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Friday, January 31, 2014

Taking the pulse of the Arkansas legislature on the private option (Part II)

Posted By on Fri, Jan 31, 2014 at 4:06 PM

click to enlarge MALONE: "I’m just going to sit back and listen to both sides."
  • MALONE: "I’m just going to sit back and listen to both sides."

Reporting this week's cover story, I  spoke with dozens of lawmakers about the private option. The fate of the policy – which uses Medicaid funds to purchase private health insurance for low-income Arkansans – hangs in the balance in the coming fiscal session.

Here's a sampling of what I heard from legislators, in their own words. See here for a previous sampling. This round focuses again on Republicans, both on leadership and on possible swing votes. I'll post a compilation of Democrats' thoughts this weekend. 

REP. STEPHANIE MALONE (voted YES on private option appropriation last session)

Obviously things have changed at the federal level, which changes it here at our level, so I’m just going to sit back and listen to both sides. I can’t say I’m committed either way because so many things have changed since we were in session.

One of my big things, there was going to be a fine to small businesses and they delayed that at the federal level. It seems like every time we turn around there’s something new that we were told was going to happen that’s either delayed or set back…everything just seems so uncertain. 

I asked about the 100,000 Arkansans (and counting) who would lose coverage I the private option is defunded.

We’re obviously going to have to fill the gap that’s left there. …That's something we'd have to figure out a way to fix. That's a strong reason — to the people against it, if you're opposed to it, then bring me a solution to that.

HOUSE SPEAKER DAVY CARTER (voted YES last session)

I still think that we’re in a good spot. I think we’ll talk about it some more. There’s a lot of stuff that’s happened between then and now that, to me, only supports the reasoning and thought process and all the original support behind it. At the end of the day, I think once we go through this process again that we’ll pass it because it continues to make sense to pass it.

[We] want to make sure everybody knows how the implementation process has gone so far and has all the updated numbers. Just look at it all again. All that data is nothing to run from. It supports [that we're] still moving in the right direction.

The implementation process nationally that’s gone on, that hasn’t helped anything. That was a complete screwup. That made all of our jobs harder.

I’ve been asking the question this past month—[enrollment in the Marketplace] has been so bad, if we don’t continue the private option, that’s what we’re going to be left with. Nobody can cast their vote in the state General Assembly to make all this stuff go away. The private option is not perfect but it’s a heck of a lot better than the alternative. I will tell you, if it was possible just to make the entire thing go away, make the ACA all go away, I bet there’d be 90+ votes in the House. But we can’t do that. 

REP. ANN CLEMMER (voted YES last session)

I’m still on the fence. I don’t think there’s a clear case that this is the right fix. Obviously we don’t want Obamacare. My favorite quote was from Rep. Ferguson, she said it was the best horse in the glue factory.

I don’t even know whose information I can trust. That’s what bothers me right now. That’s a pretty sad state for voters too.

Clemmer is facing off against French Hill in the Republican primary for Congress, Second District. The private option will likely be an issue in the primary. 

You’re trying your best to lead. But it’s that old quandary. If your voters are directing…this is a democracy so you’re trying to be a fair representative of them. [But it’s also a republic.] My judgment definitely comes in to it and I’m not taking a head count about what the voters believe. Because I know that there is mass confusion out there. But if I’m going to lead, I’ve got to have the absolute best information. I may have to sequester myself.

I think it’s fair to say that if I were convinced that it was the absolute clear-cut best decision, then let the politics go where they are. ... But I have a great deal of ambivalence about it. And then the politics can push. When we teach this stuff, we talk about the different roles of the representative. You can be a trustee. But then there are times when the public becomes so engaged that they are directing their representative to vote a certain way. Again, if I feel like it’s the clear, absolute right thing to do than I’m going to do it regardless of the politics. …I’ve always taught that what I wanted in a rep is someone who says what they believe and votes their conscience and stands for election at the end. In a perfect world, that’s the way it is. 

click to enlarge HAMMER: "We may have to go back to agencies and say, trim your budgets.
  • HAMMER: "We may have to go back to agencies and say, trim your budgets.

