This is the second in a series of articles on the trial of Alabama Speaker Mike Hubbard. Read the other installments here: part one; part three; part four; part five.

To get a sense of how Mike Hubbard has affected the lives of everyday Alabamians, type #IamMedicaid into Facebook or Twitter. Up pops a seemingly endless series of photos of children: a pigtailed toddler with a cleft lip and palette; a boy with two missing front teeth who fell into a fire and spent three weeks in a burn unit; a girl with a congenital heart defect; a boy in a wheelchair with a half-shaven head who suffers from Hirschsprung’s Syndrome, and is recovering from brain surgery to cure an infection in his central nervous system.

They’re all smiling and holding placards that bear the “I am Medicaid” slogan, a social campaign that is tied to one of the 23 felony counts the speaker of the Alabama House of Representatives faces in a trial that begins this week—the one charge that might well be the most difficult for Hubbard to beat. In 2013, Hubbard voted 12 times for a bill that would give a monopoly over Alabama’s Medicaid prescription drug program, worth some $40 million a year, to American Pharmacy Cooperative, Inc. (APCI), with which he had a $5,000-a-month contract. Hubbard has claimed that his work for APCI concerned only out-of-state business, and that he wasn’t aware that the bill would benefit the company. But one of his former colleagues, Greg Wren, who pleaded guilty during the grand jury phase of the case, is expected to testify that Hubbard directed him to insert 23 words into the bill that would give APCI its monopoly.

But Hubbard’s alleged crime is just the most flagrant example of how Alabama lawmakers abuse Medicaid. The Alabama legislature, in which the House speaker enjoys almost supreme power, has repeatedly underfunded the state’s Medicaid program, to the point that it now runs the risk of losing its federal matching funds, which would leave millions of Alabama residents without even minimal health care and imperil the state’s entire medical system. The #IamMedicaid campaign is a response to that perilous shortfall. But Hubbard’s track record suggests that as long as he’s the most powerful man in Alabama, his constituents will only be heard if they speak with dollar signs.

In 2010, Hubbard orchestrated the GOP’s takeover of the legislature, which had been under Democratic control for 136 years, since Reconstruction. Fighting corruption was a central plank of the Republican campaign, along with a promise to root out wasteful spending in Montgomery. “There was an air of optimism when they took control,” says Bob Davis, editor of the Anniston Star. It was an optimism that seemed justified when Hubbard led a special session a month after Election Day, ramming through a slate of tough ethics laws.

“But it didn’t take long to go off the rails,” Davis says.

For Davis, an early sign of trouble came when the leaders on Goat Hill, as Alabama’s capitol is known, took a hard turn toward demagoguery instead of dealing with Alabama’s perennial budget problems and finding ways to stimulate job growth. First there was the passage in 2011 of what Davis calls an “anti-immigrant” law, which called for the arrest of citizens who so much as gave food to illegal immigrants. It became national news when executives at the state’s Honda and Mercedes plants were arrested. Amid the outcry, Hubbard became the law’s number-one defender, explaining to reporters from around the country that he was merely upholding federal law and even penning an op-ed in support of the measure in USA Today. Federal courts eventually gutted its major provisions.

Then came a law requiring Alabamians to show state identification in order to vote, paired with the prompt shuttering of driver’s license offices in the state’s poorest counties, with the state claiming it lacked the money to keep them open. But to all who knew Alabama’s racist history, it was a bald-faced move to weaken the African-American vote.

And year after year, even as legislators repeatedly had to be called back for costly special sessions to fulfill their most basic duty—passage of a budget—Hubbard held up Barack Obama as Alabama’s public enemy number one. After Governor Robert Bentley laid out a slate of policies and priorities in his State of the State speech in 2013, for instance, Hubbard tweeted: “We must also start a separate track that defends our state from @BarackObama and the expanding federal gov’t.”

These moves were classic Alabama politics, Davis says. Quoting Harvey Jackson III, professor emeritus of history at Jacksonville State University and author of Inside Alabama, he explains: “The driving force in Alabama politics is making sure your constituent can see that he’s at a better station than someone else.”

