More than 150,000 Arkansans have gained coverage under the private option — the state's unique policy using Medicaid funds to purchase private health insurance for low-income residents — but the future of the policy could be in jeopardy depending on the outcome of several Republican primaries this Tuesday in state legislative races.
"I think it's the big major issue," said Sen. Bryan King (R-Green Forest), one of the most vocal critics of the private option. "As a Republican, when you campaign on less government and then you vote for the largest expansion in government in Arkansas history, it's definitely going to be an issue."
"I feel that this is an expansion of Obamacare into Arkansas," said Scott Flippo, owner of a Bull Shoals nursing home, who is running for an open state Senate seat against Rep. John Burris (R-Harrison), one of the key Republican architects of the private option (a third candidate in the race, Mountain Home mayor David Osmon, supports the policy). "The private option is the overriding issue in this campaign."
"I don't think the race will be decided by the private option," Burris said. "I think it could be decided by my opposition lying to the voters continually and repeatedly by saying that I brought Obamacare to Arkansas. I think they're attempting to tell a lie so many times that it becomes the truth to voters. I think they're going to fail, but I think they're attempting it."
Most believe that Burris and Flippo will emerge from the three-way race in District 17 (which includes parts of Baxter, Boone and Marion counties) and face off in a runoff. That race is one of three GOP state Senate primaries that opponents and proponents of the private option will be watching closely. In District 9 (which includes parts of Crawford, Franklin, Scott and Sebastian counties), incumbent Sen. Bruce Holland (R-Greenwood), who voted for the private option, is being challenged by Rep. Terry Rice (R-Waldron), who voted against it. In District 14 (comprised of parts of Garland and Saline counties), another incumbent who voted for the private option, Sen. Bill Sample (R-Hot Springs), is being challenged by an opponent of the policy, retired financial auditor Jerry Neal.
The private option has popped up in numerous other legislative and statewide Republican primaries, with lawmakers who voted for the private option under heavy attack — even Sen. Missy Irvin (R-Mountain View), who flip-flopped from voting for the private option appropriation in 2013 to voting against it this year, drew a primary opponent criticizing her original vote.
Irvin is expected to win re-election easily, but the other senate races are viewed as close calls. They are drawing particular attention because the margins in the General Assembly are so tight: In order to accept the federal money to fund the private option, both houses of the legislature must approve the appropriation by a 75 percent supermajority, a devilishly high bar. In the 2014 fiscal session, the private option was reauthorized with no votes to spare in the Senate and one vote to spare in the House. Votes in the House have been relatively fluid, but the rump group of eight Republican opponents in the Senate appears to be unmovable. Moreover, while each of these individual races will be decided by personalities and policies beyond the private option, the post-election narrative will focus heavily on the health care issue. Republican lawmakers on the fence about the private option going forward may make a political calculation based on what happens next week.
"A lot of what transpires over the next year will be determined [by these primaries]," said Sen. David Sanders (R-Little Rock), one of the key Republican backers of the private option.
The battle lines are being drawn over a deep split within the GOP in Arkansas over the private option. The split dates back to the debate over Medicaid expansion, one of the provisions of the Affordable Care Act (the ACA, or Obamacare, as many call it). Because of a U.S. Supreme Court ruling, the decision over whether to accept federal money to extend Medicaid coverage to more low-income people was left up to the states. Medicaid expansion appeared doomed in Arkansas, where a newly ascendant Republican majority had campaigned explicitly on an anti-Obamacare platform. But the debate was turned on its head when the feds approved the plan that became known as the private option, using private health insurance instead of the traditional Medicaid program to expand coverage. Republicans like Burris took ownership of the plan and pushed hard to secure passage by bipartisan supermajority.
Republican opponents of the policy point out that the private option is funded by the ACA and is bound by many of the rules of Medicaid. For them, it is a capitulation to Obamacare. Republican proponents of the private option argue that the policy is a conservative alternative to traditional Medicaid expansion, and was the best approach for the state given other features of the law that are going into effect regardless of the state's decision on expansion.
