Legislature holds effective veto over Medicaid expansion

May 25--For those pushing the state to opt into an expansion of Medicaid offered under the Affordable Care Act, it should seem obvious that Gov. Robert Bentley should be the focus.

Democrats have long called on Bentley to opt into the expansion, and dueling resolutions passed by Senate Republicans and Democrats in April -- respectively for and against the option -- were addressed to the governor.

Bentley reiterated Tuesday that he was not looking to enter into an expansion of Medicaid, though he has suggested in the past that he might look into it under certain conditions.

But health policy experts and the state official in charge of a transition of Medicaid's payment method say Bentley -- or any governor -- does not have the final say. Should Bentley ever change his mind on expanding Medicaid, he couldn't do it without the Legislature getting on board.

For example, if the governor decided to pursue a straight up expansion of the program -- just changing the eligibility requirements -- the Legislature would have to approve added money to do administrative implementation, said Dr. Don Williamson, the state's Public Health Officer and overseer of a transition into a capitation model for Medicaid payments.

If the state managed to get the feds to approve an Alabama-specific plan for Medicaid expansion -- which is not on the table -- Williamson said the changes would still need approval from the Legislative Review Committee and, likely, appropriations to implement it.

"The governor needs at the very least the Legislature to allow the necessary rule changes and to appropriate the funds necessary for the implementation," he said.

That is a point Senate Minority Leader Quinton Ross, D-Montgomery, who sponsored the Democratic Medicaid resolution in the Senate, concedes. However, Ross said the governor has to take the initiative in the process.

"Everybody would have to come on board to get it done," he said. "That's no different than any other challenge we have."

Alabama has one of the most restrictive Medicaid programs in the nation. Childless adults almost never qualify for it, and adults with children who are Medicaid eligible must make no more than 18 percent of the poverty line -- about $4,368 a year for a family of four -- to qualify for benefits. Despite that, Medicaid covers 1 million Alabamians, and pays for about half the births in the state.

The expansion would allow those making up to 138 percent of the poverty line -- $16,243 a year for individuals; $33,465 for a family of four -- to receive Medicaid benefits. About 176,000 Alabamians currently fall into an "eligibility gap" where they make too much to qualify for Medicaid, but too little to qualify for health insurance subsidies offered in the federal exchange.

The Legislature's cooperation for any Medicaid expansion becomes even more crucial in the future. The federal government agreed under the law to pay for 100 percent of the state's expansion of Medicaid through 2016; after that year, the state's share of the cost gradually increases, though the ACA requires the federal government to pay at least 90 percent of the cost of the expansion.

"As you move beyond 2016, then you need even more legislative engagement," Williamson said.

Each state does Medicaid differently. State Medicaid plans operate under an agreement with the federal Centers for Medicare and Medicaid Services (CMS) which administer the plans. According to the Kaiser Family Foundation, a nonprofit that studies the health sector, most states require at least some degree of legislative involvement in any approach to expanding Medicaid.

The governors of Kentucky and West Virginia were able to opt in at their own discretion, but they were the exceptions to rule: Other states that pursued expansion either got the Legislature to approve the measure, or included it in budgets that required legislative approval.

"There have been some Legislatures that have taken action, specifically, Virginia and North Carolina where the Legislature has acted and pre-empted the governor's ability to expand without the Legislature's approval," said Robin Rudowitz, assistant director for Kaiser's Commission on Medicaid and the Uninsured. "Aside from the expansion, different states have different rules on Medicaid that predated expansion."

To date, the Alabama Legislature has not taken specific action to pre-empt expansion, but the mood of majority Republicans toward the idea has rarely risen above hostility. Sen. Trip Pittman, R-Montrose, who sponsored the Republican resolution urging no expansion of Medicaid, said he believed the Legislature would be a "check" on any expansion. But Pittman said his resolution was mainly aimed at expressing support for the governor's moves to rework the delivery of Medicaid.

"Before we expand a program, we need to make sure what we're doing is working," he said. "Because those costs go on for decades."

Williamson said the agency has reviewed how other states have implemented Medicaid expansion, to see how the "jigsaw pieces" fit in the equation. However, he added that with so much in the air about the Affordable Care Act, including a pending Supreme Court decision on the constitutionality of subsidies offered under the law, the conversations haven't reached the planning stage.

"In terms of ideas, we have ideas, based on what other states have done, but no one's put pen to paper," he said. "There's not even a pen."

Alabama Medicaid Numbers

Alabama has one of the most restrictive Medicaid programs in the nation. Childless adults almost never qualify for it, and adults with children who are Medicaid eligible must make no more than 18 percent of the poverty line to qualify for benefits.

1 m

Alabamians covered by Medicaid (pays for about half the births in the state)

$16,243

Total that individuals must make a year to receive expansion benefits

$33,465

Total a family of four must make a year to receive expansion benefits

176,000

Number of Alabamians who currently fall into an "eligibility gap" where they make too much to qualify for Medicaid, but too little to qualify for health insurance subsidies offered in the federal exchange

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