Introduction
Health insurance coverage has always been a topical problem for the United States since the country does not have a universal health care system, unlike other countries such as the UK. As a result, on several occasions, different policymakers and political parties, as well as individuals, tried to offer their plans on reforming the existing situation with healthcare in the United States. It is clear that the most successful initiative of the past decades in the sphere of medical services was the Affordable Care Act (ACA), also known as Obamacare. Despite being a controversial law, ACA was still passed and used by numerous states in order to expand health insurance coverage to a larger number of citizens. Arkansas was also one of the states which utilized ACA, yet due to political reasons, the particular method of implementation of the law was different in its case. Despite having a government consisting of both Republicans and Democrats, Arkansas manages to maintain Medicaid expansion policies which satisfy the interests of both sides.
Affordable Care Act Basics
It is important to begin by providing more extensive background on the Affordable Care Act and the politics behind the legislation first. ACA was signed into law by President Obama in 2010 and thus marked a milestone in the realm of health care in the United States (Gaffney & McCormick, 2017). The sole aim of the law was to expand insurance coverage and thus ensure that more citizens had access to medical services. The ACA had two main ways of achieving the end goal, namely, by broadening Medicaid eligibility and mandating the uninsured people to get medical coverage. In the case of the former, Medicaid had to be expanded on the state level through the provision of special insurance programs, funded by both state and federal taxes, intended for the individuals who could not afford them. Before the passing of the ACA, some states, predominantly led by republican governments, decreased Medicaid eligibility to certain groups such as disabled people (Gaffney & McCormick, 2017). The ACA made Medicaid coverage more accessible by allowing every person with income not higher than 138% of the federal poverty level to be eligible for it.
As for the medical insurance mandates, according to the ACA, people who were not insured had to pay a fine or get coverage. In order to avoid imposing large expenses on the poorer population of the country, the law implied allocating subsidies to people whose income was between 100% and 400% of the level of poverty (Gaffney & McCormick, 2017). Such a policy had to facilitate the implementation of the law and eventually make the problem of the lack of insurance among citizens less severe.
Despite the fact that the ACA was created to solve a serious issue, the law still was controversial and caused numerous political debates between members of the Democratic and the Republican parties. Basically, the passing of the ACA was extremely divisive considering the fact that not a single member of the Republican voted in favor of the law in its final form in both chambers of Congress (Béland et al., 2019). Such a situation led to the constant desire of the Republican party to repeal the law in the next years. Essentially, by the end of 2016, there were more than sixty instances of voting against in favor of the repeal of the ACA in the House of representatives (Béland et al., 2019). The lack of unity between the two parties became a considerable factor which eventually affected the implementation of the law in many states. The local governments, consisting of members of different parties, often could not find a way of applying the law which would satisfy all sides.
The Decision of the Supreme Court
The existing problem with the absence of agreement in society on the significance and necessity of the ACA caused many people and organizations to attempt to repeal the law. In other words, the law signed into effect by President Obama in 2010 immediately received numerous allegations that it had an unconstitutional nature. The total number of lawsuits filed against the law by 2012 exceeded thirty ones and led to the important decision of the Supreme Court. Basically, United States Supreme Court decided that mandating individuals to buy health insurance was a constitutional exercise of power, meaning that the government did not violate any existing laws (Perkins, 2020). It also ruled that Medicaid expansion was not a valid exercise of spending power on the part of Congress since it forced states to accept the expansion under the risk of losing Medicaid funding (Perkins, 2020). Such an outcome was appropriate for both sides, the one supporting the ACA and the one campaigning against it.
At the same time, the most important result of the Supreme Court’s ruling was that individual states could actually decide themselves whether they were going to adopt the law’s provisions. In other words, the ACA became totally optional, which meant that the states run by the Republican governments had the power to simply avoid participating in the expansion of Medicaid (Perkins, 2020). It is also important to note that despite making a decision which repealed the coercive nature of the law, Supreme Court continued to receive cases filed against the ACA. Specifically, Supreme Court had to reject more than fifty attempts of repealing the ACA over the past ten years (Perkins, 2020). Such a situation shows that the law remained to be controversial and did not stop being a considerable topic for both parties, especially the Republican one. For instance, in 2017, Congress, controlled by the Republican party, set the penalty for not being insured at zero dollars which practically removed any incentive for people to get coverage (Perkins, 2020). Essentially, the successful implementation of the ACA’s provisions still remains at significant risk.
