The good, the bad, and the ugly … why California is more like Alabama than you think.

For someone who came of age in the seventies the realization that I now live and practice medicine in Alabama is daunting … the Alabama of my youth was someplace foreign, someplace I had never been, and someplace I had no intention of ever going.  New England born I consider San Francisco home … the deep south should seem alien.  Yet – despite the obvious stereotypes- there is little difference in my daily world between northern California and Alabama.

First of all, Alabama and California are not that different. Both states have teetered on the brink of financial ruin. Forbes (2012) determined that both states have more “takers than makers” … to use the “tragedy of the commons” metaphor both California and Alabama take more than their fair share and are heavily dependent upon government subsidy.  Comparing my home town of Mill Valley (Marin Co., CA) to my adopted home of Mountain Brook (Jefferson Co., AL) there are striking parallels and some interesting differences:

1. both towns are predominantly white (91% white and .99% black in Mill Valley, 98% and .31% black in Mountain Brook)

2. both towns are affluent although Alabama is a bit more so (median income 131K versus median income of 121K in Mill Valley),

3. both towns have the greatest number of exemptions for childhood vaccination in their respective states (again, Alabama does better … 2.8% of Mountain Brook kids are not vaccinated, it is nearly 8% in Mill Valley).

4. both communities are well educated … more than 75% of residents in each community have undergraduate or advanced degrees, and

5. both regions share unique healthcare demographics … at the end of 2012 , 623 of every 100,000 people in Jefferson Co. was living with an HIV infection diagnosis … 407 of every 100,000 in Marin  County … the incidence of HIV infection is rising in Alabama, declining in California.

Simply another way of saying that zip code is more important than state boundaries in determining community and that stereotypes – while often true – only tell one story.  Most people in my Mill Valley neighborhood are surprised to learn that my Alabama neighborhood is wealthier, better educated, and has more residents actively infected with HIV.

WhileI am not suggesting that Mill Valley is representative of California – and Mountain Brook is certainly not representative of rural Alabama –  both states have significant healthcare burdens and both states have significant resources.  The decision is how these resources are utilized and how sustainable revenue is created.

Jerry Brown raised taxes in California, Governor Bentley raised taxes by $450 million in Alabama including a doubling of the tobacco tax… not an easy task for a Republican governor in a Republican state.  Bentley is a physician and practiced medicine for many years before seeking elected office.  He has maintained that the ambiguity and realities of a medical practice have informed his decisions as governor: embracing fiscal responsibility and rejecting reactionary economics, embracing solution oriented governance, and accepting the political reality that running for office and governing are very different responsibilities.  While the South Carolina legislature debated the “correctness” of removing the confederate flag, Bentley removed the flag from the state house by executive order noting that “we have taxes to raise and work to be done … Alabama cannot be distracted by a prolonged discussion of civil war memorabilia”. Wildly unpopular, with nearly two thirds of the state in opposition, the legislature has remained largely silent raising the possibility of an even more progressive agenda.

Like California, Alabama is no friend of federal intervention.  While California struggles with the federal-state discrepancy of medical marijuana legalization Alabama seeks freedom for independent expansion of the Medicaid program. Contrary to other states we feel we can make up for reduced federal funding under a block grant by exercising the greater flexibility that block grant proposals typically allow making programs more cost-effective, without unduly cutting eligibility, benefits, or provider payments.  A community solution for a community problem.

So despite the stereotypes California and Alabama have a great deal of common ideology … a libertarian view of their own self reliance and a subtle recognition of their dependence upon federal resources.  Both states share serious and increasing inequities in wealth and access to health care.  Both states have large and expanding poor and indigent populations.  Both states have recently been blessed with effective state level leadership.  Hopefully, that leadership will continue to impact healthcare


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