REP. KIM HAMMER (voted NO last session) 

I always try to remain open-minded on everything. There’s been a lot of meetings in the last 3 months dealing with the private option as it develops and plays out, and we’re being given bits of information as we go along.

The numbers seem to be pretty fluid depending on which meeting you’re in. How many are actually signed up, how many actually have a policy from the marketplace, how many actually have the private option? [One of] my concerns is the long-term sustainability of it. Are we prolonging having to deal with it by going back and taking a look at some of the issues we could have looked at under the traditional approach? That is, is everybody that’s on the roll truly deserving to be on there? 

I asked about the $89 million hole in the budget for the 2015 fiscal year without the private option. 

As far as looking at the budget and where it’s going to come from, it’s kind of like a chess match, each move creates another move. You have to contemplate all the unintended consequences that come as a result of a decision.  ... We may have to go back to agencies and say, trim your budgets.

It’s down to — do you want to throw the baby out with the wash, and is the private option the baby you want to keep? I think the concept has merit. But you gotta throw in with that, this is an issue: How much control have we given to the insurance companies? Have much control have we surrendered? How do we hold them accountable?

The other thing is, is there flexibility in the overall Mediciad budget to maybe do some shifting? Perhaps if you had a company come in and scrub accounts. When they scrub accounts, they look at everything. They look at the SNAP program. They look at disabled. Sometimes you need a third set of eye to determine whether somebody really is or not. What kind of savings could we create? I think we need to take a harder look at what we’re doing and not just be expanding rolls of Medicaid just for the sake of expanding the rolls of Medicaid. 

SENATE PRESIDENT PRO TEM LAMOUREUX (voted YES last session)

Note: these comments were made prior to the release of Sen. Missy Irvin's statement that she plans to vote no. 

I don’t want to speak for individual members, but I’ve always said that it was very unlikely, if not impossible, that any [senator] that voted no was going to switch to yes. Basically we need the same 27 people to vote yes. To be very thorough on my end, I am going to the no votes... but there just doesn’t seem to be a lot of room for negotiation. ... I feel like [possible tweaks and adjustments to the policy] have maybe been helpful on the House side, but on the Senate side that has not brought additional support. 

I think we’re at the begging stage. We’re just saying please. Please please please. There’s a lot of valid concerns that all those people have. If you add them all together they’re not as substantial as the harm of not having the private option, the cost to the state of not having it. 

My hope is that every member that voted yes last time will vote yes this time and it will be a relatively short session. If that’s not the case then I think it would be a longer session and I’m not exactly sure what we would do. I don’t have a well-thought-out Plan B. 

We say we have an annual budget session but we really do 95 or 99% of that work in the first year and then kind of rubber stamp it in the second year, unless there’s a problem. If we figure out in week 3, 4, or 5 that we're not going to have the private option, there's no way we’re going to get a [new] budget done within the constitutional time limit. I don’t know what that means we would do. It would be something in conjunction with the governor. You can’t do a $5 million budget in two weeks.

It’s kind of funny, normally in the legislature everybody argues about who gets to do something. There’s this hot-potato argument taking place on who’s obligated to come up with a Plan B. my position has been, I’ve got a plan. My plan is to pass the private option. If you defeat my plan, maybe you should tell me what Plan B is. 


On the Blue Cross Blue Shield reimbursement cut that angered Irvin and other legislators: 

Let me say, I thought that was so dumb...[for Blue Cross] to release that right as we're trying to do this. I don’t understand why Blue Cross was thinking they could do that and that wouldn’t have any impact on these people. So many people act like what they do is in a vacuum and doesn’t have an impact on anything else. I think they’re one of those groups that’s maybe just used to doing whatever they want. If there’s going to be some stuff like that that happens — maybe it needs to, I don’t know. I wish they would do it after careful consultation with the providers, and maybe not do it as quickly as they did. 

Will the private option be separated from the rest of the DHS budget?

We don’t vote globally on the entire DHS budget. We vote on it by divisions. I think the general standpoint is to do it how we’ve always done it in the past. If you’re changing something from how we’ve done it in the past, you’re doing something to achieve a particular result. I think most people think the fairest thing to do is just do what we've always done. The division of Medical Services is where the private option portion is. ...My understanding is that whole division, that whole part of the budget would go down. I've never thought there was a clean way to just vote the [private option] portion down.

