Huntsville’s population grew past Montgomery’s and crossed the 200,000 mark in 2019, making the Rocket City the second largest city in Alabama.

If those estimates are accurate and current trends prevail, Huntsville will surpass Birmingham within the next three years to become the state’s largest city.

With the official 2020 Census count now in the field, Birmingham should hold on to the top spot when the count comes in. The 2019 estimates have Birmingham’s population at 209,403, down 1,084 from 2018. Meanwhile, Huntsville’s population grew by 2,449, pushing the city to 200,574. The 2010 Census put Birmingham’s population at 212,237 and Huntsville’s at 180,105.

Since 2010, Huntsville has added close to 20,000 residents. During this decade, Huntsville passed Mobile, which in 2019 estimated to have 188,720 residents, and Montgomery which is down to 198,525, after starting the decade with 205,593.

Birmingham’s metro area population is still growing and is more than twice the size of Huntsville’s. Six metro Birmingham suburbs ranked among the top 20 for numerical growth since 2010 including Hoover, Birmingham’s largest suburb. Since 2010, the strongest population growth has occurred in the Huntsville area, in Baldwin County, and in the two college towns, Tuscaloosa, and Auburn and Opelika.

In the most recent year, the population was strongest in the Huntsville area. Beyond the city of Huntsville, its neighbors Madison and Athens both ranked in the top five for numerical growth, each adding around 1,000 residents.

Outside the typical hotspots, Dothan saw growth, adding an estimated 604 residents.

With the exception of some cities in the Wiregrass and the Shoals, cities in non-interstate rural areas lost population in the most recent year estimated and throughout the decade. Selma, Tuskegee, and Eufaula had among the largest declines. Since 2010, Selma is down 3,551 residents, a 17% decline since 2010. That city’s 2019 population is estimated at 17,231.

No one knows what effect the Coronavirus pandemic will have on population trends or how it will affect the ongoing 2020 Census count. The stakes are high for Alabama. Population estimates suggest that Alabama is in danger of losing one of its congressional seats due to relatively slow population growth in Alabama compared to fast-growing states.

The disease outbreak has provided an additional demonstration of why it matters that the population of the state is counted as completely as possible. Much of the federal relief sent to states was distributed on Census population-based estimates.

So far, Alabama’s self-response rate to the Census is better than most other states in the Southeast but trails most states in the Midwest and Mid-Atlantic.

The Census Bureau sent out instructions for responding to the Census in March, either online, by phone, or through the mail. Starting in mid-April, the Bureau mailed paper questionnaires to homes that had not yet responded online or by phone.

Beginning in August and continuing until October 31, Census takers will be in the field interviewing at homes that haven’t responded. If your household hasn’t been counted, you can still respond.

See the menu at the top of the PARCA homepage: Updated information available at PARCA’s Coronavirus Resource page

Responding to the spread of Cornavirus, Alabama’s State Health Officer ordered Tuesday that in Jefferson and surrounding counties, public gatherings of 25 people or more are prohibited until further notice, and restaurants have been ordered to cease on-site dining operations.

According to the Alabama Department of Public Health (ADPH), the state had 39 confirmed cases of the novel Coronavirus, COVID-19, as of Tuesday, March 17, at 3:30 p.m. Jefferson County had the highest number of cases with 21. (For updates, PARCA has established a PARCA’s Coronavirus Resource page, updated tallies are available directly from ADPH here. And AL.com has established a Coronavirus update page for breaking news).

Following the lead of Jefferson County Health Officer Mark Wilson, on Tuesday Scott Harris, Alabama’s State Health Officer, has ordered the curtailment of certain activities in the counties surrounding Jefferson.

Wilson on Monday said evidence indicates the virus is now spreading in the Jefferson County community. Wilson ordered that bars and restaurants cease offering on-premise dining, that daycares and private schools close, and that senior residential facilities take additional steps to restrict visitation and mingling within the facility. Gatherings of more than 25 people are prohibited. State officials said Tuesday that those same orders are being extended to Tuscaloosa, Blount, Walker, Shelby, and St. Clair Counties. Text of the state order is here.

In support of the work of the government and health care professionals involved in the Coronavirus containment effort, PARCA plans to gather and share information and resources on a daily basis as the situation unfolds. Check back on our PARCA’s Coronavirus Resource page for updates.

The Alabama Department of Public Health (as of March 17) has not yet ordered restrictions in the rest of the state. However, they strongly recommend that people statewide take steps to limit the spread. Those include:

• No mass gatherings of 50 persons or more, or gatherings of any size that cannot maintain a consistent six-foot distance between participants. This may include festivals, parades, assemblies, or sporting events.
• Senior adults or those with chronic health problems should avoid gatherings (outside of close family) of 10 or more persons, and should avoid travel by air, train or bus.
• For retail businesses, including restaurants, limit patronage at any one time to 50% of the normally allowable capacity. Restaurants should maintain a six-foot distance between tables.
• Public buildings should consider whether visitation may be limited. Hospitals, nursing homes and assisted living facilities are encouraged to implement visitation policies that protect vulnerable persons.
• All persons should consider whether out-of-state travel plans may be delayed or canceled.
• Participants in religious services or events, weddings, funerals, and family events should exercise prudence and maintain consistent six-foot distance between participants if possible.

