Thursday, February 13, 2014

Rube Goldberg would be proud

For several reasons, I don't spend much time talking about the absolute rat's nest that is Arkansas politics, but probably the biggest one is that I spent fifteen years largely absent from the state.  It's hard to see detail when you're watching from afar.

But now that I'm back, my reticence about local politics is mostly out of disgust.  It was weird to return to an Arkansas "governed" by Republicans.  Yes, I know the Governor is a Democrat, but one of the dirty little secrets of Arkansas's political system is that the governor has virtually no power beyond the power of appointment. 

Consider for a moment the brain malfunction that must have occurred when the writers of Arkansas's constitution were deciding how the veto would work.  The canonical model is the one practiced on the federal level:  simple majority to pass legislation; two-thirds majority to override a veto.  Because it is rare for one party to have two-thirds of either house, the veto is a true power of the executive.  But that structure also promotes compromise.  The threat of a veto that can undo months of legislative work tends to shape legislation so that the legislature and the executive can come to a decision.

In Arkansas, however, a gubernatorial veto can be overridden by a simple majority of both houses (for most legislation).  Think about that as you read this dialogue:

Legislature:  We want this to be law.

Governor:  I forbid it.

Legislature:  Too bad. We want it anyway.  It's law.

This structure effectively amounts to Gov. Regis Philbin asking the Ledge, "Is that your final answer?"

But this post wasn't supposed to be a complaint about the structural problems of Arkansas government.  I could fill a book about those, and there are many times when I think it would be better simply to wipe the slate clean, call a constitutional convention, and see if we could do without the innumerable boards and commissions, the increasingly stringent supermajorities required for basic governmental functions, and all of the other intentional monkey wrenches our Know-Nothing forebears thought were best.

At issue at the moment is whether the state will continue to take federal money for the "private option."  The Affordable Care Act provided for the expansion of Medicaid by making people with incomes somewhat above the poverty line eligible.  Medicaid is one of the very best federal programs around because it provides a service that everyone needs--health care--to people who cannot afford it.  But the way that Medicaid is administered is a little weird; it's administered on the state level, but the federal government pays for 90% of the cost.  That strikes me as an unnecessary administrative wrinkle, but up to this point it has worked out OK.

The ACA requires states to accept the new Medicaid expansion dollars if they accept Medicaid dollars at all (which all states do, because even the most hard-hearted conservatives are at least not numerous enough in government to make states say no to all of the money).  But last year, the Supreme Court said that states could opt out of the expanded program.

One of the results of that was that Arkansas--which was threatening to opt out--got permission for a different use of those Medicaid dollars.  Instead of public administration of this segment of the program--the people added to the rolls because of new eligibility--Arkansas was granted the right to use those Medicaid dollars to purchase private insurance for the newly eligible.  That arrangement managed to tickle enough Republicans' political erogenous zones (Public money going to private companies! Hooray!) that the Ledge could cobble together the three-quarters' majority of both houses necessary to accept the money.

Arkansas has something of a history of this kind of thing.  Back when Mike Huckabee was the governor instead of talking about women's libidos on national television, he and the Ledge got Arkansas into some trouble with Medicaid and the State Children's Health Insurance Program ("S-CHIP").  ARKids First was--and is--Arkansas's S-CHIP program, a program that ensures that kids from low-income families get access to health care even if their families make too much money to be on Medicaid.  After all, it takes a special kind of sociopath to deny health care to children because their parents can't afford it.

The problem was that Huckabee's administration was making a special point of enrolling kids in ARKids First, which requires some out-of-pocket expense, when their families were actually eligible for Medicaid.  The public statement about this issue was that being on Medicaid carries a stigma.  That is no doubt somewhat true, and I know plenty of people who would not dare take Medicaid for themselves, except maybe in the most dire emergency, but would accept it for their children.  But the real reason is that because of the limited coverage provided--ARKids First is limited to children and pregnant women--and the co-pays, ARKids costs the state fewer dollars than it would cost to enroll the entire family in Medicaid.