I just want us to do what we’ve done in the past. I don’t want to do a bunch of work to try to isolate something. If you do that, talking about precedent, you could start doing that with every single thing. "I don’t think the Polk County DHS office ought to have a car" so we’re going to have a separate vote on whether they have a state vehicle. We can’t start doing that. 

I have always felt like there were valid reasons to oppose the private option. But I also thought you could come back here and vote for the DHS budget as a whole and still maintain that you were adamantly against the private option. People seem to have consolidated those two things unjustifiably. There’s two false links in the chain of reasoning: "If you vote for the budget, you vote for the private option; if you vote for the private option, you’re voting for Obamacare."

click to enlarge BURRIS: "A lot of people that were opposed have some really good ideas for how to make this even better policy." - BRIAN CHILSON
  • Brian Chilson
  • BURRIS: "A lot of people that were opposed have some really good ideas for how to make this even better policy."

REP. JOHN BURRIS (one of the key Republican architects of the private option, voted YES last session)

On the policy itself things are going very well. A lot of the updates you’ve heard from DHS lately speak straight to the heart of the policy, which is the most important part. The [enrollees] have proven to be health. Because of the private option, I think we’ll be the only state that hits our targets in terms of a young, healthy population enrolling [in the Marketplace as a whole]. That’s significant long term in terms of keeping premiums low for all Arkansans and attracting more carriers into the market.

Carriers are doing education and making efforts to make sure that consumers are actually accessing the healthcare system in the right way, which I think is something that’s usually lacking in traditional Medicaid. It’s not surprising if [beneficiaries] go to the ER the first time. The question is, does that pattern of behavior stick? If it doesn't, it’s very simple, carriers lose money. That behavior has to change, and that’s the great thing about the private market, be it through cost-sharing structure or education, outreach, and management. Carriers are going to make sure that behavior — that the behavior of the client is most appropriate, and gives them the best care at the most efficient cost. 

I believe that the people that voted for it did so because they believed that it was the right policy, and if they believe it’s still the right policy, then they’ll vote for it again. I don’t think they’re making decisions from a political lens. I feel very comfortable with where it is and with the debate we’re having. It should not simply be a re-appropriation— it’s okay to have some discussions, to asses, to make some adjustments, and possibly do a certain level of things better. I think that’s the process we’re going through now.

Discussions on [possible tweaks or adjustments to the policy] are actively taking place among members. A lot of people that were opposed have some really good ideas for how to make this even better policy. I’m in receiving mode.

I always have faith in the process. I don’t say that lightly. The legislature has a remarkable way of working itself out. At the end of the day, I think you have 135 people who want to do the right thing by the state and by the people they represent. I’ve got faith in the process. I’ve got faith that the right outcome will prevail. And that could very well be changes and compromises that are necessary to create the best policy.

I’ve heard discussion of a lot of NOs who are possibly becoming a YES on an appropriation. And it’s not necessarily because they believe in the private option. A lot of it is simply an acknowledgement that a defund strategy is incredibly difficult. That there’s not a clear path. That voting for an appropriation does not always equate with voting for a policy.

I try to have very honest talks with some of these folks. It takes 67 votes [to amend the appropriation] that you won't get. Then you're just at a standstill. Let’s say you even attained one of those vote thresholds to amend the appropriation [to block the private option]. I think it’s very likely at that point that Democrats would vote to block that, and you’ve got the whole DHS budget trapped. ... Then you’re in to the question of who gets the blame. I don’t know. But I just know that it's not a situation we want to find ourselves in. I think a lot of Republicans wisely want to avoid that. 

[A colleague pointed out that] when Congress passed Medicaid originally in the '60s, if we were in Congress, probably none of us would have voted for it. Now we vote for that appropriation routinely. I could use a thousand examples. People opposed the sales tax initially but they still vote to appropriate the money. Democrats voted in block against Voter ID and to override the veto. They still voted for the Secretary of State’s appropriation that spent a quarter million dollars to implement that. It didn’t mean they were for Voter ID. You can vote for an appropriation and it doesn’t mean you tacitly support the policy included in an overall appropriation. 

