More than 200,000 adults gained coverage under the state's expansion of Medicaid to households with incomes up to 138% of the federal poverty threshold, which was authorized by the Patient Protection and Affordable Care Act. To win the approval of the Republican-led Legislature for the expansion, Beebe got the Obama administration to approve a pioneering expansion model relying on commercial health plans. Under the so-called private-option approach, the new Medicaid beneficiaries enrolled in plans purchased through the federal exchange, paid for by the state Medicaid program, with 100% federal funding. Beebe and other supporters argued that using private exchange plans was a better way to expand Medicaid coverage because people could keep their same plan and providers if they left Medicaid and moved into the exchange market.
That private-market alternative to government-provided Medicaid coverage has become a template for other Republican governors and lawmakers considering expanding Medicaid without fully embracing Obamacare. Some conservatives see it as a more acceptable, market-oriented approach.
Healthcare providers have applauded the state's coverage expansion. At the University of Arkansas for Medical Sciences, the state's only academic medical center, the share of patients lacking coverage fell from 13% to 4% over the past year. Little Rock's Harmony Health Clinic, a free clinic that provides care only to uninsured people with incomes below 200% of poverty, has seen its patient population drop from 2,000 to 1,000 due primarily to Medicaid expansion.
"They're getting the best quality healthcare some of them have ever gotten in their lives," said Eddie Pannell, Harmony Health Clinic's executive director. "It's good for the economy. It's good for the hospitals. It's good for our patients. I'm going to be very heartbroken if it's overturned and now we have a thousand patients coming back to us."
This election carries high stakes for healthcare in Arkansas. Democratic U.S. Sen. Mark Pryor, who touted his support for the ACA in a TV ad discussing his own bout with cancer, is among the most endangered Senate incumbents in the country. In the polls, he has been consistently trailing Republican Rep. Tom Cotton, who repeatedly has bashed the law but who has sidestepped questions about the state's successful coverage expansion. The outcome of that race will help determine whether Republicans can win control of the Senate and gain leverage in rolling back Obamacare. In the final days of the campaign, Cotton and allied conservative groups have doubled down on their Obamacare attack ads.
The contest to replace Beebe in the governor's office pits two former congressmen, Democrat Mike Ross and Republican Asa Hutchinson. A pair of open U.S. House seats--in the 2nd and 4th congressional districts--also feature highly competitive contests despite pronounced GOP tilts in both districts. The latest polls show Democrat Patrick Henry Hays with a narrow lead in the 2nd and Republican Bruce Westerman with a slim advantage in the 4th.
And control of the Arkansas House, where Republicans currently hold a 51-49 majority, will be determined on Election Day.
The outcome of the state races could be pivotal for continuation of Arkansas' expanded Medicaid program. Under state law, the Legislature must reauthorize the expanded program annually. Because it's part of the budget, passage requires support from three quarters of the members of the House and Senate. Earlier this year, the House voted down reauthorization four times before finally passing it. The private-option plan cleared the Senate without a single vote to spare.
State Sen. David Sanders, one of the Republican architects of the private option, said supporters of continuing the expansion didn't have enough votes at the start of the legislative session. They had to entice some previous opponents, notably GOP Sen. Jane English, with conservative-friendly changes to the program. The state has submitted a request to the CMS allowing it to require Medicaid beneficiaries, even those with incomes well under poverty, to contribute to health savings accounts. Up to now, the Obama administration has refused to approve state proposals to impose premium contributions on people under the poverty level.
But Sanders said it's far from certain that the votes will still be there when the private-option expansion program comes up for reauthorization next year and beyond. "It's going to be tough," he said. "We knew it would always be tough."
The gubernatorial race potentially could have the greatest effect on whether the private option remains in place. Republican Hutchinson, who has held a steady lead in recent polls, has been noncommittal on the issue. "I view the private option as a pilot project ... that can be ended if needed," Hutchinson said in a written statement. "As governor, I will weigh the cost and benefits of the program and determine whether the program should be terminated or continued."
Jay Barth, a political science professor at Hendrix College in Conway, said he expected Hutchinson to moderate his position on the Medicaid expansion after winning a primary election in which he faced a challenge from his right flank, which required expressing hostility to all things Obamacare. "I was surprised that he didn't become a little more friendly to the private option after that point because it is pretty popular, especially with moderate voters," Barth said. "He's kind of evaded a definitive stance."
Democrat Ross has touted support for the Medicaid expansion as one of his top priorities on the campaign trail. That stance is somewhat surprising given that Ross voted against the Affordable Care Act when he was in Congress in 2010, and was one of only three Democrats to back repeal after Republicans won control of the House.
But the state legislative contests also could prove crucial. Another of the key Republican architects of the Medicaid expansion based on private plans, Rep. John Burris, lost his primary contest in June, largely because of his support for the expansion. That served as a warning shot for other Republicans willing to seek some accommodation with Obamacare.
Republican state Rep. David Meeks, who voted this year against continuing the Medicaid expansion, said the ouster of Burris and other supporters of the program means there no longer are the necessary 75 votes in the House to keep it in place. "Even those of us that oppose it, we're looking not necessarily to completely throw it out, but to make it more sustainable," Meeks said in an interview. "If we're going to throw it out, we're going to replace it with something better."
John Adams is running for the state House as a Democrat in a West Little Rock swing district. Support for the private option has been a key plank of his campaign. His Republican opponent, Jim Sorvillo, has been noncommittal about the program, focusing instead on his opposition to the overall healthcare reform law. But Adams said voters in the relatively affluent, educated district, which includes many workers from area hospitals, want more specifics.
The strategy of just repeating the president's name and his signature law ad nauseam works less well with the middle-class, professional folks who really dominate in this part of town," Adams said. "Even folks who are conservative want to hear an answer."
Back at the GOP rally in Conway, McClellan isn't interested in a detailed discussion of the Medicaid expansion. The truck driver believes any such plan is financially unsustainable given the federal deficit, worrying that future generations will bear the financial burden. That means he plans to vote for Republicans across the ticket, including Cotton over Pryor in the U.S. Senate race.
Pryor "voted for Obamacare (when) over 70% of the state was against it," McClellan said. "He votes against the state of Arkansas every time."
Follow Paul Demko on Twitter: @MHpdemko