Bean-counters in the federal government have come along to contend that federal Medicaid people let Arkansas get into the federal government's pocket a little bit.
Maybe Arkansas did. Maybe Arkansas didn't.
Either way, that's a conversation for the federal government's bean-counters and Medicaid people to have. Arkansas will be busy otherwise reforming health care.
The issue is the famous private-option form of Medicaid expansion that the federal Medicaid people gave Arkansas a waiver to implement.
Rules say any new state system approved for a waiver must be revenue-neutral with traditional Medicaid. In the Arkansas case, the federal Medicaid people accepted the Arkansas argument: If we added hundreds of thousands of poor people to regular Medicaid, we'd have to pay more under regular Medicaid to buy all these newly insured persons actual access to care. Otherwise, doctors would not take the new patients.
So the federal Medicaid people agreed: The calculation of revenue-neutrality between buying private insurance via the private option and simply expanding regular Medicaid had to be based on an estimated increase over what the state had previously been paying in straight Medicaid to providers. An assumption, if you please.
So now comes the federal Government Accountability Office, made up of number-crunchers whose job is to find efficiencies. It says in a report that the federal Medicaid people dummied up unsupportable assumptions to make the experimental program supposedly revenue-neutral.
That's par for the course, the GAO report says.
This dispute, you see, is about more than Arkansas and the private option. It's about a pattern of letting states do Medicaid differently going back well into the George W. Bush administration.
So the essential point of contention is as follows: Did Arkansas, by getting permission to use federal Medicaid money to buy private insurance for recipients, take the federal government for more federal money than the state would have received simply by expanding straight Medicaid to these people?
Put another way: Were the federal Medicaid people too desperate for conservative states to expand Medicaid? Did they contort entirely too much to make the Arkansas idea appear revenue-neutral and thus qualify the state and its new idea for a waiver?
No one can say.
We can't possibly judge until the end of the waiver after three years, at which time Arkansas probably will seek a new and broader one.
Even then, the argument will rage about whether we should have based neutrality on the old existing Medicaid rates or on higher assumptive ones.
Nothing about this issue suggests the private option will cost more than we thought it would, though that's what some right-wingers want you to think this dust-up is about.
But aren't insurance premiums necessarily designed to amount to more dollars than actual payouts for care? Isn't that the business model for private health insurance?
Sure it is. But that doesn't apply to every subgroup of insured persons every calendar year in every local health-care market.
Take the group I'm in, knock wood. Healthy. Not a frequent doctor's office visitor. Payer of a high deductible covered by a personal health savings account. My premiums are gravy for the insurance company. My actual tapping of money for claims is, in a good year, non-existent.
But all years may not necessarily be good ones, you see. That's the nature of insurance.
I'm reminded of the liberal-minded friend who called to whine that his family's health-insurance rates were going up. He hated to say it, but Obamacare was to blame, he feared.
By the time he finished the conversation, he had remembered his arthroscopic procedure and the other thing and the surgery his child needed. He concluded that, heck, he may have come out ahead for the year.
Anyway, so what if Arkansas winds up to have ventured into the federal government's pocket a bit?
Good for Arkansas. It's about time we got smart.
We have a couple of hundred thousand more people with health insurance. Our hospitals are more financially secure. All premiums on our health-insurance exchange have been held down by the flood of newly insured persons. And we have introduced co-payments and individual savings account--and maybe we'll even add some job-training element--to the system of publicly provided health insurance.
And we stand conspicuously as the state with the gumption to design the new program and implement it, both for our own good and the cause of health-insurance reform.
Sometimes it takes money to make money. Sometimes it takes money in the short term to save money in the long term.
Often the investments encouraged by visionaries and reformers are met with resistance in the bean-counting department. It's a natural stress point.
Arkansas should keep insuring people while the federal government argues with itself.
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John Brummett's column appears regularly in the Arkansas Democrat-Gazette. Email him at [email protected]. Read his blog at brummett.arkansasonline.com, or his @johnbrummett Twitter feed.
Editorial on 09/11/2014