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Close shave in Arkansas

Posted by John McDonough  March 5, 2014 07:41 PM

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Yesterday, the Arkansas House of Representatives gave approval to the state's annual budget and, after a long hard fight, included continuation of its unorthodox health insurance expansion for low-income residents under the Affordable Care Act, dubbed the "private option."

arkansas_seal.jpgDoes this matter beyond Arkansas' borders? Yes. Reversal would have been the first case of a state reversing an ACA expansion, and would have emboldened opponents to seek similar reversals in other states.

The ACA, as originally designed, required that all states expand their Medicaid programs by 1/1/2014 to all uninsured residents with incomes below 138% of the federal poverty line (about $15K in annual income for a single adult). The U.S. Supreme Court decision in June 2012 that upheld the ACA's constitutionality also required that the Medicaid expansion be optional for states.

In Arkansas, with a Democratic Governor (Mike Beebe) and a Republican-controlled House and Senate, a traditional ACA-Medicaid expansion was not in the cards. Despite the accusation that the ACA requires a "one size fits all" approach, the Obama Administration agreed to permit otherwise-Medicaid eligible adults to instead receive fully subsidized private health insurance through the state exchange/marketplace -- all private insurance all the time. Since the deal was struck in 2013, Iowa made a similar agreement, and other states such as Pennsylvania and Utah are now negotiating their own alternatives.

Sounds like a win for Republicans -- except that it's connected to the ACA/Obamacare and is thus intolerable to the Tea Party. Even though a strong majority of the Republican controlled House and Senate supported continuation, Arkansas rules require a three fourths majority to approve the annual budget, and thus came the stalemate as Republican Party leaders struggled to get the final few votes.

It took five separate votes over two-plus weeks to cross the needed threshold in the House, a margin achieved just yesterday over adamant Tea Party opposition.

Perhaps the oddest part of this odyssey involved Republican Rep. Josh Miller who opposed theMiller.jpg expansion, and voted to end health insurance for more than 95,000 low-income Arkansas citizens. Odd because Miller is disabled as a result of a drunk driving accident (he was drunk) and his life was saved because of Medicaid. Here's a bit form the Arkansas Times:

Miller, 33, was on an alcohol-fueled drive with a friend about 11 years ago (he can't remember who was driving) when their pickup plunged off a ravine near Choctaw. He was rescued, but suffered a broken neck and was paralyzed. Miller was uninsured. What young, fit man needs health insurance, he thought then. (He had some reason to know better. Not long before, he'd broken his hand in a fight and had to refuse the recommended surgery to fix the injuries properly because he was uninsured.)

Months of hospitalization and rehabilitation followed, including a long stretch in intensive care at St. Vincent Infirmary. There was a $1 million bill. Medicaid paid most of it. Miller was placed on disability and checks began. In time, between Medicaid and Medicare, all his health costs were covered by the federal government. For that reason, he need not be among the 82 Arkansas legislators (61 percent of the body) who enjoy heavily subsidized and comprehensive state employee health insurance.

Miller sees no irony in his opposition. The rest of us should be so lucky.

The ACA-Medicaid expansion holds in Arkansas and will hold everywhere else as more and more red-leaning states find ways to join.

The long and fierce war over health reform, still raging, is winding down.

This blog is not written or edited by Boston.com or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »

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