Robert Bentley suggests he could accept Medicaid expansion

Brian Lyman | Montgomery Advertiser

Gov. Robert Bentley suggested Thursday that he could support an expansion of the state's Medicaid program in the form of a block grant with employment requirements.

In remarks before lawmakers wrapping up three days of legislative orientation, Bentley — who for years has expressed staunch opposition to expansion — said he would not expand the system until proposed reforms of the state system go into effect. However, he added he would be open to discussing a block grant program, similar to an expansion that took place in Arkansas this year.

"It would have to be in the private sector and there would have to be some requirements on it," Bentley said after his presentation.

Advocates for the expansion of Medicaid in Alabama reacted cautiously Thursday to Bentley's comments, saying it was a good start but not the final word.

"We think it's a fairly creative approach," said Jim Carnes, a spokesman with Alabama Arise, which works on poverty issues in the state. "Of course, we would rather not siphon off a chunk of the money to go to accompany profits. We would support using the federal money fully for covering patients."

The Affordable Care Act as initially passed would have required the states to make Medicaid eligible to anyone making up to 138 percent of the federal poverty line — about $16,104 a year for an individual, and $32,913 for a family of four. The federal government would cover the entire cost of the expansion through 2016, and a decreasing amount afterward, though never less than 90 percent.

Alabama has one of the most restrictive Medicaid systems in the country. Childless adults do not qualify, and those with children must earn income far below the poverty level to access the program. The Kaiser Family Foundation, a nonprofit that tracks health issues, estimates that 191,000 Alabamians would be eligible for an expansion of Medicaid.

In 2012 the U.S. Supreme Court ruled that the states could not be forced to enter into the Medicaid expansion, and Bentley has stated his opposition to both the ACA and the idea of Medicaid expansion, frequently stating he could not expand the system as currently constituted. In his State of the State address in January, Bentley said the programs were "taking our nation deeper into the abyss of debt."

"That is why I cannot expand Medicaid in Alabama," he said. "We will not bring hundreds of thousands into a system that is broken and buckling."

Bentley reiterated that he did not want to expand the current system Thursday, and said that no current discussions were ongoing. However, he added that he had "never been opposed to a block grant system," in which Alabama would get the money used for Medicaid expansion and decide how to use it.

Arkansas' system, approved by the federal government in 2013, takes the money that would be used for Medicaid and uses it to help those who would qualify pay for health care plans through an exchange. Other states, such as Indiana and Pennsylvania, are pursuing similar programs. Bentley said after the speech that he envisioned something close to that system, but one tied to employment.

"They need to be working on getting a job, or having a job," he said.

Carnes said most Medicaid recipients are doing that.

"The fact of the matter is that most of the people in the eligibility category for expansion in Alabama are workers," he said. "The majority are already working. They're just working in low-wage jobs."

The governor said the grant they seek would be strictly to carry out Medicaid expansion to 138 percent of the poverty level.

Democrats at the meeting pushed Bentley on Medicaid expansion. Rep. Barbara Boyd, D-Anniston, whose question drew out Bentley's block grant support, said she was "surprised at his answer" and said she hoped it would be pursued.

Bentley's announcement came after a grim budget presentation from lawmakers about the state of Alabama's two budgets. Lawmakers said they expect to see marginal growth of $53.7 million in the state's $5.9 billion education budget in 2016; however, legislators will have to contend with a budget hole in the General Fund — which pays for most non-education programs — of between $250 million and $283 million. One-time money used to shore up the General Fund will vanish after the current fiscal year; the costs of programs such as Medicaid and Corrections continue to rise, and lawmakers have generally been opposed to creating new revenues to balance the budgets.

Most of the state's income and sales taxes — growth revenues that usually show gains each year — go into the Education Trust Fund budget. The General Fund's three dozen revenue sources generally post flat growth. Bentley told lawmakers that his General Fund budget would include growth revenues that would "not hurt education," though he declined to specify what those might be.

The governor also joked that new lawmakers had already experienced the best of their new position.

"The high point of being a legislator is when you're sworn in," said Bentley, who represented Tuscaloosa in the Alabama House of Representatives from 2002 to 2010. "It's all downhill from there."

Updated at 1:49 p.m. Friday to correct that Medicaid expansion will be fully paid for by the federal government through 2016, not 2017.