Tossing Children Overboard in Alabama: One Pediatrician's Heartrending Account

After reading Dr. Pippa Abston's chilling account about a recent Pediatric Legislative day in Montgomery, Alabama, I knew immediately that I wanted to reprint it here. In kindly granting her permission, the good doctor observed:

There’s a terrible game of chicken going on at our statehouse right now– I knew that already– I just didn’t realize until I saw their faces that they absolutely don’t care who they hurt in the process. No shame at all. 

Alabama: No State for Children? is Dr. Abston's gut-wrenching report about the callousness with which  legislators view the health needs of the very children they take an oath to protect. In her own words:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

NOTE: Read more about Dr. Pippa Abston here and about her thoughts on the war on women here.