For individuals and families, wash your hands, avoid crowds, and in public maintain a six-foot distance from others. Work from home if possible, and, if sick, stay home.

If You Feel You Need Testing for the Virus

If you suspect you have contracted COVID-19 and are experiencing symptoms, the Alabama Department of Health asks that you contact your health care provider to arrange for testing.

For those without a regular provider, call 1-888-264-2256 to find out about testing in your area.

For Travelers Returning from Affected Geographic Areas

If you recently traveled to one of these affected geographic areas within the last 14 days, visit the CDC’s page of COVID-19 Resources for Travelers. If a person has questions about being tested for COVID-19, with or without any travel history, visit COVID-19 Testing.

The Alabama Department of Public Health is posting its news conferences on the virus, including the most recent on March 17.

ADPH also provides links to local county health departments. As of yet, there is not a comprehensive list of testing sites.

Check back on PARCA’s Coronavirus Resource page for information updates.

Alabama spent 2019 looking back at its first 200 years of statehood. In 2020, it seems appropriate to look forward to the next 100.

PARCA’s annual meeting, held Friday at Birmingham’s Harbert Center, was inspired by that theme: Taking lessons from the past in order to chart the way to a better future.

Along with a detailed look at the demographics shaping our state, it also included a series of experts discussing what the future holds for education, corrections, health and opportunity in Alabama.

The meeting featured Governor Kay Ivey describing her administration’s strategic efforts to raise educational achievement and to improve access to and the effectiveness of workforce training to meet the increased demands of the 21st-century economy.

The face of America and Alabama is changing

James H. Johnson Jr., professor of business and director of the Urban Investment Strategies Center at the University of North Carolina at Chapel Hill, spoke of the demographic changes that are already reshaping the state and the nation. Both Alabama and the nation as a whole are undergoing seismic shifts that will change the country.

• Population is flowing to the South.
• The country is becoming more diverse.
• Marriage across racial and ethnic lines is increasingly common.
• The country is aging.
• Men’s share of the higher education population and the workforce is declining, while women’s share is rising.
• Grandparents are increasingly involved in or responsible for the raising of their grandchildren.

Recognizing and preparing for these changes will be essential if Alabama is going to be competitive in coming decades. A fuller discussion of Johnson’s observations can be found in a paper Johnson published last year in Business Officer, a publication of The National Association of College and University Business Officers

Though Alabama has not grown as rapidly as magnet Texas and the Southern states on the East Coast, it will feel the same shifts. The native-born white population is not reproducing fast enough to replace itself, much less grow in numbers. Meanwhile, Hispanics, blacks and other minorities are younger on average and will constitute a greater share of the population over time.

Technology is pushing the frontiers of education

Neil Lamb, the Vice-President for Educational Outreach at Huntsville’s HudsonAlpha Institute for Biotechnology, highlighted factors that will shape education over the next 100 years: the ease of information access, advances in the science of learning, the rise of personalized learning, and the development of data-driven classrooms that allow for in-the-moment shifts in teaching strategy.

Lamb said these innovations offer great promise but they can’t be deployed haphazardly or without adequate support for the teachers that will need to use the tools to help children succeed. There must be attention paid to equity in spreading technology and adequately resourced professional development to support its implementation. Lamb, who served on the Governor’s Advisory Council for Excellence in STEM, pointed the audience to that Council’s recently released report: Alabama’s Roadmap to STEM Success.

Among its first step recommendations is a proposal that is now before the Alabama Legislature: The State Department of Education proposes to hire a team of 220 math coaches to provide statewide support for improving math instruction.

The STEM Success report includes the recommendation that an evaluation process be built into the math coach initiative so policymakers will be able to measure its impact and adjust the strategy in pursuit of success.

Alabama’s crisis in corrections must be addressed now

Bennet Wright, Executive Director of the Alabama Sentencing Commission and past President of the National Association of Sentencing Commissions, challenged the audience to think differently about prevailing but largely unexamined assumptions about crime and punishment.

Wright said Alabama has created one of the most complex systems of criminal justice and corrections in the United States. New laws are laid on top of old, but the old are not repealed. A multitude of different agencies and players operating with distinct motivations keep the institutions from functioning together as a system. Wright’s presentation materials can be accessed here.

Governor Kay Ivey’s Study Group on Criminal Justice Policy, chaired by Justice Champ Lyons, released a report and reform recommendations just last week. A letter with recommendations can be accessed here.

The Study Group’s report can be accessed here. 

