-k are minimal and decline over time. Our study finds this is not the case in Alabama. Similarly, a new study from Duke University finds long-lasting effects of pre-k in North Carolina. These studies indicate that program design and implementation are key to a successful pre-k program.

Students who attended First Class Pre-K are more likely than other students to be proficient in reading and math, all else equal, and this academic advantage continues into at least middle school. These findings show that by making a positive difference in academic proficiency — something highly resistant to positive change — the Alabama First Class Pre-K program is working.

Print PDF Version Here.


PARCA collaborates on new research showing Alabama’s First Class Pre-K students are performing better on academic assessments than others

Alabama public school students who participated in the state’s publicly funded First Class Pre-K program performed better on academic assessments than those who did not, and the improved performance persists as students progress through the early grades and into middle school.

That is according to newly released findings from the First Class Pre-K Research Evaluation Team. The team, which includes faculty and staff from the UAB School of Public Health, UAB School of Education, and the Public Affairs Research Council of Alabama – provides ongoing, rigorous assessment of the program’s effectiveness. This research collaboration has been ongoing for the past five years and is funded by the Alabama Department of Early Childhood Education.

The findings are important because some studies of Pre-K programs in other states have suggested that that the academic benefits of Pre-K “fade out” after third grade. In Alabama, that is not the case. According to study findings: “Students who received First Class Pre-K were statistically significantly more likely to be proficient in math and in reading compared to students who did not receive First Class Pre-K. … The analyses also indicate no evidence of fade out of the benefits of First Class Pre-K over time.”

The First Class Pre-K classrooms in Alabama are funded through a competitive grant process in which sites must meet specific quality assurances and abide by rigorous operating guidelines. Alabama’s First Class Pre-K program has been awarded the highest quality rating by the National Institute for Early Education Research (NIEER) for the past 12 years.

The new research supports previous findings. In 2012, PARCA provided a comparison between students who had received First Class Pre-K and those who did not for the Alabama Department of Children’s Affairs, now the Alabama Department of Early Childhood Education.  That snapshot of results depended on the results of the 2012 Alabama Reading and Math Test (ARMT) for students in grades three through six.

In general, those comparisons showed that students who received First Class Pre-K performed better than those who did not and that the gap between poverty and nonpoverty students closed, even for students in the 6th grade. Encouraged by that snapshot, a more rigorous research design was implemented to examine multiple cohorts of students over time. UAB researchers provided the statistical analysis that found that the initial cross-sectional observation based on the 2012 snapshot was not a fluke.

“Observed differences in performance of First Class Pre-K students did not change over time and…the positive benefits persist as children age and progress to later grades,” the report states.

Read the briefing here.

More research on Alabama’s First Class Pre-K will be coming soon.

Several media outlets have covered the brief in recent days. Read select articles below:

Former Alabama Pre-K students score better in reading, math

Ivey touts Alabama’s nationally-recognized Pre-K program at conference

Study: Pre-K has long-term results


How Alabama Taxes Compare, 2018 Report

Alabama’s state and local governments collect less per capita in taxes than state and local governments in any other state in the union, according to new data from the U.S. Census Bureau.

Annually, the U.S. Census Bureau surveys state and local governments across the country about their revenues and expenditures. This survey makes it possible to compare the finances of state and local government across the 50 states. In PARCA’s analysis of the data, How Alabama Taxes Compare, state and local revenues are considered together, because states vary greatly in how they divide up the responsibilities between state and local governments for financing the operation of services like schools, roads, courts, health care, and public safety. In the end, the combined revenue from state and local taxes is used to provide government services. The data for 2016 is the most recent year available.[1] An interactive version of the data is also available through PARCA’s data dashboard.

Rank in Per Capita Tax Collections, 2016

State and Local Tax SourcesAlabama's Rank Among U.S. States
All Taxes50
Property50
Individual Income36
Corporate Income40
Sales and Gross Receipts29
General Sales30
Selective Sales17
- Alcoholic Beverage3
- Public Utilities5
- Motor Fuel34
- Tobacco Products35
- Other Selective Sales32
Motor Vehicle License45
Other Taxes25

The most glaring difference between Alabama and other states is our low reliance on property taxes.

  • Alabama ranks 50th in the U.S. in state and local property tax collections per capita.

If Alabama’s per capita property tax collections matched the average of other Southeastern states:

  • State and local governments would have an additional $2 billion to spend providing services.
  • Alabama’s overall tax revenue per capita would rank in the middle of Southeastern states, roughly equaling Mississippi’s tax revenue per capita and putting Alabama above Florida, South Carolina and Tennessee in per capita collections. Alabama would still trail Arkansas, North Carolina, Louisiana, Kentucky, and Georgia.

As it stands, Alabama’s traditional preference for low property taxes leaves state and local governments more reliant on other taxes for revenue. Alabama has among the highest sales tax rates in the U.S. Alabama also has some of the highest taxes per capita on alcohol and public utilities. Despite those higher rates, Alabama doesn’t make up the difference created by its low property tax collections.

Other unusual features of Alabama’s tax system include:

Sales Taxes:

  • Alabama is one of three states that continue to apply sales tax fully to food purchased for home consumption without providing any offsetting relief for low- and moderate-income families.
  • Alabama’s sales tax is not as broad as other states and doesn’t apply to most services. Consequently, despite high rates, Alabama’s sales tax isn’t as productive as some other states.

Income Taxes:

  • Alabama threshold for taxing income is the lowest in the nation. Most states set a higher income threshold than Alabama in order to allow poor households to keep more of the money they earn.
  • Alabama is one of three states that allows taxpayers to deduct from state income the full amount they pay in federal income taxes. Since federal income tax rates are higher the more you earn, the higher your earnings the larger the deduction for state tax purposes.

As a bottom line, Alabama governments operate with less revenue on a per capita basis than governments in all the other states.

This is not a new finding. This has been true since the early the 1990s. And it underlies the difficulties we face when trying to provide to our citizens the level of government services enjoyed by citizens in other states.

[1] U.S. Census Bureau State & Local Government Finance. (2016 data released on Sept. 7, 2018). Retrieved November 1, 2018 from https://www.census.gov/programs-surveys/gov-finances.html

To read the full report, How Alabama Taxes Compare, click here.

 


PARCA Statewide Constitutional Amendment Analysis

When voters go to the polls on November 6, they’ll not only be electing a governor, legislators, and other state and local officials, they’ll also be asked to vote on 19 new amendments to the Alabama Constitution of 1901. Voters statewide will decide whether to add four proposed amendments that will apply throughout the state. In addition, 15 local amendments will be voted on only in the counties in which they would apply.

The Alabama Constitution is unusual. It is the longest and most amended constitution in the world.  There are currently 928 amendments to the Alabama Constitution.


Most state and national constitutions lay out broad principles, set the basic structure of the government, and impose limitations on governmental power. Such broad provisions are included in the Alabama Constitution. However, Alabama’s constitution delves into the details of government, requiring constitutional amendments for basic changes that would be made by the Legislature or by local governments in most states. Instead of broad provisions applicable to the whole state, about three-quarters of the amendments to the Alabama Constitution pertain to particular local governments. Amendments establish pay rates of public officials and spell out local property tax rates. A recent amendment, Amendment 921, grants municipal governments in Baldwin County the power to regulate golf carts on public streets.

Until serious reforms are made, this practice will continue, and the Alabama Constitution will continue to swell.

Statewide Amendment 1

“Proposing an amendment to the Constitution of Alabama of 1901, providing for certain religious rights and liberties; authorizing the display of the Ten Commandments on state property and property owned or administrated by a public school or public body; and prohibiting the expenditure of public funds in defense of the constitutionality of this amendment.”

Amendment 1 and Amendment 2 are proposed amendments to the Alabama Constitution, but they both concern rights and protections that are governed by the U.S. Constitution and the U.S. Supreme Court’s interpretation of federal law and the Constitution.

Since the U.S. Constitution supersedes state law and the state Constitution, both these proposed amendments would not have any immediate legal effect. They are more like statements of opinion. However, considering the recently altered composition of the U.S. Supreme Court, those Alabama amendments could become operative as the new court addresses cases that may alter established precedent.

Amendment 1, proposed by Act 2018-389, restates principles of the separation of church and state that currently exist in Section 3 of the Alabama Constitution of 1901 which reads:

That no religion shall be established by law; that no preference shall be given by law to any religious sect, society, denomination, or mode of worship; that no one shall be compelled by law to attend any place of worship; nor to pay any tithes, taxes, or other rate for building or repairing any place of worship, or for maintaining any minister or ministry; that no religious test shall be required as a qualification to any office or public trust under this state; and that the civil rights, privileges, and capacities of any citizen shall not be in any manner affected by his religious principles.

