But by then, the Tomblin administration had already begun crunching the numbers surrounding the expansion question. The state Insurance Commission had hired CCRC Actuaries over the summer as it faced a series of complicated provisions and looming deadlines arising from the federal overhaul. The administration enlisted CCRC to study what West Virginia should expect — both for Medicaid and the state's health coverage landscape generally —if it expanded the program or rejected that call.
Aiding that financial analysis was Jonathan Gruber, an economist at the Massachusetts Institute of Technology. Gruber advised officials in that state when it adopted its health coverage mandate under then-Gov. Mitt Romney. Gruber also consulted the Obama administration as it developed the federal overhaul.
The analysis process proved lengthy and complex, Alsop said. The actuaries, for instance, needed detailed figures from the Department of Health and Human Resources, which runs Medicaid, to estimate the price tag for overseeing the expansion. While the overhaul pledges federal funds for the actual health care costs — the analysis concluded that West Virginia can expect $5 billion over the next 10 years — it would pay for only half of the administrative expenses.
"Once we got the numbers, it became pretty clear that the best decision for us was to expand Medicaid," Alsop said. He later added, "The governor never said, 'I don't like these numbers: go back to the drawing board.'"
In the months leading up to Tomblin's decision, Alsop fielded weekly inquiries and appeals from advocacy groups and organizations representing health care providers on the topic. These representatives appeared uniformly in favor of expansion, Alsop recalled. He said the West Virginia Hospital Association was particularly helpful by providing data. Several hospital executives appeared with Tomblin and U.S. Sen. Jay Rockefeller, D-W.Va., on Thursday to herald the Medicaid announcement.
Politics overshadowed the entire process. While Tomblin sought answers from the Obama administration and pursued the financial analysis last year, he was also running for a full term as governor. His Republican opponent, Bill Maloney, was a vocal foe of the federal health care overhaul but had at times also offered mixed statements regarding Medicaid expansion. Tomblin's fellow Democrat, President Barack Obama, was deeply unpopular in the state as he sought re-election.
"The issue of how close we were tied to the Obama administration was a huge issue in the election," Alsop said.
Tomblin noted during Thursday's announcement that his administration "may not agree with every provision" of the federal overhaul. Alsop said those areas include one limiting the range of premiums that insurance companies can charge policyholders. That language may deter young adults from buying coverage, while potentially driving up costs for those who do, Alsop said.
"There are certainly concerns about the cost and how we go about this," Alsop said. "Some of the points conservatives have raised need to be considered. On the flip side, the fact that several Republican governors have said that the scales tip in favor of expansion show that it's not a partisan political decision... We carefully weighed the pros and cons."