Health Affairs puts the spotlight on Arkansas and the so-called “private option” for Medicaid expansion.
This middle ground or “private option” appears more politically tenable for states led by conservative lawmakers intent on moving more people into the private market. Proponents of the Medicaid premium assistance option also tout it as a potential path to lowering Medicaid spending, perhaps driving down private exchange costs over time and reducing the cyclical movement of beneficiaries between Medicaid and the exchanges based on their fluctuating incomes.
In practice, the political power of the private option to get Republicans on board has been limited nationally. In Louisiana and Mississippi, it was Democratic legislators that offered it up as a compromise proposal and Republican lawmakers in those states weren’t biting. Iowa is attempting to go forward with a partial version of the private option, though it's unclear whether their approach will get approval from the feds; Tennessee's Republican governor has been looking in to a private option approach but has included poison-pill provisions to sabotage the process and in any case, the GOPs in the legislature are opposed.
Why was the private option a political game-changer in Arkansas and not elsewhere? Part of it surely is the dynamic of a popular Democratic governor pushing hard for expansion matched with a Republican legislature that was opposed. Part of it likely has to do with the idiosyncratic personalities and policy preferences of the key Republican lawmakers that took ownership of the private option.
In any case, it's kind of amazing to look at that map above and see Arkansas, basically alone in the South in offering coverage to low-income citizens. States that turn down expansion are giving up a huge influx of federal money and leaving their neediest citizens in the cold. But for many, the politics of Obamacare remain toxic. National journal has a good wrap-up today on the upshot: in retrospect, the Supreme Court decision, generally viewed as a victory for the president's healthcare law, took an ax to the law's primary goal of improving access for those that need it most. Even as more affluent citizens avail themselves of public subsidies, around 7 million Americans below the poverty line will be out of luck. Thanks to the private option, the poorest citizens in Obamacare-hating Arkansas will actually gain coverage, as the law intended.