When Elisa A. gets sick, she doesn’t immediately go to the doctor.
“I take a lot of vitamins. I eat a lot of onions,” says the Tarrant resident. “I pray a lot.”
She adds, “We’re still in touch with my great-grandmother’s American Indian [medicinal] recipes.”
Elisa goes to such lengths because she remains uninsured despite the Affordable Care Act. She is one of an estimated 300,000 Alabamians who make too little to qualify for subsidies under so-called Obamacare but earn too much for Medicaid in Alabama. She also is one of a growing number of people and organizations who are pressing Gov. Robert Bentley to expand Medicaid.
In a nutshell, ACA was designed to provide Medicaid for people whose income is below 138 percent of the federal poverty level and subsidies for insurance coverage for many whose income is higher. Federal money is available to states to cover the cost of expanding Medicaid, but a U.S. Supreme Court ruling allowed states to not expand. Bentley has chosen not to expand the program.
Medicaid expansion proponents cite statistics from two studies done by the University of Alabama at Birmingham in 2012 and the University of Alabama this year. Both studies conclude that Alabama would see tremendous economic gains if Medicaid was expanded.
The UA study, which expounds on the UAB study, concludes that 308,000 people would be added to the Medicaid rolls. The study says more than 30,000 jobs would be created because of the need for new healthcare workers and the overall economic impact of the expansion. Those jobs would have earnings of $1.26 billion and create overall business activity of $3.5 billion.
The UA study concludes that the total cost to the state between 2014 and 2020 would be $772 million.
A separate study by the Manuel H. Johnson Center for Political Economy at Troy University in 2013 had a different conclusion. That study states that “the cost of expanding Medicaid will outpace the benefits.”
Organized support for Medicaid expansion appears to be growing. Save OurSelves: A Movement for Justice and Democracy, made up of about 40 faith-based groups, held a rally at the Alabama State Capitol May 31. According to published reports, organizers presented signatures of more than 10,000 Alabamians who do not qualify for Medicaid because it has not been expanded.
A substitute teacher for the Tarrant City Schools, Elisa is frustrated by Bentley’s decision not to provide coverage for her and others like her. “Governor Bentley, it’s a Hippocratic oath, not a hypocrite’s oath,” she says, referring to the oath Bentley had to take as a physician.
Elisa, a divorced mother with two children still at home, would have to earn $19,600 a year to qualify for a subsidy. She makes about $1,200 a month during the school year but doesn’t get paid during the summer, putting her far below the limit. Her children receive Medicaid because of different rules for children under 19.
At 42, Elisa would like to work on a teaching degree so she could become a teacher and qualify for benefits, but she says she has been unable to because she has to support her children.
Adriane McIver, a Montgomery resident, understands Elisa’s predicament. McIver, 56, had a career as an administrator at a water authority and a university before health problems led to her going on federal disability in October 2012. That meant her employer-provided health insurance ended.
“You have a two-year waiting period [after getting disability] until you can get Medicare. Because he [Bentley] didn’t expand Medicaid, I have no insurance,” McIver says. She will qualify for Medicare in October.
McIver is a patient at Medical Outreach Ministries in Montgomery, where a doctor sees her about every 60 days. But she needs to see specialists, who often don’t see patients who are uninsured. “I have so many things that I need checked or assessed that it’s ridiculous. … If I need immediate care, I do have to go to the emergency room,” she says.
“It’s been almost demoralizing. … You feel like you’ve done something wrong. I’ve worked all my life and I expected that something would be there when I needed help.”
Drivers on the Red Mountain Expressway have been seeing billboards advocating Medicaid expansion since last week. Two electronic billboards – which display the message for 10 seconds every minute – were placed there by Engage Alabama, an organization started by Dough Hoffman and his wife, Pat Vandermeer.
Hoffman, who retired as finance director of Children’s of Alabama, served as a navigator helping people sign up for the Affordable Care Act. “I was the first certified navigator in the state. I enrolled hundreds of people and I heard story after story after story,” he says. “I had to turn down about half of the people I met with because they didn’t meet the income qualifications.”
Hoffman says he and his wife decided to start Engage Alabama “to engage the citizens of Alabama in civic issues we feel are important. Our first issue – and we are going to stick with this issue as long as it takes – is expanding Medicaid.”
About 15 percent of Alabama adults would benefit from Medicaid expansion, he says, but he doesn’t think the general public is aware of the issues involved. “Our overarching goal is to get a billboard campaign going from Huntsville in every city down to Mobile…to raise the public’s awareness of this issue,” he says.
Engage Alabama is currently raising money to pay for billboards across the state. Hoffman says the organization will use all the money that is raised to pay for billboards and also will provide the first $100 for any billboard sponsored by other like-minded groups. On average, a billboard costs about $1,000, he says.