The Situation in Arkansas
As mentioned above, Supreme Court’s ruling in 2012 made the adoption of the ACA virtually optional for each state, leaving the local governments to make the decision. As a result, local legislatures had more flexibility in adjusting and tailoring the possible program to the interests of the political parties. There were states which completely refused to participate in the expansion of Medicaid, as well as those which offered their own models. One of the states which opted for a custom solution was Arkansas which designed its own program reflecting the state’s interests. The core problem with the expansion of Medicaid in the state concerned the political division existing in its government. Specifically, the governor of Arkansas was Mickey Beebe, a member of the Democratic party, while both houses of the General Assembly were controlled by the Republicans. Such a situation created significant tension taking into consideration the fact that the Medicaid expansion was a divisive issue. Nevertheless, Arkansas became the first state to demonstrate that cooperation between two parties was possible even in the sphere of healthcare policies.
It is also important to note that despite the fact that states had the ability to refuse to participate in Medicaid expansion, in this case, they did not receive the additional resources allocated to it. The primary beneficiaries of the new legislation were hospitals, and many lobbyists tried to influence the state politicians to adopt the expansion since it would bring a substantial inflow of federal money (Banks, 2018). Essentially, the ACA would entail significant advantages for the state not only in terms of access to healthcare services but also the economy. Nevertheless, Arkansas’ Republicans were ready to agree to the expansion only if the state designed its own program. At the same time, the Obama administration also was interested in the Medicaid expansion in all possible forms and therefore was willing to provide individual states with the ability to adjust their policy.
Thus, the administration was ready to consider any requests from the states for waivers from different requirements of the law. Moreover, Section 1115 of the Social Security Act had for a long time been used as the basis for the provision of special waivers even before the passing of the ACA (Banks, 2018). Moreover, the Supreme Court’s ruling on the optional nature of the law made the President and his administration more willing to consider proposals of states. Since the Republican-controlled legislature of Arkansas was against the passing of the expansion in its standard form, it used the situation to its advantage and offered a deal to the Democratic governor. The main idea of the Republican’s proposal was that the expansion had to embrace a different approach, namely, a market-based one.
Although the federal officials were open to dialogue on the proposal, the negotiations did not go without problems. As a result, the United States Department of Health and Human Services (HHS) had to reject several of the adjustments of Arkansas but allowed it to adopt a modified ACA (Banks, 2018). Finally, the alternative expansion of Medicaid in Arkansas was finalized at the beginning of 2013 in the form which satisfied both the Republican legislature, the federal officials, as well as the Democratic Governor (Banks, 2018). Thus, Arkansas became the first state to adopt the ACA with considerable changes, which caused several other states to do the same.
Health Care Independence Program
The official name of the expansion adopted by Arkansas became the Health Care Independence Program, which also was called colloquially as the “Private Option.” The latter name highlights the nature of the expansion, making the influence of the Republican legislature clear. Essentially, the standard policy implied simply expanding the Medicaid insurance coverage to a larger number of people on a fee-for-service basis. The program developed by Arkansas involved utilizing the federal funds in order to purchase health insurance plans which were private using the federal ACA exchange (Bollinger et al., 2021). Moreover, the program was intended for Arkansas residents who were eligible for the traditional Medicaid coverage due to their low income (Goudie et al., 2020). Basically, Arkansas created a system which relied on premium assistance to buy private insurance for individuals whose income was not higher than 138% of the federal poverty level, as mentioned earlier.
The motivation of the Arkansas legislature behind the decision to design such a program involved several factors. First of all, the state wanted to establish a system of medical services which would be more efficient and would have a higher level of competition. Additionally, Arkansas did not have a Medicaid-managed care system which caused the legislators to think that the inflow of new recipients would make it difficult for fee-for-service providers to operate (Patel & Rushefsky, 2019). The new program had to solve the problem by enabling the recipients to gain access to better-quality providers irrespective of their income level. In other words, all people who received access to insurance through Medicaid had a chance to choose from a wider selection of plans and providers. Moreover, the providers themselves would be paid more than under Medicaid, and thus better access to services would be achieved (Weissert et al., 2017). Essentially, the core idea of the legislature was to make the program both more efficient and effective.