I asked whether he's gamed out what happens if the policy is defunded. 

I haven’t. I would leave that up to the people that believe that it shouldn’t pass. I have not gamed out that scenario. I have a plan. It’s to pass the private option. If somebody doesn’t think that’s a good plan, I’ll have to leave it to them to come up with their own. 

REP. KELLEY LINCK (voted YES last session) 

I’m still not solid either way. I still can’t tell you if the vote I made last time was right or wrong. A few things have changed. I’ve looked at them, tried to evaluate should we continue with this or not. I’m probably as much on the fence this time as I was last time.

I’m trying to figure out what happens with a NO vote. Not so much what happens with a YES vote, it’s what happens with a NO vote. 


REP. LES CARNINE (voted YES last session)

I’m not ready to say one way or the other how I will finally vote. I am very open minded. I voted for it the last time. However, I had serious concerns. It was a difficult vote but I felt like for business in the state and jobs in the state that that was probably the right thing to do at that time. 


REP. JON EUBANKS (voted YES last session) 

Right now, I think a lot of the folks that voted for it may be leaning against it for a variety of reasons. I think that if the employer mandate had been delayed when we voted on it, I don’t think it would have been passed the first time. ... I think people have a trust issue with D.Cc if they’re going to follow through with their parts of everything. Are they a reliable partner in this?

I would probably have to say that I am [leaning against]. I am not going to say that I’m firm one way or the other. 

While enrollment in the Affordable Care Act through healthcare.gov has been extremely rocky, the implementation of the private option has been generally viewed as a success. 

That seems to be the perception that I’m hearing. Really, one thing doesn’t necessarily have anything to do with the other, other than we wouldn’t be in this position now if it hadn’t been for the ACA. As far as I know there haven’t been any major problems with [the private option]. There were some people that may have had some questions about auto-assignment. 

What about the 100,000+ people who would lose coverage if the private option was defunded?

I’m not worried about it politically, I’m worried about it individually, how you affect people’s lives. One of my concerns — my hesitation in supporting it to begin with, and I was probably one of the last holdouts on it — was that you’re still adding to the deficit. You’re still adding to an entitlement program to some degree. Where does it stop?

It was appealing that maybe we had an opportunity to try something at a level that we could afford. … Arkansas is one percent of the population. If you’re going to try a program, where better to try it than a situation like this? If it works, great. If it needs to be changed to make it even better, than you do it. See if you can see things that you can apply across the nation.

I’m going to let people make their arguments and I’ll make a decision. At this juncture, I’m dissatisfied with D.C., and I’m afraid it may carry over with what my vote is.

I really don’t get that much local feedback with regard to it. ... Back when this was all taking place, I did not get a whole lot of input from my district. I had to start making some phone calls on my own. 


REP. ALLEN KERR (voted YES last session

The bottom line is I’m going to need a whole lot more information before I can make up my mind whether to vote for it or not. … I need to know exactly who this is helping and who — for every action there’s an equal and opposite reaction. If we help some, it’s going to have to hurt someone else. Some money’s got to come from some place. Don’t get me wrong, I want everybody to have health insurance. I’m in the insurance business. But at the same time, I don’t want us to hurt ourselves doing it.

I’m trying to keep an open mind, but I’m skeptical. If you made me vote today I’d have to vote no. I’m going to look at all the information. And I’m hoping that we have a lot more information this go-round than we had the last time.

We’ve dipped our toe in it, we’ve started implementing it. I need to see results, I need to see projections. Before it was just an idea. We had no idea if the feds were even going to accept our offer. So it was simply an offer that went to the federal government and said we’d like to do it this way. Now we’re working with a whole different set of parameters. They’ve accepted the offer, now we’ve got this thing started. Now we need to — anything in my business, I'm constantly monitoring it to make sure it’s working the way we want it to work. If it doesn’t, I can make adjustments or I can just bail off it altogether and go do something else.

They’re going to have to re-sell this thing from the get-go, is what they’re going to have to do. 


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