Arkansas has never really deserved its smart and thriving Medicaid expansion program, considering its primitive politics of the last decade.
Poor people have deserved the health care. Rural hospitals have deserved the reimbursements. State government has deserved the favorable federal matching money. The responsibly insured population has deserved the restraint on rising premiums provided by publicly paid customers in the private-insurance pool.
But the voters? Not so much.
Pragmatic governorships deftly advancing the program allowed voters to escape consequence from their raging know-nothingness and right-wingness.
Now what we call Arkansas Works will be put on trial yet again in the current session, and there is cause for concern.
Would this Legislature dare eliminate health insurance for a quarter-million poor people with a pandemic still afoot? Have you seen this Legislature?
The right-wing infection has spread. The federal waiver by which the state got permission to do this privatized option is up for renewal, requiring legislative approval.
The pieces of disaster are in place.
Medicaid expansion is the element of the Affordable Care Act that sends money to states choosing to expand basic Medicaid to cover health care for the working poor. To avail ourselves of it, Arkansas has had to rely on brinkmanship, trickery and the good fortune of two solid chief executives disregarding polarized partisan rhetoric for the right thing.
Mike Beebe birthed the program by acquiescing to a trio of innovative conservative Republican legislators who devised seeking the waiver to use the federal millions to buy private health insurance for the poor, rather than simply paying the medical bills.
It was enough of a conservative privatizing notion to get the program going.
Hutchinson saved it once by inserting a line in the Human Services Department appropriation that expressly killed it, though there was money for it in the bill.
He did so on the transparent understanding that he'd use his line-item veto to extract that phrase even as the phrase provided the sole basis for Sen. Bart Hester's essential vote for the bill. Hester wanted to oppose Medicaid expansion personally but not be responsible for ending it.
Another time, state Sen. Jane English, long obsessed with improving work-force training programs in the state, provided the final needed vote after she was assured that she could have her desired work-force training changes. Thus, she made the argument that we would do a better job getting poor people off the Medicaid she was voting to expand.
Later, of course, the Hutchinson administration imposed its requirement to kick people off Medicaid expansion if they weren't working, which was an attempt to placate mean-spirited right-wingers -- a redundancy, perhaps.
All of that has played against the absurdly onerous provision of the antiquated state Constitution requiring a three-fourths vote to pass the appropriation.
So, amid logic and a tenuous conventional wisdom that the program had become accepted through regularity and success, we confront a potentially troublesome situation.
It is that the state Human Services Department is designing its new waiver request and changing it in a few ways in part to better appeal to the Biden administration. Meantime, the state Senate has become a place where the new president pro tem, Jimmy Hickey, advocates closer scrutiny of administrative budgetary assumptions. It's also a place where eight right-wing senators were petty enough recently to block for a few days the utterly customary appropriation allowing Hutchinson to hire a few legislative liaisons.
Several legislators, not just senators, have asked DHS to provide numbers reflecting the state general-fund effect of four options -- renewing the private option for Arkansas Works essentially unchanged, updating the waiver request to make the few changes DHS advises, changing to the original fee-for-service model or simply dropping the state's participation in Medicaid expansion entirely.
If you like irony: It appears that some conservative legislators now do not like the privatized option because it pays premiums for people who don't go to the doctor. But they are intrigued by the fee-for-service model to pay costs only as incurred, which was the Obama administration's original idea until Beebe and a few Republican innovators got permission to change the rules for Arkansas.
Conversely, I initially recoiled at the private option but now prefer it.
Though the waiver renewal request needn't be filed by the end of the session, the Senate, at least, seems to want to decide on the waiver -- whether and how -- before bothering with the usual appropriation.
I don't like the sound of that, but Hutchinson, ever the optimist, says, "While achieving a three-fourths vote is challenging, I expect we will get it done."
Let's hope so. Otherwise, the next governor, who'll probably be bad enough on her own, will inherit a strained state budget and boarded-up rural hospitals.
John Brummett, whose column appears regularly in the Arkansas Democrat-Gazette, is a member of the Arkansas Writers' Hall of Fame. Email him at firstname.lastname@example.org. Read his @johnbrummett Twitter feed.