Anyway, back to Medicaid expansion.  The "private option" was crafted to solve a problem, namely the Republicans' desire to make Obamacare as unsuccessful as possible, by giving the GOP a carrot it could not refuse--injecting a profit line into government programs. Now that it has become necessary to renew the acceptance of these Medicaid dollars, the Republicans that run (ruin) the show have different motivations.  Handing a few more dollars to Blue Cross isn't enough to defeat their monomaniacal hatred of all things Obama.  They are desperate and scared because the ACA isn't the all-out disaster they had hoped to make it.

(Have you noticed, by the way, that the word "Obamacare" has disappeared from the Republican lexicon?  It's now back to the "Affordable Care Act."  There's only one reason for that:  The ACA is succeeding in getting uninsured people insured.)

In Arkansas, the ACA has been so successful that nearly 100,000 Arkansans who did not have insurance before have now become insured under Medicaid expansion.  In a state just shy of 3 million people, that's significant; among other things, it's a bunch of people who won't be clogging emergency rooms with non-emergency conditions because they can't afford to go to a doctor.

Of course, that's a true disaster for the Republicans.  We can't have a government that does things well, they say.  People will start to want a government that does well all the time.

So, when a Democratic state senator had to resign over some campaign finance irregularities and was replaced in a special election by a special breed of know-nothing, the Republicans saw their chance.  They would simply discard the private option entirely, reject the money for upcoming years, and kick those people off their health insurance.

And they could do that.  All it takes to block acceptance of the money are nine seats in the Senate and 26 in the House; they have those numbers easily.  But can you imagine the ads their opponents will run next time out?

But it turns out that the Democrats have a few cards to play.  They could force the GOP to take the money by threatening to block other appropriations in the current session, which would shut down the state government.  Arkansas Republicans saw the damage done to their federal brethren last October, and apparently the prospect of schools, colleges, and state agencies shutting down is hard to swallow.

So, instead of refusing the money outright, the GOP has decided that the real problem with this money is that the state is spending money to make people aware of the program.  Bear in mind, by the way, that the state gets the money it spends for that purpose from the federal government.  State Sen. Nate Bell, a (what else) Republican, is pushing an amendment to the appropriations bill that would do just that.  Bell isn't coy about his reasoning:

"[W]ithout active marketing, you probably get declining enrollment. ... In general, as a conservative, if I have the opportunity to reduce government spending in a program from what’s projected … I’m probably going to take that deal."
So, let's check the scorecard a moment.  The easiest, least expensive, and most comprehensive resolution to the health care issue would have been simply to expand Medicare to everyone.  Obamacare rejected that approach, instead providing federal subsidies and an individual mandate for private insurance, thereby guaranteeing a complex, meshy (as in full of holes) patchwork that, for all its faults, is better than what we had before.  Last year, Arkansas Republicans took one of the few solid aspects of Obamacare and turned it into an even more complex, expensive program.  And now, as a condition of continuing that plan, the Republicans are demanding that we not tell anyone about the plan, hoping that people who are eligible will simply not sign up.  And as a result of that, we will get less care per dollar.

Why is that last bit true?  Three reasons.

First, the pool of people in those "private option" plans will be smaller and, on average, sicker, because the people who have a more immediate need for health care will make a greater effort to find out about and therefore utilize programs that cost them less money (and, by extension, cost the government more money).  That puts upward pressure on premiums.

Second, insurance companies will have a motivation to gain more subscribers via the private option, because the government must pay for eligible enrollees.  The expense of that marketing will put upward pressure on premiums.

Third, because enrollments will almost certainly go down, the number of uninsured people will go up.  That means more people utilizing county health clinics and hospital emergency rooms for conditions that could have been treated more effectively or earlier in doctors' offices.  That costs all of us more money, not just in tax dollars, but in the expense of services overall (which, again, puts upward pressure on premiums).

The Republicans' intentional stupidity is costing you money.  This whole thing reminds me of my story about epicycles.  When will enough be enough?

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