An ounce of prevention saves lives and money

Monica L. Baskin, Professor of Preventive Medicine and director for Community Outreach and Engagement at the O’Neal Comprehensive Cancer Center at UAB, described the tremendous cost borne by Alabama as a consequence of poor health and pointed to opportunities to address health problems and health disparities before they become issues.

According to estimates by the Milken Institute, the direct and indirect costs of chronic disease in Alabama total more than $60 billion a year, more per capita than any other state except West Virginia.

In her presentation, Baskin cited several promising initiatives aimed at preventing the development of chronic disease, and encouraged partners statewide to increase innovation, collaboration, and equitable dissemination in order to get information to the people and places that need it most.

Time to speed up innovation in pursuit of opportunity

And Michael Chambers, Associate Vice President of Research at the University of South Alabama, argued that we, as a state, need to speed up our pace of experimentation and change. Chambers, an experienced businessman, entrepreneur, and attorney, said businesses have had to learn to act quickly, be flexible, be competitive, to avoid complacency, and to plan on change. If Alabama’s leadership and citizens expect to be competitive, Chambers said, we should do the same.

Looking back to look forward

In preparation for the program, PARCA produced a series of charts that present key indicators of the economy, health, education, and criminal justice over a long time span. Interactive versions of those charts are available below. The charts compare Alabama to the U.S. average or to other Southeastern states. In the interactive version, you can change comparison states.

New estimates from the U.S. Census Bureau show Alabama attracting more migrants from other U.S. states, but the state likely doesn’t have enough population momentum to avoid losing a congressional seat after this year’s Census count.

Alabama added 15,504 residents between July 1, 2018, and July 1, 2019, the period covered by the estimates. Only one other year this decade, 2012, did Alabama add as many new residents. Since the 2010 census, Alabama is estimated to have added 123,060 new residents. PARCA’s interactive charts allow you to explore the new statewide estimates. The button on the bottom right allows for a full-screen display.

That 2019 performance ranks Alabama 20^th in numeric change and 25^th in percentage change among the states. Ten states, including Mississippi, Louisiana, and West Virginia lost population in 2019, according to the estimates.

The net number of residents moving to Alabama from other states was 9,387, by far the highest total in domestic migration since 2010. During the middle years of the decade just-ended, Alabama was losing residents to other states.

Alabama’s birth rate, 11.7 per 1,000, is also slightly higher than the national average of 11.6 per 1,000. Census estimates that 57,313 new Alabamians were born in 2019.

However, Alabamians die at a higher rate than people in other states. Among U.S. states, only West Virginia has a higher death rate. Alabama saw 53,879 deaths in 2019, according to the estimates. That’s a rate of 11 deaths per 1,000 population, compared to 8.7 per 1,000 nationally. As the population ages, the death rate in Alabama and across the U.S. has increased over the course of the decade, while the birth rate has declined.

Alabama is also in the bottom 10 states when it comes to attracting international migrants. The Census Bureau estimates Alabama had a net gain of 2,772 international immigrants in 2019, compared with a gain of 3,379 the year before.

The 2019 net gain was the smallest gain through international immigration for Alabama since 2010. Before 2016, the state saw several years in which international immigration was contributing a net of 5,000 new residents to the state each year. Alabama is not the only state to see a drop-off. Nationwide, the number of new residents moving to the U.S from abroad was estimated to be 595,348 in 2019. That compares to more than 1 million immigrants moving to the U.S. in 2016.

While Alabama is seeing modest population growth, its growth rate is under the average for the South.

The Census South region includes many of the fastest-growing states in the country: North and South Carolina, Florida and Texas, Georgia and Tennessee. Overall, the states in the region grew by 9.6% since 2010. Alabama’s population grew by 123,060, or 2.6% over the same period.

North Carolina, which has added almost 1 million people since the last Census, and Florida, which has added almost 2.7 million, are expected to gain additional representation in Congress.

The following feature, which describes an alliance between the City of Montevallo, The University of Montevallo (UM), and Shelby County, marks the launch of an occasional series on creative cooperation between governments and other civic partners. Through the series, we hope to identify, share, and spread best practices and lessons learned.

Why We’re Writing This

Neighboring communities are inextricably linked in metropolitan or regional economies. Traditional ways of operating can lead to siloed thinking, inefficiencies, and, in some cases, counterproductive competition. Increasingly, neighboring governments and agencies are looking for ways to partner to achieve common interests. In recent years, PARCA has engaged in studying issues of municipal fragmentation and efforts to overcome its effects through cooperation among local governments in Greater Birmingham and in north Alabama’s Shoals region.

In April 2019, Greater Birmingham saw progress on cooperation with the crafting and signing of a Good Neighbor Pledge by members of the Jefferson County Mayors’ Association. Developed with the support of the Community Foundation of Greater Birmingham, the Pledge seeks to increase trust and prevent incentive bidding wars between local municipalities over business relocations.

Meanwhile, the Committee for A Greater Shoals used PARCA’s report on its local government landscape to launch an array of civic improvement working groups, involving hundreds of citizens. Those working groups have now identified opportunities for further progress on intergovernmental cooperation, joint efforts on tourism, digital infrastructure upgrades, and increasing investment in higher education and training.

