The key Republican architects of the Arkansas private option healthcare expansion are pressing for an additional waiver of federal Medicaid rules to end the mandate that the state must provide non-emergency medical transportation to private-option beneficiaries without the means to get to their healthcare provider.   

The private option uses Medicaid funds to purchase private health insurance plans for low-income Arkansans. Non-emergency medical transportation (NEMT) is the most prominent example of a required “wraparound” service — a guaranteed Medicaid benefit that the state must provide if the private plan does not. If a private-option beneficiary can prove they have no way to get to the doctor, the state has to offer transportation. 

Iowa recently received permission from the feds to pursue an approach to Medicaid expansion similar to the Arkansas private option, but while Arkansas had agreed to ensure that private option beneficiaries had access to all Medicaid benefits, Iowa got a one-year waiver from the NEMT requirement. Now, as Sen. David Sanders — one of the key Republican backers of the private option — put it: “we want what they have.” 

This is one example of the sorts of “tweaks and adjustments” that proponents of the private option are hoping will attract or solidify Republican votes for the policy, which faces an uphill climb to a supermajority in this year’s fiscal session (see our recent cover story for more on possible tweaks to the policy, which would likely come as special language tied to the appropriation rather than changes to the underlying law). Even some opponents of the private option, as Rep. Nate Bell has told us, may be willing to support the appropriation in 2014 if they can get some concessions, figuring that they’ll be on stronger political ground to actually fight the policy in 2015 given the constraints of the fiscal session. 

“We’ve got a pretty active discussion with House members,” Sen. Jonathan Dismang, one of the key Republican backers of the private option said. “If it were to stay in place, what would the members that oppose like to see? There were some concerns for instance about the wraparound services. …[Iowa] got a waiver to eliminate the [NEMT] requirement. Those are all positive things we should be looking to do. …That’s part of the ongoing conversation.” 

Given that more than 100,000 (and counting) Arkansans have gained coverage because of the private option, a request to the feds for an NEMT waiver is likely something Republicans could get without losing Democratic support for the needed supermajority, but progressives won’t be happy. Advocates for this Medicaid benefit argue that it provides vital access to care for those without access to transportation, particularly in rural areas of the state, and that it ends up saving money by directing people to primary care rather than the ambulance and the ER. See, for example, this Twitter back-and-forth between Sanders and Joan Alker of the Georgetown Center for Children and Families, a strong proponent of protecting benefits for beneficiaries. 

As soon as Iowa got the NEMT waiver, Alker worried that Arkansas would follow with its own request: “this is the concern about Iowa going down this path even for one year — it’s a bad precedent.” 

I’ve mentioned a few times the question posed by the Washington Post’s Sarah Kliff: “Could Obamacare make Medicaid more Republican?” The dynamic is this: The Supreme Court decision last June left it up to states to decide whether or not to expand Medicaid. The Obama administration is desperate to get states on board—24 states have refused, including big-population states like Texas and Florida, leaving millions of uninsured folks in a coverage gap. In order to bring states on board, the administration has been more willing to bend and be flexible than some initially thought. Some Republicans, instead of flatly saying no, came with requests that might get them to a yes. Readers of this blog know that one of the first examples of this flexibility in response to Republican skepticism of expansion was the “private option.” Now, states like Iowa are seeing what else might be on the table. As Kliff put it, “In a weird way, Obamacare could end up changing the Medicaid program not just by making it bigger — but by making it more Republican, too.”

This dynamic — red states asking the feds for what the last state got, +1, and continually piggybacking off of each other — is precisely Sanders’ vision for the private option. Here’s Sanders in an exchange with Medicaid Director Andy Allison in testimony at the joint Public Health committee last month. (It appears that DHS officials are very much on board with seeking an NEMT waiver.) 

Sanders: “One of the things we have seen…because [states] are laboratories of democracy, we have other states that are seeking similar waiver authority. Utah is seeking similar waiver authority. Gov. Terry Branstad, the governor of Iowa, has received the authority to pursue a similar plan. One of the things that we saw [in Iowa] — we knew other states would also innovate. What we all hoped for was that when other states innovated that we would also have an opportunity to use their innovation, so it’s not just viral but a viral relationship that moves back and forth. … I’m interested in the push for innovation and some of the things we’re seeing in other states. Specifically, one of the concerns here was the idea of wrap coverage — what we have to provide in addition to the benefits that are in the health plans. … Our friend to the north, Gov. Branstad, got a waiver for non-emergency transportation. What are we looking at on that and what do we think the opportunity is?”

Allison: “We noticed that Gov. Branstad got something that we didn’t. And certainly a great percentage of the time in developing and implementing the private option has been spent on this thorny issue of wraparound services and at every turn we have avoided them [through routing the medically needy to traditional Medicaid rather than private plans]… I regret that we didn’t get transportation as well. But if it be the will of the legislature, we would be glad to listen to the will of the legislature. We would certainly consider that.”

Sanders: I think we want what they have — so I think at least for this guy, yes, let’s get a waiver for non-emergency transportation. 

Rep. John Burris, another key Republican backer of the private option, confirmed that a waiver on non-emergency transportation “is something people are interested in.”

I was never too concerned about the argument of wrap because it was so small and we handled it in such a good way. But you know what, it is symbolic to say ‘you don’t even have to provide that service.’ That really is the last checkbox…to telling people this simply is not Medicaid. At that point there’s no wrap, it’s just straight-up healthcare coverage just like you and I have. I think that’s something that we should look at and possibly pursue. I think that’s what some members are working on. 

But if Republicans are excited about the prospect of chipping away at mandated benefits, local progressives are concerned. Arkansas Advocates for Children and Families has been front and center in rallying support for the private option. I asked their Health Policy Director Anna Strong, about the possibility of Arkansas pursuing a waiver of NEMT. Her response:  

Non-emergency transportation to medical appointments is an important component of access to care for lower-income families. Access to preventive and primary care help keep the costs of health care low by keeping people out of ambulances and emergency rooms. However, this works only if enrollees can take advantage of their health care benefits, and some may need the Private Option’s transportation benefit to access primary care.

Arkansans eligible for the Private Option are less likely to have access to reliable transportation due to their lower incomes. An insurance card isn’t very useful if the cardholder isn’t able to afford a ride to an appointment or if the ride means missing a meal or not making rent. In many rural areas of our state, affordable transportation to specialist appointments in a larger city may be non-existent or overly expensive without this benefit. When used as a last resort, transportation to medical appointments is a cost-effective investment.

Arkansas needs to stay its course and continue to provide non-emergency transportation to medical appointments as part of the full benefit package for Private Option enrollees.