Without a vote to spare, the Arkansas House passed the appropriation for the state's Medicaid program on Tuesday, overcoming opposition from some Republicans who had sought a wait-and-see approach after a federal judge struck down work requirements for some on the health insurance rolls.
The vote of 75-18 effectively granted another year of spending authority, starting July 1, for the programs that benefit more than 882,000 Arkansans who receive their health insurance through traditional Medicaid and the state's "private option" expansion. The bill required 75 votes for passage in the House.
The House action sent the appropriation, Senate Bill 99, to the desk of Gov. Asa Hutchinson, who said he will sign it.
"This is a key part of my budget and provides essential funding for health care needs of those Arkansans who are struggling financially," Hutchinson said in a statement Tuesday. "This appropriation also allows us to continue the fight for reform, such as the work requirement."
Uncertainty over SB99 began last week after a federal judge in Washington, D.C., struck down a waiver that Arkansas and Kentucky had received from the U.S. Department of Health and Human Services. The waiver allowed those states to impose work requirements on some recipients of their Medicaid expansion programs.
Under Arkansas Works, enrollees who didn't qualify for an exemption had been required to spend 80 hours a month on work or other approved activities and report what they did through a state website or over the phone, an option that was added in December. The work requirement resulted in 18,164 Arkansans losing their coverage last year and in January. The ruling by U.S. District Judge James Boasberg caused the state to scrap another round of terminations that were to take place Monday.
The requirement was added by the Arkansas Legislature in 2017, after several years of lawmakers voting narrowly, sometimes after several tries, to authorize the annual appropriation for the Department of Human Services' Division of Medical Services. SB99 was that appropriation.
[RELATED: Complete Democrat-Gazette coverage of the Arkansas Legislature]
The bill includes more than $8 billion in spending authority for both traditional Medicaid and the expansion, which uses Medicaid dollars to purchase private insurance plans for people earning up to 138 percent of the federal poverty level. About 235,000 Arkansans receive their insurance through the expansion.
"I, like many of you, have concerns," said Rep. Vivian Flowers, D-Pine Bluff, while speaking for the bill Tuesday. "There needs to be a lot of planning; there will be a lot of changes. But no matter what, we still have a responsibility to our constituents, we still have children, we still have seniors in nursing homes, we still have people who work every day who are relying on us to make sure that we take care of them."
On Friday, a House vote on SB99 fell 23 votes short of the three-quarters threshold needed to pass. Hutchinson and House leadership promised to try again, and they were able to cobble together the necessary support for a second vote four days later.
Hutchinson addressed the House Republican Caucus on Monday, according to House Speaker Matthew Shepherd, R-El Dorado. The governor answered lawmakers' concerns but did not offer assurances of an appeal of the court case.
Several House members who switched their votes from "no" on Friday to "yes" on Tuesday said the governor's overtures were persuasive.
The House majority leader, Rep. Marcus Richmond, R-Harvey, said several members believed that they need to keep funding for the expansion program to keep the potential for an appeal of the federal court's ruling alive -- a point that Hutchinson made last week.
"I think that made some members hold their noses and vote for it," said Richmond, who was one of the members to change votes.
Rep. Joe Cloud, R-Russellville, also voted for the bill Tuesday after voting against it Friday. He said he was uncomfortable last week voting for the appropriation less than 48 hours after the work requirement was struck down. The freshman lawmaker added that he wanted to ensure dialogue began on reining in Medicaid spending, which he thought has indeed started.
"I didn't want to be part of kicking the can down the road," he said.
Cloud added that it was his impression that the federal ruling will be appealed.
The decision of whether to appeal is up to the U.S. Department of Justice, which defended the federal government's decision to grant Arkansas and Kentucky waivers to implement work requirements. Shepherd said that while there have been no assurances, the expectation among lawmakers is that the federal government will appeal the ruling by Boasberg.
The Justice Department declined to comment Tuesday on the possibility of an appeal.
"If there's the likelihood of an appeal, then I think it makes sense to continue to appropriate as is, because of the fact that there's still issues to be resolved," Shepherd said.
Others on the House floor Tuesday said they still had reservations about the future of Medicaid expansion.
Rep. Mary Bentley, R-Perryville, said SB99 and the growing cost of Medicaid in the state gave her a "stomachache."
"We're on a road that we cannot pay for," Bentley said.
The state pays 7 percent of the cost of the Medicaid expansion program, with the rest of the money coming from the federal government. That share will increase to 10 percent in 2020, under the provisions of the 2010 Patient Protection and Affordable Care Act.
For fiscal 2019, the state's share of the cost of the program has been projected at $135 million and the federal government's share at $1.95 billion, according to Scott Hardin, a spokesman for the state Department of Finance and Administration. In fiscal 2020, which begins July 1, the state's share is expected to increase to $177 million, while the federal government's share will drop to about $1.91 billion.
Rep. Austin McCollum, R-Bentonville, asked whether the appropriation for traditional Medicaid could be separated from the appropriation for the expansion, to hold separate votes on both. House leadership last week had said they planned to continue running the two services together.
The House chairman of the Joint Budget Committee, Rep. Lane Jean, R-Magnolia, had offered lawmakers assurances that the Department of Human Services could cover an estimated $20 million shortfall should an appeal of Boasberg's ruling not prove successful.
That shortfall would come as a result of a return to the Medicaid expansion rolls for some or all of the roughly 18,000 people who have had their health insurance canceled for failing to comply with the work requirement.
Democratic lawmakers on Monday filed legislation to return health coverage to all of the people kicked off the rolls. That proposal, however, drew swift opposition from Hutchinson, who said the legislation would do "more harm than good."
Only 2,000 people kicked off their health plans have applied for reinstatement, Hutchinson said. The governor said it is likely that other people kicked off the rolls are no longer eligible for the Medicaid expansion program, either because they are earning more money or because they are not working.
Soon after the Medicaid appropriation vote, the House passed House Bill 1821, requiring that Medicaid reimbursement rates reflect increases to the state's minimum wage that were approved by voters last November.
The bill, sponsored by Rep. Reginald Murdock, D-Marianna, passed 85-8.
Information for this article was contributed by Michael R. Wickline and Andy Davis of the Arkansas Democrat-Gazette.
A Section on 04/03/2019