Montevallo’s Shared Investment in Shared Vision

Cooperative efforts in Montevallo between the county, the city, and the university which have been brewing for a decade, have in recent year produced a significant transformation.

For most of its history, Montevallo (current population 6,674) has been a trading center for the surrounding area. Area residents have worked at the university and local schools, in some small-scale manufacturing, in coal mining, timber, and in farming. If you visited Montevallo about a decade ago, you would find a typical Alabama small-town downtown, going through the usual struggles such towns face as retail and travel patterns shift to Interstate corridors.

Meanwhile, the university was something of a separate bubble. Founded in 1896, as the Alabama Girls’ Industrial School, the school grew into a respected college for women, and, after going co-ed in the 1950s, was re-christened the University of Montevallo in 1969. UM evolved into an unusual school: a public college, but one with qualities of a private college, due to its small class sizes and liberal arts concentration. While the university was obviously important to the town as an employer, there was an odd sense of separation from the downtown, despite the fact the two were only a few short blocks apart. Students tended to commute rather than live and spend in town.

Now, the lines between town and campus are deliberately blurred. The small town with a small college is beginning to have the look and feel of a “college town,” a place where campus life and energy animates the town and the town embraces and enlivens the college.

The downtown is updated, with new signage, lighting, and sidewalks, plus a couple of pocket parks and new greenery. What had been a long-shuttered, modernist Alabama Power office building on Main Street has been transformed into the University of Montevallo on Main, a classroom building that draws students and professors off the campus and into town for at least some of their classes. Another Main Street storefront has been renovated to serve as the University of Montevallo Bookstore.

On the edge of campus closest to downtown, a $25 million, 36,000 square-foot Center for the Arts building is rising. According to the University, the Center will include a 350-seat theater with state-of-the-art acoustics and technology for music concerts and theater performances, a 100-seat black box theater, and a courtyard suitable for outdoor performances and receptions. The building is expected to build on UM’s traditionally strong arts and theatre program, while also serving as a venue for drawing events and competitions from K-12 schools throughout the year.

The blocks between downtown and the University of Montevallo campus have been reworked with sidewalks and landscaping, an inviting pedestrian connection. The wrought iron gates to the university are open wide, and from them, a University of Montevallo purple “Welcome” banner hangs.

New sports venues have been added, strategically placed to intermix the college and the town. A new women’s softball field was built on city property across Main Street, adjacent to K-12 schools and the public library. Meanwhile, the school’s running track, developed with investment from the county, is open for use by the Montevallo public.

Blurring the Lines between Town and Campus

This mixing of university and town life is deliberate. It flows out of a strategy developed by the partners to bolster the University of Montevallo, the town’s biggest asset and one of the largest employers in Shelby County, and to build it into a more productive engine for the town’s economy and culture.

Big employers are valuable in Shelby County. The county is one the most affluent and fastest-growing in the state, but about half its residents work outside the county. UM employs almost 500 full-time employees with gross wages for non-student employees totaling $29.35 million in 2018. Campus and dining operations employ another 70, approximately 40 full-time, with gross wages of around $1.5 million.

Even before the three-way collaboration came about, Shelby County, recognizing the strategic importance of the University, began investing lodging tax revenue in University projects that would help the university recruit and retain students. Shelby County uses its lodging tax revenue to promote tourism and economic development. In those investments, the county looked for projects that would provide benefit to the local community as well.

A comprehensive plan for the City of Montevallo, developed in 2008, sketched a vision of a revitalized downtown, complete with interconnection to the University. However, progress toward realizing that vision began in earnest in 2012, with the City’s passage of a 1 cent sales tax and with the formation of a Montevallo Development Cooperative District (MDCD). Organized as a Capital Improvement Cooperative District under AL Code § 11-99B (2016), MDCD is a partnership between the city, the county, and university. MDCD can act like a corporation. It can buy, sell, or lease property, and enter into contracts.

The City of Montevallo pledged 90 percent of the revenue from that 1 cent tax to the MDCD, which, in turn, used that pledged revenue stream to issue $5 million in bonds. Overall, the city has invested about $6 million through the MDCD, about $1.75 million in joint projects and $4.25 million in city projects including paving, relandscaping, and the construction of a new city hall. Both within and outside the MDCD, the county has invested $4.5 million with another $900,000 pledged for projects now underway. Meanwhile, the University of Montevallo is providing $21.7 million of the funding needed for the new Fine Arts Center and has invested more than $1.1 million in other projects with MCDC and the county. Investment by local partners on transportation projects also drew in close to $5 million in federal funding.

Not every project flows through the MDCD and not every MDCD project involves more than one partner, but the District keeps communication constant between the partners, and when one or more of the partners want to engage in a joint venture, the mechanism is there and waiting. It also serves as a vehicle for operating ongoing cooperative ventures like the jointly-owned buildings Montevallo on Main and The Main Street Tavern, another MDCD-restored building now leased to a restaurant.

