At the state Capitol on Wednesday, bill custodian JoAnn Drew sorts through appropriation bills that will be introduced in the Senate when the legislative fiscal session begins Monday. ( Mitchell PE Masilun

Ahead of Arkansas' fiscal legislative session that starts Monday, supporters of the state's version of Medicaid expansion have been urging Senate critics of the controversial program to vote to fund it once lawmakers convene.

The program provides health insurance to about 285,000 low-income people.

Appropriation bills granting spending authority to state agencies require more than a simple majority for approval. The Arkansas Constitution requires 27 votes in the 35-member Senate to approve them. But the Senate has three vacant seats because of the November death of Greg Standridge, R-Russellville, and resignations of Eddie Joe Williams, R-Cabot, in November and Jake Files, R-Fort Smith, effective Friday of last week.

The Medicaid expansion -- called Arkansas Works under Republican Gov. Asa Hutchinson -- was initially authorized in 2013 by the Republican-controlled Legislature and then-Gov. Mike Beebe, a Democrat. The funding is in the Department of Human Services' Division of Medical Services appropriation.

Because the program has deeply divided Republicans, the Legislature has struggled each year to obtain the required three-fourths vote in the Senate and the 100-member House to reauthorize the program's spending authority. (The House also has a vacancy, resulting from the resignation of David Branscum, R-Marshall.)

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Opponents of the program don't like the cost to the state. The state's share of the cost is 6 percent this year, 7 percent next year and eventually will increase to 10 percent by 2020, with the federal government covering the rest.

The state's share is projected to be $108 million in fiscal 2018, which started July 1, and is projected to increase to $135.6 million in fiscal 2019, according to the department.

The state is awaiting word from the Trump administration on approval of changes that would reduce costs, and proponents are explaining how much eliminating the program would cost the state.

The major issue in this year's fiscal session will be, "do they have enough votes to pass Arkansas Works in the Senate," said Rep. Lane Jean, R-Magnolia, co-chairman of the Joint Budget Committee. "If they don't pass it, we'll just come back in a special session when additional senators are elected and seated." He was referring to special elections to fill the vacancies.

Asked if he had a vote count on the Division of Medical Services appropriation in the Senate, Hutchinson said Friday, "We are working it."

He said senators were getting answers to their questions.

"I feel good about the vote because we are putting in place reform that the General Assembly asked for, and we have proven that our systems are in place to make sure those [who] are ineligible are actually disqualified from being on the program. So all of this gives a higher level of confidence, and we probably won't know the exact vote count until all the questions are answered, but I'm optimistic that we'll be able to get that through in regular order," he said.

Hutchinson said he hopes he doesn't have to call a special session after the May 22 special elections to further consider spending authority for the Medicaid expansion.

During the 2017 regular legislative session, the Senate voted 27-1 to approve spending authority for Medical Services and Arkansas Works. Files and Williams voted for the measure, and Standridge didn't vote.

Last year, Republican Sens. Scott Flippo of Mountain Home, Alan Clark of Lonsdale, Terry Rice of Waldron, Gary Stubblefield of Branch, Linda Collins-Smith of Pocahontas and Ron Caldwell of Wynne, also didn't vote on the the measure. Sen. Bryan King, R-Green Forest, voted against it.

THINKING IT OVER

If those who voted for the appropriation last year vote the same way this year, supporters will be two votes short. But some senators on both sides said they haven't made up their mind on this year's vote.

Flippo said he doesn't "feel boxed in" this year to vote against the appropriation. He won his seat after a June 2014 runoff election when he defeated then-Rep. John Burris, R-Harrison, who was one of the three key legislative architects for the Medicaid expansion.

"Things have changed since 2014," he said last week. If the Trump administration approves a work requirement for some Arkansas Works participants, that would be new as well, he said.

Constituents expect him to make sure he has all of the relevant information before he votes, he said.

Clark said last week that he has stood against the program for five years. "At what point do I say, 'This ship has sailed.' I don't know what I am going to do."

He said he is happy about the prospect of a waiver to allow a work requirement in the program. "So it makes it a lot more palatable," Clark said of the program. "I am just quite frankly trying to find a way to vote for it and I'm not sure I will get there, but I am trying."

"I have said all along I will continue to listen," Rice said. "I hope we have a short and anti-climactic session. I have been told so many things since the actual private option started. I want to see something actually happen and go into effect."

Stubblefield said in a written statement that "the feds have not approved our waiver yet, and if they do I still want to have a discussion about whether the work requirements actually require 19- to 49-year-old able-bodied people to work.

