Ken Hare In Depth: Could Medicaid decision cover Alabama immigrants, but not citizens?

MONTGOMERY, AL (WSFA) - If Alabama Gov. Robert Bentley and members of the Legislature do not take advantage of billions of federal dollars to expand health care to Alabamians, they could end up having to explain why they are denying the health services to U.S citizens living in Alabama but not to legal immigrants living in the state.

That's because under a provision of the new federal law, dubbed "Obamacare" by the president's political opponents, the expanded health  provisions for low-income and disabled people would be available to legal immigrants -- emphasis on "legal" -- living in Alabama regardless of whether the state chooses to participate in the program.

So if the governor and Legislature choose not to expand Medicaid, some legal immigrants would qualify for the health services but they would not be available to U.S citizens living in Alabama.

Ken Hare In Depth: Medicaid expansion would attract billions to the state

An Associated Press news story described that situation as "politically awkward" for Republican governors who have said they will oppose the expansion of Medicaid under Obamacare.

But "awkward" doesn't begin to describe the kind of heat that could cause for political leaders in states that choose not to participate in the expansion.

Several Republican governors have balked at the Medicaid expansion under what they term Obamacare, despite the fact that the federal government would bear the overwhelming brunt of the cost of the program.

The Associated Press reported that the "quirk" in the law came to light when Arizona Republican Gov. Jan Brewer, who had been an outspoken opponent of the president's health care plan, opted to support the Medicaid expansion.

Documents filed by Arizona officials recently pointed out the glitch in the new law.

"If Arizona does not expand, for poor Arizonans below (the federal poverty line), only legal immigrants, but not citizens, would be eligible for subsidies," the documents said.

"By rejecting the expansion, you are essentially rewarding the immigrant population at the expense of full citizen," said Matt Salo, executive director of the National Association of Medicaid Directors, in describing the documents to the Associated Press.

Unlike some other Republican governors, Bentley has not slammed the door completely on a Medicaid expansion here.

The governor's office has not yet responded to a request made today for comments on Medicaid expansion or on the legal immigrant issue. But as I noted in an earlier column on the issue, Bentley has said that he did not favor a Medicaid expansion "at this time."  And a spokesman for Bentley has said that the governor will not expand Medicaid "under its current structure."

The spokesman said the governor's first priority "is fixing the system we have, not expanding a broken system."

Bentley has named a Medicaid advisory commission to come up with ways to reform the state's Medicaid delivery system.

Alabama's state health officer, Dr. Donald E. Williamson, who chairs that advisory commission, told me that he hopes if reforms to make the Medicaid program more efficient are successful, the changes and new efficiencies would allow the state's political leaders to reconsider expansion. The Medicaid advisory panel headed by Williamson is expected to recommend sweeping changes to how Medicaid works in Alabama -- changes likely designed to shift it from a fee-for-services approach to more of a managed-care approach.

So there appears to be at least a possibility that Alabama eventually could participate in the expansion.

If Alabama chose to expand Medicaid under the federal Affordable Health Care Act starting in 2014, the federal government would assume almost the full cost of the expansion through 2016. The state would have to start assuming a larger share of the cost after that, but the state's share would top out at 10 percent starting in 2020.

The federal government would cover 100 percent of actual health care expenditures from 2014 through 2016, although Alabama would be responsible for a share of administrative costs amounting to about $39 million a year.

The total cost to the state through 2020 would be $771 million. Meanwhile, during that seven-year span, the federal government would pump an additional $11.7 billion into Alabama health care. Over the next 10 years, according to a report by the Kaiser Commission on Medicaid and the Uninsured, Alabama would spend about $1 billion for the expanded Medicaid coverage while getting about $14 billion in additional federal support.

But back to the quirk in the new law that would allow it for poor legal immigrants even in those states that choose not to participate.

According to the AP, that discrepancy occurred when the U.S. Supreme Court allowed states to opt out of the program while not addressing the section of the new law that expanded coverage for poorer immigrants in the country legally. (Both the Medicaid law and the new health care law deny such benefits to immigrants in the U.S. illegally.)

Alabama would not have as many legal immigrants who would qualify for the new benefits as such states as Arizona and Texas, for instance. But the discrepancy in coverage for legal immigrants and U.S. citizens could prove to be just as politically embarrassing here as it would in those states.

Many conservatives oppose Obamacare because they feel it is too costly and too intrusive. But now that the U.S. Supreme Court has ruled in its favor, it is not likely to go away.

Again, the bulk of the funding will come from the federal government. If Alabama's political leaders choose not to have the state participate in the program, they will create a situation in which Alabama taxpayers will have to pay for the expansion through their federal taxes even though their fellow Alabamians living near the poverty level won't qualify for it.

The Kaiser Commission study estimated the expansion would make 313,000 more Alabamians -- most of whom currently have no medical coverage -- eligible for Medicaid and the health benefits that would come with that coverage.

But if the state's political leaders opt not to allow Alabama to participate, the only people who live in Alabama who could benefit would be legal immigrants.

Now does that make sense?


Ken Hare was a longtime Alabama newspaper editorial writer and editorial page editor who now writes a regular column for WSFA's web site. Email him at

Copyright 2013 WSFA 12 News.  All rights reserved.