Robert Bentley interview, Part 2: Budgets and fighting the Affordable Care Act

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Gov. Robert Bentley discusses his first two years in office on February 21, 2013. (Montgomery Advertiser, Mickey Welsh)

Gov. Robert Bentley sat down with the Montgomery Advertiser Thursday for a wide-ranging interview about his first two years in office and the issues facing the state.  We’ll be running excerpts from the interview over the next few days, along with video shot by Montgomery Advertiser photographer Mickey Welsh.  (Transcripts will be edited for clarity.)  Bentley and other lawmakers weighed in on the governor’s performance in a piece published Sunday.

In the first installment, Bentley talked about the state’s employment situation, state government jobs and the ongoing gambling fight.   In this excerpt, Bentley talks about trying to manage the costs of Medicaid and Corrections, and why he thinks the state should put up “roadblocks” to the implementation of the Patient Protection and Affordable Care Act.

One of the major drains on the budget is the situation in Corrections.  Your budget calls for the hiring of 100 additional correctional officers.  What other steps does the state need to take to deal with prison overcrowding?  Do we need to see more sentencing reform?

We do.

What kind of sentencing reform?

I believe we need to look more realistically at some of our drug-related incarcerations.  I believe we need to have more rehabilitation, working with (the Department of) Mental Health, working with agencies to help rehabilitate those that are on drugs.  We need to truly try to help people get off drugs.  Drugs and alcohol cause most of our crime in the state anyway.  I think we do need some sentencing reform related to that.  The drug courts across the state, we have certainly tried to do that, and that has helped in areas.  We can’t put in jail everyone who’s addicted to drugs.  We really need to work on that situation.

Do you think sentencing reform is something that’s realistic?  It’s not on anyone’s Legislative radar this year.  Is it something realistic for 2014, 2015?

It’s not a popular subject.  Everyone wants to be tough on crime.  But people who are addicted to drugs – it’s really a disease.  We don’t incarcerate people who have diseases.  I’m not saying if they commit crimes, they shouldn’t be punished for those crimes.  I’m not saying that.  We do need to try to get people rehabilitated and try to get them off of drugs.  I know we can’t do that for everyone.  But we can try for everyone.

State Public Health Officer Don Williamson is leading efforts to make changes to the Alabama Medicaid Agency.

Let’s go to other major drain on the General Fund, which is Medicaid.  You’ve described Medicaid as a broken system.  Describe what needs to be fixed.

This year, we are the third-lowest state in the country as far as expenditures on Medicaid, as far as our match from the General Fund.  With this year’s budget of $615 million, we probably will be the lowest.  It’s hard to fix a system where you have so little money with which to fix it.  Now, I’m not advocating we spend more than $615 million.  I am advocating we do what Dr. (Don) Williamson and Stephanie Azar and the people I have in the Medicaid Agency are doing right now: Have actuarial looking at the situation there, having a good CFO in place, having a good accounting system, look at how we actually fund the matches.

We’re going from (certified public expenditures) to intergovernmental transfers – all this is very complicated.  For the first time ever, we’re getting a handle on how Medicaid is working in the state.  In the past, we’ve poured stimulus dollars in there to cover everything up.  And no one really understood how this system worked.  For the first time ever, we’re beginning to understand with the people we have in place now how the system actually works.

What we want to do is take the advice – and I believe the Medicaid Advisory Council will give me some good advice on looking at setting up regional managed care systems around the state.  I know some people are pushing for commercial managed care.  But there’s not a whole lot of money available for commercial managed care companies to make money.  And they have to make money, or they’ll be out of business.  So most of what we will do, if not all of what we will do, will be a regional managed care with local areas.

We’ve got to have strict guidelines.  You can’t compare apples to oranges.  You’ve got to draw the map in such a way that is as equal as possible when we look at this.  It is a very complicated issue.

I guess what I’m interested in learning is: What do you think are the major problems with Medicaid?  Is it access?  Is it the cost of the program?  Is it the quality of services?

One of our problems is lack of flexibility.  The federal government will not give us any ability to change our maintenance of care methods.  They will not give the flexibility to change co-pays, or do some of the things we would like to do.  This is not on Medicaid, but on CHIP (Children’s Health Insurance Program):  We wanted to go from 300 percent above poverty (for eligibility) to 100 percent of poverty.  They wouldn’t give us that waiver.  And that would have saved us a lot of money in this state.  They won’t give us the flexibility necessary to get this situation working correctly.  But we’re continuing to work on it.  We meet with them on a regular basis.  Just this last week, our representatives were up in Washington, meeting with Medicaid, and presenting our plan to do these regional managed care type programs.

You mentioned seeking this CHIP waiver, seeking to go from 300 percent of the poverty line to 100 percent of the poverty line.  Wouldn’t that effect be to reduce the number of people who are eligible?

It would.  But you know, if you’re 300 percent above poverty line for a family of four, I believe that’s somewhere around $60,000 a year.  (According to federal poverty guidelines for 2013, 300 percent of the poverty line for a family of four is $70,650 per year; the poverty line for that same family – i.e., 100 percent of the line — would be $23,550 – ed.)   I could be wrong; you’ll have to figure that out.  But that’s pretty high.  That’s a good salary.

