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It's Time to Expand Medicaid for Rural Alabama

Updated: Apr 25, 2022

The health and wellbeing of the people of our state is my priority as a practicing physician, as it was when I was honored to serve as governor. Earlier this year at the start of the 2022 Legislative Session I reached out to Governor Ivey as well as Legislative leadership to share my concerns and offer insight into what I believe are solutions to the issues facing many of our fellow Alabamians, from the unique perspective of both a physician and a former elected official. The Healthcare needs of our state are growing and will continue to increase as underserved regions, particularly rural areas, continue to lack in basic healthcare services and have limited access to family doctors, local hospitals and even specialists.

Solving the challenge of limited access to doctors and hospitals for underserved Alabamians is not simple, but it’s also not impossible if state leaders are willing to look beyond politics to the needs of our rural communities. That is why I am urging Governor Ivey and the Legislature to expand Medicaid, and to accept additional federal funding to extend Medicaid health insurance coverage for more Alabamians living in rural and underserved areas.

Having come into office in 2011 on the heels of the passage of the Patient Protection and Affordable Care Act, our Administration was faced with the daunting task of implementing the mandates and requirements of the new health care law. 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. When given the choice by the US Supreme Court to implement or to refuse Medicaid Expansion under the ACA, we had no choice at that time but to refuse based on the dire lack of state funding we had 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. 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.

While the COVID Pandemic has stretched thin our resources and created new obstacles for our state leaders, it has also provided a once in a lifetime opportunity to truly improve the lives of all Alabamians. In addition to the increase in revenue impacting our state budgets, billions in additional funding have been provided to the states under the American Rescue Plan Act. Those funds simply must be used to fundamentally improve the lives of every Alabamian.

In her 2022 State of the State address, Governor Ivey addressed the Legislature regarding the use of the ARPA funds and told them those funds were not “free money”. I couldn’t agree more. The federal ARPA funds allocated to our state come at a very high cost. Nearly 20-thousand 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. I can think of no better way to honor the lives of those nearly 20-thousand Alabamians than fundamentally improving the quality and availability of basic healthcare for everyone in our state by expanding Medicaid health insurance for more uninsured Alabamians, for our rural doctors and for our rural hospitals.

The extension of Medicaid health insurance opens new doors to improving the quality of health care across our state, not just to those men, women and children who fall in the coverage gap. 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. 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.

I know these needs are great, and that is why I travel to these areas and practice medicine through free clinics made possible by a non-profit I established. Imagine the impact a rural hospital and additional doctors would have on a town like Rockford in Coosa County. There is no practicing full time physician in that entire county. We recently held a free clinic there where we detected numerous cancers and provided treatment options patients otherwise would never have access to. 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.

Throughout my terms as governor, we had no choice but to repeatedly turn to “one-time” solutions to fund even 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. 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.

There is no doubt Governor Ivey and Legislative leaders are very aware of the estimated 300,000 additional Alabamians who would be able to have health insurance coverage under Medicaid Expansion. We have all seen countless reports, studies and estimates forecasting the impact expansion would have on the state. 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. 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.

I understand well the position Governor Ivey and members of the Legislature find themselves in. Our state has many pressing needs, all of which must be addressed. But Healthcare simply must be prioritized when determining where to allocate funds. Expanding Medicaid is not a political decision to be made. It cannot be based on a poll or the direction of the political winds. The opportunity to fund expansion has been given to Governor Ivey and the Legislature and they now have the rare but gratifying opportunity to do good for the entire state.

They were able to do this once before in 2019, when potential political consequences were set aside for the passage of a gas tax increase. 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. 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.

As former governor and a former legislator, I know the opportunity state leaders have today is unique and something few in their position ever see. I urge our state leaders not to squander it in the name of politics. This is the greatest opportunity for lasting good for our state.

Robert Bentley, MD FAAD

53rd Governor of Alabama


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