Ferguson: "mark me as undecided" on the private option because of Blue Cross reimbursement issue Brian Chilson

Previous installments of this series — lawmakers in their own words on the private option (see here and here) — focused on Republicans. No surprise there since, as Rep. Warwick Sabin puts it, “all of the drama has taken place on the Republican side.”

But the supermajority threshold for the private option – which uses Medicaid funds to purchase private health insurance for low-income Arkansans – was only possible because Democrats voted as a block for the policy every time. It sounds like Democrats will continue to be solid in their support (though the issue of reimbursement cuts to specialists by Blue Cross Blue Shield  was cited by at least one Democrat as giving her pause), but Democrats may play a bigger role in the drama this time around for a few reasons. For one thing, if a minority of lawmakers block the private-option appropriation, Democrats (or a bipartisan majority) could counter by blocking any appropriation without the private option. They will also be the key arbiters in striking a balance on any tweaks or adjustments to the policy — a modification that picks up a Republican vote does no good if it loses one on the Democratic side. 


In any case, according to House Minority Leader Greg Leding, we’ll be hearing more from that side of the aisle: “We have about 100,000 Arkansans out there that now have health insurance and are counting on it and I really don’t want to stand by quietly while people debate the possibility of taking that away.” 

The fiscal session begins Monday, with the future of the private option hanging in the balance. Here’s a sampling of what I’ve been hearing from Democratic lawmakers and officials, culled from reporting on our recent cover story on the private option


REP. GREG LEDING (House Minority Leader)

I asked Leding if Democrats would still be united in support of the private option in the fiscal session, as they were last year.


I do. We do have some members who have some questions about the way some of the things have unfolded. But I believe that when it comes time to vote we will all be on board.

A few members are concerned by what Blue Cross Blue Shield has done with the specialist rates. I know that those members have met, and are continuing to meet with Blue Cross. I believe the governor’s office has had some talks with them. I still feel pretty good that they’re going to be able to come to a resolution and that we’ll have all 48 democrats on board.

I don’t know how insistent those particular members are going to be if Blue Cross Blue Shield doesn’t act. I certainly understand, the main complaint is that they changed the rates they would pay specialists, and specialists would get paid less than general practitioners [for the same procedure]. Whether or not that’s fair, I’m not in that field.

That anybody would cast the vote against this for the sake of — I think it’s about four thousand specialist doctors this would affect — against the one hundred thousand who now have health insurance. I don’t know how you cast that vote no matter how unfair you think that might be. 

What about Republicans?

I originally suspected that perhaps those members who had picked a primary opponent this year might have second thoughts. But I read where Rep. Sue Scott, one of those who picked up a primary opponent, stands by her vote. That gives us some hope there.

You even had members just recently like Rep. Nate Bell come out and say that they’re keeping an open mind.

That makes me kind of suspicious about these changes [Repulicans] are talking about. It is something we’re going to have to watch closely. We can’t necessarily just take the 48 Democrat votes for granted. I don’t know where that line would be but I suspect if it was changed too much, it might become unpalatable for some of us. And then we’re in a very difficult position. I’m hoping that they are minor.

Anything could happen. The governor remains committed. The Speaker and President of the Senate too. Burris, Sanders and Dismang have worked too hard on this to let it go. Our caucus is committed to keeping it. I’m still hopeful at the end of the day. If you’ve got people like Sue Scott who’s willing to stand by her vote, which I think is a pretty brave and the right thing to do…I’m hopeful. …I still feel like we’ll get it passed. … I think right now the biggest obstacle is the Blue Cross issue.

Last time even though it was very, very difficult, we decided that the best approach was [for Democrats] to stay quiet to an extent. We felt that – if a few of us, like me, who represents a very liberal district, got out there and really wrapped their arms around this thing, that might scare away the votes that we need. We kind of just marched forward. This time around, I honestly don’t want to be that quiet again. We have about 100,000 Arkansans out there that now have health insurance and are counting on it and I really don’t want to stand by quietly while people debate the possibility of taking that away. 


You know it’s going to be a close vote. You know you’re going to have some people who may hesitate. But you had some people who hesitated last time. And you had some people who hesitated last time and just barely fell on the other side of things. I think that you just keep talking to people, you keep sharing information with people. You make sure that good information, real information is getting out there. And you clear up misconceptions that are arising, whether intentional or otherwise.