You might have seen that your colleague in Florida, Gov. Rick Scott, said he was going to opt into the Medicaid expansion.  The reason he gave was he felt that Floridians who were paying for the Affordable Care Act should enjoy some of the benefits of the services that go along with it.  I’m wondering if Gov. Scott’s announcement has affected your thoughts at all about the Medicaid expansion in Alabama.

No, I’m not surprised.  And I’m not surprised at those who have opted into the Medicaid expansion.  I have met with all of those governors.  I know which ones of those were on the fence in the beginning and had not totally made up their mind on what they were going to do.  They have to make the decisions for their own state.

But I do believe we as much as possible need to stand together to deal with the creation of state-based exchanges; 30 governors have said they’re not going to do that.  And we need to stand together on  Medicaid as long as we possibly can, because those two things are necessary in order to implement the Patient Protection and Affordable Care Act.   My goal is to make some changes in that law.

You have been very critical of the Affordable Care Act.  According to the Kaiser Family Foundation, about 677,000 Alabamians go without health insurance each year.  If the Affordable Care Act isn’t the answer, how would you go about getting those nearly 700,000 residents health insurance?

I’m not too sure we will always get them health insurance.  However, I love health savings accounts.  If we’re going to put federal dollars into something, let’s create a health savings account for everybody.  If you’re going to put hundreds of millions or trillions of dollars, for indigent families, let’s create health savings accounts for those children or for those families so it’s their money, and they can make decisions where that money is spent.  You can put free enterprise and consumerism back into health care, and that’s what we need to be doing.  I think health savings accounts are a way to do it, and we could do it with federal dollars.  If we’re going to pay for them anyway, it would be a much better system, because it would put them in control of the dollars.  And if they don’t spend those dollars, you’re actually creating for them a 401K type entity that they could pass on to heirs in later years if they don’t use it.  Let’s just start it at the beginning for these children.  If we’re going to create Medicaid, let’s create health savings accounts for these children.

Other things we can do, even on the state level for indigent patients.  For doctors who see indigent patients, we need to give them tax credits off their state income tax.  If a doctor is willing to see indigent patients for nothing, I don’t care if they don’t pay any state income tax.  That’s not a lot of money, but doctors are not going to turn them away.  I never turned anyone away because they didn’t have money.

 

Gov. Robert Bentley on February 21, 2013. (Montgomery Advertiser, Mickey Welsh)

Could you extend a tax credit to doctors who already see Medicaid patients and get a substantially lower reimbursement for their work?

Absolutely.  And I have been for that.  We talked about some legislation to actually do that.  I don’t know if we have it ready or not, but that was one of the things we talked about at the beginning of the year.  We’re having to cut the reimbursement rate on many of our providers because of our low Medicaid payments.  And we’re actually having – we’ve even talked about a five percent cut on our providers.  I think we need to reward those who take Medicaid.  And not just one Medicaid patient.  You have to take enough that it’s significant.  If you’re willing to take whoever walks through the door, whether it’s Medicaid or Medicare, or private pay or no pay, whatever it is, I think you ought to reward doctors who are willing to do that.

In 2011, your commission that studied the health insurance exchange released a report recommending the state set up its own exchange.  At the time, your office released a statement that quoted you as saying “An Alabama health insurance exchange specifically tailored to the needs of Alabamians should ensure that our citizens have numerous options when shopping for health insurance coverage.”  A year later, you announced you would not have the state set one up.  What changed?

First, what I advocated for as I ran for governor was a free marketplace, that could be set up where people would have the opportunity to purchase insurance.  And hopefully, the competition with the companies being involved, then they could get (insurance) at a lower cost.  And they would understand what they were buying.  (It) was very much modeled after the Utah model.  So I was very much for that.

What changed was this.  When the Patient Protection and Affordable Care Act was passed, there was no mention of anything other than state-based exchanges.  I saw an opportunity as a governor to put up roadblocks against a piece of legislation that I was very much against.  If state-based exchanges are not set up, and that’s why 30 governors have said that they’re not going to do that, I’m not sure the federal government can by law set up a federally-facilitated exchange.  The reason I don’t believe they can is because the Supreme Court, in their ruling, they used Prince v. United States in their ruling against the individual mandate.  Prince v. United States says a state cannot be forced to set up a regulatory agency within the state that has to carry out federal rules and regulations.  I don’t believe they can do it.  I don’t believe they can force the states to do it.  They’re trying to do it through regulations related to the IRS right now.  But I’m just not sure they can do it.  And I think constitutionally, that is a way we can fight this particular piece of legislation.

You talk about trying to block this federal law.  Somebody reading a transcript of this might think you’re talking about trying to nullify this federal law. 

I would like to nullify this law.

But that’s not constitutional. 

I don’t know if it’s constitutional or not.  I don’t know that they can implement it.  If they can’t implement it, they’re going to have to go back to the drawing board.  And that’s what we’re trying to do.  We’re trying to keep from the implementation of this bill.  And I think the states are the last great hope for this.  And I think governors are the last great hope for this.

Tomorrow:  Bentley discusses getting his relationship “right” with the Legislature, what he liked and didn’t like in the state’s immigration law, and his thinking about running for re-election.

– posted by Sebastian Kitchen and Brian Lyman

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