At the same time, there were also obvious disadvantages of the Health Care Independence Program compared to the traditional system implied by the ACA. Due to the changes, some experts believed that the insurance cost in Arkansas would be higher than the standard Medicaid one, in certain cases, by 50% (Patel & Rushefsky, 2019). Nevertheless, the quality of services would still be higher due to the competition in the market among providers.
Today, the results of the implementation of an alternative Medicaid expansion program are quite clear, and numerous studies have been conducted on the topic. Research shows that the introduction of the program led to an increase in the rate of Arkansas residents receiving checkups and a decrease in the number of uninsured in the state (Sommers et al., 2016). Moreover, when Arkansas’s results were compared to that of Kentucky, one of the states which relied on the traditional Medicaid model, no significant differences were observed (Sommers et al., 2016). Thus, it is possible to conclude that Arkansas’ approach to the expansion of Medicaid was successful and did not cause any problems.
Arkansas Works
The passing of the Health Care Independence Program, nevertheless, did not make it a solution for the next decades, and certain changes had to be added. Nevertheless, the utilization of an alternative program enabled the Arkansas authorities to consider their experiment as successful and decide to extend it. Due to the fact that the program was allowed to take place by the United States Department of Health and Human Services, Arkansas’ government had to apply for a waiver once again. Basically, the state had to ask the federal officials for approval to continue using a private insurance-based approach to Medicaid. Since the first program was initially adopted to be effective until the end of 2016, efforts to design a new policy began in 2014 (Johnson, 2016). The state wanted to prepare for the continuation of the policy in advance and decided to make a proposal early.
Moreover, the adoption of the new legislation was also preceded by political tensions in the states. In 2015, Governor Asa Hutchinson was appointed in Arkansas, yet, despite being a member of the Republican party, he still faced disagreements with the local legislature (Johnson, 2016). Many members of the Arkansas General Assembly strongly opposed Obamacare and saw the state’s participation in the expansion as the promotion of the law. Governor Hutchinson, in his turn, believed that the Private Option had to be viewed as separate from Obamacare since it simply implied accepting federal funds as part of Medicaid (Johnson, 2016). In other words, Governor Hutchinson supported a reasonable view that it was wrong to avoid receiving additional funds for the improvement of the local healthcare system.
Eventually, Governor Hutchinson’s view was supported by the majority of the legislature, and a new program was introduced called “Arkansas Works.” The official waivers were approved by the United States Department of Health and Human Services, and the program constituted a modified form of the first version (Johnson, 2016). The policy’s additions included premium payments of less than 2% of income for certain beneficiaries and an end of a 90-day retroactive eligibility coverage (Johnson, 2016). The passing of the program proved that the success of the Private Option model developed and pioneered by Arkansas.
Additional Requirements
Since the government of Arkansas was primarily controlled by the Republicans during the years after the passing of the ACA, it remained one of the main states to continue opposing Obamacare. Moreover, in order to increase the efficiency of the provision of the program, Arkansas developed special requirements. Basically, the state introduced certain terms which people had to observe in order to be eligible for Medicaid. Arkansas established community engagement requirements which mandated people to work at least 80 hours a month and participate in activities such as job training with exemptions for people with disabilities (Sommers et al., 2018). The policy aimed at promoting better health outcomes for the beneficiaries and encouraging them through incentives to escape poverty.
At the same time, it is possible to assume that the core idea behind the requirements was to limit the access to subsidized medical services to people who intentionally remain unemployed to receive social support. Critics of the initiative stated that similar policies which were introduced in the past did not produce any positive impact on the income of its beneficiaries (Sommers et al., 2018). The main penalty for avoiding following the requirements established in Arkansas was the loss of access to Medicaid (Sommers et al., 2018). Based on the official data, by December of 2018, the total number of people removed from the program exceeded 15,000 people (Sommers et al., 2018). Basically, a large portion of the Medicaid beneficiaries in the state simply could no longer receive free medical services. Nevertheless, in 2019, a federal judge had to halt the requirements policy saying that it had a negative effect on the coverage (Sommers et al., 2018). Essentially, the efforts of the state to introduce additional adjustments to the program are at risk of being repealed by courts.
