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In perhaps his most direct comments to date, Gov. Robert Bentley said Thursday his administration is looking at expanding Medicaid, the health care program that serves one million Alabamians.
"We are looking at that (Medicaid expansion). We have not made a final decision on that yet, exactly on how that will work," said Bentley in response to a question from an audience of lawyers he addressed this morning in Montgomery.
The governors response Thursday was more than the hint he dropped last month when in response to a question of whether he was nudging toward expanding Medicaid under the federal Affordable Care Act (ACA) he said this:
"You know I wouldn't say nudging toward it," said Bentley. "But we are certainly looking at that; not right now. We are not at that stage right now."
Just before that comment the governor had told a group of seniors about the need to improve healthcare in rural areas and how Medicaid expansion might come into play.
"But you know we do have to realistically look at whether we have adequate funding for rural doctors, primary care doctors. They cannot treat a third of their patients and stay in business. It is a business they run," said the governor.
On Thursday the governor told the lawyers that improving health care in the state, especially in the state's rural areas, is one of his top priorities during the last three years in office.
Expanding Medicaid would pump several billion dollars in mostly federal money into what is Alabama's primary health care program for children and the poor and provide more dollars for primary care doctors to serve those patients.
But Bentley said Thursday that Medicaid expansion will cost Alabama in matching dollars that it does not have.
"If we were to accept that (Medicaid expansion and federal dollars) you have to realize it is going to cost the state of Alabama over the next six years $710 million in the General Fund," said Bentley who noted that he had just finished a bruising battle with the Legislature over raising taxes to better help fund the beleaguered General Fund.
"Now folks, I can't even get them to raise a hundred million dollars," the governor told the audience. "So we've got to look at a funding stream if we're going to do it."
Bentley has for five years been a critic of the ACA overall and also opposed to the expansion of Medicaid under it in Alabama saying the state's Medicaid program was so broken and inefficient that pumping additional dollars into without first reforming it would be unwise and ineffective.
Many believe, including Bentley, that the legal fight over the ACA ended this summer when the nation's highest court upheld the law.
Since becoming governor in early 2011 Bentley has pushed for reforms to Medicaid that he maintains will slow the growth in Medicaid costs and improve care. He has sought to primarily do that by changing Medicaid to a managed care system.
Under the ACA, the federal government pays states most of the cost of expanding Medicaid to cover people earning up to 133 percent of the federal poverty level - about $15,600 for individuals and just over $32,000 for a family of four.
About 1 million Alabamians currently receive some level of medical care and/or benefits from Medicaid. Expanding the program under the ACA is estimated to add somewhere between 160,000 to 300,000 more Alabamians to the program.
Bentley in the past has talked about the possibility of a block grant program where ACA dollars might be used provided those receiving benefits in the program held a job or are enrolled in job training. Largely a block grant would allow the state to use the dollars with fewer federal restrictions and the state could request proposals from private insurers to provide the expanded coverage.
All of that would require federal approval through waivers. At the time Bentley brought up the possibility of a block grant system no talks with federal officials had started in the process of seeing some waivers from the law.
That has changed. Bentley has been personally involved in negotiations with the Department of Health and Human Services Secretary Sylvia Mathews Burwell about the ACA and waivers the state is seeking from some requirements of the law.