There's a lot to digest in the new Medicaid "private option" deal, and we've looked at the fiscal and legal implications. But ultimately, the real question remains political. Will 75 percent of the Republican-controlled General Assembly give the go-ahead?
Early signs suggest that the tides have turned. No Republican has come out and endorsed it, but they are taking ownership of the idea and generally speaking (and tweeting) as if they are ready to move forward. Unsurprisingly, House Speaker Davy Carter and Senate President Pro Tem Michael Lamoureux have spoken quite favorably about the new plan. More strikingly, Sen. Jonathan Dismang — who had previously stated that there was no way he could support full expansion and has been a key driver of ideas to offer the expansion population private insurance instead of Medicaid — has signaled support. At the Senate Public Health committee meeting last Wednesday, he publicly thanked the same administration officials he had sparred with a month ago. He said "we're a at a different point today" because of their help "work[ing] through the ACA and try[ing] to build up a program that we feel would be best for Arkansas." He added, "we have the rules to play by...now we start moving forward. Hopefully we'll have some agreement and get a solution."
Even Sen. Jason Rapert, who was basically a preacher of the anti-Obamacare gospel, seems to have softened. He had previously attacked the federal-state partnership exchange, wanting to send it back to Washington. After the "private option" news, he suddenly seems to be in favor of a state-run exchange.
The D-G's Charlie Frago managed to track down (paywall) a couple of Republicans still expressing opposition. Rep. David Meeks dusted off the old classic: What happens to people that gain coverage if the state decides some time in the future that it can no longer afford the expansion? Like Sen. Cecile Bledsoe, he believes that it's better that low-income people never have health insurance than to get it and then possibly lose it in the great by and by. Rep. Nate Bell, meanwhile, said, "[m]y biggest heartburn about it at this point is that it's still an expansion of government."
Of course, in the hunt for 26 Republicans in the House, the far-right Bell was never going to be a target. Bell is correct about one thing: though the money would be shifted from a public program to private health insurance companies, we're still talking about government expenditures to offer folks health insurance.
In the end, even if this approach costs more, Arkansas Republicans just have a visceral dislike of the Medicaid program and are much more comfortable with funneling taxpayer money through private companies. It was amusing to hear Rep. John Burris crowing about "Medicaid contraction." This was in reaction to DHS outlining the populations transferring to the expansion pool, where they will get the better match rates, saving the state money. Of course, within the Medicaid program, these same transfers would have happened under the old Medicaid expansion plan. Republicans didn't believe DHS numbers about savings back then.
Here's Burris: "Draw the line, close the door, turn the page: We are moved past Medicaid expansion. We will not add a single person to the rolls of Medicaid in this session. If anything, we are going in the other direction." Fair enough. Whatever works.
Beebe called this Republican preference for a private approach "philosophical" and former Romney healthcare advisor Avik Roy does a great job articulating the conservative case for this kind of plan here (Roy acknowledges that costs go up). Arguably Republicans could have gotten a deal like this from the get-go if they'd been willing to bargain with Obama on healthcare reform.
But my suspicion is that it's also important that the "private option" can plausibly be sold as NOT OBAMACARE. Folks like me (and I would speculate moderate Republicans like Carter and Lamoureux too) have been searching for months for some avenue, some argument, that would allow Republicans to say yes to federal money to expand coverage without betraying their campaign pledges to fight Obamacare to the death from the state capitol.
Maybe Gov. Mike Beebe, with an assist from the feds, has found a way.