Meantime, Hubbard set about building his fiefdom on Goat Hill. Despite campaign promises of fiscal conservatism, his office’s budget ballooned. His predecessor, a Democrat, spent a little less than half a million a year. Under Hubbard, spending doubled, rising to almost $900,000, the independent news site Alabama Political Reporter revealed in 2013. Of this, $96,000 went to pay David Azbell for co-writing Hubbard’s book, Storming the Statehouse: The Campaign that Liberated Alabama from 136 Years of Democrat Rule. And Hubbard spent tens of thousands of dollars to furnish a cloakroom in the statehouse and to decorate his suite of offices, covering the walls with giant flat-screen TVs, including one that ran a continuous loop of photos of Hubbard with George W. Bush and other Republican heavy hitters.

The state’s finances didn’t fare much better. Alabama’s budget has carried a structural deficit for generations, due mainly to the state’s tax structure, which is skewed in favor of wealthy landowners. “Our state constitution was explicitly written to establish white supremacy,” Davis explains. “And while all of the racist language in it has been rendered a dead letter by the federal courts, the part that established power in Alabama remains.” As a result, Alabamians “have the lowest property tax in America. And if we doubled it, it would still be the lowest.”

But with the exception of a 25-cent cigarette tax, Hubbard and his fellow Republicans have refused to generate new revenue, so state programs have limped along with meager funding and the state has repeatedly raided its rainy day coffers just to cover its obligations. “Instead of tax-and-spend Democrats, we’ve had borrow-and-spend Republicans,” says Claire Austin, a Montgomery lobbyist and longtime Republican.

“There is nothing good that has come from the Republicans being in power in Alabama, and I’m a Republican,” says Arthur Payne, a former state representative from Birmingham. “Since the Republicans have taken over, we have borrowed more money than we ever have in the history of the state, and our budget is in worse shape than it’s ever been.”

That’s saying a lot for a state that for decades has ranked near the bottom of just about every socioeconomic measure. Nearly 660,000 Alabamians go without health insurance. The state has the highest infant mortality rate in the nation, and ranks in the top ten in heart disease, cancer, stroke, influenza, pneumonia, and kidney disease. It has the seventh-lowest percentage of residents with college degrees, the fifth-lowest with high school diplomas, and the sixth-highest unemployment rate. The median income is $42,278, third-lowest in the country, a mere 3 percent increase over what it was in 2010, when Hubbard and the Republicans took control. Over the same period, the nation’s median income has increased 8 percent.

But it’s been boom time for Hubbard and his friends. In addition to the fancy furnishings and high salaries for his staff and personal book writer, Hubbard pulled in nearly $420,000 a year in contracts with companies that employ lobbyists in Montgomery. He also directed his fellow legislators—many of whom he personally recruited, raised funds for, and helped campaign—to support legislation backed by, and in many cases written by, a handful of lobbying firms with which he had a personal connection. Most notable of these was Bob Riley and Associates, which former Governor Bob Riley—Hubbard’s political mentor, after whom he named his son—opened within months of stepping down from political office in 2011.

One of the most striking examples of Hubbard’s cronyism was an education reform bill that came up in 2013. It started as an eight-page measure that would allow families to move their children from “failing” schools to better-performing ones. But after the measure passed the House and Senate with slight differences, Hubbard sent it to a subcommittee that met with almost no notice in a room that was different from where it normally met. Only the Republican members showed up, but they comprised a quorum that unanimously approved a 27-page replacement bill that was rushed onto the House floor and quickly passed. The new bill established a scholarship program that now helps middle class and wealthy families send their kids to private schools, creating a multi-million-dollar program that Riley now runs.

“Hubbard is a guy who wants to control everything and everybody, and that’s his biggest problem,” Payne says. “His problems permeated the whole legislature, because he determines what bills flow through. In some cases, he supported bills to help his own [criminal] case.” For example, he pushed a bill that would’ve created a House committee with line-item control of state departments’ budgets, including the attorney general’s. In theory, the Hubbard-controlled House could’ve forced the attorney general’s office to eliminate its white-collar crime division.

