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ARKids turns 20 

Medicaid expansion in 1997 brought huge change for children's health. What will the next 20 years bring?

click to enlarge GRATEFUL FOR ARKIDS: Amanda Tucker says it would take half her paycheck to pay for medications for her son, Benjamin. - BRIAN CHILSON
  • Brian Chilson
  • GRATEFUL FOR ARKIDS: Amanda Tucker says it would take half her paycheck to pay for medications for her son, Benjamin.

Twenty years ago, Marquita Little was among the first Arkansas children to get health insurance under then-Gov. Mike Huckabee's Medicaid expansion initiative, ARKids First. Surrounded by kids, Huckabee signed the act creating the program on March 10, 1997, with a crayon.

Today, Little is the health policy director for Arkansas Advocates for Children and Families. Like other children of working parents who earned too much to qualify for traditional Medicaid but did qualify for ARKids, she got the medical care she needed to have a healthy childhood, which surely contributed to her successful adulthood.

Unlike the president of the United States, who expressed surprise at the complexity of health insurance, Little is knowledgeable about Medicaid and how federal laws, including the Affordable Care Act, affect ARKids. She and her colleagues at Arkansas Advocates worry about ARKids' next 20 years.

Will the past 20 years be one day remembered as the Golden Age of health insurance in Arkansas, an age in which hundreds of thousands of children could afford to see a doctor and, more recently, when more adults had access to health care, an era before Congress dismantled the Affordable Care Act and also put new restrictions on Medicaid? That's a real concern.

How ARKids First came about is one of those great stories in Arkansas politics. Huckabee, concerned about how much of Arkansas's budget was dedicated to Medicaid, convened a task force to find ways to reduce Medicaid spending. Amy Rossi, then the director of Arkansas Advocates for Children and Families and a member of the task force, decided she was going to ask the governor to increase Medicaid spending instead, so that children whose parents' income was too high for traditional Medicaid but too low to afford private insurance could get regular doctor visits.

"I remember calling my colleagues," Rossi said, to tell them she planned to ask for more spending on children's health care. The governor had asked the task force "to put everything on the table," so she told fellow task force members that she would "put out there that there is a growing problem," and that improving children's access to health care "is going to make a difference in the economy."

The response from her colleagues was skeptical. "They pretty much said, 'You do that,' " Rossi said. The pediatricians were the only ones who encouraged her to try it. Dr. Gil Buchanan, a highly regarded pediatrician, asked Rossi, "What could it hurt?" she recalled.

Her economic argument was that sick kids miss school, which means parents miss work. Sick kids who go untreated get sicker, and may require more expensive care down the road. Uncompensated care is a burden on hospitals.

Rossi also had a startling fact on her side: At the time, almost one in four Arkansas children had zero health insurance. The governor "was truly surprised" at that, she said. "He had no clue it was that bad. And he had an affinity for low-income families." Huckabee's Medicaid director, Ray Hanley, confirmed the numbers.

Huckabee didn't say yes to Rossi when she followed through and raised the issue at the task force meeting, which she remembered was held on a Thursday. But the following Monday, Huckabee called Rossi and told her he wanted to talk to her more.

That was November 1996. In December, Huckabee released his budget, and funding for ARKids First, which would cover children whose parents earned up to 200 percent of the federal poverty level, was included.

Huckabee, in a video produced by Arkansas Advocates for ARKids First's 20th anniversary, called the expansion an alternative that "put a wider net around people that had nothing. These were working people." The former governor, who traveled the state to promote the program, said he talked to a man in Mena who was getting his antibiotics for his children through a farm supply store. "It was all he knew to do, because he couldn't afford meds at a pharmacy. He was making do. That got to me. I thought, my gosh, here's a dad who can't afford meds getting an antibiotic intended for a puppy. ARKids changed that. How can you not think that's a good idea?" Huckabee campaigned on his role in creating ARKids in his subsequent presidential bids.

When representatives from the state Department of Human Services took to the road in the late 1990s to explain the ARKids program — a media campaign funded by matching grants from the Daughters of Charity and the Robert Wood Johnson Foundation — they were surprised to learn that parents didn't want free coverage, Rossi said. "They would say, 'What do I need to pay?' " she said, and when told the coverage would be free, "they'd say, 'I want to put my share in.' ... It was a pride element."So the decision was made to ask for a federal waiver to be able to charge a co-pay: $10 for doctor visits and $5 for medications. It was controversial; Medicaid required no co-pay. "I took a lot of flak" for going along with the idea, Rossi said. The waiver request "went all the way to the White House." It was allowed after it was agreed there would be a safety net for parents who couldn't afford the co-pays, like those with multiple children who would go to the doctor at once.