"The private option was a nice-sounding name," said Neal. "I believe it's Obamacare, Obama says it's Obamacare. The only people who don't are the Republicans who voted for it and then are being challenged in primaries."
In a television ad, Rice says, "My opponent was the deciding vote to pass the implementation of Obamacare." An ad from Holland counters: "You might have heard that I am for Obamacare. That is false. I am against Obamacare. ... The Obamacare law gave us hard choices to make and I supported the private option. We would have Obamacare with or without the private option. We can debate the private option, but saying I am for Obamacare — that's just a lie." (Both Rice and Holland did not respond to repeated interview requests.)
"You've got to start with what Obamacare took from us," Burris said. "You add up Medicare [reimbursement] cuts and tax increases, it's $1.25 billion a year out of our economy. I couldn't stop those things. I couldn't stop the essential health mandates driving up the cost of your premiums. I couldn't stop the individual mandate that's penalizing people for not buying insurance they can't afford. I tell people, call somebody you trust in another state [that said no to expansion] and ask them if they have Obamacare, too." The private option, Burris argued, was a way to bring money back to the state and use it "to reform our Medicaid system and our health care system ... and get waivers [of federal rules] to put our fingerprint on the system."
Flippo said, "My opponent and I disagree. He says that [the private option] is not per se Medicaid expansion. I believe that it is. Medicaid expansion is one of the key pillars of Obamacare."
Burris said he has no regrets about his vote for the private option. Sample said the same. "As a legislature, we have to have the guts to make tough decisions," Sample said. "This wasn't an easy decision. I've compared the decision that we made on the private option to the decisions that some of the legislatures had to make years ago when they were deciding segregation. It was a tough issue, it was not a pleasant issue, but sometimes you have to stand up and say, whether I get elected or re-elected, I'm going to do the right thing and I'm going to take care of my constituents. I'm going to take care of the citizens of Arkansas, and I feel like that's what we did."
Sample said that while in his district "everybody is against Obamacare," he believes that the majority of his constituents support the choice he made on the private option. Neal countered that "unless I'm living in an alternate universe, the vast majority of people I talk to are against it."
Outside advocacy groups opposed to the private option have been aggressive in trying to tilt the scales in the primaries. Americans for Prosperity has done two mailers attacking Sample (including one criticized by factcheckers for implying that Sample had been responsible for Medicare cuts). "They're an out-of-state entity that's trying to buy a Senate seat," Sample said, who added that he believed that part of Neal's rhetoric "is based on information that he gets from them." (Neal said he had not looked closely at the AFP mailers, but believed that they were accurate.)
Meanwhile, a variety of PACs and advocacy groups co-founded and at least partially funded by Fayetteville businessman Joe Maynard, a vocal opponent of the private option, have donated or spent tens of thousands of dollars in this election cycle, much of it targeted at Burris. One of the groups, Conduit for Action (via its independent expenditure committee) has issued one mailer attacking Holland for his vote on the private option and three mailers and a television ad attacking Burris. One mailer features goofy pictures of Burris culled from social media (wearing a bandana, eating a sandwich) while a hologram of President Obama hovers in the background.
"I think the mailers are very dishonest and in poor taste," Burris said. "It's not illegal. It's not against the rules. I've dealt with a lot tougher, but I think it's juvenile, and I think voters I'm hearing from think it's juvenile and in poor taste." Conduit for Action's Director of Governmental Affairs David Ferguson said that Burris was targeted because he was "pretending that the private option and Obamacare have nothing to do with each other" and that all of Conduit's materials were footnoted with sources.
All of the candidates the Times spoke with noted that there are many issues voters are concerned about in their districts outside of the health care expansion, and all believed their races would not be determined by the private option alone.
"For me, this race is not all about the private option," Burris said. "For my supporters, it's not all about the private option. But for everybody else, it is."