Hoffman believes even those who have insurance have reasons to support Medicaid expansion. “Everyone’s premiums in the state are higher because of uncompensated care. Everyone who has to go to a hospital ER and can’t pay, that cost is shifted to higher [insurance] premiums. Expanding Medicaid would actually reduce our private premiums,” he says.
“In order to fund all this Medicaid expansion, the federal government is collecting our tax dollars,” Hoffman adds. “If we choose not to use those tax dollars, that money will be spent in other states. We are passing up $1.7 billion every year we don’t do it and we will never get it back. … That’s just bad government.”
A coalition of organizations called Alabama’s BEST (Better Economy Starts Today) is working to get Bentley to change his mind. Alabama Arise, which focuses on issues affecting the poor, is one of those organizations.
“First and foremost, people are suffering because they could have gotten health coverage as of Jan. 1, but the governor has denied them that protection. … We have estimates that vary but 300,000 is a good number,” says Jim Carnes of Alabama Arise. “The majority of them would be hardworking people.”
Carnes says the majority of those who have fallen in the gap make minimum wage. “Think of all the people who we see every day who make minimum wage. … We don’t stop and think about their health coverage.”
The Alabama Hospital Association is a participant in Alabama’s BEST. Rosemary Blackmon, the association’s chief operating officer, says the AHA did a survey of state hospitals in December.
“Forty-one are operating in the red. Already, you have hospitals that are struggling financially,” she says. The problems will get worse because the federal government already has cut reimbursement to hospitals for Medicare patients and will cut that for Medicaid patients in 2015, she says.
If Alabama expanded Medicaid, the hospitals could make up revenue by having more patients who were covered by the program, she says. Without the expansion, the uninsured go to hospital emergency rooms. “The hospital ends up absorbing the cost,” she says.
“In some of the rural areas of the state…up to 70 percent of patients are Medicare and Medicaid.”
Supporters of Medicaid expansion warn that some hospitals, especially those in rural areas, might not survive their revenue shortfalls. Blackmon agrees that is possible, saying, “It is safe to say there are hospitals that are struggling. … They would do anything they could to keep from closing. At some point, there is no more room to cut without sacrificing care.”
Greater Birmingham Ministries, which provides aid for low-income people, is also part of Alabama’s BEST.
“Our board voted to join Alabama’s BEST the last Thursday in May. We are just getting actively involved,” says Scott Douglas, GBM’s executive director. “We do know that there are a number of our clients who would benefit” from Medicaid expansion.
He says Medicaid not being expanded “is doubly painful in Jefferson County with the mess that is around Cooper Green. Medicaid expansion would go a long way to ease the burden for the indigent in Jefferson County.”
Bentley’s office was asked for comments from the governor about the Medicaid expansion issue. In an email to Weld, Jennifer Ardis, the governor’s communications director, wrote, “The governor’s focus now is reforming the current Medicaid system and not expanding the broken system.” She provided links for news releases and other items about Medicaid reform.
Bentley focused on Medicaid in his 2014 State of the State address. He said the Affordable Care Act and Medicaid expansion were taking the nation deeper into “the abyss of debt.” He said expansion is essential to Obamacare and that Medicaid accounts for 35 percent of the state’s general fund.
“Under Obamacare, Medicaid would grow even larger – bringing millions more people to a state of dependency on government, and saddling our state and our nation – the taxpayers – with the enormous expense.
“Here in Alabama alone, an estimated 300,000 more people would be added to the Medicaid roll, to a system that by our own admission is absolutely broken and flawed.”
He continued, “The federal government has said they will give us money to expand. But how can we believe the federal government will keep its word? The anything but Affordable Care Act has done nothing to gain our trust.”
Bentley said “nothing is free. The money the federal government is spending with wild abandon is not federal dollars – those are your dollars, your hard-earned tax dollars. There is no difference between federal money and your money.
“Our great nation is $17.2 trillion dollars in debt and it increases by $2 billion every single day. That is why I cannot expand Medicaid in Alabama. We will not bring hundreds of thousands into a system that is broken and buckling.”
The hospital association’s Blackmon hopes Bentley now will reconsider. “We feel like we are doing our part. We are certainly working with the leadership…to reform the system and coordinate care,” she says. “Hopefully he will change his mind.”
She adds, “Everybody is working to move ahead with the reform. … The Medicaid expansion would significantly help. I think we would have a system that would care for those individuals.”
Supporters of Medicaid expansion question whether the issue will become a political one in coming months. Democratic gubernatorial candidate Parker Griffith, who is also a physician, favors expansion. Supporters also say a poll earlier this year showed that two-thirds of Alabamians are in favor of expansion.
“The governor has to make a difficult choice between saving lives and saving face. … I think everyone agrees it was a political decision,” Greater Birmingham Ministries’ Douglas says. “I just hope he’ll do the right thing and save lives.”