Thus Arkansas became only the third state in the nation to expand Medicaid eligibility for children up to 200 percent of the federal poverty level, Arkansas Advocates says, and the first in the South, acting even before Congress passed the State Children's Health Insurance Program (SCHIP, now known simply as CHIP) to specifically cover the population between 133 percent and 200 percent.

ARKids was the Obamacare of its time: It was Medicaid expansion, offering coverage with low co-pays to working families who could not afford private insurance.

In ARKids' first year, an estimated 30,000 children enrolled.

The ARKids First brand now includes both Medicaid, called ARKids A (for children, up to age 19, of families whose income is at or below 138 percent of the federal poverty level), and the CHIP-funded expansion, now known as ARKids B. Combining the two programs under the ARKids First moniker helped remove the Medicaid "stigma," Arkansas Advocates Director Rich Huddleston said.

On Feb. 28, there were an estimated 381,907 children enrolled in ARKids First, Brandi Hinkle, a spokesperson for DHS, said. (Out of that number, 50,759 were enrolled in ARKids B). That's nearly half of all Arkansas children. Another 7,000 were covered under ACA marketplace plans, AACF's Little said. AACF data shows the percentage of children who don't have health insurance in Arkansas, which before ARKids was near the top nationally, is down to 4.9, below the national average.

Some of the recent enrollment in ARKids First is due to the "welcome mat" effect: When parents get insurance, they tend to get insurance for their children, too. This effect could be seen in 2015, after the ACA made health insurance accessible to hundreds of thousands of adults in Arkansas: The uninsured rate for children, which had been at 9 percent, dropped to 6 percent.

Our "thank God for Mississippi" state is ranked at the bottom in many indicators of social well being, but in 1997, thanks to ARKids, it became a national leader in its support for expanded health care to children. In 2013, Arkansas became the first state in the nation to get a waiver to offer Medicaid insurance through private plans — the "private option" — and the program now covers 310,000 Arkansans, many of them previously uninsured.

click to enlarge ARKIDS ALUMNA: Marquita Little, whose mother was able to provide health insurance to her under the original ARKids program, is now the health policy director for Arkansas Advocates for Children and Families. - BRIAN CHILSON
  • Brian Chilson
  • ARKIDS ALUMNA: Marquita Little, whose mother was able to provide health insurance to her under the original ARKids program, is now the health policy director for Arkansas Advocates for Children and Families.

"You have to give Huckabee a lot of credit," Arkansas Advocates' Huddleston said. "He could easily have said it was not [going to work]." It's likely that today's Republican legislature would not have gone along with expanding children's health care coverage to 200 percent of the federal poverty level.

"I'm deeply concerned," Huddleston said, "about the political environment and what it's going to mean for kids' health."

The ACA brought additional benefits for children as well as adults. Before the ACA came into being, the eligibility cutoff for ARKids A was at 133 percent of the federal poverty level for children younger than 6 and at 100 percent of the poverty level for children 6-18. Now it's 138 percent for all children up to age 19.

The CHIP program comes up for congressional reauthorization in September. Once under a renewal schedule of every four years, Congress changed that, first to every two years, and then every year. Those who want to dismantle the ACA see the renewal of CHIP as a bargaining tool.

But "the big flashing light" that says danger when it comes to the revision of the Affordable Care Act being proposed by Republicans in the U.S. House of Representatives, Little said, is that it would restructure the entire Medicaid program, putting caps on dollars to be provided to the states.

"I don't think that it's an understatement that this would radically change how Medicaid works," said Elizabeth Wright Burak of Georgetown University's Health Policy Institute in Washington, D.C., at the Clinton School celebration of ARKid's 20th anniversary. Burak said the caps will shift an estimated $370 billion in health care costs to the states over the next 10 years. If states can't afford the costs, "it would reverse all the success we've seen, not just in children but in seniors and folks with disabilities."

The caps would be based on the cost of health care in 2016 plus a small inflation factor, Little said. But the rise in the cost of health care significantly outpaces the inflation rate. See, for example, the hike in costs of EpiPens, an essential medication for people with certain allergies: A pack of two that once cost $100 rose to $600 in 2016.

It appears that families who insure their children through ARKids can breathe easy until 2020. There is a "maintenance of effect" clause in the Affordable Care Act that says there can be no changes in eligibility for kids covered by Medicaid through 2019, Little explained. What 2020 holds for children's insurance coverage is what worries Arkansas Advocates.

But Huddleston worries that Medicaid caps will require states to "rethink who is eligible. States are going to have to make cuts in either the population [to be covered] or in benefits."