The new proposed amendment adds to that by specifically authorizing the display of the Ten Commandments on public buildings, public property, and public schools, as long as that display is made in conformity with Constitutional principles.

As interpreted by the U.S. Supreme Court, a display of the Ten Commandments on public property is allowed, but only if it is not a specific endorsement of a religion. Displays of the Commandments are permitted when they are contained in a secular context, surrounded by other educational and historical displays. For example, the display might include other historical documents, like the Code of Hammurabi, the Magna Carta, the Declaration of Independence, the U.S. Constitution or historical documents or personalities associated with the development of law.

The proposed amendment also specifies that no public funds may be expended in defense of the constitutionality of the amendment. That prohibition of public funding for the defense of the amendment would not prevent public funds being expended to defend a challenge to the constitutionality of a specific display of the Ten Commandments created by any agency or local jurisdiction.

Statewide Amendment 2

“Proposing an amendment to the Constitution of Alabama of 1901, as amended; to declare and otherwise affirm that it is the public policy of this state to recognize and support the sanctity of unborn life and the rights of unborn children, most importantly the right to life in all manners and measures appropriate and lawful; and to provide that the constitution of this state does not protect the right to abortion or require the funding of abortion.”

Amendment 2, proposed by Act 2017-188, concerns the state’s position on abortion rights and the rights of “unborn children.”

It would add an amendment to the Alabama Constitution that would specify that it is the “public policy of this state to recognize and support the sanctity of unborn life and the rights of unborn children, including the right to life.” The proposed amendment does not define at what point a fertilized embryo or developing fetus would be considered an unborn child. The amendment also specifies that “nothing in this Constitution secures or protects a right to abortion or requires the funding of an abortion.”

The right to an abortion is currently protected by the Supreme Court’s 1973 Roe v. Wade decision. In Roe, the Court ruled that governments, federal, state, and local, could not prohibit a woman from having an abortion during the first trimester and placed limitations on state regulation of abortion in subsequent trimesters. The Court held that a woman’s right to an abortion fell within the right to privacy (recognized in Griswold v. Connecticut) protected by the Fourteenth Amendment. As summarized by Oyez, a compendium of information on the Supreme Court compiled by Cornell’s Legal Information Institute, Justia, and Chicago-Kent College of Law, the Roe decision gave a woman total autonomy over the pregnancy during the first trimester and defined different levels of state interest for the second and third trimesters.[1]

In subsequent Supreme Court cases, the Court preserved the right to an abortion but allowed states to regulate abortion and to ban it after the fetus had reached viability, the point at which the fetus could survive outside of the womb. Other restrictions on abortion throughout pregnancy were permissible, the Court ruled, if those restrictions did not put an “undue burden” on a woman’s ability to obtain an abortion.

In Alabama, abortion is prohibited when the pregnancy has reached 20 weeks, except in cases of life or health endangerment to the mother. Alabama has also passed numerous regulations pertaining to all abortions. In Alabama, abortions must be performed by a licensed physician. Abortion providing facilities must meet multiple requirements. If the fetus is deemed viable, the abortion must be necessary to preserve the life and health of the mother, a second physician must participate, and it must be performed at a hospital.

Public funding can only be used for an abortion in the case of life endangerment or rape or incest. Alabama requires pre-abortion counseling and a 48-hour waiting period after counseling. If a minor is involved, a parent must give his or her written consent before the procedure can occur.

A 2016 Alabama law would have criminalized dilation and evacuation (D&E) procedure, a procedure used throughout pregnancy and the most common method of second-trimester abortions. In August of 2018, the 11th U.S. Circuit Court of Appeals in Atlanta upheld a lower court ruling blocking the law, finding that the ban would create and undue burden on the right to end a pregnancy before the fetus is viable.[2] Alabama also has not repealed its law that was in place before Roe v. Wade.[3] That law makes it a crime to perform an abortion and contains no exceptions for the life or health of the mother.

Passage of the proposed amendment to the Alabama Constitution would not have any practical effect under current law. However, if the Supreme Court were to overturn Roe vs. Wade and turn abortion regulation back to the states, the language in the Alabama Constitution would potentially have an effect. Any attempt to alter restrictions on abortions could be challenged on the grounds that it would harm the right to life of unborn children. If states were granted the full authority to regulate abortion, the rights to life and liberty guaranteed to individuals (the mother, in this case) in Section 1 of the Alabama Constitution would have to be weighed against the right to life of an unborn child contained in this amendment, if it is adopted.

Abortion rights groups, like Planned Parenthood, and anti-abortion groups, like the Eagle Forum of Alabama, agree that Amendment 2 would lay the groundwork for an abortion ban in Alabama if Roe v Wade is overturned.

Statewide Amendment 3

“Proposing an amendment to the Constitution of Alabama of 1901, relating to the Board of Trustees of the University of Alabama, to specify that the congressional districts from which members are appointed continue to reflect those as constituted on January 1, 2018, to remove the State Superintendent of Education from membership, and to delete the requirement that members vacate office at the annual meeting of the board following their seventieth birthday.”

Under current law, the University of Alabama Board of Trustees is composed of 16 people: three members from the congressional district in which the Tuscaloosa campus is located, two members from each of the other six congressional districts in the state, the Governor, and the State Superintendent of Education. If the number of congressional districts in Alabama increased or decreased in the future, the number of trustees would also increase or decrease. Additionally, other than the Governor and the State Superintendent of Education, current law requires a trustee to retire from the board following his or her seventieth birthday.

Amendment 3, proposed by Act 2018-132, does three things:

First, it provides that the board will be composed of members from congressional districts as those districts existed on January 1, 2018.  This eliminates the need to make changes based on the number of congressional districts in Alabama. It does not impact the number of board members. Based on population trends, Alabama is at risk of losing a congressional seat in the U.S. House of Representatives.[4] Second, it removes the State Superintendent of Education from automatically having a seat on the board. The Superintendent currently serves on the Auburn University Board of Trustees.[5] The State Superintendent was removed by statute from the board of the University of North Alabama in 2018 but remains on the board of the University of West Alabama.[6] Third, it allows a trustee to serve after his or her seventieth birthday.

Composition of the governing boards for SEC universities varies. Currently, in addition to the University of Alabama System, the Universities of Arkansas, Missouri, and South Carolina also have a state superintendent on the boards.[7]  The Universities of Florida, Kentucky, and Tennessee include seats for faculty members on the governing boards, with the University of Florida having two such positions and the University of Tennessee Board of Trustees rotates the position by each of its four instructional institutions.

Along with the Universities of Arkansas and Georgia, both Auburn University and the University of Alabama System rely on congressional districts for apportioning seats on their boards, while the Mississippi State Institutions of Higher Learning apportions seats by each of its supreme court districts, and the University of South Carolina recruits board members from each of its 16 judicial districts through a College and University Trustee Screening Commission.[8]

Tennessee requires that the governor appoint at least two residents from each of the state’s three grand divisions, with at least five of the members being alumni of the University of Tennessee, and at least seven must be residents of Tennessee.[9] Missouri requires that board members be U.S. citizens and residents of the state for at least two years. Missouri also prohibits more than five members being from one party.

If a majority of voters vote “Yes” on Amendment 3, future changes to the number of congressional districts in Alabama will not change the number of board members. The State Superintendent of Education will no longer be an ex-officio member of the board, and trustees will be allowed to serve on the board after their seventieth birthday.

If a majority of voters vote “No” on Amendment 3, future changes to the number of congressional districts in Alabama will have an impact the number of board members, the State Superintendent of Education will continue to have an ex-officio seat on the board, and trustees will not be allowed to serve on the board after their seventieth birthday. 

Statewide Amendment 4

 “Proposing an amendment to the Constitution of Alabama of 1901, to provide that, if a vacancy in either the House of Representatives or the Senate occurs on or after October 1 of the third year of a quadrennium, the seat would remain vacant until a successor is elected at the next succeeding general election.”

Every four years, all members of the Alabama State Senate and House of Representatives stand for election. The subsequent four-year term for which those Senators and Representatives are elected is called a quadrennium.

Currently, if a seat in either house of the Legislature becomes vacant during the quadrennium, a special election must be conducted in order to fill the vacant seat. The Governor must call for a special election if the vacancy happens before the next scheduled general election. The governor has discretion in setting the date of the election along with the nominating deadlines. This special election to fill vacancies can be held at any time during the four-year cycle, and the winner fills the term until the next general election.

When a special election is held, all costs and expenses incurred are paid from funds in the State Treasury not otherwise appropriated. Each legislative special election costs the state roughly $120,000.[10]

Alabama is one of twenty-five states in the U.S. that fill vacancies in the state legislature through special elections. Twenty-two states fill vacancies through appointments and three states fill vacancies through a hybrid system that uses both appointments and special elections.[11]

Amendment 4, proposed by Act 2018-276, would keep the current procedures for calling a special election in place but would change the current law so that when a vacancy occurs in the Senate or House of Representatives on or after October 1 of the third year of the quadrennium, the seat will remain vacant until the next general election – approximately 14 months or less.

