JOHN BRUMMETT: A foot on the bridge

Posted: March 6, 2018 at 4:30 a.m.

Monday was a moderately big day for the state's Medicaid expansion program, the wisdom of which is well-known to people who keep up with state government and health issues.

But that wisdom bears re-establishing today for context.

Initially called the private option and now branded Arkansas Works, the program provides health insurance for more than a quarter-million poor people. Their now-reimbursed care, formerly absorbed by providers, has fortified otherwise failing rural hospitals.

By using Medicaid expansion money to buy private insurance for the eligible population, Arkansas has held down already-too-high premiums for everybody. By paying 90 percent or more of the costs--a significantly higher rate than it pays for basic Medicaid--the federal government funnels needed cash into the state treasury.

Gov. Asa Hutchinson, who understands all that, has championed the program at the expense of support from some people on his right flank. Those people simply do not believe government ought to aid vast numbers of people who should get up off their behinds and find jobs and carry their own weight.

Medicaid is mostly for the working poor, meaning people who work but not for enough money to afford unsubsidized--and darned expensive--private health insurance. But facts and empathy are not abundant in some contemporary conservative political positions.

The Medicaid expansion money is routed through the state Department of Human Services appropriation, which requires a three-fourths majority vote in both the House and Senate. The Republican-dominated Legislature has consistently reached that threshold by hook, crook, tooth-pull and clever finesse.

In the current fiscal session, the state Senate confronts three vacancies in its membership of 35. But the three-fourths threshold remains as a factor of the full membership--meaning that 27 votes are still required although only 32 senators will vote.

There are more than five senators of the extreme-conservative Republican persuasion who have voted "no" in the past and who could put the program out of business if they all voted "no" this time.

Hutchinson has had a plan to achieve their grudging interim acquiescence. He asked the Trump administration to grant Arkansas a couple of conservative-flavored waivers.

One would require able-bodied Medicaid recipients--those between 18 and 49 and without dependents--to work or enter work training or do volunteer service.

The other would remove about 60,000 recipients, those between 100 percent and 138 percent of the federal poverty level--meaning those likeliest to be working, though not for much money--from the expansion population. It would dump them on the Obamacare exchange, where they'd get subsidies paid fully by the federal government. It's mostly a bookkeeping switch from the flush state budget to the deficit-swallowed federal one, and thus ironic.

Those waiver requests have been held up, complicating Hutchinson's effort to persuade the conservative holdouts during the current fiscal session.

But on Monday, the Trump administration was kind enough to send down, in person, the head of the federal Medicaid program to do Asa a nice turn with a little dog-and-pony show and do a ceremonial on-site signing of ... one of the waivers.

The official announced that the Trump administration is granting the waiver allowing the state to tie Medicaid expansion coverage to a requirement for work, job training or volunteer service--depending on what's available in the area--for recipients determined to be able.

It was wholly expected. The Trump administration is reliably conservative on such things even if the president himself varies minute to minute on gun control or immigration or trade, and gets mostly ignored, blessedly.

But about that other request, the one to dump 60,000 off the state's Medicaid expansion rolls and put them on the exchange where they'd qualify by low income for near-complete federal premium subsidies ... that one is still pending, and probably in deserved trouble.

If the Trump administration allowed Arkansas to get 90 percent federal matching for serving fewer people than the program mandates, then it's conceivable other states would want the same thing.

It might even prompt states that have chosen not to expand Medicaid to do so if they could get by with a smaller coverage population by the same deal Arkansas got.

It bears remembering that the Trump administration opposes Medicaid expansion altogether, indeed all of Obamacare. It likely would be loath, then, to (1) assume more costs through subsidies on the exchange, and (2) make Medicaid expansion more affordable to a nonparticipating state.

So, it's a split decision for now. The work requirement ought to be enough to appease the fiscal session, which was the point of the dog-and-pony show.

But it might not be enough by the time the regular session comes around next year, especially if the other waiver gets denied.

For a while longer, Medicaid expansion looms as a bridge to be crossed when gotten to in a state with a bit of a mean streak.


John Brummett, whose column appears regularly in the Arkansas Democrat-Gazette, is a member of the Arkansas Writers' Hall of Fame. Email him at Read his @johnbrummett Twitter feed.

Editorial on 03/06/2018