OPINION: Guest writer


Medicaid expansion in Arkansas

Ten years ago this month, Arkansas' Medicaid expansion program began providing coverage to a portion of the state's population for whom health insurance was previously out of reach.

The anniversary of the program, today known as Arkansas Health and Opportunity for Me, or ARHOME, provides an opportunity to reflect on what it has--and has not--accomplished in its first decade.

For Arkansas, a state with one of the lowest median household incomes in the nation, the impact of Medicaid expansion on health coverage has been profound. The Arkansas Center for Health Improvement calculates that over 718,500 Arkansans--nearly a fourth of the state's population--have been enrolled in the program at some point over the past decade.

Medicaid expansion also offered a lifeline to Arkansas' hospitals. Within the program's first year, uncompensated care costs at the University of Arkansas for Medical Sciences dropped from 14 percent of operating costs to about 4 percent--and private hospitals around the state experienced similar impacts.

Thanks in part to this support, no rural Arkansas hospital has closed, without later being reopened or replaced, in over a decade. This is especially notable in contrast with the six states surrounding Arkansas, where 58 rural hospitals have permanently closed since 2012.

Arkansas has taken an innovative approach to Medicaid expansion. Instead of simply expanding its Medicaid rolls, the state received permission from the federal government to use mostly federal funds to provide private health coverage to the expansion population, Arkansans earning up to 138 percent of the federal poverty level.

The state also made the key decision to enroll people who are medically frail in traditional Medicaid, resulting in a relatively younger, healthier, and lower-risk population for insurers to cover. This system, combined with careful management by the Arkansas Insurance Department, has resulted in a stable insurance market and lower premium increases than most states have experienced. Arkansas has had lower average marketplace premiums than any of the surrounding states every year since 2017, and only 11 states in the nation currently have lower average marketplace premiums than Arkansas.

But there is more work to do.

Ten percent of Arkansans under age 65 remain uninsured, despite the availability of ARHOME and federal assistance to purchase plans on the Health Insurance Marketplace. Our rural communities also face access and quality of care issues. A recent analysis by the Arkansas Center for Health Improvement found that in 2020, six Arkansas counties had only one full-time primary care physician apiece.

And nearly half of Arkansas counties are maternity-care deserts, meaning they have no obstetric providers or health-care facilities providing obstetric care, according to a 2022 March of Dimes report.

Health outcomes in Arkansas typically are well below national averages. The state has been ranked as the 48th healthiest state for the past three consecutive years in the annual America's Health Rankings report by the United Health Foundation and the American Public Health Association. Among people of color in Arkansas, health outcomes tend to be even worse than state averages. For example, Black women in Arkansas are twice as likely as white women to have pregnancy-associated deaths, according to a 2021 report by the Arkansas Department of Health.

For Arkansas' hospitals, the lifeline that Medicaid expansion provided has become frayed. Labor shortages that began impacting hospitals during the covid-19 pandemic, combined with rising costs, have put new strains on facilities' finances, especially in rural areas. In August 2022, the Arkansas General Assembly set aside $60 million in federal American Rescue Plan funds as emergency relief for rural hospitals. More than $40 million of that amount has been allocated to struggling facilities to date.

Finally, as a nation, we must address health-care costs. In 2022, U.S. health-care spending reached $4.5 trillion, which averages to $13,493 per person, or about twice the average per-person cost in other wealthy nations.

Despite outspending the rest of the world, the U.S. has the worst health outcomes of any wealthy nation--the lowest life expectancy, the highest death rates for avoidable or treatable conditions, and the highest maternal and infant mortality rates.

Ten years after coverage in Arkansas' Medicaid expansion program began, we can see that the program has improved health-care coverage, extended the lives of rural hospitals, and helped to limit premium increases. The challenge for policymakers in 2024 and beyond is to build on what we have accomplished in ways that address problems such as access issues, poor health outcomes, health disparities, new financial challenges to rural hospitals, and soaring costs.

These are tall mountains to climb, but thankfully Arkansas is in a better position for the journey than it was a decade ago.

Joe Thompson, M.D., M.P.H., is president and CEO of the Arkansas Center for Health Improvement and was Arkansas' surgeon general under Govs. Mike Huckabee and Mike Beebe.

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