The Governor would no longer have the power to schedule a special election to fill a vacancy in these circumstances, and public funds that would have been spent on the special election would be saved.

This amendment would not apply to U.S. Congressional or Senate seats.

If a majority vote “Yes” on Amendment 4, state legislative seats that become vacant within the final 14 months of the four-year term of office will remain vacant until the general election.

If a majority vote “No” on Amendment 4, the Governor will continue to be required to schedule a special election whenever a vacancy occurs in the state legislature.

For more information, see the analysis provided by the Alabama Fair Ballot Commission at https://sos.alabama.gov/alabama-votes/voter/ballot-measures/statewide.

[1] “Roe v. Wade.” Oyez, 3 Oct. 2018, www.oyez.org/cases/1971/70-18.
[2] Stempl, Jonathan. U.S. appeals court finds Alabama abortion law unconstitutional. Reuters. August 22, 2018. https://www.reuters.com/article/us-alabama-abortion/us-appeals-court-finds-alabama-abortion-law-unconstitutional-idUSKCN1L71ZP
[3] Ala. Code § 13A-13-7
[4] Cason, Mike. “Amid Census Controversy, Alabama Launches ‘Maximum Participation’ Effort,” Tribune News Services, http://www.governing.com/topics/politics/tns-alabama-ivey-census.html
[5] A member of the State Board of Education sits, ex officio, on the Alabama College System Board of Trustees for the two-year college system. See https://www.accs.cc/index.cfm/board-of-trustees/
[6] See https://www.billtrack50.com/BillDetail/914457; University of West Alabama Board of Trustees, https://www.uwa.edu/about/boardoftrustees
[7] In Arkansas, the Superintendent of Public Instruction is the board president and votes as a tie breaker, like U.S. Vice President does in the Senate.
[8] College and University Trustee Screening Commission https://www.scstatehouse.gov/CommitteeInfo/Universities&CollegesScreeningCommittee/Univ&CollScreening.php
[9] HB 2115 http://wapp.capitol.tn.gov/apps/BillInfo/Default.aspx?BillNumber=HB2115
[10] Gattis, Paul. “’No logic’ to Alabama’s special elections, which may be outlawed anyway.” AL.com March 2, 2018. https://www.al.com/news/huntsville/index.ssf/2018/03/no_logic_to_alabamas_special_e.html
[11] How vacancies are filled in state legislatures, Ballotpedia.com https://ballotpedia.org/How_vacancies_are_filled_in_state_legislatures


K-12 Education Ranks as the #1 Priority Among Alabama Voters

In late 2017, the Public Affairs Research Council of Alabama (PARCA) surveyed Alabama voters to determine their thoughts about the general direction of the state and the issues that most concern them. PARCA partnered with Samford University to survey policy professionals from across the state including academics, journalists, business and nonprofit leaders, and lobbyists. Their responses provided a list of 17 critical issues facing Alabama. PARCA partnered with USA Polling at the University of South Alabama to ask registered voters about these 17 issues. The voters’ responses generated the Top Ten list of voter priorities. Details about the survey and its methodology can be found in the full Alabama Priorities report.

Alabama Priorities

1. K-12 Education
2. Healthcare
3. Government Corruption and Ethics
4. Mental Health and Substance Abuse
5. Poverty and Homelessness
6. Jobs and the Economy
7. Crime and Public Safety
8. Job Training and Workforce Development
9. Improving the State's Image
10. Tax Reform

Key Findings

  • Voters broadly agree on the critical issues facing the state.
  • Voters are not polarized along traditional political, ideological, racial, or generational lines. There is a significant gap between the priorities of experts and the priorities of voters.
  • Policymakers have an opportunity to inform and educate voters on critical and systemic challenges facing the state.
  • Policymakers have an opportunity to respond to immediate, often highly personal issues that concern voters.
  • Elected officials and candidates have an opportunity to show leadership and to build broad coalitions to address Alabama’s most pressing challenges.

This summer and fall, PARCA will produce summary briefs on each of the top ten priorities chosen by Alabama voters. Each brief will answer four critical questions: what is the issue, why it matters, how Alabama compares, and what options are available to Alabama policymakers.

#1: K-12 Education

What is the issue?

K-12 public education is the highest concern for voters in Alabama. Seventy percent said they were very concerned, and this issue cuts across all political parties as a major concern. Eighty percent of Democrats indicate they are very concerned, followed by 60% of Republicans and 66% of independents. The key concerns cited by voters included funding, teacher preparation, class size, and low student achievement.

Funding

Forty-four percent of voters said that funding was their top priority related to education.

Alabama ranks 39th among the 50 states when it comes to per-pupil spending on K-12 education. According to data from the Alabama Department of Education, there is a wide disparity between spending in Alabama school systems, ranging from over $12,000 per student in Mountain Brook to $7,615 per pupil in Autauga County.

In 2015 Augenblick, Palaich, and Associates (APA) was commissioned by the Alabama Department of Education to study the adequacy and equity of school funding in the state.

To determine adequacy, APA looked to see what successful districts in Alabama spend per student. They also formed fifteen panels of school representatives from across the state tasked with estimating the resources needed to educate any student in Alabama and meet state standards. Chart 1 shows that the expenditures of state and local funds per student across the state in 2013 was considerably less than the estimated expenditure per student needed to provide an adequate good education, as estimated by the two approaches used by the APA study.

These actual and estimated expenditures of state and local funds per pupil are from 2012-13. Actual expenditures per pupil in 2015-2016 were $7,900 per pupil, still below what is recommended.

In addition to concerns about adequate funding, there is concern about the equity in the distribution of state school funds.

Alabama’s funding formula essentially treats all general education students the same, regardless of whether they need extra assistance, which costs money.

Differences in local property wealth enable wealthier districts to spend more on education and potentially create unequal opportunities to learn. A number of analytical studies have shown that Alabama’s school finance system has not met accepted equity standards.

Teacher Preparation

Surveyed voters expressed concern over teacher preparation, with 24% indicating it is their greatest concern related to education.

PARCA has documented the importance of teaching quality in developing student success. Effective teachers can produce gains of 1.5 grade levels, compared to gains of only a half grade among teachers at the bottom of the pool.

In September 2018, the Alabama State Department of Education issued report cards for the state’s teacher training programs, the   Overall, new teachers scored on knowledge of teaching methods, but teacher candidates at a number of colleges fared poorly on mastery of the subject matter they planned to teach. In some cases, only 25% passed these subject matter exams on their first try, though most did pass by their third attempt.

Also included were results from a survey of school principals assessing the degree to which first-year teachers in their schools showed promise as effective teachers.  The pie chart below shows that the majority (59%) entered the profession as effective teachers, with 41% still emerging and needing support, and a small percent needing more corrective remediation.

These are mostly encouraging results as research shows that new teachers learn and grow and become better with experience. Still, state policies surrounding teacher certification vary, and there is debate on what aspects of teacher training are most important. Knowledge of teaching methods and human development continues to be highly valued, but critics in the field argue that more time needs to be spent actively learning through practice teaching in the field with a mentor observing and providing meaningful feedback. Studies are also showing a strong connection between teacher subject matter knowledge and impact on student learning.

Class Size

Class size was identified as a concern by voters in Alabama, and 10% said it was the issue about which they were most concerned. In Alabama, mandated class sizes are established through a teacher-pupil ratio, which provides for smaller classes in earlier grades. Established ratios in Alabama include Grades K-3: 1-18; Grades 4-6: 1-26; and Grades 7-8: 1-29. When districts have to cut their budgets, teachers are let go and class sizes rise.

Support for reducing class size came from research that found small classes could have a positive influence on student achievement. Other researchers have warned that caution is needed, finding that teachers do not necessarily change their instructional practices when class size is reduced and that some subjects may be taught equally as well in larger classes.

Still, it does appear that very large class-size reductions of 7-10 fewer students per class can have significant long-term effects on student achievement. The academic effects seem to be largest when introduced in the earliest grades, for subjects focused on hands-on group activities, and for students from less advantaged family backgrounds. They may also be largest in classrooms of teachers who are less well prepared and effective in the classroom. This leads critics to point out that concentrating on developing effective teachers is the best approach since effective teachers can help students learn in both large and small classes.

