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Arkansas's distinctive form of Medicaid expansion has been precarious since its creation in 2013 by a bipartisan coalition. Again and again, first when initially rolled out as the "private option" while Mike Beebe was governor, and even after being rebranded and revised as Arkansas Works by Governor Hutchinson, the program has been on life support. There are signs, however, that Medicaid expansion may now be a permanent fixture in the Arkansas policy environment.

This week, Talk Business & Politics-Hendrix College released results of a survey of the voters most likely to participate in the May Republican primary. The survey revealed a comfortable lead for Hutchinson in his race for renomination over populist outsider Jan Morgan and also showed Arkansas's GOP electorate to be an emphatically conservative one on issues like guns, abortion and taxes. The most interesting result, however, was a shift in the GOP electorate in attitudes about Medicaid expansion in the state.

Throughout the six-plus years of debate over Medicaid expansion, Arkansas's Republican voters have shown persistent dubiousness about the program. The wording of questions about Medicaid expansion in the Talk Business & Politics-Hendrix College surveys have varied a bit since 2012, but — until the most recent survey — consistently more GOP respondents have opposed rather than supported the concept. In 2012, as debate over Medicaid expansion began, 64 percent of GOP respondents opposed the notion of Medicaid expansion with only 21 percent supportive. During the debate on reauthorization of the program in Beebe's last fiscal session in the spring of 2014, GOP voters still opposed the program by a healthy 54 percent to 23 percent margin. Two years later, with Governor Hutchinson having become a strong supporter of the program rebranded and somewhat restructured as Arkansas Works, Republicans were split with 34 percent in opposition, 32 percent favoring, and the final third unsure about their views.

While originally a thoroughly bipartisan endeavor, the law's survival of it has been based on unwavering support among Democrats, along with enough Republican support to eke out the necessary legislative supermajorities to keep it in place. And over the course of its five-year history, more moderate Republican legislators and legislative candidates have lost GOP primaries because of their support for the program.

But in 2018, with the program now including a work requirement (and a pending but not yet approved request to the federal government to reduce the top tier of income eligibility), the program appears to have genuinely bipartisan public support. A strong plurality of GOP voters now support the program rebranded and redesigned in the Hutchinson era. Republican adherents favor the program by a 45.5 percent to 21.5 percent margin. While plurality support is shown across most all subgroups of GOP voters, support is highest among the oldest and youngest age groups, among the best and least educated voters, among more secular voters, and among Second District voters (48 percent of Central Arkansas GOP voters support the program). There is also a gender gap on the program — while a similar percentage of men and women support the program, opposition to the program is 10 points higher among men.

The alterations to Arkansas Works that have helped build support among Republicans do not come without costs — participation rates are estimated to drop by about 63,000 Arkansans (from a peak nearing 300,000), a deeply worrisome change. Still, tens of thousands of Arkansans who would have lacked health coverage before the program came into existence will remain covered by health insurance. Rural hospitals previously in dire straits because of uncompensated care remain open. The survival of Arkansas Works marks a clear example of pragmatic policymaking in a progressive direction. Moreover, if Medicaid expansion is to ever come to some of the more conservative states such as Texas and Florida that have not yet expanded coverage, it is likely to look something like the Arkansas private option model.

In 2014, Mike Ross, the Democratic candidate for governor, made protecting Medicaid expansion a centerpiece issue in his campaign, arguing that Hutchinson — who lacked a clear stance on the topic during the general election campaign — would fail to protect the program. As it turns out, it is a conservative Republican who has helped to ensure the program's longevity.

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