In Arkansas lawmakers and health officials have been exploring the outer limits of Medicaid expansion for several years now, typically pushing for more restrictions on the insurance program for low-income residents made possible by the Affordable Care Act. And under a Donald J. Trump presidency, some conservatives are eager to push the parameters of coverage to require more from low-income beneficiaries.
Indiana's version of Medicaid expansion includes requiring that beneficiaries pay premiums or risk losing coverage. Democrats say that is counter to the idea of Medicaid expansion, which is to provide insurance to people who are too poor to pay for insurance. But, conservatives in Indiana argue the premiums are small enough to be reasonable and that it will encourage responsibility in financial and health matters.
NPR's dive into Medicaid includes a talk with Joe Thompson, who was Arkansas's surgeon general when Medicaid expansion was adopted by a bi-partisan legislative coalition while Democrat Mike Beebe was governor. Thompson now heads the Center for Health Improvement.
His take: Arkansas had tried similar approaches and asking poor people to put up money for health insurance is a bridge too far for both residents and the state bureaucracy.
Joe Thompson, CEO of the Arkansas Center for Health Improvement, says it's just hard to be poor.
"The social stresses of low-income individuals probably make most aspects of managing through the day more difficult than if you have more affluence and have more resources available to deploy," he says.
Thompson, who's a former Arkansas surgeon general, helped develop a Medicaid program in his state that had many of the same features as Indiana, including premium payments and health savings accounts. In the end, Arkansas decided it just wasn't worth it.
"We had about a year and a half of experience there, and candidly the administrative cost and the operating aspects exceeded what the legislature subsequently perceived the benefit of that program was," Thompson says.
So the state scrapped the health savings accounts. He says the ideas about personal responsibility are politically popular, but implementing them is too complex.
"We lose too many folks along the way, and we may be causing more challenges than we're solving," he says.
Arkansas still charges nominal premiums for some Medicaid recipients, but they pay them directly to insurers. The carrots and sticks and individual accounts are gone.
The general notion behind the expansion of Medicaid is to provide insurance to low-income people who otherwise wouldn't be able to purchase insurance. The ACA expanded coverage to people earning up to 138 percent of the federal poverty level. But the federal health care law also allowed for some flexibility at the state-level to modify the terms of Medicaid.
Arkansas has successfully sought waivers to use federal dollars to purchase private insurance for beneficiaries rather than utilizing the federally run Medicaid program. Governor Asa Hutchinson's administration this year got several new waivers approved by federal officials at the U.S. Department of Health and Human Services. Changes to the state's program include workforce training referrals and small premium payments for the richest of the l0w-income beneficiaries.
A Supreme Court ruling made Medicaid expansion an optional component of the ACA. Arkansas was one of a handful of Republican states that chose to participate and accept federal dollars for Medicaid expansion. Over 300,000 Arkansans have gained coverage through the program. All of them would lose coverage if the ACA is repealed by Congress.
Governor Hutchinson has said he supports the repeal of the federal healthcare law but favors some form of continuation of federal funds to keep Arkansans covered by Medicaid expansion insured. He also has interest in seeking new waivers under the Trump administration geared toward workforce participation and more employer-based coverage.