Student Achievement 

Student achievement was identified as an important issue and was the top concern of 16% of voters. In reality, each of the concerns identified in this brief are justified as concerns primarily in how they affect student achievement or student learning, the primary goal of schooling in most settings. Ultimately student achievement is influenced by a number of factors. Research has found that the education level and income of a student’s parents are the most influential factors shaping how a student performs in school and their later success. At the same time factors at the school and teacher level can make a difference:

  • High-quality expectations for all students
  • A rigorous and relevant curriculum
  • Extracurricular activities that encourage student personal growth
  • High-quality teaching that encourages student investigation, active learning, and methods that appeal to students with different learning styles
  • Enriched use of new technology in teaching and learning
  • Effective use of small classes
  • After school support, tutoring, assistive technology, and more intense individual support as needed
  • Effective instructional leadership
  • Quality leadership, culture, and resources

Why Does Education Matter?

Education is important to a number of people because it will impact their future and the future of their children. Research shows that education has a positive impact on employment, lowers cost for crime, and improves personal health.

Employment and Economic Development

In 2017 the median wage for college graduates was more than twice that of high school dropouts and more than one and a half times higher than that of high school graduates. The unemployment rate was three times lower than for high school drop-outs and two times lower than for high school graduates. Eeducation supports economic development and helps build communities that draw businesses and strengthens cultural institutions.

Lower Crime

Research has found that schooling significantly reduces the probability of incarceration. According to data from the U.S. Bureau of Justice, 56% of federal inmates, 67% of inmates in state prisons, and 69% of inmates in local jails did not complete high school. Education becomes a strategy for reducing crime, personal tragedies, and the economic costs associated with crime.

Impact on Health

Finally, among many other outcomes, education is positively associated with good health. In the US, adults without a high school diploma can expect to die nine years sooner than college graduates. In today’s knowledge economy, an applicant with more education is more likely to be employed and land a job that provides health-promoting benefits such as health insurance, paid leave, and retirement. Conversely, people with less education are more likely to work in high-risk occupations with fewer benefits. Furthermore, education is positively associated with the likelihood of eating healthy foods and exercising regularly.

How Does Alabama Compare?

Unfortunately, Alabama’s education system has consistently ranked among the lowest in the nation, and low among other southern states. Education Week, a highly recognized national publication, annually publishes a ranking of state educational systems using rigorous methods focused on 1) student chance for success (family income and education, enrollment in pre-K, enrollment in postsecondary education); 2) adequacy and equity of educational funding; and 3) student achievement measured by math and reading performance, high school graduation and results from AP testing. Their ranking continually places Alabama between 43rd and 45th among the states, with a grade of D- or C- overall. Where Alabama ranks best is in “chance for success” (grade of C )[i].

Ed Week gives Alabama’s education funding a D+ overall. On various spending indicators it gets an F. Alabama’s education spending is low when compared to other states and the nation. But when spending is adjusted for cost of living differences, it is comparable to other southern states, though still below national averages. For equity, it gets a B+, which raises a few eyebrows. The state share of all education funding is relatively high in Alabama and in other southern states, as well as the amount generated by Federal funds. This creates equity. It is in the capacity of local districts to raise funding through property taxes that inequities occur. Still, the relationship between per-pupil spending and district wealth in Alabama is comparable to other southern states.

Ed Week’s rankings gave Alabama an F for the current status of student achievement, though the state received a D+ for improvement over time and a B for lower achievement gaps between low- and high-income students.  There clearly are large differences in scores on state tests between the wealthiest and poorest districts in the state, and performance appears to be correlated with wealth. At the same time, PARCA’s report on student achievement in 2017 found both high poverty and low poverty students in Alabama scoring low when compared to national averages on the National Assessment of Education Progress (NAEP). NAEP provides standardized tests in math and reading that serve as benchmarks for comparing Alabama to other states. Chart 2 compares the percentage of students in Alabama and the US scoring proficient or above on those tests.

NAEP tests are highly demanding, and students in the highest performing states generally do not score beyond 50-60% proficient or above. On a positive note, though Alabama’s results on NAEP have not substantially changed in recent years, results show significant improvement over the past 12-15 years.

What Can Alabama Do?

Strengthen student-based funding

The Augenblick and Palaich report recommended that Alabama consider adopting a student-based funding model that recognizes differences in student needs. This model would seek to spend funds strategically to help each student reach their potential. Another related approach is to adopt a zero-based method focused on estimating costs for meeting state standards that would account for student differences.

Other proposals for improvement focus on setting a long-term plan for achieving adequacy in funding and increasing local funding as a percent of total funding. One approach is for the state to provide a match for local funds with extra fund devoted in low-wealth communities. Both solutions require more funds devoted to public education. One frustration is that increasing funds for education does not always lead to better schools, teaching, and student achievement. While a fair, base amount of funds is critical, other issues get in the way, such as how districts and schools use their funds and the degree to which high performing teachers are motivated to teach in particular communities or schools. Still, studies have demonstrated that when local funds are strategically targeted at supporting students who have been flagged for needing assistance, a positive impact on learning can occur.

Improve Teacher Effectiveness 

Alabama’s report card for teacher training program indicates that new teachers would benefit from greater expertise in subjects they will be teaching. A review of varying approaches to strengthening knowledge of subjects being taught is merited.

Practice in a live classroom setting is essential for new teachers. Alabama already assesses classroom performance in the credentialing process, but attention should also be paid to giving prospective teachers experience in a variety of settings including high-poverty and high-risk schools.

Research has also shown value in pairing prospective teachers with experienced teacher coaches and mentors. Moreover, once teachers enter teaching, it is important that they continue to be supported by access to high-quality, standards-aligned instructional resources and curriculum-based professional learning.

Decisions regarding class size reduction should be made strategically and combined with professional development.

The substantial expenditures required to sustain smaller classes must not only be justified by the impact on student learning by itself but also weighed in regard to other interventions that impact learning.

Research has identified conditions under which small classes and class size reduction is most effective. Rather than mandating across the board reductions or increases in size (in response to budget cuts) districts and schools might benefit from having the freedom to strategically maintain small classes where they are most needed and increasing class size where they are less likely to make a difference.

Furthermore, not all teachers are prepared to take advantage of the benefits of a small classroom. Implementation of small classrooms needs to be accompanied with professional development on how best to maximize learning in a small class.

In addition to the Alabama Reading Initiative, expand access to high-quality Pre-K educational support.

The early years of school through the 3rd grade are critical points in brain development and in shaping a child’s educational and life experiences. Learning to read in the early grades, as promoted through the Alabama Reading Initiative – is an essential part of early development.

But even before that, a stimulating and supportive environment during the preschool years provides a foundation for sustained success.

Pre-school services in Alabama are offered through a diverse delivery model that includes public school systems, childcare centers, Head-start centers, university-based labs, and community organizations such as the YWCA.

To improve the quality and availability of Pre-K education, Alabama nationally recognized First Class Pre-K program provides training, materials, and financial support through the Alabama Department of Early Childhood Education (DECE), Office of School Readiness (OSR). Continued investment in the spread of quality Pre-K is warranted as many families and children are still on waiting lists for attending First Class Pre-K programs

Strengthen the capacity of local school systems to collect, analyze and use performance data aligned with college and career readiness.

Alabama has made progress in setting standards for college and career readiness that can serve as benchmarks goals for helping students learn and grow. Assessment data can be used to measure the impact of school and classroom interventions on student learning. Effective assessments that produce fine-grained data identify students who need assistance. Support can be targeted at helping these students through after-school programs, tutoring, study skills workshops, personal counseling and mentoring, and individual reading support. Currently, a number of districts lack the capacity to effectively engage data in this way and assistance through regional centers, universities, or organizations like PARCA is needed.

Experimenting with School Vouchers for Low-Income Students

School vouchers provide funded scholarships that allow students to attend a private school of the family’s choice, an option otherwise unavailable to low-income families. After reviewing research some analysts have surmised that vouchers are not likely to increase or reduce student learning, but that competition induced by vouchers has led to improved public schools. This needs to be studied further.

The Alabama Accountability Act provides for a form of vouchers through a program which distributes scholarships to low-income students in Kindergarten through 12th grade to use in participating non-public and public schools. Through the scholarships, parents can choose school environments they perceive as being better equipped to help their children succeed as well as develop attributes and values that go beyond academic test scores.

Recent research conducted by the University of Alabama Institute for Social Science Research found that students receiving scholarships performed similarly to public school students on standardized tests.  The study did not compare scholarship recipients with students attending the public school they would have attended without the scholarship, but rather compared them with public school students across the state. Continuing attention should be paid to assessing the results on for students benefiting from scholarship and the impact on of the scholarship program on public schools.

Conclusion

Developing an education system that helps all children learn is good for Alabama. Low performance and unequal opportunity to learn in public education are often described as “wicked problems” because they are highly resistant to being resolved. PARCA believes Alabama can do better. With effective Pre-K, the growing belief that all students can learn, and new economic development led by strong leaders – Alabama’s educational goals are within reach – and this gives us hope.