"If this group can meet the work requirements by volunteering for an hour every week or two, then I am a no on the DHS appropriation," he wrote of the Department of Human Services.

But department spokesman Marci Manley said in an email that "volunteering an hour or two a week would NOT meet the work requirement.

"People 19-49 who are considered able-bodied (childless, not disabled) must meet the work requirement, and there are a few ways they can do that. Beneficiaries who are not exempt from the requirement must report 80 hours of work activities per month. Those activities include working, job training, job search, etc., going to school [and] volunteering," she said.

King, who was the only senator to vote against the appropriation last year, described the program as "this insurance scam" under which low-income Arkansans are provided private health insurance. He said he plans to propose turning the Medicaid expansion into a fee-for-service program. The current program is unsustainable, King said.

But Hutchinson said he aims to use savings from reducing the growth rate of the Medicaid program to help provide the state matching funds for the Medicaid expansion. He also said the program is now financially sustainable after the reduction in its rolls from about 330,000 people.

Caldwell said he was not taking a position on the program "until we look at the big picture with the whole budget."

ELIMINATION COST

Sen. Jimmy Hickey, R-Texarkana, said he is leaning toward voting for the appropriation. He said that "since it has been such a lightning rod" issue, he is trying to ensure that program-skeptical senators have all of the pertinent information, including the general revenue cost of eliminating the program.

According to a document that Hickey provided to this newspaper and that Human Services Department spokesman Amy Webb said is from the governor's office, "The elimination of Arkansas Works, which currently covers 285,000 Arkansans, would cut $2.09 billion from the state's economy.

"For the state alone, the cost of eliminating Arkansas Works is estimated to be an additional $88.6 million in general revenue," the document says.

"If the Arkansas Works program ended this year, the proposed budget for [fiscal] 2019 would rise to $5,715,734,615. The increased costs would eliminate the projected surplus of $64 million and instead require $25 [million] in cuts to state operations," the document says.

The general revenue cost of eliminating Arkansas Works is based in part on an estimated 86,500 people in the program instead signing up for traditional Medicaid. The result would be nearly $149 million in additional costs because of the lower federal match for traditional Medicaid; nearly $42 million more for a handful of state agencies that would incur more costs from the elimination of the Medicaid expansion program; and the loss of $33 million from a tax on insurance premiums that were created by the expansion to support Medicaid.

These increased costs add up to about $224 million. Subtract the state's projected costs for the program -- about $136 million in fiscal 2019 -- and the difference is $88.6 million, according to the document.

And hospitals would incur more uncompensated care costs, with the University of Arkansas for Medical Sciences alone at $53 million more every year, the document says.

Hutchinson said Hickey and other legislators asked for that cost information.

"We want to have a straightforward figure on it and it is what it is," the governor said.

Hutchinson said he will tell opponents of the Medicaid expansion that the program "is something that's ingrained into the health care system of our state. It is ingrained into our economy."

He also plans to refer to program changes. "So it's not like they are having to flip positions for many of them, because they said, 'We want this kind of reform in place, we want to make sure the system is in place, we can't vote for it because there is not a real work requirement. It is a weak work referral waiver that we got last time.' So when we put all those in place, they are not changing their position. They are being consistent with it, saying, 'Now you got these in place. Then that works for us,'" Hutchinson said.

Two weeks ago, Hutchinson said he expected the federal government to soon approve the work requirement, but approval of other changes may come later. Those include cutting about 60,000 program enrollees by reducing the upper income eligibility limit to 100 percent of the poverty level, instead of 138 percent.

Hutchinson said he expects Trump administration approval of the work-requirement waiver before the legislative session ends.

The Arkansas Constitution limits fiscal sessions to 30 calendar days, but they can be extended by up to 15 days. The 2016 fiscal session lasted 27 days.

During the session, the Legislature will consider Hutchinson's proposed general revenue budget of $5.626 billion for fiscal 2019, an increase of $172.8 million over funding in the current fiscal year.

Senate President Pro Tempore Jonathan Dismang, R-Searcy, said he hasn't heard much push-back from lawmakers about the proposed budget.

"There are always members that want to spend more money," he said. "But at this point I think it is pretty fractured on where they would like to spend those dollars, so I don't see there being a consensus to make a big change to the governor's balanced budget."

For example, Sen. Will Bond, D-Little Rock, said he plans to seek more money for parole and probation officers for the state Department of Community Correction.

But Hutchinson spokesman J.R. Davis said that department has 1,332 positions filled and will be budgeted for 1,455 positions in fiscal 2019.

"We have an increase, and based upon their current needs and their resources, I think we are at the right level," Hutchinson said.

SundayMonday on 02/11/2018