As Alabama’s struggling hospitals and uninsured residents face the unknowns of the coronavirus, political leaders say the state can’t afford to grant healthcare through Medicaid expansion to some of its most vulnerable and uninsured residents.

“It would be irresponsible to think about expanding Medicaid just for the sake of expanding Medicaid without having a complete and honest discussion about the source of stable funding to pay the match,” Alabama Gov. Kay Ivey said at a Tuesday press conference.

She added that she is concerned about the health and welfare of all citizens.

“It is an option. I’m aware of the interest that’s there. But there’s a lot of exploring that has to be done on how you pay for it.”

Proponents of Medicaid expansion in Alabama say now is the time to act.

That’s why Sen. Doug Jones (D-Ala) is pushing for federal coronavirus stimulus to include a way for states to expand Medicaid programs at no cost for three years, a deal similar to the one Alabama rejected several years ago.

“Most of the people that would benefit from expanded Medicaid are working people, said Jones. “These are folks that are falling through the cracks.”

Without such federal intervention, if the state expands its program, it will be on the hook for 10 percent of the costs and the federal government will pay the other 90 percent. A 2019 study from UAB shows that would cost the state an initial $168 million, assuming tax revenues generated from the expansion don’t arrive in the first year. The subsequent years would cost the state about $25 million to insurance a couple hundred thousand low-income Alabamians.

Jones believes the coronavirus crisis changes the equation and estimates expanding Medicaid would bring significant money to the state.

“A billion dollars (a year) for the healthcare industry, for healthy people, and so I would hope that people would put their political views aside,” he said pointing to other Republican-led, southern states that have expanded in recent years.

Jones estimates there are closer to 340,000 Alabamians who fall into the Medicaid coverage gap; they earn too much to qualify for traditional Medicaid but too little to be included in the Affordable Care Act’s exchange.

Uninsured rate in Alabama counties | Graphic by Ramsey Archibald

He says an opt-out provision may be included in any plan as a “guard rail” of sorts.

“I think they would really jump on it,” Jones said of Alabama political leaders, “Because it would be something they could do without spending a dime.”

Alabama is one of 14 states that opted not to expand Medicaid, largely because lawmakers opposed it as an entitlement program.

Jones introduced a similar bill last year to reduce state match rates that failed.

On the state level, David Becker, professor of public health at UAB, believes President Trump’s failed effort to repeal and replace the Affordable Care Act has likely shifted the views of Republican lawmakers who initially held out against the program.

Becker says there’s a “game of chicken” going on between Democrats at the national level, that would like to see Medicaid expanded everywhere, and Republicans in states like Alabama that don’t want to pay up front costs for deferred benefits. He sees an opportunity for Democrats in congress to draw on federal stimulus money to give states an incentive.

“This is no longer just an Alabama issue about our decision to expand,” he said. I think there’s going to be this waiting period where governors are waiting to see… ‘Well, where’s the money gonna come from?”

The UAB study by Becker last year estimated that expansion would reduce the number of uninsured people in the state by 223,000 while generating $3 billion a year in economic activity. The study estimates there would be a net benefit in taxpayer dollars. Becker says he anticipates the coverage numbers will be higher now due to the coronavirus.

For Rep. Steve Clouse (R-Ozark), chair of the Ways and Means General Fund Committee, his opposition to expanding Medicaid is financial, not philosophical.

He says the state will likely face revenue shortfalls from residents sheltering in place for coronavirus, and so far federal stimulus has done little to address those needs.

But he says if the federal government would drop the initial match rate costs back to zero, Alabama lawmakers would reconsider.

“(There) would be certainly benefits to health care providers, not just hospitals, but you know, pharmacies, doctors, nurse practitioners, different health care fields,” said Clouse.

Experts say that states that did expand Medicaid created broad financial and health benefits for patients and hospital systems, with little negative impact on state revenues.

In such states, uncompensated care costs to hospitals fell on average 30 percent, according to the Center for Budget and Policy Priorities. Avoiding such costs could present a lifeline to struggling hospitals in Alabama. As of February, 25 percent were at risk of closure. The coronavirus is taxing Alabama hospitals in ways not fully yet measured.

But Sen. Albritton (R-Range) who chairs the Finance and Taxation General Fund Committee, says the pandemic is no reason to expand Medicaid.

“I don't think it shifts the calculations at all,” he said. He has little confidence that the federal government will continue shouldering the costs of the program long term.

“(It) scares the daylights out of me,” he said.

And even without expansion, he worries about the costs of rising Medicaid enrollment numbers stemming from coronavirus fallout.

Former Sen. Phil Williams (R-Rainbow City), also policy director of the conservative-leaning Alabama Policy Institute, is concerned about the possible expense.

“The expansion of Medicaid is a policy decision that should not be made as a matter of crisis management. The overall implications to future state budgeting would be severe," he said.

On Wednesday, Cover Alabama, a statewide alliance of organizations, announced its formation to push for Medicaid expansion.

“We know that Alabama appears high on the list of states for virtually every bad health measure, especially chronic conditions, and a large factor in that is the inequitable access to (healthcare) across our state,” said Jim Carnes, policy director for Alabama Arise, one of the groups involved in the alliance, on a press call.

He says long term financial recovery from coronavirus will require the state to look for new forms of revenue. A federal 9 to 1 match for healthcare growth is advantageous.

“As we look to digging our way out of a hole that none of us has ever seen before,” he said, “we’re going to have to maximize the value of every state dollar.”

For Rep. Coleman-Madison, (D-Pratt City), Alabama has done far too little to address the needs of its most vulnerable citizens, like seniors and low-income people.

“Sometimes it takes a real wake-up call. I think this is it,” she said of the possibility of Medicaid expansion.

She noted that in a pandemic, when some people lack healthcare, it puts others at greater risk.

“Everybody’s life is at stake right now. It is incumbent upon all of us to work together to do whatever we can to row the same boat and push it in one direction to try to make sure that Alabamians are protected,” said Coleman-Madison.

To Sen. Jones, federal aid to address the crisis may as well go toward a longer-term healthcare solution.

“Whether we do it on the front end with Medicaid expansion or on the back end, trying to provide states particular money (for coronavirus)…What we really want to do is to make sure that people get coverage and they can stay covered.”

This story has been updated to include comment from former Sen. Williams

Correction: This story has been changed to reflect Williams’ title and that he is a former senator.