Arkansas Health and Opportunity for Me
The passing and implementation of the “Arkansas Works” program once again were proven to be successful, and currently, the state is preparing to adopt a new Medicaid alternative. Arkansas Health and Opportunity for Me (ARHOME) is the program designed by Arkansas which will have to replace “Arkansas Works” in the near future (Huberfeld, 2021). Yet, compared to the previous iteration, the new program also has several important additions and changes. One of them is the aforementioned community engagement requirement which, nevertheless, no longer entails a punishment but serves as one of the conditions for eligibility. According to the program, a person who fails to observe the conditions specified by the policy will be denied access to qualified health plans and will be transferred to a fee-for-service Medicaid program instead (Huberfeld, 2021). Such terms may actually be more acceptable for courts, as well as federal officials.
At the same time, there is still a possibility that the new legislation will not be approved, considering the fact that President Biden’s administration may be opposed to the policy. Another condition of the new program involves imposing premium and cost-sharing obligations on every person who enrolls in ARHOME (Huberfeld, 2021). Yet, initially, the Medicaid extension was intended for poorer populations who could not pay for healthcare expenses. Thus, the existing situation puts the United States Department of Health and Human Services in a difficult position where it should potentially approve a conflicting program. Moreover, since ARHOME was drafted primarily by the Republicans, it is unclear how the Biden Administration will approach the policy.
Conclusion
Since its adoption, the ACA has been considered a divisive law which still affects the healthcare systems of states in different ways. Arkansas is an example of a state which refused to adopt the standard form of the ACA and designed its own Private Option based on purchasing qualified health plans. Despite political tensions between the members of the Democratic and Republican parties, Arkansas manages to maintain its policies at the level appropriate for every stakeholder. The Health Care Independence Program became the first alternative to the Medicaid expansion adopted in Arkansas. Several years later, the state legislators have introduced several additions to the initial law and now require people to pay out-of-pocket for certain medical services. At the same, the example of Arkansas shows how two parties can collaborate together to overcome existing issues and find effective solutions.
References
Banks, C. (2018). Controversies in American federalism and public policy. Routledge.
Béland, D., Rocco, P., & Waddan, A. (2019). Policy feedback and the politics of the affordable care act. Policy Studies Journal, 47(2), 395–422. Web.
Bollinger, M., Pyne, J., Goudie, A., Han, X., Pharm, T., & Thompson, J. (2021). Enrollee experience with providers in the Arkansas Medicaid expansion program. Journal of General Internal Medicine, 36, 1673–1681. Web.
Gaffney, A., & McCormick, D. (2017). The affordable care act: Implications for healthcare equity. The Lancet, 389, 1442–1452. Web.
Goudie, A., Martin, B., Li, C., Lewis, K., Han, X., Kathe, N., Wilson, C., & Thompson, J. (2020). Higher rates of preventive health care with commercial insurance compared with Medicaid. Medical Care, 58(2), 120–127. Web.
Huberfeld, N. (2021). Medicaid waivers, administrative authority, and the shadow of malingering. Journal of Law, Medicine & Ethics, 49(3), 394–400. Web.
Johnson, B. (2016). Arkansas in modern America since 1930. University of Arkansas Press.
Patel, K., & Rushefsky, M. (2019). Healthcare politics and policy in America. Routledge.
Perkins, J. (2020). The affordable care act in court: Litigation continues unabated. North Carolina Medical Journal November 2020, 81(6) 386–388. Web.
Sommers, B. D., Goldman, A. L., Blendon, R. J., Orav, E. J., & Epstein, A. M. (2019). Medicaid work requirements — Results from the first year in Arkansas. New England Journal of Medicine, 381(11), 1073–1082. Web.
Sommers, B., Blendon, R., Orav, J., & Epstein, A. (2016). Changes in utilization and health among low-income adults after Medicaid expansion or expanded private insurance. JAMA Internal Medicine, 176(10), 1501–1509. Web.
Weissert, C., Pollack, B., & Nathan, R. (2017). Intergovernmental negotiation in Medicaid: Arkansas and the premium assistance waiver. Publius: The Journal of Federalism, 47(3), 445–466. Web.