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Alabama health insurance

AL opposes ACA, but governor continues Medicaid expansion talk

If you live in Alabama, or you’re considering moving to the state, you should certainly be aware of the state’s perceived healthiness and its attitudes toward providing health coverage and healthcare.

To help you learn more, we’ve put together a brief guide to health and healthcare reform in Alabama.

Alabama health ratings

The Commonwealth Fund’s Scorecard on State Health System Performance, 2014, rated Alabama 44th among the 50 states and District of Columbia. The state placed in the bottom quartile for two of five indicators, including avoidable hospital use and healthy lives, and in the bottom half for the other three — access and affordability, prevention and treatment, and equity. The state’s rank fell two spots from 2009, the last time the scorecard was published. More details on Alabama’s score can be found here.

Similarly, Alabama came in 43rd, in the 2014 edition of America’s Health Rankings — an improvement from 47th in 2013. Improvements in smoking, binge drinking and infant mortality rates likely helped the state’s rank. However, the state fared poorly in several measures, including diabetes, infant mortality, cardiovascular deaths, premature death, poor mental and physical health days, and availability of dentists.

For yet another look at health indicators that might explain Alabama’s health rating, check out the 2015 listing of Key Health Data About Alabama compiled by Trust for America’s Health.

Alabama and Obamacare

In 2010, Alabama’s Congressional delegation opposed the health reform law. Sens. Jeff Sessions and Richard Shelby both voted no on the law while six Alabama representatives voted no in the House.

At the state level, Gov. Robert Bentley indicated early on that he would support a state-run health insurance exchange, but ultimately sided with the state legislature, which decided to cede exchange control to federal government. The state did not expand Medicaid in 2014.

How the ACA has helped Alabama

According to figures from The Henry J. Kaiser Family Foundation, an astounding 46 percent of Alabama’s 660,000 uninsured nonelderly residents were eligible for financial assistance under the ACA.

Gallup survey showed Alabama’s uninsured rate dropping 3.2 points following the ACA’s first open enrollment period. The state’s uninsured rate was 17.7 percent in 2013, and it fell to 14.5 percent by the end of 2014.

By mid-2015, the state’s uninsured rate fell 2.5 additional points to 12 percent. Nationwide, the uninsured rate was 11.7 percent. Among other states that only expanded Medicaid, only created a state/partnership exchange, or did neither, the uninsured rate was 13.4 percent.

Alabama enrollment in qualified health plans

The Kaiser Family Foundation in 2013 estimated Alabama’s potential market size to be 464,000 people and that 270,000 of them would qualify for tax credits to help lower their premiums. As of April 2014, there were 97,870 people enrolled in qualified health plans (QHPs) through Alabama’s health insurance exchange (i.e.,

That number increased significantly during 2015 open enrollment when 171,641 Alabamans selected QHPs from the exchange – more than half (54 percent) were new consumers. Within a few months of open enrollment, some of those enrollees had dropped their coverage or failed to make their first premium payments, as happens in every state. By June 30, 2015, effectuated enrollment was 141,361. Nearly 91 percent were in plans with advanced premium tax credits and 72.6 percent had silver plans with cost-sharing subsidies.

Three carriers have continued to offer health plans through Alabama’s exchange for 2016: Blue Cross Blue Shield, Humana and UnitedHealthcare.

Medicaid expansion and Alabama

Alabama’s opposition to the Affordable Care Act also meant that the state opted to not accept Obamacare’s Medicaid expansion. As a result, 27 percent of Alabama’s uninsured nonelderly population fall into the coverage gap, with no access to financial assistance with their health insurance.

Gov. Bentley, however, re-ignited a discussion of Medicaid expansion in late 2014. Bentley said he is interested in tapping into Medicaid expansion funding to expand health insurance coverage, perhaps through a block grant. Expansion opponents and proponents quickly weighed in. The conversation continued well into 2015, with Bentley negotiating with HHS Secretary Sylvia Mathews Burwell about the ACA and waivers sought by the state.

From 2013 to 2015, Alabama Medicaid enrollment has increased 10 percent under the state’s current eligibility criteria. During the 2015 open enrollment period, 10,408 people enrolled in Medicaid through the state’s federally facilitated exchange. Medicaid enrollment last year-round, however. As of August 2015, Alabama’s monthly Medicaid enrollment was 881,412.

See for a full overview of Alabama’s Medicaid and CHIP programs.

Other reform provisions in Alabama

The Affordable Care Act established a federal loan program to encourage the creation of nonprofit, consumer-run health insurance issuers – called Consumer Operated and Oriented Plans (CO-OPs).  By January of 2013, 24 CO-OPs had received loans totaling $1.98 billion. However, several of these CO-OPs struggled with low enrollment or faced financial difficulties in their infancy and 12 CO-OPS had announced their closure by 2015.

Alabama did not create a CO-OP.

Does Alabama have a high-risk pool?

Before the ACA reformed the individual health insurance market, coverage was underwritten in nearly every state, including Alabama.  Because pre-existing conditions were a factor in eligibility for coverage, some people were unable to purchase a private plan at all, or were only able to get one that excluded their pre-existing conditions.

The Alabama Health Insurance Plan (AHIP) was created in 1998 to give applicants an option for coverage if they were ineligible to purchase individual health insurance because of their medical history.  But unlike risk pools in many other states, AHIP was only available to applicants who were HIPAA eligible, coming off of a group plan with no more than a 63-day gap in coverage.

Under the ACA, all new health insurance policies became guaranteed issue starting on January 1, 2014. This change largely eliminated the need for high risk pools and MCHA stopped enrolling new members as of January 1, 2014.  In March 2014, the Alabama Senate passed SB 123, allowing AHIP to “cease operations upon allowing current participants enough time to transition out of the plan.”  But the plan website has not yet announced a termination date for existing members.

State-based health reform legislation

Here’s a summary of recent Alabama bills related to healthcare reform:

SB147 was signed into law and became Act Number 2015-227 in May 2015. This legislation ensures that insurance executive compensation in Alabama will be kept confidential. As such, it is not subject to open records requests, Freedom of Information Act (FOIA) requests, or subpoena.

Medicare enrollment in the state of Alabama

Alabama Medicare enrollment reached 960,848 in 2015, about 20 percent of the state’s population compared with 17 percent of the population enrolled in Medicare nationwide.

Historically, Alabama has had the second-highest percent of Medicare recipients listed as disabled, 27 percent, right behind Kentucky’s 28 percent. The other 73 percent of Alabama Medicare beneficiaries qualify based on age alone.

Medicare pays about $9,717 per Alabama enrollee each year and ranks 19th in overall spending with $8.04 billion annually.

Alabama Medicare recipients can opt to enroll in Medicare Advantage plans instead of original Medicare if they wish to gain additional benefits beyond what traditional Medicare coverage offers. Nearly 26 percent selected Medicare Advantage in 2015, compared with 32 percent nationwide.

Forty-seven percent of Alabama Medicare beneficiaries are enrolled in Medicare Part D plans, which provide stand-alone prescription drug coverage. This is slightly higher than the national average of 43 percent enrolled in stand-alone Rx plans.