[i] Ed Week (2018).  State grades on K-12 Education: Map and rankings.  Quality Counts 2018https://www.edweek.org/ew/collections/quality-counts-2018-state-grades/report-card-map-rankings.html

To read the full PDF brief, including tables and charts, click here.


Healthcare Ranks #2 Among Alabama Voter Priorities

In late 2017, the Public Affairs Research Council of Alabama (PARCA) surveyed Alabama voters to determine their thoughts about the general direction of the state and the issues that most concern them. PARCA partnered with Samford University to survey policy professionals from across the state including academics, journalists, business and nonprofit leaders, and lobbyists. Their responses provided a list of 17 critical issues facing Alabama. PARCA partnered with USA Polling at the University of South Alabama to ask registered voters about these 17 issues. The voters’ responses generated the Top Ten list of voter priorities. Details about the survey and its methodology can be found in the full Alabama Priorities report.

Alabama Priorities

1. K-12 Education
2. Healthcare
3. Government Corruption and Ethics
4. Mental Health and Substance Abuse
5. Poverty and Homelessness
6. Jobs and the Economy
7. Crime and Public Safety
8. Job Training and Workforce Development
9. Improving the State's Image
10. Tax Reform

Key Findings

  • Voters broadly agree on the critical issues facing the state.
  • Voters are not polarized along traditional political, ideological, racial, or generational lines. There is a significant gap between the priorities of experts and the priorities of voters.
  • Policymakers have an opportunity to inform and educate voters on critical and systemic challenges facing the state.
  • Policymakers have an opportunity to respond to immediate, often highly personal issues that concern voters.
  • Elected officials and candidates have an opportunity to show leadership and to build broad coalitions to address Alabama’s most pressing challenges.

This summer and fall, PARCA will produce summary briefs on each of the top ten priorities chosen by Alabama voters. Each brief will answer four critical questions: what is the issue, why it matters, how Alabama compares, and what options are available to Alabama policymakers.

#2: Healthcare

What is the issue?

Alabama voters rank healthcare as the 2nd most important issue facing the state, with 65% of voters saying they are very concerned. Majorities of every demographic group and political party say they are very concerned about healthcare. Healthcare is the #2 issue for Democrats, #3 for Republicans, and #4 for Independents. When considering ideology, healthcare is the #3 issue for conservatives, moderates, and liberals. Healthcare is the #1 issue for low-income and middle-income voters and #4 for high-income earners. Those who are self-employed or employed less than full-time are even more likely to say they are very concerned. In this survey, men placed a greater priority on healthcare than did women. Those with lower levels of education also showed more unease related to healthcare. Finally, though there were few differences between African Americans and whites, minorities did voice a greater concern for the current state of healthcare. In a follow-up question, voters indicated their top concerns about healthcare were cost (51%), expanding Medicaid (17%), rural access (16%), and cost of prescription drugs (12%).

Why Does it Matter?

A 2017 study of state health outcomes finds Alabama ranks 42nd in primary care physician access, 43rd in cancer deaths, 44th in physical activity, 46th in frequency of physical distress, 47th in frequency of mental distress, 48th in rate of low-birth weights, 49th in cardiovascular deaths, 49th in diabetes prevalence, and 50th in access to mental health providers. These factors, along with the state’s comparatively low number of primary care providers, mental health providers, dentists, and other healthcare professionals per capita earned Alabama 47th place in the nation for overall health and well-being concerns.[1]

Why does this matter? At the individual level, health and well-being is a critical component to quality of life. At the societal level, a healthy population is a critical component of economic vitality, productivity, and reduced public expenditures. Simply put, healthy people create a healthy, vibrant economy and community.

How Does Alabama Compare?

Healthcare is a very broad topic with many aspects. This brief will explore two core concepts – healthcare coverage and healthcare access.

Healthcare Coverage

Alabamians find themselves in one of four healthcare coverage situations: 52% are covered by a commercial insurer such as Blue Cross and Blue Shield, United, or VIVA through an employer or by self-pay; 19% are covered by Medicaid, 15% are covered by Medicare, 11% are uninsured.[2]

The Affordable Care Act has helped increase the number of people with healthcare coverage. Data suggests the number of insured people under age 65 in Alabama (10% in 2016) matches the national average, but the rate trails a number of states with rates as low as 6%.[3]

Essentially, all Alabamians age 65 and over are covered by Medicare. Policymakers at the national level continuously tweak Medicare, and there are long-term concerns about the program’s viability. Medicare is not a major component of current healthcare policy debate.

In contrast, Medicaid has been at the center of the healthcare reform debate since 2010. Alabama, like 26 other states, chose not to expand its Medicaid program. However, since 2014, nine of those states have reversed course and expanded Medicaid. Three more are currently considering expansion.[4]As currently structured, Alabama Medicaid serves the visually impaired and those with disabilities, as defined by the Social Security Administration, children under 19 living in families earning less than 146% of the poverty rate, adults over 65 in poverty, and other adults, frequently for maternity services only. Save very few exceptions, Medicaid does not cover able-bodied adults, without children, regardless of their income.

Healthcare Access

Healthcare coverage does not necessarily mean healthcare access. Structural barriers like service availability and viable transportation,[6] as well as more individual barriers like job flexibility and the affordability of deductibles and copays, are critical factors in accessing healthcare, regardless of a person’s insurance status. Access to care has been identified as the number one healthcare priority.[7] Only 28 of Alabama’s 67 counties have reached an optimal level of healthcare accessibility, though these counties continue to need special outreach and services to low-income communities.[8]

Further complicating access is the number of healthcare providers. As noted above, Alabama suffers from a lack of primary care providers. The number of primary care providers is a nationwide challenge driven, in large part, by the economics of the healthcare industry – as a society, we prioritize, and thus pay more for, specialty care and treatment rather than prevention and health maintenance. Thus, there are economic disincentives to practice primary care. This helps explain why Jefferson County, the county with the highest number of healthcare professionals in the state, is cited as a Healthcare Provider Shortage Area for low-income residents with only 25 physicians providing primary care to low-income residents in the county.[9]

A second, and increasing, barrier to access is the continued closure of rural hospitals. Since 2010, six Alabama hospitals have closed, tying Georgia with the 3rd highest number of closures in the country.[10] Currently, eight Alabama counties have no hospital. Hospital economics are complex, affected by cost inefficacies, decreasing populations, changing patient preferences, state regulations, and change to federal reimbursement structure.

How Do Alabama Counties Compare?

When Alabama counties are compared, there is considerable variation in essentially every health statistic. Comprehensive county comparisons can be found at http://www.countyhealthrankings.org/app/alabama/2018/overview. While Alabama’s overall uninsured rate was 12% in 2015, the rate ranged from a low of 8% in Shelby County to 18% in DeKalb County. Uninsured rates among minorities in Alabama is between 10% to 28%.[11] There is also considerable variance in healthcare access. The ratio of primary care providers to population ranges from 1:10,461 in Lowndes County to 1:940 in Jefferson County. Nationally, the ratio is 1:1,030. A majority of Alabama counties, 39, had ratios greater than 1:2,060.[12]

When considering outcomes, Shelby County enjoys the highest health outcomes and health factors rating, followed by Madison, Baldwin, Limestone, Colbert, and Lee counties. Shelby County reports the highest in lifespan, quality of life, and access to clinical care. Wilcox County ranked lowest in lifespan, Greene ranked lowest in quality of life, and Conecuh ranked lowest in access to clinical care.[13]

What Can We Do?

Alabama has much room for improvement in healthcare. Robert Wood Johnson’s County Health Ranking and Roadmaps[14] lists several hundred policy recommendations across a broad range of healthcare topics, including access, outcomes, and behaviors. Recommendations can be searched by population, geography, decision maker, and more. This resource, along with community health assessments prepared for the state and each county every five years provide a wealth of recommendations for state and local policymakers.

Changing health outcomes is not easy, but it is not impossible. States like Florida and Utah were able to achieve meaningful change in just one year, changes that resulted in their national average improving by four positions.[15] By improving health behaviors, clinical access, community and environment, and policy, Alabama could see similar changes.

Drafted by Cassidy Clevenger, graduate student, Department of Social Work, Samford University, and the staff of the Public Affairs Research Council of Alabama.

Read the full PDF Healthcare brief here.

[1] America’s Health Rankings Annual Report 2017, (2017) United Health Foundation. https://assets.americashealthrankings.org/app/uploads/ahrannual17_complete-121817.pdf.

[2] “Health Coverage: State-to-State: 2017,” America’s Health Insurance Plans, https://www.ahip.org/wp-content/uploads/2017/10/StateDataBook_2017.pdf.

