Supporters of Arkansas' "private option" agree that keeping the state's compromise Medicaid expansion alive is going to require overhauling a program providing coverage to thousands of residents. The challenge is coming up with changes that can win the support of federal officials and skeptical lawmakers on both sides of the debate.
The program's fate is expected to become clearer this week, with Republican Gov. Asa Hutchinson set to deliver a speech Thursday on the future of health care in Arkansas that will also address his plans for the private option.
Hutchinson has signaled that if he supports keeping private option in place, he'll want to transform the program and the overall Medicaid system. Senate President Jonathan Dismang, R-Beebe, one of the architects of the private option, has said it "is not going to exist in its current form" given the number of opponents elected to the Legislature.
State officials say they don't have to look further for ideas than states that followed Arkansas' lead in creating a hybrid approach to expanding Medicaid.
"We were really the first out of the gate with something really innovative," Department of Human Services Director John Selig said. "I think other states have said let's build on that, and I think one of the things Arkansas will want to come back and say is 'Do we want to learn from that and go further?'"
Under the program Arkansas approved two years ago, the state uses federal funds to purchase private insurance for more than 213,000 low-income residents. The plan was crafted as an alternative to expanding Medicaid under the federal health law. Most changes to the program would require approval not just from the Legislature, but from federal officials.
One idea that Dismang has floated is tying private option enrollment to a requirement that beneficiaries work or be actively seeking employment. Selig said no state has received approval for a work requirement, but federal officials have approved tying it to job referrals or training.
Rep. Kelley Linck, chairman of the House Public Health Committee, has said he'd be interested in measures aimed at promoting or providing incentives for healthier lifestyles. Another possibility could include further restrictions on non-emergency transportation for private option participants.
Other changes lawmakers could weigh may include expanding cost-sharing by participants through copays and coinsurance.
"I'm not hearing near as much 'we've got to do away with it, we've got to do away with it,' but maybe what can we do to make it even more conservative?" said Linck, R-Flippin.
The federal government late last year approved some amendments to the private option, including requirements that some participants contribute monthly to health savings accounts and new limits on transportation for non-emergency services. The changes were proposed to win the three-fourths support needed in the House and Senate to keep the expansion alive.
The Legislature also approved a provision barring the state from spending any public funds to promote the private option or other parts of the federal health overhaul.
It's unclear what changes, if any, could convince lawmakers who ran against the private option to support its reauthorization. Reauthorizing the program will require three-fourths support in the House and Senate, a hurdle supporters barely cleared last year.
Sen. John Cooper, R-Jonesboro, said he'd support gradually phasing out the program but not any proposals that stop short of that.
"I think it's pretty clear (newly elected lawmakers are) there to make pretty significant changes, which to me means at some point ending it," Cooper said.
Another obstacle may be Democrats, who express weariness about any compromise plan that limits enrollment or puts too many restrictions on a program advocates have credited with cutting the uninsured rate in Arkansas.
"We are not here to ... succumb to erroneous amendments this time that may impede the actual progression and growth of the private option as it currently stands," said House Minority Leader Eddie Armstrong, D-North Little Rock.