As expected, there was again no vote today in the Arkansas House of Representatives on the private option. The House adjourned until Monday, with the count for the private option apparently still at 73, two short of the needed 75-vote supermajority.

House Speaker Davy Carter
has been meeting with opponents over the last two days and proponents have said that progress is being made. Details remain scant on just what’s being discussed. It remains hard to imagine substantive changes to the bill that could maintain the needed support, though there may be possible concessions not directly included in the appropriation itself. 


Opponents now appear to be focused on limiting enrollment. That, of course, was the goal of the Bell amendments and Democrats are unlikely to go any further. 

Officials from Department of Human Services and Surgeon General Joe Thompson have been meeting with the governor today, so they may be working on the outlines of a deal.


UPDATE: Here is the deal potentially on offer, according to multiple sources [the broad outlines of which have now been confirmed publicly by the Speaker]: a limited enrollment period in the private option itself (access to private plans). But outside of that enrollment period, beneficiaries could still sign up for traditional Medicaid. Just why opponents of healthcare expansion would make this a priority is a little unclear to me (focus on personal responsibility and initiative in order to get in to the private plans?), but I will update with details. This would require federal approval to enact (shouldn’t be a problem) and would likely take effect some time in 2015. Nothing would be added to the bill itself, so it would not need to go back through the Senate. Most likely this would simply entail a commitment from DHS to seek permission from the feds to pursue this path — no legislative approval would be required at all. 

Details are still being hammered out, but it sounds like the potential enrollment period might operate similarly to the way the Obamacare exchange functioned this year. From Jan. 1 through March 31 of 2015, eligible people could enroll in private plans. Then, for the rest of the year, eligible people would only be able to enroll into traditional Medicaid, and would then only have the opportunity to enroll in private plans during the enrollment period the following year. Unclear whether the folks signed up to traditional Medicaid would then be required to enroll in a private plan during the enrollment period or could just choose to stay in traditional Medicaid, not an option under current policy. Presumably people already enrolled in private plans in 2014 would have a more streamlined process of re-enrolling. 


The federal match rates — with the feds covering 100 percent of the costs for the first three years — would be the same whether folks were in traditional Medicaid or the private plans. It’s already the case that people are covered by traditional Medicaid as soon as they’re deemed eligible until they complete the enrollment process. In practice, this approach would simply have them start in Medicaid for a longer period of time if they signed up outside of the enrollment period. 

This might add a small layer of administrative hassle or expense and a bit of additional confusion for beneficiaries, but from the perspective of covering low-income Arkansans, it would achieve the same results. It’s just that a small group of people would end up on traditional Medicaid for a while before ending up on private plans, if they signed up outside of the enrollment period. Oddly, the private option was a compromise to get Republicans aboard by routing the Medicaid expansion through the private market, but this deal would in effect shift some people, at least for part of the year, from the private market to the state-run Medicaid program. 

One other small point is that it would keep a small portion of the private option group out of the risk pool on the Health Insurance Marketplace for part of the year, which might add some uncertainty for carriers and have a minor impact on premiums. (It would also, of course, lead to less months of paying customers for insurance companies.)

One question: given Rep. Nate Bell‘s amendment banning outreach — how would beneficiaries be informed of a limited enrollment period? It’s hard to see the point of a special enrollment period if people don’t know about it. 


Given that the private option is intended as an experiment in using private insurance to expand coverage to low-income people, having a portion of those folks on the old state-run fee-for-service Medicaid program for part of the year seems like an unnecessary layer of complexity. As a policy idea, it’s not good. But given that it would maintain the same level of coverage, I expect this is something private option supporters could live with if it brings a few votes aboard. Will it be enough to finally close the deal next week? As always, things remain fluid. We’ll see. 

The idea came out of discussions between House leadership and private option opponents, according to House Speaker Davy Carter. The opponents were focused on the idea of some sort of a limited open enrollment period to make the private option more like private employer-sponsored insurance or the private insurance sold on the Health Insurance Marketplace. That was an idea “worth of discussion,” Carter said, though he acknowledged that he personally might prefer to simply enroll people in private plans year round. 

Carter said that many opponents had come to an understanding that the votes weren’t there to dramatically alter the bill itself. “Reasonable minds can get together and figure out — if that’s not an option, what is,” he said. Carter said that details were still being hammered out with DHS to figure out how the idea might be enacted and how it will fit within federal and state law. “This is a complex issue as far as this open enrollment goes,” he said. Asked about people potentially being routed to the traditional Medicaid program, he said DHS officials were also exploring just how the process would work for eligible beneficiaries outside of the open enrollment period, and that no one yet had a “definitive answer” on that. 

Carter was upbeat about prospects for passing the private option next week: 

We’re going to take care of our business here. We’re not going to let the people of Arkansas down. I hear that a lot from the members and we’re going to do that. We’re not going to leave here without having a budget. We’re going to get this issue resolved. Hopefully we’re much closer to having this issue resolved today than we were yesterday. We’ll show up on Monday and try and get it done. 

Nearly everyone I spoke with this afternoon at the Capitol believes that we’re heading to the finish line, with a final vote Monday or Tuesday snagging the needed votes. But after the last few weeks, take any optimistic prediction on the House with a grain of salt the size of Mt. Magazine. It would be a fitting conclusion, I guess: this weird deal, made to reach our state’s quirky supermajority requirement, needed to pass our oddball version of Medicaid expansion. Arkansas! 

p.s. The filing deadline for primaries is this Monday at noon, which may be as big of a factor in making progress on the private option as any “deal.”