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How the private option flipped the Medicaid expansion debate 

If you see a crowd at the Capitol, it usually means something controversial is about to happen. Maybe there's an abortion bill in committee. Or maybe one prominent lawmaker is having a spat with another and wants to talk some trash to the media.

But late in the afternoon on Feb. 26, the swarm of journalists, cameramen, lobbyists and hangers-on gathered outside of the governor's conference room were there to get some nitty-gritty policy details. Behind the conference-room doors, the governor was talking to about 20 legislators. He had just returned from Washington, where he had met with U.S. Secretary of Health and Human Services Kathleen Sebelius to ask whether the federal government would grant the state some flexibility in tackling Medicaid expansion. Now he was relaying the results to local lawmakers.

The debate over Medicaid expansion had cycled around and around and seemed to be going nowhere. The governor wanted to move forward, but he needed three-fourths approval from the legislature, which was controlled by Republicans dead set against it.

As legislators and state officials slowly began to exit the conference room, there was a bit of confusion. The news from Washington was good, that much was clear. But the details seemed so different from everything that had been publicly discussed so far that reporters weren't quite sure what had happened.

Finally Gov. Mike Beebe ambled out of the conference room to meet the press, with the satisfied look he sometimes gets when he is very pleased with what he is about to say. He let the scrum gather around him, and he smiled. At the tail end of a long career, he was enjoying himself. What had the feds offered? "Basically," he said, "they've agreed to give us about everything we've asked for."

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Last week, the governor signed into law bills that accept federal money through the Affordable Care Act (ACA) to expand healthcare coverage to low-income people in Arkansas.

You'd be forgiven if your eyes have glazed over from time to time over the course of this long and often confusing debate. Healthcare reform is a subject that can get complicated quickly, with a lot of acronyms and numbers and jargon.

It also has a real impact on real people's lives. One in four Arkansans between the ages of 19 and 64 does not have health insurance; more than 200,000 of the state's citizens will be gaining coverage from expansion. The decision will also have an outsized impact on the state's fiscal future — the state will have hundreds of millions more in its coffers because of expansion, along with the economic impact of billions in federal spending in Arkansas. Whatever your position, it was one of the biggest questions before the legislature in years, if not decades.

That question was turned on its head by the "private option" (that's the common nickname for the new framework that HHS gave Arkansas the go-ahead to pursue). The private option achieves expansion of coverage using private insurance companies on the healthcare exchange instead of Medicaid. This new approach has gotten Arkansas national attention, representing the possibility of a third way for states trying to decide whether to go forward with expansion or stick with the status quo. Here at home, it turned Republicans who had been ferocious critics of the Affordable Care Act into advocates of using billions of dollars in government assistance to help the poor secure healthcare access. Without the private option, Medicaid expansion was all but dead in Arkansas. Now the state may well be the only one in Dixie to do right by its people.

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