De-funding the Medicaid expansion “private option” in the fiscal session won’t be easy | Arkansas Blog

De-funding the Medicaid expansion “private option” in the fiscal session won’t be easy


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Rep. John Burris: premium prices key in keeping super-majority support
  • Rep. John Burris: premium prices key in keeping super-majority support

Starting in October, low-income Arkansans will begin signing up for health insurance plans under the so-called “private option,” the state’s unique version of Medicaid expansion. Opponents of the plan couldn't stop a legislative super-majority last session, and they couldn’t muster enough signatures to get a repeal on the ballot, but they are holding out hope at another crack at stopping the policy: the February fiscal session.

Last spring, the appropriation got the needed three-fourths super-majority with two votes to spare in the House and one in the Senate (though one of those was the now-resigned Paul Bookout), but that appropriation will now be re-visited every year. Get ready to re-hash this fight! (Note: the feds pick up the full tab for the first three years, so for now the question is simply whether to accept federal funds.)

No one has publicly flipped, but there have been murmurs that political pressure from the anti-Obamacare forces on the right make another super-majority a dicey proposition (certainly some Republicans that voted for the “private option” will face a primary challenge; perhaps some Democrats –all of whom voted for AYE — will be nervous about the issue in the general election).

“I never predict,” said Rep. John Burris, one of the key Republicans behind the “private option” policy. “But I haven’t heard anybody that voted for it say that their opinion has changed. I’ve read a lot of the same criticisms from people that were opposed.” Burris said that the keys were getting federal approval and getting prices for the private healthcare plan in line with actuarial projections for the “private option.” State officials are hoping to hear back from the feds in October; details on plan premium prices should be available in mid-September.

“The pricing needs to be right,” Burris said. “That was the key to everything. There was a lot of confidence placed in the actuarial study. There’s been a lot of criticisms…even talk of premiums being upwards of 50 percent more than the actuary was predicting. To me that is the meat and potatoes of a lot of this….When we presented this legislation, we laid out some key principles. In February we need to be able to down the checkboxes and say that we delivered. We said it would cost this, and it did. We said that we could get the approval, and we did.”

Of course, even if the policy progresses more or less as planned, there will be immense political pressure to attempt to de-fund the “private option” – particularly on Republicans facing primary opponents. Glenn Gallas’s petition drive for a ballot initiative to repeal the policy may have fallen short, but  30,000 signatures is nothing to sneeze at. Healthcare expansion has some very angry, very vocal opponents. On the other hand, the political risks run both ways: those who voted for the appropriation on the first go-round are unlikely to appease their fired-up Tea Party critics by flipping and may make new enemies among the variety of interests in the state that pushed hard for the policy. Moreover, tens of thousands of folks will have signed up for health insurance. It’s one thing to refuse to give people health coverage; politically, it’s a harder sell to take it away.

But keep this in mind as you hear speculation about the appropriation battle to come: Even if enough votes flip to fall below the super-majority (a big if), any effort to de-fund the “private option” would face huge procedural hurdles. After the jump, a look at what would happen if the super-majority was in jeopardy come February. 

The first thing to bear in mind is that there is not a special “private option” appropriation for the General Assembly to vote on. There’s an appropriation for the Department of Human Services. The DHS budget could be amended to extract the “private option” special language, but doing so would require a simple majority in the Joint Budget Committee, then a simple majority on the floor of the House and Senate. The JBC has 29 Republicans and 26 Democrats, but includes a good chunk of Republicans who voted for the policy, including some of the policy’s strongest advocates. Even if opponents of the "private option" could peel votes from the super-majority, they'd still need a simple majority to remove the policy from the DHS budget. 

In other words, Democrats and pro-“private option” Republicans could, with relative ease, stop an appropriation vote over the “private option” alone from ever taking place, forcing a standoff over the entire DHS budget. It’s true that 26 votes in the House could then block the DHS appropriation, but that would mean refusing to appropriate money for everything. Kicking granny out of the nursing home, etc.

Opponents of the policy such as Rep. David Meeks have argued that the “private option” should get a separate vote. But there’s not a way to make that happen without simple-majority support, which they don’t have. A number of Republicans I spoke with also worried about setting a precedent of a minority of lawmakers trying to change policy through the appropriation process. What if, for example, Democrats held up the Secretary of State’s budget over Voter ID?

Even if the legislature declined to appropriate the money for the “private option,” confusion would remain over what would happen next in terms of policy. The law, which mandates that DHS enact the policy, would still be on the books (overturning it would take a simple majority, and again, opponents of the “private option” are nowhere close to a majority).

Here’s what Section 3 of the law (not to be codified) says:

a) The implementation of this act is suspended until an appropriation for the implementation of this act is passed by a three-fourths vote of both houses of the Eighty-Ninth General Assembly.

b) If an appropriation for the implementation of this act is not passed by the Eighty-Ninth General Assembly, this act is void. 

Well, an appropriation for the implementation has passed by a three-fourths vote of the Eighty-Ninth, and implementation will be well under way by the fiscal session. The executive branch would be in a quandary, and it’s possible that it might have creative ways to continue implementing the policy, at least in the short term.

I asked DHS whether they had thought these scenarios through and got this response from spokesperson Amy Webb:

Any serious discussions about future appropriations are months away. Rather than get into hypotheticals, we prefer to focus our energy right now on doing the work necessary to ensure people can enroll in the Health Care Independence Program on Oct. 1. It is our hope and expectation that once those discussions begin, continued funding will be approved. Otherwise, we’ll have to tell hundreds, if not thousands, of people in each county in Arkansas that the coverage they just received is being taken away.


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