"What does that mean for pocketbooks?" the AACF director said. "Will medical bankruptcies start to skyrocket again?"

Governor Hutchinson announced a couple of weeks ago that he will ask the Republican-friendly federal government to lower Medicaid eligibility from 138 percent of the poverty level to 100 percent. That would boot one in five Arkansans off Arkansas Works (Hutchinson's name for the adult Medicaid expansion under the ACA) or about 60,000 people. They would have to shop for more costly plans in the marketplace.

click to enlarge WORRIED ABOUT THE FUTURE OF HEALTH INSURANCE: Rich Huddleston, director of AACF, hopes congressional action on Medicaid won't mean people will have to go bankrupt paying for health care. - BRIAN CHILSON
  • Brian Chilson
  • WORRIED ABOUT THE FUTURE OF HEALTH INSURANCE: Rich Huddleston, director of AACF, hopes congressional action on Medicaid won't mean people will have to go bankrupt paying for health care.

The benefits of Medicaid, the Georgetown University Health Policy Institute's Center for Children and Families says, are great. Research into heath care over the past 30 years shows that the program has reduced childhood mortality and increased long-term health with fewer hospitalizations. It has reduced school dropout rates, protected families from medical-care bankruptcies, increased incomes and increased tax payments. One study of tax benefits showed that by the time a child reached the age of 28, the government had recouped 32 percent of the dollars spent on childhood Medicaid eligibility and 56 cents on the dollar by the age of 60. That study was of tax receipts alone, not incorporating other benefits, like college attendance and lower rates of mortality.

The immediate benefit to Elizabeth Woods, 4, who has been on both ARKids A and B as her family's income has waxed and waned, is that she's been able to have her chronic ear infections treated. ARKids has paid for tubes in her ears — she's already had three — and medicine for those ear and sinus problems. That's a relief for her mother, who is single, working and going to college.

The benefit to Benjamin Hernandez, 10, was the medication he was able to receive for his attention deficit hyperactivity disorder — ARKids B paid for his ADHD meds, otherwise $200 a month — and chronic allergies. His mother, Amanda Parker, realized, "I didn't have to worry if he came down with something."

"It would take half my paycheck" to pay for his medications, Parker, who is membership coordinator for the nonprofit Quapaw Quarter Association, said.

Parker has had no trouble with the re-enrollment required for Benjamin's ARKids B: "It's a sheet of paper to fill out." That is by design: Huckabee wanted the signup for ARKids to be much simpler than regular Medicaid, which required a face-to-face meeting and assets tests at the time. Those were eliminated for the expansion program.

ARKids "has saved my butt. ... It has always been a blessing," Parker said.

If Benjamin were to lose his ARKids eligibility because of changes to Medicaid, Parker could get a second job. But she's not crazy about the idea. "I'd hate to get a second job to work from 8 a.m. to 8 p.m. and not spend time with my son," she said.

Elizabeth Woods' mother, Hawley, 34, is a parent educator for the Family Network, a nonprofit in Springdale that helps families in need find services, including ARKids First. That means she's savvy when it comes to Medicaid: When her own insurance expired two years ago because of an infamous Department of Human Services computer glitch, she knew whom to call. Not everybody knows how to apply for Medicaid or what recourse they have when their coverage lapses, or has the confidence to call and ask for help, Hawley Woods said.

(Woods, who had breast cancer and had had a mastectomy, required emergency surgery to treat an infection during the time she'd lost her Medicaid coverage during the DHS glitch. Fortunately a surgeon volunteered his services to perform the emergency procedure.)

Because Woods, 34, is working toward a bachelor's degree, she has had to limit her work hours. Even so, she said, she "needed help" even when she worked full time. Medicaid "is a huge deal for my family," Woods said, as it is for others "working as hard as they can to provide for their child."

click to enlarge HAPPY AND HEALTHY: Hawley Woods said ARKids coverage means she can get timely doctor visits for her daughter, Elizabeth, 4. - JUSTIN RUCKER
  • Justin Rucker
  • HAPPY AND HEALTHY: Hawley Woods said ARKids coverage means she can get timely doctor visits for her daughter, Elizabeth, 4.

Elizabeth is prone to sinus infections as well as ear infections, "so we were at the doctor quite a bit," Wood said. She said the stress would be huge "if I didn't have the knowledge that her coverage was good and affordable." Having coverage "gives me confidence. When I notice something is going on with her I can get her in. What I see in my job is that parents wait because of the expense," and then their children need more intensive care. "I can go in as soon as I know something's going on."