[3] “Health Insurance Coverage of Nonelderly 0-64.” (2018) Kaiser Family Foundation. https://www.kff.org/other/state-indicator/nonelderly-0-64/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

[4] “Status of State Action on the Medicaid Expansion Decision” (September 11, 2018) Kaiser Family Foundation, https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D#note-1.

[5] “Who Does Alabama Medicaid Serve?”  Alabama Medicaid Agency, http://www.medicaid.alabama.gov/documents/2.0_Newsroom/2.3_Publications/2.3.5_Annual_Report_FY16/2.3.5_FY16_Who_Does_Alabama_Medicaid_Serve.pdf.

[6] “Access to Care,” (August 23, 2018) Alabama Department of Public Health. http://www.alabamapublichealth.gov/healthrankings/access-to-care.html.

[7] State of Alabama Community Health Assessment, (2015) Alabama Department of Public Health, https://www.alabamapublichealth.gov/accreditation/assets/CHA2015_Final_RevAugust_R.pdf.

[8] “Access to Care,” (August 23, 2018) Alabama Department of Public Health. http://www.alabamapublichealth.gov/healthrankings/access-to-care.html.

[9] “HPSA Find,”  U.S. Department of Health and Human Services Health Resources & Services Administration, https://data.hrsa.gov/tools/shortage-area/hpsa-find

[10] Ellison, Ayla, (March 26, 2018), ”7 states with the most rural hospital closures,” Becker’s Hospital Review https://www.beckershospitalreview.com/finance/7-states-with-the-most-rural-hospital-closures-032618.html, and July 13,2018) “9 hospital closures in 2018 so far” https://www.beckershospitalreview.com/finance/9-hospital-closures-in-2018-so-far.html.

[11] Givens, M., Jovaag, A., & Wilems Van Dijk, J. 2018 Alabama State Report University of Wisconsin Population Health Institute http://www.countyhealthrankings.org/rankings/data/al.

[12] Givens, M., Jovaag, A., & Wilems Van Dijk, J. 2018 Alabama State Report University of Wisconsin Population Health Institute http://www.countyhealthrankings.org/rankings/data/al.

[13] Givens, M., Jovaag, A., & Wilems Van Dijk, J. 2018 Alabama State Report University of Wisconsin Population Health Institute http://www.countyhealthrankings.org/rankings/data/al.

[14] “What Works for Health,” University of Wisconsin Population Health Institute,  http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health.

[15] America’s Health Rankings Annual Report 2017, (2017) United Health Foundation. https://assets.americashealthrankings.org/app/uploads/ahrannual17_complete-121817.pdf.

 


Government Corruption and Ethics Ranks #3 Among Alabama Voter Priorities

In late 2017, the Public Affairs Research Council of Alabama (PARCA) surveyed Alabama voters to determine their thoughts about the general direction of the state and the issues that most concern them. PARCA partnered with Samford University to survey policy professionals from across the state including academics, journalists, business and nonprofit leaders, and lobbyists. Their responses provided a list of 17 critical issues facing Alabama. PARCA partnered with USA Polling at the University of South Alabama to ask registered voters about these 17 issues. The voters’ responses generated the Top Ten list of voter priorities. Details about the survey and its methodology can be found in the full Alabama Priorities report.

Alabama Priorities

1. K-12 Education
2. Healthcare
3. Government Corruption and Ethics
4. Mental Health and Substance Abuse
5. Poverty and Homelessness
6. Jobs and the Economy
7. Crime and Public Safety
8. Job Training and Workforce Development
9. Improving the State's Image
10. Tax Reform

Key Findings

  • Voters broadly agree on the critical issues facing the state.
  • Voters are not polarized along traditional political, ideological, racial, or generational lines. There is a significant gap between the priorities of experts and the priorities of voters.
  • Policymakers have an opportunity to inform and educate voters on critical and systemic challenges facing the state.
  • Policymakers have an opportunity to respond to immediate, often highly personal issues that concern voters.
  • Elected officials and candidates have an opportunity to show leadership and to build broad coalitions to address Alabama’s most pressing challenges.

This summer and fall, PARCA will produce summary briefs on each of the top ten priorities chosen by Alabama voters. Each brief will answer four critical questions: what is the issue, why it matters, how Alabama compares, and what options are available to Alabama policymakers.

#3: Government Corruption and Ethics

What is the issue?

Government corruption and ethics is the 3rd most important issue for Alabama voters. Nearly two-thirds of respondents, 65%, indicated that they were very concerned about the issue. On a scale of 1 – 5 where 1 is “not at all concerned” and 5 is “very concerned,” respondents on average rated corruption and ethics 4.24.

By comparison, only 47% of voters indicated they were very concerned about the issue of tax reform and only 56% were concerned with jobs and the economy.

Majorities of nearly every demographic or political group are concerned, but there are some differences among partisan identifiers: a majority of Republicans are very concerned, while two-thirds of independents and over 80% of Democrats are very concerned.

For Republicans, Government Corruption and Ethics ranks 7th in the top ten issues; for both Independent and Democrats, it ranks as 3rd.   Conservatives rank it 5th; moderates, 2nd; liberal, boomers, and the Greatest/Silent generation, 3rd. For Gen Xers and for millennials, government corruption and ethics ranks 4th, behind K-12 education, healthcare, and mental health or poverty and homelessness, respectively.

The issue of corruption has drawn a great deal of attention in Alabama’s media for decades as the result of several high-profile scandals involving state officials. Alabama’s most eminent historian, Wayne Flynt, recently noted that three of the last six elected governors have been removed from office due to some form of corruption.[1] The previous Speaker of the House, several legislators, and community college administrators have been convicted on corruption charges, as have some local officials, such as those involved in the scandal surrounding the Jefferson County sewer system.

The key feature of corruption is the diversion or use of public resources for private use, whether to an official or to the official’s supporters, businesses, friends, family, or others. Self-dealing is a common feature, with bribery and corruption usually spoken in the same breath, while graft is also used to describe various kinds of illegal side payments. While bribery, a quid quo pro arrangement with a public official for an official act, is almost universally illegal, there are loopholes and legal blind spots that allow some behaviors to avoid legal sanctions.

Why Does Corruption Matter?

Empirical studies[2] have correlated public corruption with numerous negative outcomes, including:

  • bureaucratic inefficiency
  • low business investment
  • poor health outcomes
  • weakened civil and political rights
  • slower economic growth
  • higher income inequality and poverty
  • loss of political legitimacy
  • expansion of black markets or shadow economies
  • “brain drain”
  • fiscal deficits
  • weakened education system

The economic effects could perhaps be seen in Alabama’s slower than average economic recovery after the Great Recession, which also meant that Alabama’s education revenues were among the slowest to recover as well, creating a vicious cycle of poor performance.[3] These factors may chase off educated people and deter highly-skilled people from considering moves to Alabama.

Corruption diminishes opportunities for economic and social advancement, causing highly skilled people to leave, resulting in a brain drain and diminishing the economic vitality of the state

Voter concern about government corruption in Alabama is cause for concern for policymakers. People outside Alabama can be deterred from investing in Alabama, and highly-skilled people in Alabama may emigrate to other states, as many of the state’s college-educated residents tend to do.[4] Fortunately, there is also a great wealth of research on how to minimize corruption. Most of those methods involve removing the opportunity to engage in corrupt behavior. Of course, resistance to reform is typically most intense by those who benefit from lax controls and private gains from the status quo.

How Does Alabama Compare?

Some practices, typically prohibited in other states, have long skirted ethical boundaries in Alabama. Activities such as dual office holding, nepotism in employment, revolving doors between legislators and lobbyists, as well as legal but questionable practices, such as allowing sheriffs to pocket monies intended to feed inmates have drawn scrutiny. Until the passage of the 2010 ethics law, fees paid to legislators for referring people to lobbyists were not considered illegal. Instances such as these have been highlighted in Pulitzer Prize-winning news reports and commentaries by reporters for Alabama newspapers and frequently provided leading stories for Alabama radio and television stations.[5]

Alabama has also received attention from organizations that are specifically focused on government corruption. The Center for Public Integrity has produced two 50-state studies, under the banner of State Integrity Investigation: one in 2012 looking at 14 specific categories of state government and a slightly modified follow-up in 2015 looking at efforts to fight corruption.[6] Alabama earned a C- minus in 2012 and a D+ in 2015.

Although Alabama’s grade declined from a C+ to a D- between the two studies, the ranking of Alabama actually improved as so many other states also declined in their rankings. In the 2015 study, Alabama scored well in executive accountability and internal auditing but had problems with public access to information and political financing. Other areas of concern included judicial accountability, state civil service management, procurement, and lobbying disclosures.

