MONTGOMERY, Ala. — Governor Robert Bentley’s Alabama Health Care Improvement Task Force on Wednesday recommended expanding Medicaid, the government healthcare program designed to provide coverage for low-income and disabled individuals. The task force said the most significant barrier to improving healthcare outcomes in Alabama is eliminating the “coverage gap” — people who do not have private insurance, but earn too much to qualify for Medicaid. Their recommended solution is to offer Medicaid to individuals who make more money than the current program will allow.
Medicaid is jointly funded by the federal government and the state, but administered exclusively at the state level. The program is currently the largest line item in Alabama’s budget, comprising 37 percent of the General Fund. According to the Alabama Policy Institute, the state’s Medicaid expenditures increased by 53% between 2001 and 2013, and as the state’s senior population increases, costs are expected to grow even further.
The governor, whose position on Medicaid expansion has shifted significantly since winning re-election last year, concedes that expanding the program would be a costly proposition.
“(Y)ou have to realize it is going to cost the state of Alabama over the next six years $710 million in the General Fund,” Bentley said last week. “Now folks, I can’t even get (the Legislature) to raise a hundred million dollars. So we’ve got to look at a funding stream if we’re going to do it.”
The governor’s office has not yet taken an official position on expanding Medicaid, but has made it clear in recent weeks that Bentley is strongly leaning in that direction.
Task force packed with Democrats, Medicaid expansion advocates
The governor appointed the state’s Health Officer to chair the task force, which was given the responsibility of finding ways to improve the accessibility, affordability, and quality of healthcare for Alabamians. The governor appointed 37 other people to the task force, including legislators, healthcare professionals, and insurance company representatives.
Among those appointed are several members who have been longtime Medicaid expansion advocates, including three Democratic members of the state legislature, the policy director of the liberal advocacy group Alabama Arise, and an employee of Blue Cross Blue Shield of Alabama.
Several representatives from the University of Alabama at Birmingham (UAB) were also appointed to the task force. In 2014 UAB released a study saying Medicaid expansion would create thousands of jobs and bring increased tax revenue to the state. Governor Bentley called the study “bogus” at the time, and another study from Troy University later refuted the majority of its claims.
The only two Republican legislators on the task force were the chairmen of the Alabama House and Senate Health committees.
Recap: Bentley packed a Medicaid "task force" full of Medicaid expansion advocates who concluded expanding Medicaid would be a good idea.
— Cliff Sims (@Cliff_Sims) November 18, 2015
Understanding the likely structure of expansion
Similar to Pennsylvania and Arkansas, which are also led by Republican governors, Gov. Bentley has suggested he would like to be able to funnel federal tax dollars through the state government and into private insurers. The private insurers would then use those taxpayer dollars to cover uninsured individuals up to 138 percent of the federal poverty level, the same ultimate outcome as Medicaid expansion under ObamaCare. The political benefit is that by receiving a “waiver” from the Obama administration, Republican governors have been able to expand the program while selling it as something completely different. In Pennsylvania they call it the “Healthy PA” plan. In Arkansas it’s commonly referred to as the “private option.”
Conservative policy and advocacy groups have taken to calling such plans “Medicaid expansion by another name.”
Gov. Bentley has insisted he would only pursue such a plan as a “block grant” from the federal government. Block grants are federal funds granted to states that include more flexibility in how they are spent than traditional “categorical grants.”
“It would have to be in the private sector and there would have to be some requirements on it,” Bentley told reporters in December. One specific requirement he mentioned was that he’d like to see the system tied to employment. “(Recipients) need to be working on getting a job, or having a job.”
Other states that have tried to tie work requirements to Medicaid benefits have been denied. In rejecting such a proposal from Utah earlier this year, U.S. Health and Human Services Department spokesman Ben Wakana said, “encouraging work is a legitimate state objective. However, work initiatives are not the purpose of the Medicaid program and cannot be a condition of Medicaid eligibility.”
The bottom line is, the Obama administration will have to sign off on any plan Alabama pursues.
Bentley’s evolution on Medicaid expansion
Governor Bentley’s 2014 State of the State address was a passionate defense of the free market and refutation of government dependency.
In one particularly notable portion of the speech, the governor attempted to put Medicaid expansion rumors to rest once and for all. At the time, his Democratic opponent was accusing him of not being entirely forthcoming about his intensions.
The Affordable Care Act – or Obamacare and Medicaid expansion is taking our nation deeper into the abyss of debt, and threatens to dismantle what I believe is one of the most trusted relationships, that of doctors and their patient.
Essential to Obamacare is Medicaid expansion – a federal government dependency program for the uninsured, which is administered by states. Since 1980, Medicaid spending has increased nationally by over 1,500-percent.
Here in Alabama, Medicaid takes up 35% of our General Fund.
Under Obamacare, Medicaid would grow even larger… Here in Alabama alone, an estimated 300,000 more people would be added to the Medicaid role, to a system that by our own admission is absolutely broken and flawed.
The federal government has said they will give us money to expand. But how can we believe the federal government will keep its word? The anything but Affordable Care Act has done nothing to gain our trust.
First, they told us we could keep our doctor – that turned out not to be true. Next, they told us we could keep our policy – that’s not true. Then they told us our premiums would not go up – nothing could be further from the truth. Now they are telling us we’ll get free money to expand Medicaid.
Ladies and Gentlemen, nothing is free. The money the federal government is spending with wild abandon is not federal dollars – those are your dollars, your hard-earned tax dollars. There is no difference between federal money and your money.
Our great nation is 17.2 trillion dollars in debt and it increases by 2-billion dollars every single day.
That is why I cannot expand Medicaid in Alabama. We will not bring hundreds of thousands into a system that is broken and buckling.
But after securing re-election in November of last year, Gov. Bentley’s 2015 State of the State address took a sharply different tone.
A year removed from declaring he would “not bring hundreds of thousands into a (Medicaid) system that is broken and buckling,” Bentley insisted he would not allow the “flaws” of ObamaCare to keep the state from expanding taxpayer-funded healthcare for the “poorest and most vulnerable.” He also said some hospitals are “dependent on Medicaid to survive,” further signaling that an expansion of the program may be imminent.
Republicans in the Alabama Senate responded by passing a resolution urging the governor to not give in to expansion.
“The state should pursue reforms based on reducing Medicaid dependence, rather than increasing dependence,” the resolution stated. “Expansion of Medicaid would further strain the state General Fund, where Medicaid is already the largest line-item… We express our intention that the State of Alabama not expand Medicaid above its current eligibility levels.”
The resolution, which was sponsored by Sen. Trip Pittman (R-Montrose) and co-sponsored by 20 other Republican senators, was passed on a vote of 22-8 along party lines.
“This resolution expresses my resolve to be fiscally responsible and protect taxpayer funds,” Sen. Pittman, who now chairs the General Fund Budget Committee, told Yellowhammer at the time. “Medicaid reform legislation has already been put in place, and we need to measure the outcome of those reforms before rashly expanding Medicaid. Right now, we simply can’t afford to expand Medicaid.”
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