At the top of the list is retail giant Wal-Mart, whose Alabama work force had 4,700 children on Medicaid, according to a snapshot of state enrollment data collected by agency officials last month at the Mobile Register's request. Also well-represented were fast-food chains McDonald's, Hardee's and Burger King. Ranking fifth was Alabama state government, where one official acknowledged that some workers earn so little that the $164-a-month family health plan is out of reach.
The numbers were drawn from information voluntarily provided by the applicants, and a Medicaid spokeswoman described the data as estimates. At least for private companies, however, the results resemble those of surveys in other states.
In Wal-Mart's case, organized labor and other critics charge that the nation's largest employer keeps its store prices low, in part, by shifting costs to taxpayers -- an accusation that the company denies. Nonetheless, some observers fear that broad economic shifts are sapping the Medicaid system of affordable employer-provided health benefits taken for granted by many Americans.
"I think it is eroding," said Martha Teitelbaum, senior health analyst at the Children's Defense Fund, a Washington, D.C.-based advocacy group. "As it gets more expensive, the kids are the ones who get dropped."
Although small businesses have always been less likely to provide coverage to their workers, a national study two years ago found that the rate of uninsured people in larger companies -- those with 500 or more employees -- edged upward from 7 percent to 11 percent between 1987 and 2001.
While the overall proportion of uninsured at those large companies remained small, almost half of the low-income workers went without coverage for some point during a sample year, 1998, compared to 8 percent of the best-paid employees, according to the study, which was released by The Commonwealth Fund, a New York-based foundation that sponsors research on health issues.
In Alabama, a recently released survey by the state Department of Industrial Relations also found wide gaps in coverage. Although 81 percent of all companies offer full-time employees health insurance, only 13 percent do so for part-timers. And even for full-time workers, the odds of getting benefits depend on where they work. About nine out of 10 manufacturers offer medical insurance; in the hospitality and leisure industry, which includes hotels and restaurants, the comparable figure is just two-thirds.
A complex medley of factors underlies the growth in the ranks of the uninsured, experts said, including fast-rising health care costs, the steady loss of unionized manufacturing jobs and the inability of low-paid employees to afford coverage even when the company makes it available.
For Medicaid, a state/federal program intended to cover the poor and disabled, the upshot appears to be a steady spiral in the number of youngsters on its rolls.
Last year, more than 488,000 Alabama children, 37 percent of the state total, were signed on for services at some point. That was up from 29 percent only four years earlier. If current growth rates hold steady, some 43 percent of Alabama children will be making use of Medicaid by fiscal 2009, Medicaid Commissioner Carol Herrmann predicted last week.
"I think we need a better way of covering these kids in the private market," Herrmann said.
Among the options, she said, would be incentives to encourage businesses to provide insurance, or mandating coverage from companies that can afford to offer reasonably priced benefits but choose not to.
Large corporations have to take "some responsibility" for providing family coverage to their employees, Herrmann said, stressing that she was speaking for herself, not Gov. Bob Riley's administration.
Medicaid's eligibility standards vary, but for a family of four seeking to cover any children ages 6 to 19, the yearly income limit would be about $19,400, according to agency figures.
Although coverage of individual children is relatively cheap, it still cost the Medicaid program hundreds of millions of dollars last year.
For Riley and the Legislature, Medicaid has become the equivalent of a throbbing fiscal headache. Already the single largest expense on the state ledger after education, Medicaid is seeking almost an 18 percent increase in its share of the state General Fund budget next year, from $364 million to $429 million.
As of last month, more than 154,000 Alabama Medicaid children came from working families, according to the numbers compiled for the Mobile Register by agency officials. Almost 4,400 had parents or caregivers who said they were self-employed, but many others came from households that included employees at such familiar companies as the Winn-Dixie grocery chain, poultry processor Gold Kist and apparel maker Russell Corp., the figures indicate.
Nationally, the lightning rod in the debate over health care coverage has been Arkansas-based Wal-Mart. In Alabama, the retailer employs about 38,500 full and part-time workers at more than 100 stores and three distribution centers.
"They have a bigger work force than anyone else and they have the biggest low-wage work force," said Philip Mattera, research director of Good Jobs First, a Washington, D.C. research clearinghouse that receives labor support. Because Wal-Mart also seeks government incentives in return for going ahead with major projects, Mattera said, "it seems to be part of their business plan to, in essence, soak the public sector."
But Wal-Mart spokesman Dan Fogleman said the company makes health coverage available to both full-time and part-time employees at a monthly cost of about $153 for a family plan. "As the nation's largest employer, almost by default we'll be the largest on many types of lists," Fogleman said.
A company survey commissioned late last year found that only about 5 percent of hourly Wal-Mart store associates were on Medicaid, he said, and that figure dropped to 3 percent for those employed two years or more. Fogleman declined to provide a copy of the full survey, calling it "proprietary."
The company's detractors respond that many Wal-Mart employees cannot afford coverage because they do not receive sufficient pay. Despite a threatened veto by Maryland's Republican governor, that state's Democrat-controlled legislature recently passed a bill requiring large companies to spend at least 8 percent of payroll on employee health coverage or else make up the difference through a state tax payment.
In this year's regular session of the Alabama Legislature, state Rep. Sue Schmitz, D-Huntsville, is sponsoring a bill to require job-holding applicants for Medicaid and other public assistance programs to identify their employers. Each year, state officials would have to report the name of any company with 50 or more beneficiaries in such programs.
The intent of disclosure, Schmitz said, is to give employers an "incentive" to either pay their workers enough to purchase health insurance or to provide coverage themselves. The bill overwhelmingly passed the House of Representatives, but has been caught in an unrelated logjam of legislation in the Senate. Officials for the Business Council of Alabama could not be reached for comment Friday on whether the lobbying organization has a position on the measure.
Private companies aren't the only employers receiving criticism in the health insurance debate.
Highway laborers and other employees at the low end of the Alabama state government pay scale make so little that their children would qualify for Medicaid, said E.J. "Mac" McArthur, executive director of the Alabama State Employees Association, which represents many state workers.
"We know there are a lot of them out there," agreed William Ashmore, executive director of the State Employees' Insurance Board, which runs the state health insurance program.
Almost 440 children of Mobile County employees are also on Medicaid, the agency statistics indicate, although the records don't specify whether they work in the school system or for county government. But Danny Goodwin, a director of the Mobile County branch of the Alabama Education Association teachers union, said bus drivers and other support workers generally make no more than $20,000 a year, which -- depending on the size of their families -- could allow them to put their children on Medicaid.
"I think it's an absolute shame," Goodwin said.