Institute for Corruption Studies (ICS), an independent research institute within the Department of Economics at the Illinois State University, produces a Corruption Convictions Index which tracks the number of public corruption convictions per 100,000 state employees. In 2015, Alabama had 4.12 convictions per 100,000 state employees,[7] 11th highest among the 50 states. However, in 2006 it was 11.02 per 100,000, the 3rd highest total; and in 2007 11.13 per 100,000 the 2nd highest. Those high rankings came in the wake of convictions concerning the Jefferson County sewer system and the two-year college system.  Again, this is a lagging indicator of corruption as cases may take years to build and the number of defendants may be quite large for some instances of corruption involving multiple people colluding.

In 2018, ICS ranked Alabama as the having the most perceived corruption in the United States based on data from its fourth Corruption in America Survey done in 2017. The map below combines the aggregate scores for both types of corruption in all three branches. Alabama’s combined aggregate score was the highest in the United States.

What Can We Do?

The historical absence of strong structures to monitor and prevent corruption have resulted in attempts to shore up the legal foundations for prosecuting corruption, with one such legislation passed in 2010. In 2011, the legislature also provided a guaranteed budget to the Ethics Commission.  The 2010 law, together with subsequent reforms, also made it illegal for public officials and employees to accept most gifts valued at $25 or more. Subsequent to passage, the commission began a training program to ensure that officials and employees knew details of the ethics laws.

Spend Money Where it Matters

Electing “better people” has almost no empirical foundation. Watching people who are elected more closely has a great deal of empirical support, especially when transparency about their activities is accompanied by vigorous enforcement and sanctioning capabilities.

Eliminating opportunities for corruption by eliminating the conditions for self-dealing has been effective in stopping corruption as well.[8] To stop corruption, there have to be independent eyes and ears in the field, with the capacity to review records and investigate reports of wrongdoing. Local news reporting has been shown to reduce the costs of local government as a result of their presence.[9] Auditors and inspectors general almost always produce a high return on investment.[10]

One of the key functions of the Alabama Ethics Commission is to educate public officials on the ethics law. Ironically, at least one of the same legislators who passed ethics reform has been convicted of violating the new law. Would training have helped? What evidence is there that ethics training reduces the incidence of corruption?  These are questions that need to be answered. Some experts are not convinced.

“Certainly there is a place for ethics training, but it will not do the work of a reasonable set of internal controls, and everything is off the table without good leadership.”[11]

While it is difficult to mandate good leadership, spending more money on monitoring and enforcement would probably do more to change behavior than explaining rules to officials about things that they should not be doing in the first place.

Transparency and Open Data

One of the most efficient ways to deal with corruption is to require transparency and open data to the public.  This is increasingly less costly than it has been in the past as technologies have improved and prices have dropped. Nevertheless, the way that information is packaged can make it difficult for anyone outside agency staff to access information. One obstacle to searching ethics disclosures in Alabama is that there is no way to browse the records. One must know the name of a specific individual to find any document. One tried and true way to obscure access to information is to require requestors to know highly specific information to make the request.

Information systems that lock up data behind queries give the impression of releasing information but are actually obstacles to access to information. The ability to download entire databases of public records is the best practice in this regard. The Sunlight Foundation, a national, nonpartisan, nonprofit organization that advocates for open government, has published guidance on how to provide open access to government data, for better public engagement and access at https://opendatapolicyhub.sunlightfoundation.com/.  Policies developed with the Civic Commons provide additional guidance on good policies: http://wiki.civiccommons.org/Open_Data_Policy/.

A Systemic Response

Just as many symptoms can emerge from a single problem, often the right answer is not one thing, but many things. Unfortunately, when corruption is perceived as isolated and unique, the response is also isolated and unique. This is displayed during every legislative session as local acts  are passed to address matters that are truly statewide in scope.

For example, the response to Jefferson County’s sewer system debacle was addressed with a narrowly focused legal remedy specifically for Jefferson County, leaving the rest of the state unprotected from an identical scenario. The Jefferson County bankruptcy was an unnecessary opportunity for corruption on a grand scale – and one whose lessons have not been fully learned.

For the full PDF summary brief, click here. 

[1] 2018 Brewer Tolbert Award acceptance speech to the Alabama Appleseed Center for Law & Justice, September 20, 2018.

[2] Eugen Dimant and Guglielmo Tosato “Causes and Effects of Corruption: What has Past Decade’s Empirical Research Taught us? A Survey,” Journal of Economic Surveys, January 2017, p. 13.

[3] Crain, Trisha Powell, “Alabama K-12 education spending third worst catching up to recession cuts,” AL.com, Posted Dec 4, 2017 https://www.al.com/news/index.ssf/2017/12/alabama_k-12_education_spendin.html

[4] Quoctrung Bui, “The States That College Graduates Are Most Likely to Leave,” The New York Times, Nov. 22, 2016, https://www.nytimes.com/2016/11/22/upshot/the-states-that-college-graduates-are-most-likely-to-leave.html

[5] Brett Blackledge of The Birmingham (AL) News, http://www.pulitzer.org/winners/brett-blackledge; John Archibald of Alabama Media Group, Birmingham, Ala., http://www.pulitzer.org/winners/john-archibald-alabama-media-group

[6] For additional discussion of the methodology and rankings, see State Integrity Investigation 2012 at https://www.publicintegrity.org/accountability/state-integrity-investigation/state-integrity-2012; and State Integrity Investigation 2015 at https://www.publicintegrity.org/accountability/state-integrity-investigation/state-integrity-2015

[7] “Corruption Convictions Index,” Institute for Corruption Studies, http://greasethewheels.org/cci/

[8] It is worth noting that one governor’s conviction for corruption involved a board that issues certificates of need to hospitals, a practice that does not exist in 12 states, including large states like Texas and California. See “CON-Certificate of Need State Laws,” National Conference of State Legislatures. http://www.ncsl.org/research/health/con-certificate-of-need-state-laws.aspx

[9] Gao, Pengjie and Lee, Chang and Murphy, Dermot, Financing Dies in Darkness? The Impact of Newspaper Closures on Public Finance (August 10, 2018). Available at SSRN: https://ssrn.com/abstract=3175555 or http://dx.doi.org/10.2139/ssrn.3175555

[10] John Hudak and Grace Wallack. “Sometimes cutting budgets raise deficits: The curious case of inspectors’ general return on investment.” Center for Effective Public Management at Brookings, April 2015.  https://www.brookings.edu/wp-content/uploads/2016/06/CEPMHudakWallackOIG.pdf

[11] Mark Funkerhouser, “Why Ethics Training is a Waste.” August 9, 2012. http://www.governing.com/gov-institute/on-leadership/col-corruption-waste-abuse-ethics-training.html


Mental Health and Substance Abuse Ranks #4 Among Alabama Voter Priorities

In late 2017, the Public Affairs Research Council of Alabama (PARCA) surveyed Alabama voters to determine their thoughts about the general direction of the state and the issues that most concern them. PARCA partnered with Samford University to survey policy professionals from across the state including academics, journalists, business and nonprofit leaders, and lobbyists. Their responses provided a list of 17 critical issues facing Alabama. PARCA partnered with USA Polling at the University of South Alabama to ask registered voters about these 17 issues. The voters’ responses generated the Top Ten list of voter priorities. Details about the survey and its methodology can be found in the full Alabama Priorities report.

Alabama Priorities

1. K-12 Education
2. Healthcare
3. Government Corruption and Ethics
4. Mental Health and Substance Abuse
5. Poverty and Homelessness
6. Jobs and the Economy
7. Crime and Public Safety
8. Job Training and Workforce Development
9. Improving the State's Image
10. Tax Reform

Key Findings

  • Voters broadly agree on the critical issues facing the state.
  • Voters are not polarized along traditional political, ideological, racial, or generational lines. There is a significant gap between the priorities of experts and the priorities of voters.
  • Policymakers have an opportunity to inform and educate voters on critical and systemic challenges facing the state.
  • Policymakers have an opportunity to respond to immediate, often highly personal issues that concern voters.
  • Elected officials and candidates have an opportunity to show leadership and to build broad coalitions to address Alabama’s most pressing challenges.

This summer and fall, PARCA will produce summary briefs on each of the top ten priorities chosen by Alabama voters. Each brief will answer four critical questions: what is the issue, why it matters, how Alabama compares, and what options are available to Alabama policymakers.

#4: Mental Health and Substance Abuse

What is the issue?

Alabama voters rank mental health and substance abuse as the 4th most important issue facing Alabama, with 56% of respondents indicating they were very concerned about the issue. A plurality of Millennials and majority of voters of every other generation are very concerned about the issue. These findings are in keeping with the State’s Community Health Improvement plan, which found Alabamians rank mental health as the second greatest health concern.[1]

Mental illness includes a range of mental health conditions from mild anxiety, treatable with counseling, all the way to major psychiatric issues requiring psychotropic medication and long-term hospitalization.

