Down to the math

As you might recall, Gov. Asa Hutchinson has been trying by hook or crook to keep alive the private-option form of Medicaid expansion.

He calls it Arkansas Works because that sounds mean, or at least tough.

Medicaid expansion is an Obamacare program that has been modified conservatively by the state, and which Hutchinson now seeks to modify more conservatively still.

He wants to keep the program because it’s good for the state budget and maybe even because he thinks it’s the right thing to do for needy people. But he wants to tamp down raging enrollment—because there’s a lot of Arkansas people living under the eligibility cutoff at 138 percent of poverty and the state has a financial obligation to match the federal largesse by small growing amounts as the years go on.

Anyway, we’ll never get the Republican Legislature to settle down permanently on this issue—and not fight about it every biennium—until we punish more of these sick poor people, at least for being poor, since being sick is not necessarily their own fault.

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So, Asa shot up to Washington a waiver request that Arkansas be permitted to use the Medicaid expansion money only on people up to 100 percent of poverty, throwing those between 100 and 138 percent of poverty off the state-shared Medicaid tab and into the federally subsidized private market.

He also asked for a work requirement—or at least enrollment in a work-training program or in volunteer work—for those not excused by child-care obligations, like single parents, or illness.

Basically, he wants fewer poor people on the program because the rising state share is worrisome, and because his base doesn’t like the program in the first place, considering that it’s from a Kenyan and poor people ought to suck it up.

I’d written confidently that the Trump administration would approve the waiver request forthwith because you can’t get too mean or tough for the Donald.

So it was interesting the other day when Hutchinson was telling me by phone that, while he remains eagerly optimistic the waiver will be approved, he has been perhaps a little surprised himself that Trump’s Department of Health and Human Services has been given this much pause by the still-pending Arkansas request.

To hear Asa tell it, Trump’s Health and Human Services people are saying wow, gee whiz, these ideas are great—so great, in fact, that other states may want to do them, and we need to stop and consider that we essentially may be making federal policy by this single-state exception for your marvelous ideas.

Apparently, it’s not the work requirement. It’s the math. The dollars.

“I think some of them may be thinking, ‘If we do this for Arkansas, then maybe Texas and Mississippi will want to expand the same way,’ and they have federal cost concerns about that,” Hutchinson told me.

Health insurance for poor people does not grow on trees, apparently.

Upon further contemplation, I’m figuring the Feds are worried first about the very idea of a state using Medicaid expansion to cover fewer people and throwing some of the previously covered people over to the federal government’s exclusive tab through subsidies on the Affordable Care Act’s health-care exchanges.

That’s simply a cost shift from a budget-balanced state government to a deficit-riddled federal government. Smooth, brazen. That Arkansas is a spunky little rascal of a state, isn’t it?

The Feds might do that for a small isolated state like Arkansas, especially since Arkansas is promising coinciding cuts in its basic Medicaid. But, indeed, as the governor says, Texas might come along and say, hey, fair is fair, and we want that Arkansas deal—that is, we will now do what we previously refused to do and expand Medicaid, giving the Feds 90 percent of the costs for our vast state, but we will expand it only to the Arkansas level. Meantime, you in the federal government can continue subsidizing our lower-income people on this exchange.

Arkansas might be managed with a pat on the head. But Texas could put the Donald and his budget, already strained by tax cuts, into real money.

So there are several moving parts. Arkansas is not ground zero on national health-care policy and pricing. But it might be the vanguard if it gets this waiver and other states start whining for it.

But, again, Asa remains optimistic. And, he hastens to add, this is nothing for legislators to worry about in the fiscal session in February.

We don’t need another legislative donnybrook right now. In January 2019, maybe, but not now.

John Brummett, whose column appears regularly in the Arkansas Democrat-Gazette, was inducted into the Arkansas Writers’ Hall of Fame in 2014. Email him at jbrummett@ arkansasonline.com. Read his @johnbrummett Twitter feed.