Former Alabama Governor Urges State Lawmakers To Expand Medicaid

TUSCALOOSA, AL — Tuscaloosa dermatologist and former Alabama Republican Governor Dr. Robert Bentley is urging Gov. Kay Ivey and the Alabama Legislature to expand Medicaid and accept additional federal funding to extend Medicaid health insurance coverage for more Alabamians living in rural and underserved areas.

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In a lengthy letter submitted to Patch, Bentley said at the start of the 2022 Alabama Legislative Session, he reached out to Ivey and legislative leadership to voice his concerns from the perspective of both a practicing physician and former elected official.

Indeed, even after his 2017 resignation from the state's highest office, Bentley has remained outspoken about the need to address the lack of basic healthcare services and limited access to family doctors, local hospitals and specialists in rural parts of Alabama.

"Having come into office in 2011 on the heels of the passage of the Patient Protection and Affordable Care Act (ACA), our administration was faced with the daunting task of implementing the mandates and requirements of the new health care law," he said. "The financial condition of our state at that time was dismal. Unemployment was in double digits, state rainy day funds had been depleted, and we faced unprecedented recovery from the worst natural disaster in Alabama’s history, not to mention the manmade disaster in the Gulf Coast."

As governor, Dr. Bentley initially opposed Medicaid expansion as outlined in the Affordable Care Act, but did say at the time that he would have considered it had the state been given control of the federal dollars made available, in addition to lending his support to a measure requiring that "able-bodied" enrollees must be employed to receive benefits. This is a nuanced view, obviously, but one that still leans heavily conservative.

According to healthinsurance.org, the state of Alabama is leaving $2 billion in federal funding on the table by refusing to expand Medicaid. What's more, if the state did move forward on expansion, data suggests that 340,000 additional Alabamians would have access to insurance, raising the number of those covered in the state to nearly 1.4 million.

The Alabama Medicaid Agency reports that, just in Tuscaloosa County in 2019, a total of roughly 45,000 residents — 22% — are eligible for enrollment.

Dr. Bentley went on to say that when his administration was given the choice by the United States Supreme Court to implement or refuse Medicaid expansion under the ACA, state leadership had no choice at that time but to refuse based on the lack of state funding available.

"Today, 11 years later, Governor Ivey and the state legislature are facing a much different situation with record low unemployment, replenished rainy day funds and more robust state budgets," he said. "The Legislature just passed the largest General Fund budget in state history at $2.7 billion, including prepayment to the state’s emergency funds for the next six years. When the budget is balanced and the storehouse is full, state leaders should prioritize those issues that don’t otherwise get attention when money is tight."

Focus in his letter then turned to the COVID-19 pandemic, with Dr. Bentley arguing that while the crisis has stretched state resources and created new obstacles, it has also provided an opportunity to improve the lives of all Alabamians. What's more, he pointed to the increase in revenue and its impact on state budgets, as billions of dollars have been made available to states by the American Rescue Plan Act (ARPA).

"One of the more profound budget impacts of Medicaid expansion would be the new federal dollars that will replace state-only spending on other health care programs administered by the Department of Corrections and the Department of Mental Health, among others," he said. "By using ARPA Funds to pay the estimated 5-10% of the state share of expansion we will save additional dollars we spend now for other state agencies to treat Medicaid patients."

It's important to note that the federal government pays roughly 70% of the cost of Alabama's Medicaid budget, according to the Alabama Medicaid Agency, while the remaining 30% comes from the state general fund and other in-state funding sources.

"The federal ARPA funds allocated to our state come at a very high cost," Dr. Bentley said. "Nearly 20,000 Alabamians have died since 2020 because of the Covid pandemic. Much like mitigation funds after a natural disaster, these funds are intended to be used to do everything we can to prevent more deaths, more illnesses, and more tragedy."

In its most recent annual report, which was published in 2019 prior to the COVID-19 pandemic, the state Medicaid agency reported just shy of $7 billion in related expenditures, with the largest allocation — 36% — going to hospitals. Additionally, the Alabama Medicaid Agency reports that Medicaid enrollees make up 61% of nursing home patients, while 50% of all births in Alabama are paid for by Medicaid.

Dr. Bentley insists that the extension of Medicaid health insurance opens new doors to improving the quality of health care across Alabama, not just to those who fall in the coverage gap.

A 2020 study by the Robert Wood Johnson Foundation— the nation's largest philanthropic organization focused on healthcare — claimed that of the 15 states blocking Medicaid expansion, Alabama would see the largest decrease in its uninsured rate by doing so.

The organization reports that the statewide uninsured rate would drop by an estimated 43% if the Alabama moved forward with expansion. This is compared to an estimated 39% decrease in Mississippi, 36.4% in Missouri and 36.3% in South Carolina.

"Alabama’s rural hospitals and doctors will see a significant impact in their ability to effectively treat patients in areas that are deeply underserved by any hospital or healthcare provider," he said. "I can tell you from my personal experience not just as a former governor, but mostly as a physician myself, rural Alabama must be prioritized when it comes to healthcare."

As Patch previously reported, the former governor and state representative has been active in providing free clinics through a nonprofit he co-founded in 2021. As part of this initiative, the nonprofit began by providing free skin cancer screenings in places like Pickens and Marion counties.

Dr. Bentley also speculated on the impact a rural hospital and additional doctors would have on a town like Rockford in Coosa County. Despite having a population of roughly 10,000 people, the county has no practicing full-time physician, while nearly 30% of its residents are eligible for Medicaid.

"We recently held a free clinic there where we detected numerous cancers and provided treatment options patients otherwise would never have access to," he said. "Expanding Medicaid Insurance coverage would allow these patients to have a local physician and maybe even a small hospital in their county where they would be able to be treated."

Funding, like many other longstanding issues, remains the primary concern for many state leaders in the Medicaid expansion debate, a notion which Dr. Bentley says is a problem that is historic in nature.

For instance, he says the state repeatedly had no other choice but to turn to “one-time” solutions just to fund the basic state Medicaid budget.

"After failing to pass a lottery referendum to fund Medicaid in 2016, the Legislature relied on funds from the historic BP Oil Spill settlement to fund the Medicaid budget," he said. "By using ARPA funds readily available to our state to leverage even more federal dollars to pay for the expansion of Medicaid health insurance, we should never again as a state be left with the option of relying on one-time funds as we’ve done in the past."

Time and again, though, Dr. Bentley mentioned the opportunity in front of state lawmakers, even drawing parallels to the passage of the gas tax increase in 2019 — a move that received sweeping bipartisan support.

"If they were bold enough then to aggressively push for passage of an increase in the gas tax people of this state pay, then surely, they can be bold now to improve the quality of healthcare across our state," he said. "Expand the Medicaid insurance coverage for more Alabamians, and we will see the ripple effects on every small town, rural hospital and, in turn, every Alabamian."

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This article originally appeared on the Tuscaloosa Patch