The public investment has spurred private interest and investment. A Montevallo chapter of Main Street Alabama has been formed, supported by local businesses. That group has spearheaded a grant program that has repainted building facades in the historic core of storefronts. Some of those storefronts are occupied with businesses new and old, and some are in the midst of cleaning or restoration. They share Main Street with chain stores like McDonald’s, KFC, Taco Bell, and CVS, but the chains have new urban signage and design, which blend better with the appearance of the historic core.

Dee Woodham, a former Montevallo councilwoman who continues to serve as Montevallo’s representative to the MDCD, said the vision for a revitalized college-oriented Montevallo formed over a decade ago, but it was not until the county, the city and the university joined together and committed resources to the vision that things started to happen. “This is an impactful way of doing nice things in a small town,” she said.

Challenges

The investments made at UM and in Montevallo are not just feel good improvements. They are strategic responses to challenges. All parties recognize that the University of Montevallo has been, and will be, facing stiff competitive headwinds.

In the early 2000s, the University of Alabama launched an aggressive effort to grow its enrollment from 20,000 to its current total of over 38,500. Colleges and universities across Alabama felt the effects of UA’s well-resourced recruitment efforts, sparking increased competition for in-state students.

And because the rising generation is smaller and because the state hasn’t seen much in-migration, the pool of in-state, college-age students has been relatively constant and may actually decline in coming years.

While the University of Montevallo’s historic dedication to the liberal arts is a selling point, the current fashion in higher education, considering the cost of college, is to emphasize programs that more obviously and directly lead to careers. UM’s annual tuition and fees of over $13,000 are the highest among Alabama public colleges. However, its 13 to 1 student to faculty ratio is lower than any Alabama public college, and its tuition is lower than the private liberal arts colleges with whom it competes.

The University’s current enrollment of about 2,600 is down from about 3,000 several years ago.

Responding to Challenges

As a recruitment tool and to broaden its appeal, the University is adding sports teams, with the county aiding in that investment. The county helped develop the lacrosse field, allowing UM, which participates in NCAA Division II athletics, to become the second public university in Alabama to offer men’s and women’s lacrosse. That’s a draw for both in-state and out-of-state students who want to continue playing in college and don’t have many options in the Deep South.

The county also helped with the construction of a stadium for women’s softball, which was built on land provided by the City of Montevallo.

The University has also expanded other sports offerings hoping to attract scholar-athletes. It added a swimming team, taking advantage of an existing Olympic-sized pool at the student center.

On the slightly offbeat note, UM has a nationally-ranked collegiate bass fishing team, taking advantage of Montevallo’s proximity to the fertile lakes of the Coosa chain. UM also added an “Outdoor Scholars” program to showcase its proximity to the Black Belt’s fishing and hunting grounds.

And starting this fall, UM will field a competitive eSports team, with the aim of recruiting students who are interested in electronic gaming, in particular, a game called, League of Legends.

While UM’s investments haven’t yet produced a surge in enrollment, the University believes it has positioned itself for growth through its recruitment efforts, expansion of sports, and other investments like the Fine Arts Center and a new home for its School of Business. And the joint investments with the city have created an atmosphere more conducive to having students who will enroll in and live in Montevallo rather than commute.

Defining Goals and Expectations

For the partnership to thrive, all parties agreed that it was important to spell out their objectives, define the organizational structure, operate transparently, and come to a written understanding of expectations. The Shelby County Commission’s detailed resolution that endorsed the partnership describes underlying motivations and history of the partnership. Together, the parties agreed to articles of incorporation. Another practice followed by Shelby County when it commits to joint ventures is a performance contract, like the one adopted by Shelby County and the UM as a condition of the county’s support for the new fine arts center.

The county agrees to provide up to $1.2 million over seven years to support the project in order to aid the University’s recruitment and retention of students and the attraction of visitors to the community. But that contribution is conditioned on UM developing a schedule of events, performances, conventions, and competitions, targeting not only university students but also high school and middle school students. The University agrees to set goals for attendance, track it, and report back its results. UM has already laid out a draft calendar of more than a dozen proposed events each year through 2025. Depending on how well UM does in meeting performance expectations, the Shelby County Commission can decide to accelerate, slow down, or terminate its support to the project.

The MDCD has three members, one appointed by each entity. Within the parameters set out for it by its authorizing bodies, MDCD can operate more nimbly than a government. However, in MDCD’s case, the District functions as a public body under the open meetings law. Advance notice of meetings are posted. Decision-making takes place in public meetings. Minutes are taken and published on the web, as are financial reports and audits.

Caveats

While collaboration has clear advantages, it is not without risks.

In any partnership, questions can arise over whose interests are being served. For example, some townspeople worry that the town’s relationship with the university is too close. The mayor and two council members are university employees. A third council member is married to a university employee.