An estimated 43.6 million Americans from all backgrounds suffer from mental illness or substance abuse. If current trends continue, by 2020, there will be more people suffering from mental and substance abuse disorders than people suffering from all physical diseases worldwide.[2]

Mental illness and substance abuse disorders share some underlying causes, including changes in brain composition, genetic vulnerabilities, and early exposure to stress or trauma.[3] Individuals that suffer from drug addiction frequently experience one or more symptoms of mental health issues.[4]

Experiencing both mental illness and substance abuse, what professionals call a dual-diagnosis, is very common.

Why Does it Matter?

Mental illness and substance abuse can alter reasoning skills, coping mechanisms, emotions, and behavior. This can have a profound impact on the individual and family, but also on the broader society.

Serious and untreated mental health concerns, including substance abuse, can place a strain on the communities by increasing unemployment, crime, and healthcare costs. Substance abuse alone has been estimated to cost $504 billion in direct and indirect costs, including lost productivity, in 2015 alone.[5]

Left untreated, mental health and substance abuse disorders can hinder an individual’s ability to live a healthy, confident life, and the ability to be productive members within the community. Untreated mental health and substance abuse issues can be significant contributing factors to job loss, homelessness, criminal behavior, and premature death. Suicide and drug-related deaths have increased in the nation in recent years with suicide ranked 11th in 2014 as the leading cause of death.[6]

More than one in four adults living with a severe mental health issue is also struggling with substance abuse issues. The effects on the communities can have direct and indirect consequences. “Direct consequences can include injuries, social and legal problems, impaired health, overdose, deaths, and babies born with neonatal abstinence syndrome. Indirect consequences include higher health care costs, the spread of infectious diseases, drug-related crime, interpersonal violence, unintended pregnancy, and stress within families.”[7]

How Does Alabama Compare?

Mental health care and substance abuse are critical issues in Alabama. In 2014, Mental Health America ranked the fifty states and Washington, D.C. in a number of mental health categories.[8] Overall, in the composite ranking of 15 mental health metrics, Alabama ranked 41st, ahead of neighboring states South Carolina, Tennessee, Mississippi, but behind North Carolina, Florida, Arkansas, and Louisiana. Georgia led all Southeast states at 26. Alabama ranked 27th in overall adult mental health and 28th in overall youth mental health. Looking at individual components, Alabama ranked:

  • 30th in the number of adults suffering from any mental illness;
  • 18th in the number of adults suffering from acute suicidal ideation;
  • 9th in the number of youth suffering from a major depressive episode in the previous year;
  • 42nd in the number of adults diagnosed with any mental illness without insurance, representing 20.8% of the adult population; and
  • 48th in overall access to care, ahead of only Texas, South Carolina, and Mississippi.

In spite of all this, less than half (43.5%) of adults in Alabama living with mental illness have received any form of treatment.[9]

Alabama now faces the daunting task of combating the opioid crisis. In 2013, Alabama had the highest per capita number of opioid prescriptions in the country – 141.1 per 100 compared to the national average of 79.3 per 100 people. Since then, the rate has dropped to 120.3 per 100 in 2015 – but this number still represents 1.2 prescriptions for every man, woman, and child in Alabama.[10]

While Alabama ranks 34th in deaths from drug overdose, the number of overdose deaths continue to climb: from 169 in 1999 to 756 in 2016, a 347% increase.[11]

Lack of accessible care and lack of sufficient insurance coverage for substance users exacerbates the issue. There is a high correlation between availability of preventative mental health services and mental health treatment. Alabamians have less access to mental health services than do residents of many other states.

What Can We Do?

Access to Care

One of the most significant factors facing mental health and addiction treatment in Alabama is simply the lack of access. Alabama has one mental health provider for every 1,180 people. Mental health providers include psychiatrists, psychologists, licensed clinical social workers, counselors, marriage and family therapists, and advanced practice nurses who specialize in mental health. However, at the county level, the ratio ranges from 270:1 (Macon County) to 33,840:1 (Chambers County).[12] Focusing on just substance abuse, statewide, there are 505 beds for residential and high-intensity residential substance abuse treatment – and these beds are located in just 13 counties. There is a waiting list of 319 people.

Individuals without insurance may wait for months to see a mental health professional. More often than not, this results in a crisis that ends with the individual in the hospital or jail. In effect, Alabama’s hospital emergency departments, jails, and prisons serve as de facto mental health providers. At the same time, while most people know how to access physical health care, people may be less familiar with when and how to access mental health care.

  • The state could expand Mental Health First Aid, described as ‘CPR’ for mental health, and Crisis Intervention Training for law enforcement personnel.
  • The state could also explore a waiver, which would allow Medicaid to fund treatment of substance abuse.
  • The state could explore expanding access to substance abuse treatment, particularly residential treatment. There are currently no substance abuse facilities, public or private, in Autauga, Bullock, Coosa, Lawrence, Lowndes, Perry, Washington, or Wilcox Counties.

Mental Health Workforce

Access is largely, but not exclusively, a function of size of the mental health workforce. Alabama faces a growing workforce shortage in many industries, including mental health services. There is a particular shortage for trained professionals serving the elderly. Unaddressed, this shortage will escalate as the senior population is growing faster than other age groups.

  • The state could explore incentives to attract and retain mental health professionals.
  • The state could explore licensure regulations to allow all medical professionals to practice at the highest levels of their training and certification.

Social Stigma

Mental health experts recognize that even if there were sufficient mental health providers, there is still a significant stigma attached to accessing treatment for mental health or substance abuse issues. Moreover, often when treatment is sought, the individual is already in a state of crisis, rather than seeking care earlier.

  • The state could seek to reduce the stigma by promoting and expanding peer programs—mental health services led by, or in conjunction with a person who has experienced mental illness himself or herself.
  • The state could develop an awareness campaign for the general public.

Standards of Care

There are a number of evidence-based and standards of care treatments that could be considered for expansion or modification in Alabama.

  • The use of medication to treat opioid addiction could be expanded.
  • The state could require healthcare professionals who prescribe medication treatment for addiction, do so only in consultation with a trained mental health professional.
  • The number of state-funded residential beds for substance abuse treatment could be expanded.
  • The number of nonprofit or low-cost methadone clinics for those with heroin addictions who suffer multiple relapses could be expanded.
  • The state could create a harm reduction program for opioid users, which includes education, counseling, referrals to treatment, and needle services and which has been shown to reduce the spread of HIV and Hepatitis C and increase the likelihood an individual will seek treatment.
  • The state could expand mental health and substance abuse treatment in the corrections system, which could also help reduce recidivism rates.

Drafted by Anita Perry, graduate student, Department of Social Work, Samford University, and the staff of the Public Affairs Research Council of Alabama.

Full PDF report available here.

[1] Alabama Department of Public Health, State of Alabama Community Health Improvement Plan (2015), http://www.adph.org/accreditation/assets/CHIP_2015_RevAugust.pdf.

[2] Rosenberg, L. 2012. “Behavioral disorders: the new public health crisis.Journal of Behavioral Health Services & Research 39(1):1-2.

[3]  U.S. Department of Health and Human Services, “Mental Health and Substance Use Disorders” (2017), https://www.mentalhealth.gov/what-to-look-for/mental-health-substance-use-disorders.

[4]  U.S. Department of Health and Human Services, “Mental Health and Substance Use Disorders” (2017), https://www.mentalhealth.gov/what-to-look-for/mental-health-substance-use-disorders.

[5] U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Facing Addiction in America: The Surgeon General’s Report on Opioids (2018), https://addiction.surgeongeneral.gov/sites/default/files/surgeon-generals-report.pdf.

[6] U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Facing Addiction in America: The Surgeon General’s Report on Opioids (2018), https://addiction.surgeongeneral.gov/sites/default/files/surgeon-generals-report.pdf.

[7] Walden, Nicole. “The Opioid Crisis in Alabama” Alabama Department of Mental Health, November 27, 2017, http://www.alabamapublichealth.gov/alphtn/assets/112717handouts.pdf.

[8] Mental Health America, “The State of Mental Health in America, 2018” (2018), http://www.mentalhealthamerica.net/issues/state-mental-health-america.

[9] U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Behavioral Health Barometer Alabama, 2015, (2015), https://www.samhsa.gov/data/sites/default/files/2015_Alabama_BHBarometer.pdf.

[10] National Institute on Drug Abuse, “Alabama Opioid Summary” (2018), https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/alabama-opioid-summary

[11] U.S. Department of Health and Human Services, Centers for Disease Control, “Drug Overdose Mortality by State: 2016” (2018), https://www.cdc.gov/nchs/pressroom/sosmap/drug_poisoning_mortality/drug_poisoning.htm

[12] Robert Wood Johnson, 2018 County Health Rankings, (2018), http://www.countyhealthrankings.org/app/alabama/2018/measure/factors/62/map