November 06, 2014
By Margot Sanger-Katz,
In Arkansas, a bipartisan policy compromise has led to one of the country’s most successful health insurance expansions under the Affordable Care Act. But this week’s election results put the future of the state’s Medicaidexpansion in jeopardy.
Arkansas negotiated with the Obama administration to expand its Medicaid program by using federal dollars to buy private health insurance plans for its low-income residents on the new marketplace. More than 200,000 people have enrolled in the program already.
But voters replaced an enthusiastically supportive governor with one who is noncommittal. And, more critically, they replaced legislators in both houses who supported the expansion with those who campaigned against it. The program is up for reauthorization this year, and local advocates say they’re worried it could be eliminated.
Around the country, Republican victories in governors’ races mean that Medicaid expansion is unlikely to happen in many new places. In Arkansas, it looks as if a state government might pull the plug on an existing expansion, eliminating health insurance coverage for its poor residents.
The choice before the state’s Obamacare opponents is in many ways the same one facing Congressional Republicans, now that they have won a Senate majority: Are they willing to roll back a social welfare program that is now established? As in Arkansas, any federal legislation to eliminate important provisions of the health law will mean eliminating benefits from people who have already received them. (President Obama’s promised veto means that wholesale repeal is off the table, but congressional Republicans are talking about a series of possible changes that could reduce benefits.)
“This is a microcosm of the fight within the Republican Party about repealing the Affordable Care Act,” said Joan Alker, the executive director of the Center for Children and Families at Georgetown University, who tracks Medicaid policy closely and is worried about the Arkansas program’s future.
Because of a quirk of the Arkansas state constitution, all budget bills must pass the legislature with a three-quarters majority of both houses. That’s a high bar for controversial matters of public policy. “Getting a three-fourths vote on motherhood is hard,” said Gov. Mike Beebe, a Democrat who is leaving office because of term limits. “It only takes a small percentage of folks that are ideologically opposed to anything that is akin to Obamacare to dig in against it.”
Opposition to the program comes from those opposed to the Affordable Care Act, generally, and those concerned about the possible budgetary impact of the program, which is funded by the federal government now but will require the state to pay part of the costs in coming years.
“We can’t afford it,” said Linda Collins-Smith, a newly elected state senator, who campaigned against the program and expects the legislature to eliminate it. “Obamacare by any name, it is absolutely horrible policy.”
Asa Hutchinson, the Republican governor-elect, has said that he views the state’s expansion as a “pilot project” that could pay off but might need to be ended if its costs and benefits are not appropriate. On Thursday, a spokesman said that Hutchinson would wait to say whether he thinks the program should be reauthorized until January, when the legislative session begins.
The Medicaid expansion, known locally as the private option, has passed the legislature twice, but narrowly; last year, it squeaked through with no votes to spare in either house. But Republicans who oppose the program have made gains in both the state House and Senate, picking up four seats in the 35-seat Senate and about 15 in the 100-seat House, according to the Arkansas Hospital Association. A recent association study found that the program had reduced hospitals’ uncompensated care this year by $69 million over six months.
“We’re very concerned,” said Jodiane Tritt, the association’s vice president of government relations. “The 75 percent threshold is a big deal.”
Though a substantial minority of the state’s legislators oppose the program, many Republican members have supported it over the last two years. It is quite different from the conventional Medicaid expansions that other states pursued. Instead of offering low-income residents a government-run insurance plan, the “private option” program lets participants choose among the same insurance plans that higher-income people can buy on the state’s new marketplace.
The hope was that allowing the state’s poor to enroll in these private plans would make it easier for them to seek medical care, since more doctors tend to take private insurance. It has also helped stabilize the insurance market for higher-income people; because the Medicaid population tends to be young and healthy, mixing the groups has kept the insurance pool healthier than it would have been with marketplace buyers alone. Insurance premiums will be going down for Arkansas marketplace health plans in 2015, and more insurers have joined the market.
State officials were also creative in getting eligible people signed up. They made it easy for people who had signed up for other income-based federal programs, like food stamps, to get private option plans, and also opened up the state online enrollment system to the public, so brokers and other advocates could help new people enroll. The result: an estimated 205,000 people in the new plans, and an overall reduction in the state’s uninsured rate of 10 percentage points, according to a Gallup survey.
“It has exceeded all of our expectations as far as how it’s worked so far,” said Davy Carter, the departing Republican state House speaker, who helped devise the program and find the votes to pass it over the last two years. Mr. Carter thinks that the new legislators will be persuaded to support the program once they learn more about it.
Mr. Beebe was less optimistic. “It will be extraordinarily difficult with some of these people who were elected,” he said. “I’m concerned for the hospitals, I’m concerned for the people, I’m concerned for the budget.”
David Ramsey, a reporter at The Arkansas Times, a Little Rock newspaper, has been covering the policy since its inception. His assessment this week: “This is likely to be a long, complicated, unpredictable, messy fight.”
It’s a fight worth watching in the year ahead.