The prospect that changes to the Affordable Care Act and Arkansas Medicaid could alter ARKids eligibility or coverage "is terrifying," Woods said. "The thing is a catch-22. You're working really hard to get out of where you are, but there is this middle area where you start losing supportive services, but you're not making enough money [to afford private care]. I've had to get creative and work harder than I've ever worked in my life to get ahead. The system is against you."

"If I was poorer, I would qualify for the Supplemental Nutrition Assistance Program," Woods said. But because she works, she's not. Bettering herself could cost her access to Medicaid as well. "It seems counterintuitive to me, to set people up to fail."

AACF's Little, who was 14 when ARKids came into existence, said that because her own health care costs were so low, her mother was "able to move up the ladder without fear of us losing coverage. ... That's one of the beauties of the state filling in that gap: It's a support for working parents.

"There is so much conversation about encouraging work and independence; that's why programs like ARKids are critical. My mom was able to go from being a janitor at an elementary school while she was in college to now being a director at the agency" where she works. Connie Little is agency relations director at the Arkansas Foodbank.

Marquita Little pointed to data that shows kids who have access to health care become economically stable adults, and that is true for her. "I was able to finish college, pursue a graduate degree, and here I am advocating for that access."

Little holds a bachelor's degree from Hendrix College and a master's degree from the Clinton School of Public Service. She worked at DHS before moving to Arkansas Advocates.

In addition to the prospect of fewer dollars is the disruption in provision of services that changes in the ACA and Medicaid will mean for the states. DHS' well-known problems in dealing with system changes brought about by the ACA, such as the requirement that all re-enroll, plus technological problems with computer databases and software, data input mistakes, mailing errors and the constant turnover in employees has meant that thousands of eligible Arkansans, adults and children, have suffered lapses or been dropped altogether from Medicaid. Because of changes in DHS computer systems, Little said, Arkansas Advocates has not been able to get county-level enrollment numbers since 2014. AACF has been relying on Georgetown University's Center for Families and Children, the Annie E. Casey Foundation and census data for yearly enrollment figures.

Changing things up again, as the Republican Congress want to do, would mean DHS would have to reprogram once again. Expect trouble.

Dr. Aaron Strong, a pediatrician in practice with the Little Rock Pediatric Clinic, said he is "passionate about the benefits of extended access to care that ARKids provides to children of working families."

ARKids A's EPSDT coverage — early and periodic screening diagnosis and treatment — means doctors "can stay on top of their general health and catch potential problems so they can be treated early and aggressively and don't become bigger problems."

The developmental screenings covered under ARKids allow him to refer patients for developmental evaluations and therapy if he suspects the need. "If I identify a problem, [children] have resources under their insurance. It doesn't give me a dead end: I don't have to say your child may have a problem with growth but, sorry, I can't help you."

ARKids also provides dental care. "In terms of numbers, if you are thinking about common diseases, dental problems — cavities, caries — are one of the most frequent health problems we see for kids," and may go undetected in children without coverage. "With ARKids, you don't have to worry that."

Strong, who is on the board of Arkansas Advocates, said people may not appreciate "how unique ARKids is, as far as how Arkansas has arranged its CHIP program. There really are not a lot of states that have worked it the way we do. It's excellent insurance. A lot of times I have more trouble finding opportunities for kids with private insurance, like referrals for therapy and medication coverage. It's comprehensive at its best."

click to enlarge PEDIATRICIAN DR. AARON STRONG: Says he is "passionate about the benefits of extended access to care that ARKids provides to children of working families." - BRIAN CHILSON
  • Brian Chilson
  • PEDIATRICIAN DR. AARON STRONG: Says he is "passionate about the benefits of extended access to care that ARKids provides to children of working families."

Dr. Creshelle Nash, formerly an assistant dean at the College of Public Health at the University of Arkansas for Medical Sciences and medical director for the Arkansas Minority Health Commission, is now with Arkansas Blue Cross Blue Shield. At the Clinton School's celebration of ARKid's 20th anniversary, she was asked if there would ever be the political will to join the rest of the developed world and extend government insurance, like Medicare, to everyone.

"I still think we have a sense of rugged individualism here as opposed to the collective good," Nash said.

"I look at it this way: Life is a journey, a trajectory, right? And necessarily we're all going to need health care at some point in time. ... And I would want to have, just in case I need it, when I need it, it's there ... and I want that for everyone.

"I don't think we have that sentiment. I still think that we, as a culture, operate in a zero-sum game: That means, if you have any, I have less. That's a problem.

"So until we get past, get to the value point of that this is a common good that we all want in the United States of America, that's going to be a tough thing to get done."

In the current political climate, even limited programs like ARKids and expanded coverage for adults appear to be at risk.


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