Janice Seamon, a Montevallo realtor involved in historical preservation causes, said cooperation is important and has produced positive, tangible results. But in her opinion, in any town, if the largest employer directly or indirectly employs the majority of the council, that has the potential to create conflict. “Having the major employer in control of city government is not good practice,” Seamon said.

Also, one of the virtues of the MDCD — its nimbleness and lack of bureaucratic structure — can lead to questions about accountability. Montevallo Councilman Rusty Nix points out that many of the projects that have run through MDCD are really city projects and don’t involve the other partners. Why, he asks, are these public expenditures run through MDCD, an alternative body on which the city’s representative is not an elected official? Why aren’t at least those solo projects reviewed for approval by the elected City Council?

Woodham, the former councilwoman and the current City of Montevallo representation to the MDCD, acknowledged that the potential for a conflict of interest exists with university employees serving on the council, but at the same time the town needs the interest and input from the university community. Woodham thinks that so far officials have been able to pursue mutually beneficial projects under terms fair to all parties. Ultimately, voters will pass judgment on that.

As for her representation of the city on MDCD despite no longer being an elected official, that’s up to the city council. Neither the county nor the university representatives are elected, but all are accountable to their appointing authority.

Measuring Success

The partnership effort of the county, the university, and the city has already achieved undeniable results. Time will tell to what extent success will fully flower.

The City of Montevallo is showing population and revenue growth, above and beyond the extra revenue produced by the increased sales tax rate. The accumulation of improvements is creating a sense of new possibilities. There are still vacant storefronts to fill, but almost two dozen new businesses have opened in the past three years, including a bakery, a bar, a cake and coffee shop, a Taco Bell, and a popsicle shop. Coming later this fall, Slice Pizza plans to open in Montevallo, its third location in the metro area.

At the same time, the aggressive changes at the University of Montevallo have not yet yielded a surge in enrollment. UM is well short of its Fall 2019 goal of 3,000 undergraduates. Officials hope that as the new sports teams become established and as UM’s new full-time student recruiters in Georgia and Tennessee spread the word, interest and enrollment will gather steam and the investments made by the partners will pay long-term dividends for all parties.

This partnership may be a model that other colleges and communities in our state can explore.

Huntsville continues its trajectory towards becoming Alabama’s largest city, while Birmingham, Montgomery, and Mobile continue to drift lower, according to the most recent city population estimates released by The Census Bureau. The two major college towns Auburn and Tuscaloosa continue to grow, as do several cities in Baldwin County.

The new estimates cover the time period between July 1, 2017, and July 1, 2018, and also look back to 2010, the year of the last official Census. Data from the same time period has already been released for state level, metro areas, and counties, and PARCA has published analyses and interactive tools exploring that data. The new cities data is below. Use zoom and drag tools to explore a particular area. Use the button in the bottom right corner if you want a full-screen display.

Huntsville and North Alabama

The city of Huntsville added more residents than any other Alabama city with an estimated 2,262 gain in 2018. If current trends continue, Huntsville (197,318) will surpass Birmingham (209,880) as Alabama’s largest city within the next several years. However, Birmingham’s metropolitan area population (1,151,801) is more than twice as large as Huntsville’s MSA (462, 693).

The Huntsville suburb of Madison ranked third in numeric gain adding 1,289. Huntsville has avoided the dilemma faced by many center cities: becoming hemmed in by and losing population to newer suburbs. In fact, Huntsville, through strategic annexation, has now completely surrounded Madison. While Madison can continue to add residents in its current footprint, it will not be able to spread out by annexing contiguous territory.

Though Madison County cities are capturing most of the North Alabama growth, nearby Athens in Limestone County appears to be receiving some of that inflow. In the farther reaches of the Huntsville orbit, Florence and Muscle Shoals had bigger gains in population in 2018 than in any year other in the decade.

Birmingham Area

In the Birmingham metro area, the core city of Birmingham was estimated to have lost over 1,000 residents between 2017 and 2018. Birmingham has bobbed up and down through the decade, but this most recent year saw the steepest decline.

However, there is population growth south and east of the core city, and the most recent estimates indicate that growth is shifting to suburbs farther south. In the most recent year, the suburbs immediately south of core city, Homewood and Mountain Brook show slight population losses, and Vestavia a slight gain. Hoover, while it did add 246 residents, is growing more slowly now than smaller cities to the south like Chelsea (+503), Helena (+457), and Calera (+393). Meanwhile, to the east of Birmingham, Trussville added 446 residents, according to the estimates.

Montgomery Area

The estimates show Montgomery losing 1,674 residents in 2018, while its emerging suburb of Pike Road gained 445. Suburbs to the north, like Prattville (+202), Millbrook (+133), and Wetumpka (+37) saw gains, but the Montgomery metro area as a whole has seen a population outflow.

