The road to Alabama Medicaid expansion might run through an insurer’s pockets

April 3, 2023 6:59 am
The chamber of the Alabama House of Representatives includes tightly-packed desks arranged in semi-circles; two columns running from the floor to the ceiling; a dais for the speaker and staff, and an electronic board for vote tallies.

The Alabama House of Representatives in session on March 14, 2023. (Stew Milne for Alabama Reflector)

Alabama doesn’t have a popular referendum system, where voters can bypass the Legislature and put measures on the ballot themselves. But I can think of a few proposals that would be near-locks for passage.

A lottery? Lots of people want that. I’m not sold on the merits, but the fact is that Alabama is the last state east of the Mississippi River without a lottery. Alabamians travel to other states to buy Powerball and Mega Millions tickets. Give voters a chance to cut the trip down to a block or two, and they’ll take it.

Repealing the state grocery tax? Do you know anyone who likes paying an extra 9% or 10% for food? (I don’t.) I’ve never understood why politicians don’t put the issue front and center in their campaigns and find another way to fund education. Other states manage.

Medicaid expansion? Well, there’s a 2022 survey done by Cygnal, a Republican polling firm, that found 66% of Alabamians supported it. Approval jumped to 71% after the pollster described the program’s potential to create jobs — more jobs than an overbudget prison or an underfunded water park.    


Expansion would also allow 300,000 people, most in households making under $34,307 a year (138% of the poverty level for a family of three) to get health care.  

Access to medical care means better health outcomes, stable hospitals and less government spending. When people have insurance, they can see a doctor regularly, preventing costly emergency room visits that taxpayers cover. 

Put all of that in front of Alabama voters, and it will pass.

But that’s not how Alabama operates.

Our Constitution, after all, gave all the power to a tiny white aristocracy that terrorized Black Alabamians and exploited poor white people in the state. It doesn’t quite work that way now. But Alabama still operates on the principle that government is too important to be entrusted to the governed.

The state Constitution centralizes power in Montgomery. It gives enormous weight to powerful interests. It allows the Legislature to override laws approved by democratically elected bodies. And thanks to a 1984 amendment that tried to make the budgets the first order of business, nearly every bill needs the effective approval of 60% of lawmakers — not a simple majority — to pass. (This is a big reason why we don’t have a state lottery.)

Like any other proposal, Medicaid expansion must navigate this system designed to foil human mercy. But in recent weeks, the prospects of expansion have gone from flickering to dim, thanks to Blue Cross Blue Shield of Alabama, the state’s largest insurer.

The Arkansas model

Ted Hosp, BCBS’ chief lobbyist, appeared with Danne Howard, the deputy director of the Alabama Hospital Association, before the state’s House Health Committee on March 22. The meeting was billed as “educational,” meant to discuss people in the insurance gap — those who make too much to qualify for traditional Medicaid, and too little to get subsidized Affordable Care Act plans.

The insurer’s appearance with the hospital association was significant. Rural hospitals are in dire straits, and Medicaid expansion would throw them a lifeline. The Alabama Hospital Association has done everything short of grabbing legislators by their lapels and throwing them into the wall to get that message across.

Hosp was carefully noncommittal about BCBS’ approach and said the insurer was “looking into” the coverage gap created by Alabama’s indifference. Medicaid expansion could impact the private market, he added. When Rep. Laura Hall, D-Huntsville, tried to get specifics on these broad statements, Rep. Paul Lee, R-Dothan, the chair of the committee, said that anything at this point would be “speculation.”

But earlier in the meeting, Howard mentioned the Arkansas model of Medicaid expansion. The thumbnail of that: When a state expands Medicaid, the federal government picks up about 90% of the costs.  Most states just add the new Medicaid recipients to their rolls. But when Arkansas expanded Medicaid in 2014, the state got approval to use expansion money to buy private insurance for the new folks. 

It’s not efficient. States like New Hampshire and Iowa that tried something similar eventually returned to the traditional route. But it’s better than Alabama’s I-got-mine approach to health care. And the appeal to an insurer like Blue Cross Blue Shield is obvious: The company suddenly sells a few hundred thousand policies.

Republican legislators, of course, fear anything that whispers Obamacare or requires a bold step into 2013. They could call Medicaid expansion the Majestic Eagle of Jesus Freedom Plan. Or the Alabama Is Certainly Not Dependent On The Federal Government Act.

BCBS isn’t revealing what decision-makers there are thinking. But the Arkansas model might be the only way to get Medicaid expansion through a Republican-controlled Legislature. And GOP leaders have stopped shaking their fists at the idea. Asked recently about Medicaid expansion, House Speaker Nathaniel Ledbetter, R-Rainsville, said we need “an Alabama solution for Alabama problems when it comes to health care.”  

If the Big Mule that’s BCBS starts pushing, things could get interesting. Republican legislators, of course, fear anything that whispers Obamacare or requires a bold step into 2013. They could call Medicaid expansion the Majestic Eagle of Jesus Freedom Plan. Or the Alabama Is Certainly Not Dependent On The Federal Government Act. 

It would be petty to complain about the methods if the result means better living for hundreds of thousands of people. Squish Huntsville, Montgomery and Birmingham together, and you still wouldn’t match the number of Alabamians living in poverty. That’s a huge barrier to physical well-being. Medicaid access will lower that barrier.  And it will be a start in improving our dreadful record on cancer, heart disease, stroke and infant mortality.

So if buying private insurance is how we get Medicaid expansion, fine. Health care providers, activists and patients have fought far too long. The need is there. The popular will is there. The benefits are obvious.

But we won’t get expansion because the people want it. We’ll get it because the oligarchs gave us permission. And they’ll do it as soon as they can benefit — not because their constituents are dying.

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Brian Lyman
Brian Lyman

Brian Lyman is the editor of Alabama Reflector. He has covered Alabama politics since 2006, and worked at the Montgomery Advertiser, the Press-Register and The Anniston Star. His work has won awards from the Associated Press Managing Editors, the Alabama Press Association and Robert F. Kennedy Center for Human Rights. He lives in Auburn with his wife, Julie, and their three children.