Shortly after President Barack Obama ushered the Affordable Care Act through Congress, the U.S. states expanding Medicaid were for the most part Democratic-dominated states in the northeast and west coast with a sprinkling of left-leaning midwestern states.
There was, however, a notable exception: ruby red Arkansas.
To this day, most of the 10 states that have refused to expand Medicaid are located in the South, so Arkansas and a few other notable exceptions continue to stand out.
Still, in 2013, former Arkansas Gov. Mike Beebe viewed expanding Medicaid as “a no-brainer” to provide health care coverage to primarily the working poor.
“But it was Obamacare and nearly every Republican opposes Obamacare philosophically, especially those in Southern states,” Beebe, who is now retired from politics and living in his hometown of Searcy in north central Arkansas, recently told Mississippi Today in an interview.
When Beebe proposed being one of the first states to expand Medicaid in 2013, he was a second-term Democratic governor with a Republican-majority Legislature. And to make matters even more difficult, the Arkansas Constitution requires a three-fourths vote of each legislative chamber to pass an appropriations bill, meaning a high threshold was needed to pass Medicaid expansion.
Still, Beebe set his sights on doing something historic in 2013 by expanding Medicaid.
“It is a no-brainer whether you are Democratic or Republican if you care about your people,” the veteran Arkansas politician said.
In the South, only Kentucky and Louisiana have followed Arkansas’ lead in expanding Medicaid. North Carolina has recently expanded Medicaid, though it has not yet been enacted.
In Mississippi, Brandon Presley, who is trying to become the first Democrat elected governor since 1999, said if elected he will work to expand Medicaid despite having a Republican Legislature.
If elected, Presley might study how Beebe succeeded in expanding Medicaid despite some difficult obstacles.
In 2013, Beebe said he was able to prevail by first approaching moderate Republican businessmen and making the argument that Medicaid expansion was good for the state’s economy and its people — "people I called the working poor, who worked but could not afford health care and their employers did not provide it," he said.
Beebe can still rattle off all the arguments he used in 2013 to convince lawmakers to expand Medicaid. Many of those arguments have been used – unsuccessfully – in Mississippi.
But there has been no one advocating for expanding Medicaid in Mississippi with the bully pulpit that Beebe had in Arkansas as governor. Current Mississippi Gov. Tate Reeves and Phil Bryant, his predecessor, were vocal in their opposition to Medicaid expansion.
Besides having the bully pulpit, Beebe had a vast knowledge of the workings of state government. He previously served as attorney general and for 20 years in the state Senate, including 10 of the 12 years that future President Bill Clinton served as governor. For many of those years, he was the leader of the Senate.
"I knew how to work the Legislature because I had been worked by the best," Beebe said matter of factly. "But I think the arguments carried the day."
Still, Beebe said, getting the expansion bill through the legislative process was difficult and took several votes. In the 100-member House the proposal, needing 75 votes, garnered 72 or 73 multiple times.
“I believe it finally passed with 77,” Beebe recalled. “It was the same in the Senate where there were 35 members.”
It passed in 2013 and went into effect in 2014.
A key to passage was the unique form of Medicaid expansion proposed by Beebe. Recognizing the difficulty in getting the proposal needing a three-quarters vote, through the Arkansas Legislature, Beebe proposed Medicaid expansion be offered through private health insurance companies instead of by a government entity.
Instead of money going to the government entity to pay the health care costs of those covered through expansion, the money would go to the private insurance companies that provided the health care coverage. Some Republicans could support the proposal under the pretense it was not expanding a government program.
The state of Arkansas would need a waiver from the federal government to approve such a unique plan.
“The Obama administration needed a win in a Southern state so they approved it,” Beebe said. Plus, it helped that Obama’s Health and Human Services Secretary was Kathleen Sebelius, whom Beebe knew from her time as governor of Kansas.
Beebe said the plan helped to attract more insurance companies to Arkansas, resulting in insurance premiums not skyrocketing in costs at a time when they were rising dramatically in the rest of the South. He reasoned that health care providers were not having to pass on costs to people who had insurance to pay for the people who received treatment, but had no means to pay for it.
He said that provided a powerful argument for expanding Medicaid. Another strong argument, Beebe said, is that if Arkansas did not expand Medicaid the citizens of the state would still be paying for the expansion in states like California and New York.
Expansion helped Arkansas hospitals and actually resulted in less costs for the state.
A lot has changed in Arkansas since Beebe was elected to his second term as the only governor in Arkansas history to win every county. Now, former Donald Trump spokesperson Sarah Huckabee Sanders is governor, but Beebe said he is not hearing anything about repealing Medicaid expansion, though it continues to be tweaked.
“They changed the name,” he said.
Beebe said it would be difficult to remove coverage for 300,000 Arkansans.
“Plus, the budget could not afford it,” Beebe said.