Some of the population loss in the Montgomery area may be due to the strong growth being seen in Lee County, home to Auburn University. A separate Census survey tracks residential migration across county lines. A look at that data reveals that Elmore County had a net loss of 352 residents to Lee County. Nearby Tallapoosa and Macon County, which are not officially part of the Montgomery metro area, are also losing residents to Lee County.

Meanwhile, Lee County’s two larger cities have been among the state’s biggest gainers in population according to the estimates. Auburn is second to Huntsville in numerical gain, having added an estimated 12,000 residents since 2010. Over the same period, Opelika ranks No. 10 in the state with an estimated gain of 4,000.

Mobile Area

The 2018 estimates have the City of Mobile declining in population by 953 residents. Census estimates the city has lost about 5,000 people since 2010. Some nearby communities in Mobile County like Semmes and Saraland have gained population over the past decade, but the growth in those communities isn’t enough to offset Mobile’s population loss. One might assume that the rapid growth just across the bridge in Baldwin County is being fed by residents moving out of Mobile. However, other Census data sets indicate that isn’t necessarily the case. While there is some movement from Mobile to Baldwin County, there is also a considerable residential movement back and forth between Baldwin County to Mobile. When moves to and from the county in question are accounted for, Jefferson County had a net gain of about 500 people from Mobile County, compared to a gain for Baldwin of about 250.

Other Urban Centers and the Rest of the State

Like Auburn and Opelika, Tuscaloosa and Northport both continue to grow, though at a slower pace than the rival towns to the east. Tuscaloosa remains substantially larger than Auburn, about 100,000 vs 65,000. Opelika is larger than Northport: about 30,000 vs. 25,000.

As mentioned, Florence and Muscle Shoals showed slight growth in 2018, according to the estimates, as did Phenix City. Dothan was flat, and Anniston and Gadsden both experienced net out-migration.

A scattering of smaller towns in northeast Alabama and southeast Alabama showed population growth. However, most smaller cities in rural counties lost population. Selma was particularly hard hit, with a net loss of almost 500 people in 2018. Since 2018, Census estimates Selma’s population has declined by 2,898 dropping from around 20,000 down to 17,000, a 14 percent population decline. Small towns in Black Belt counties, cities like Tuskegee, Eufaula, and Demopolis, continue to experience population declines, but so do towns in east central and northwest Alabama like Jasper, Alexander City, and Sylacauga.

Energized by a climate of opportunity and a burst of positive attention for the region, civic leaders in the Shoals have launched a new effort to improve the economy and quality of life through cross-community collaboration.

More than 150 people attended the launch of the effort, which is organized by the Committee for a Greater Shoals, a group of Shoals business leaders. The event featured the release of A Greater Shoals: a Pathway, a report authored by PARCA on the current state of the region and avenues of opportunity.

Shortly after the event, 110 people had signed up for one or more of six committees:

• Broadening the Definition of Economic Development
• Developing High-Tech Infrastructure/Recruiting
• Quality of Life
• Workforce Development and Education
• Unified Tourism
• Government Cooperation and Structure.

Off the Interstate corridor and tucked away in the Northwest corner of the state, the Shoals is often described by residents as a well-kept secret. That is part of the region’s charm, but it’s also a frustration.

Taken together, the four cities at the heart of the Shoals — Florence, Muscle Shoals, Sheffield, and Tuscumbia — have a population of over 70,000. A combination of the four adjacent cities would rank as Alabama’s 7th largest city. Leaders in the Shoals have long wondered if the region was held back by the fragmented nature of the Shoals, with four principal cities, and six school systems spread across two counties.

Building off research PARCA performed on the Birmingham metro area, PARCA found evidence that fragmentation did have discernable negative effects in the Shoals but also identified cooperative structures the Shoals has developed to pull the region together.

The report recommended building on those existing cooperative structures to capitalize on immediate opportunities, while embarking on a longer-term process to decrease governmental duplication and work toward greater unity.

The report found success to build on in the area of education. According to PARCA’s analysis, when the K-12 school systems in the Shoals metropolitan area were considered together, they produce a higher college and career readiness rate among high school seniors than any other Alabama area.

The Shoals also has the second highest college-going rate among Alabama MSAs, thanks in part to a local civic initiative, Shoals Scholar Dollars, that provides scholarships for residents of Colbert and Lauderdale counties. The Shoals is home to a community college, Northwest-Shoals Community College, and a four-year university, the University of North Alabama, both of which are poised for growth.

The Shoals has developed vehicles for bringing its counties and cities together in pursuit of economic development, including a unified economic development authority, a unified economic development fund, and a united two-county Chamber of Commerce.

Those cooperative structures create a strong competitive position for the Shoals in pursuing industrial projects, like suppliers for the Toyota-Mazda Manufacturing plant under construction in Huntsville. But they also provide a framework for cooperation on further developing the Shoals natural and cultural assets.

