Expansion Evasion: Alabama’s Near Miss
In the waning weeks of 2014, a handful of Republican governors—fresh off the heels of their re-elections—began flirting with the idea of embracing Medicaid expansion under the Affordable Care Act. Alabama’s own Republican governor admitted that he was “looking at” expansion, despite having kept a safe distance from the issue in his first term. While eleven Republican-led states ultimately did expand, several Republican governors—including Alabama’s—had their impulses impeded with help from their states’ own Republican-controlled legislatures.
On April 5, 2015, the Governor Robert Bentley announced the formation of the Alabama Healthcare Improvement Task Force—tasked, presumably, with a predetermined recommendation for him to expand Medicaid. Days later, an effort arose in the Alabama Senate to curb the momentum. It came in the form of a Senate Joint Resolution introduced by Senator Trip Pittman (R-Daphne) and co-sponsored by twenty of his Senate colleagues. The two-page resolution made a succinct case against expansion and concluded with these words:
- Whereas, the Legislature has no intention of allocating funds to support Medicaid expansion; Be it resolved…that we express our intention that the State of Alabama not expand Medicaid above its current eligibility levels.
In a way, these senators were “prophets in their own land,” bucking their party’s governor and other state figureheads attempting to exert pressure, and enduring a two-day tongue-lashing from Democrats on the Senator floor as punishment for the resolution’s passage. Pittman, who at the time served as Budget Chairman for the Education Trust Fund, recognized the fiscal dangers associated with expansion, especially given the near unsustainability of the state’s current Medicaid costs. He, along with many of his colleagues, also feared the very real possibility that Congress would eventually renege on its irresistible offer.
Eventually, talk of expansion dissipated—so much so, that the governor now seems pleased with the outcome. He recently remarked:
- We want to make sure that the states that did not expand Medicaid, that we are taken care of properly. They [Members of Congress] are not for expanding Medicaid further; in fact, there will be a reduction over time. We will be rewarded because we did not expand Medicaid…in the long run, we are gonna be better off for the way we handled it in the beginning.
As I have written about in greater detail here, Medicaid already accounts for one of Alabama’s most onerous financial obligations. At same time, it is one of the state-administered programs over which the state has the least amount of control and flexibility. Alabama’s share of Medicaid spending has now reached nearly $2 billion a year (for an Alabama total of $6.3 billion, including federal funds) and has increased by an average of 9.5% annually over the last decade. Not only would Medicaid expansion have driven up these costs, but it would have done so while the federal government simultaneously siphoned even more of the state’s already-nominal control over the program.
Today, after six failed years in existence and under the control of a Republican president and Republican majorities in both houses of Congress, the Affordable Care Act is on life support. Conservatives in the House of Representatives are fighting to see that Medicaid expansion is not only closed, but that payments to expansion states cease altogether. With Alabama’s estimated expansion price tag at (at least) $700 million, where would that have left the state financially? Would Alabama have been able to support the expansion population without jeopardizing funding for the lowest- income beneficiaries who were already enrolled? What about the able-bodied individuals who dropped out of the private market because they’d become newly eligible for Medicaid?
The foresight of the Alabama Senate should rouse Alabama’s congressional delegation to lead the fight for an end to Medicaid expansion, more state authority over Medicaid, and ultimately, a better method of healthcare delivery for low-income families. Those representing red states that acquiesced to the short-term political gains of expansion won’t have that freedom, but will instead be forced to defend the cost-prohibitive measure, and by extension the Affordable Care Act, likely to their long-term political detriment.
Katherine G. Robertson is a former counsel to then-Senator Jeff Sessions (R-AL) and currently serves as Chief Counsel to the Attorney General of Alabama. The opinions expressed in this commentary are her own.