There have been some rumblings at the Capitol that Democrats are warning that Gov. Asa Hutchinson shouldn’t take their votes for granted on the private option, the state’s unique version of Medicaid expansion. They believe that they have some leverage, and could threaten to withhold their votes if they don’t get concessions or a seat at the policy table. Without the support of Democrats, the private option would have no hope of being re-authorized this spring.
There’s been a lot of fireworks on social media the last few days on this topic, but not much by way of public comment from Democratic lawmakers. I spoke with House Minority Leader Michael John Gray today to get a read on what the Democratic caucus is thinking.
“We’re absolutely in favor of the private option, that’s a no-brainer,” Gray said. However, he said that the caucus didn’t want to take a position on “Arkansas Works” — a continuation of the private option with some alterations pushed by Hutchinson — until they actually see the legislation.
That’s fair enough. We have a relatively clear picture of what “Arkansas Works” will look like, and the federal government has already done a lot of the legwork in terms of constraining the governor’s worst impulses, but of course the details matter and Democrats should work to ensure that beneficiaries are protected and that the core goals of the coverage expansion are still being served.
But I wanted to ask Gray directly about the idea of actually threatening to end the coverage expansion in order to try to get something from Hutchinson. If the private option ends, it would mean 267,000 poor Arkansans lose their health insurance. The end of the PO will also mean that billions of dollars stop flowing into the states’s economy, hospitals will be hit with hundreds of millions of dollars in uncompensated care costs, and the state budget will take a hit of more than $700 million over the next five years.
“We have a moral imperative to continue Medicaid expansion in Arkansas, period,” Gray said. “I’m not interested in playing chicken with the insurance of 300,000 Arkansans. I think it’s bad policy, I think it’s bad politics, I think it’s bad morals. That’s what Tea Party Republicans have done and I don’t think it’s the right thing to do. This is people’s lives. We’re not advocating playing chicken with people’s lives.”
However, Gray said, the Democratic minority wants to ensure that the governor doesn’t run them over in terms of budget priorities, Arkansas Works details, or his push for managed care in the traditional Medicaid program.
“If we have to stand firm a little bit to make sure the right thing gets done, we want to use what influence we can to improve quality of life in Arkansas,” he said. “If that means talking about budget issues, if that means asking for some baseline budgets to be restored that were cut in the name of capital gains taxes, then we want to use that leverage a little bit.”
Here’s where I get a little confused about the endgame. It’s certainly true that Democrats have leverage in this sense: If Democrats don’t vote to re-authorize the PO, it will be impossible for Hutchinson to get the needed supermajority to keep the coverage expansion in place. The math isn’t complicated — a substantial number of Republicans won’t vote to accept the federal funds to continue Medicaid expansion under any circumstances. Without the support of Democrats, the private option — and health insurance for 267,000 Arkansans — will come to an end. But that leverage only works if Democrats are actually willing to make good on this threat. And if you care about the well-being of poor people in Arkansas, that would be a catastrophic outcome. If Gray and the Democrats believe (correctly, in my view!) that it is a moral imperative to continue the Medicaid expansion in Arkansas, will the governor or the Republican leadership actually believe that Democrats will join forces with Tea Party Republicans to end the coverage expansion?
Gray acknowledged that it was a sticky issue, and he said that all legislators, whether Democrat or Republican, should vote to continue the coverage expansion because it was the right thing to do for the state of Arkansas. But he said that Democrats needed to signal that the governor has to form a “reasonable partnership” with them if he wants their votes on the private option.
“Democrats are going to have to not commit our vote,” Gray said. “We’re going to have to say that while we absolutely have a moral imperative for these Arkansans, we’re not going to blindly support policies that hurt these people while doing it.” Gray said that Democrats would tell the governor: “You need us to vote for this, we want to vote for this, but we need some goodwill extended.” In addition to health care issues, Gray mentioned the “restoration of budget items that were cut in the name of capital gains tax cuts,” perhaps additional funding for after-school programs or public libraries. “If we can effect something that improves the lives of Arkansans that they cut this last session, then we want to do it,” he said.
Gray said that the need for Democrats’ votes on the private option was a rare leverage point. “A lot of times, 35 members aren’t going to be able to make that difference,” he said. “Now we can.”
Gray noted that several Democrats abstained from yesterday’s task force vote on “Arkansas Works,” in part to protest the governor’s tactics to advance his plan for managed care for certain populations in the traditional Medicaid program. There might be similar tactical or symbolic moves that Democrats could use to send a message without literally ending the coverage expansion. It’s not hard to imagine opportunities for political theatrics as pressure points along the way: Some Democrats could abstain from voting for the enabling legislation in the special session, which only needs a simple majority, or some could withhold their votes on the first vote on the appropriation. That would represent a series of headaches and hurdles that the governor would presumably like to avoid given that he’s already facing a steep climb to pass the PO. “Nobody wants to get to that point,” Gray said.
In other words, Gray seems to be offering an opportunity to lock in 35 votes for the PO in the House if the governor is willing to work with them.
“Let’s continue this reasonable partnership,” he said. “But don’t just count us as a yes and plan 17 other tax cuts based on the savings you’re fixing to realize from our yes votes. We have to be willing to send that message.”
I asked whether there are Democratic lawmakers who would actually carry out a threat to end the coverage expansion if they didn’t get their way.
“The reality is that there are Democrats within the caucus who could take a nonvote on this and not be hurt,” Gray said. “That’s a personal decision they’ll have to make on whether they can live with [the possibility that] they might have been the reason it didn’t pass. That’s a personal and moral decision. But realistically, there are some districts that it can be messaged that this was not the private option, this was not good for their people and the governor has been not good for the people that they represent, and they couldn’t support this. But that’s not the track I want to take. The track I want to take is: Governor, the leverage here is you need all of us, and if we can use this leverage to improve the lives of the people we represent, that’s what we’re going to do.”
Gray said that the governor needs to do something to hold those potential rogue Democrats on the Yes side. “It’s not a hollow threat, it’s not empty leverage,” he said. “It’s you want us to be reasonable — help us find that space to be reasonable in. If you want us to be the adults in the room, then you’ve got to start listening to us on the front end.”
p.s. There’s a whole other can of worms I’m not getting into here — the possibility that some Democrats might threaten to withhold private option votes in order to block managed care for the developmental disability and behavioral health populations in the traditional Medicaid program. I’ll tackle that in a subsequent post.
Support for special health care reporting made possible by the Arkansas Public Policy Panel.