With the Tennessee River running through its heart, the Shoals has unrivaled natural assets, ripe for further recreational development. On the cultural front, the Shoals has enjoyed a surge of national and international attention to the Shoals’ historic and contemporary contributions to American music. That’s drawn a stream of tourists to the FAME and Muscle Shoals Sound Studios. Florence has emerged unexpectedly as a fashion hub, serving as home base for designers Billy Reid and Natalie Chanin. That new interest builds on top of tourist attractions like Helen Keller’s home in Tuscumbia and W.C. Handy’s in Florence. Traditional down towns in Florence, Sheffield, and Tuscumbia have been revitalized with local investment.

A coordinated cooperative effort to build on these strengths would bring more resources and reach, the report observes. Though traditional economic development has focused on developing sites and luring employers with incentives, contemporary economic development includes a focus on developing an ample and high-quality workforce and providing a high quality of life that benefits locals and attracts new residents and businesses.

As Alabama approaches its 200^th birthday, the state is still adding population but at a slower rate than most of its Southeastern neighbors.

The U.S. Census Bureau released new state-level population estimates in December, providing estimates of state populations as of July 1, 2018. The data release also includes state-level estimates for the underlying components of population change.  A closer look at the components provides insight on the factors affecting Alabama’s growth rate. According to the Census, Alabama has:

1. The second highest death rate among U.S. States. West Virginia’s is the highest.
2. The fourth lowest rate of international in-migration.
3. A positive rate of domestic in-migration, but a rate that is slower than some Southeastern neighbors.

For the most part, the 2018 estimates extend trends among Southeastern states that have been in place since 2010: more rapid growth along the East Coast and in Tennessee, slower growth and even some estimated population loss in the Southeastern interior states.

In the national context, the highest percentage population growth is taking place in the Mountain West states of Nevada, Idaho, Utah, and Arizona, with Texas and Florida also placing near the top. A second group of states — Washington and Oregon on the West Coast; Colorado in the Mountain West; and the Carolinas and Georgia on the East Coast; constitute a second tier of growth states with population increases of 1 percent or greater. Alabama falls into a third tier, with growth under 1 percent. Alabama’s population increased an estimated 0.3 percent increase. Eight states, including Mississippi and Louisiana, in the Southeast, lost population in 2018, according to the Census estimates.

To estimate population change, Census tracks births and deaths in a state and estimates the number of people moving in and moving out. According to the 2018 estimates, these are estimated totals for Alabama:

Alabama 2018 Components of Change	Values
Births	57,216
Deaths	53,425
Net Natural Increase	3,791
Net Domestic Migration	5,718
Net International Migration	3,344
Net Migration	9,062
Net Population Change in 2018	12,751

To be able to compare those numbers to other states, it is necessary to compute a rate for each measure. The Census expresses rates as a number per 1,000 residents. For example, Alabama had a death rate of 10.9, that’s 10.9 deaths for every 1,000 residents. Alabama’s death rate has been consistently high according to Census estimates, which are based on population estimates and death records collected by public health agencies. Alabama’s population is older than the average state. That effects population in two ways. Older residents are more likely to die, and younger people are more likely to have children. In addition, Alabama residents, by many measures are less healthy than residents in other states and have a shorter life expectancy than residents of most other states. Alabama’s high death rate ultimately depresses the state’s rate of natural increase, which ranks 43 among U.S. states.

Rates of Change, by Components	Rate of change per 1,000	Rate's Rank among U.S. States
Death Rate	10.9	2
Birth Rate	11.7	28
Natural Increase Rate	0.8	43
Domestic Migration Rate	1.2	19
International Migration Rate	0.7	47
Net Migration Rate	1.9	24

The other way states grow or shrink is residents leaving or new residents moving in. Alabama has a positive rate of domestic migration, netting 5,718 new residents that moved to Alabama from other U.S. states. However, Alabama doesn’t attract many transplants from other countries. Alabama ranked 47th in its international migration rate, adding only 3,344 new residents from other countries. That left the state’s overall migration rate in the midrange of U.S. states.

According to the estimates, Alabama continues to be outpaced in population growth by South Carolina, a demographically similar state that was smaller than Alabama at the time of the 2010 Census. Since 2018, South Carolina’s population growth has accelerated, particularly in terms of domestic migration. Since 2010, South Carolina has surpassed Alabama in population, adding more than 450,000 new residents, while Alabama has added just over 100,000.  The interactive maps and charts below allow you to explore the data and make your own comparisons of numeric change, percentage change and rates of change. Expand the display by clicking on the full screen icon on the bottom left of the graphic.

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 2^nd 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 47^th 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.

 

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 4^th 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 11^th 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 41^st, 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 27^th in overall adult mental health and 28^th in overall youth mental health. Looking at individual components, Alabama ranked:

• 30^th in the number of adults suffering from any mental illness;
• 18^th in the number of adults suffering from acute suicidal ideation;
• 9^th in the number of youth suffering from a major depressive episode in the previous year;
• 42^nd in the number of adults diagnosed with any mental illness without insurance, representing 20.8% of the adult population; and
• 48^th 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 34^th 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