That bill failed, but several Republican legislators paid the price for opposing it. Hubbard yanked Phil Williams from the Technology Committee, even though Williams represents a district near Huntsville where aerospace engineering is one of the leading industries. “I spoke out and was ostracized,” he says. And Hubbard ran things this way from the start. Payne, who had served in the Republican minority for years, was stripped of a seat he’d long held on the powerful Rules Committee simply because he didn’t vote for Hubbard to be Speaker when the GOP took the majority, Payne says.

Hubbard’s speakership has been “very much like a dictatorship controlling all branches of government with an iron fist,” Austin says. “He’s very vindictive, with a long-term memory. It’s like nothing I’ve ever seen in my 20 years here.”

Amid this environment, the children of the #IamMedicaid campaign have had little hope. Alabama offers the absolute minimum in Medicaid services necessary to qualify for federal matching funds—coverage for children, people with disabilities, and low-income elderly. With the passage of the Affordable Care Act, the state could’ve expanded Medicaid to provide health care coverage to hundreds of thousands of uninsured Alabama residents with the help of hundreds of millions of dollars from the federal government.

So why didn’t the state take the money? “It’s branded with the name of a president they despise,” Jim Carnes, policy director for the Arise Citizens’ Policy Project, says of the ACA. “It’s an Obama program, and they’ve dug in to resist everything he supports.”

In the most recent legislative session, Alabama faced another budget shortfall, and instead of raising taxes or finding places to cut state programs, legislators took it all out of Medicaid’s budget. As it stands, health-care providers under the system are looking at their already meager Medicaid reimbursements being cut by nearly a fourth. This will assuredly lead to staff cuts, reductions in patient rolls, and early retirements. Worse, Alabama will face a very real risk of losing federal funding entirely, and that threatens the state’s entire health system. Medicaid funds comprise a huge percentage of the revenue stream at the state’s hospitals, especially ones in rural areas, says Danne Howard, executive vice president and chief policy officer for the Alabama Hospital Association. “Medicaid is part of the fabric of our entire health care system,” she says.

Hubbard and other Republican leaders have insisted their resistance to Medicaid expansion is not a purely political opposition to the nation’s first black president, claiming that the state simply can’t afford to spend the additional funds expansion would require. But budget analyses by Howard’s group and other health advocates have shown that the state could shift funds it is already spending on mental health and health care for prisoners to more than cover the bill—an assertion that was backed up recently by a Medicaid task force appointed by Governor Bentley, which recommended Alabama embrace Obamacare. Moreover, the federal match would pump hundreds of millions of dollars into the state’s lagging economy, and polls show that the majority of Alabamians support the expansion of the program, even as they continue to oppose the president.

The governor is expected to call a special session to address the Medicaid shortfall. But it’s unclear how much clout the governor wields, since he is caught in a sex scandal that comes on top of the dark money scandal that has shaken Goat Hill. Backers of #IamMedicaid hope that expansion is still in the cards, especially now that fellow red state holdout Oklahoma has reversed course. But it’s more likely that the legislature will go for a one-time fix, this time using money from a settlement with BP over the Gulf of Mexico oil spill that ravaged the coast in 2010. For that money, the #IamMedicaid kids will be competing with a plan for a beachfront conference center to be designed and built by unnamed, no-bid architects and developers, then handed over to a private corporation to run.

What’s more, the special session will also grapple with another Hubbard priority that legislators were unable to nail down during the recent regular session—a plan for unnamed, no-bid contractors to design and build four new prisons with an $800 million bond issue. Many in Alabama see the initiative as an indication of the kind of future Hubbard and his fellow Republicans have in mind for the #IamMedicaid kids.

“We expect prisons to be the future of Alabama,” Darrio Melton, chair of the Democratic Caucus in the Alabama House, wrote in a recent column for Alabama Political Reporter, adding that state leaders have “given up on fixing mental health programs, creating expansive educational opportunities, rebuilding our communities, and rehabilitating our people.”

A lot will depend on how Hubbard’s corruption trial in Lee County turns out. What we know for sure is that much more than Hubbard’s personal fate is at stake.