The governor has said all along, the facts of this and what it does for the state are pretty indisputable and that continues to be the case. Because what you see as the comeback a lot of times are not the facts as they apply to the private option. It’s ACA-related stuff or it’s a confusion of the actual facts.

DHS keeps putting out the numbers as we get them and we answer questions as we get them and we’re happy to clear things up. It’s by no means a simple issue.

It’s clear that you have people in this state who have needed health insurance who have not had an option available to them until now. You’re seeing not only those people start to get insurance but you’re seeing the story start to get out of what that has meant to them. Along with a lot of the politics you’re going to hear in the next few weeks, you’re also going to a hear a lot of the direct, on-the-ground human stories about what this really does mean to a lot of people in this state.

This time around it’s not all theoretical, because of these people who do have insurance now, because of the money that’s starting to flow in the state now. And of course the real federal money flowing into the state starts in July. There’s a lot more that’s certain now than there was a year ago. As far as what’s actually now happening — now that we have the waiver, now that we have people enrolled. … We’re on a lot more steady ground than we were last time around. Everything is in place and the model is in place that other states are looking to emulate. It’s most of what other states wanted to talk to the governor about when we were in D.C. [at a National Governors Association meeting]. 

The vote itself, we look at the same way we did a year ago. It’s a tough threshold, you can’t take anything for granted. It’s going to be a lot of hard work, just like it was last year. You had enough people who realized what it could do. And guess what? It’s doing what we said it could do for the state. There’s definitely more real information, real people, real results to show, that we will have this time that we did not have a year ago. Of course that helps, but again, you can’t assume, we’re still going to have to count just like we did a year ago. 

Concerns about precedent demanding a supermajority for any policy?

I don’t know if it’s a precedent. It’s a unique situation because the policy is so closely tied to the federal money. The federal money is what needs to be approved every year. You’re going to have people who make that appropriation a policy issue even if you’re not passing new policy laws. And when you’re looking at an election year…of course every fiscal session falls in an election year. Your’e looking at something that’s very polarizing on a national level. You have a lot of people who are making it a big political issue on the state level. I don’t think it’s a precedent as much as it is that everything with the ACA has been unique, I think. …I don’t think it’s the start of a future [trend], I think it’s just something unique unto itself. 

I asked whether possible tweaks or adjustments to the private-option policy was something the governor was considering.


Right now it’s not because we haven’t heard of anything specific. Of course the governor is reticent to open that door [to legislative changes] in fiscal sessions anyways. He’s considering it on the Lieutenant Governor issue this time around, but otherwise it’s not something we’re looking to do. The governor always says he’ll sit down and talk to anyone who wants to come in and talk to him about anything but right now that’s not something that we’re examining or initiating ourselves. 

SEN. KEITH INGRAM (Senate Minority Leader)

I’m chairman of the Southern Legislative Conference. I am constantly asked — how did y’all do this? You’re the only state in the South that did something so unique. We are talked about and featured in conferences across the country. Quite frankly I shared with them that we had great collaboration with Democrats and Republicans. We found a way to reach across the aisle. We had Republicans put their state and the needs of their people ahead of their party. That is so different than what’s going on with Washington. I think people applaud that. I think they’re amazed that we’ve been able to do that here in Arkansas. I’ve been very proud of what has been accomplished here.

I’m an eternal optimist. I feel like in some way, shape, or form we’ll find a way to get it done during the fiscal session.

As you know, the Senate leadership in the Republican Party, Senate Pro Tem Michael Lamoureux and Senator Jonathan Dismang, have been supporters of the private option. They see the wisdom in it. Just the business side of the private option — if this wasn’t an issue that had gotten politically charged, the business side of this, it’s an easy decision. It’s the political side that makes it tough. They’ve provided great leadership. They’re very well respected in their party. I think they will again work very hard to demonstrate how fiscally responsible this is.

The thing that is remarkable is the hurdle to pass this is extremely high. I don’t think anyone appreciates the 75 percent hurdle to make this happen. … I think it’s remarkable that on such a highly charged topic that it was able to gather a supermajority. Everybody has to work together for that to happen on any issue that requires a supermajority.

I know we focus, and rightly so, on the individual that’s going to be without coverage. But I can tell you in the delta there will be hosptials that are forced to close if we do this. They can’t make it. Most are operating in the red now and this would seal their fate.

We have done something so unique and we’re going to kill it within six months? And we’re still going to be under the federal healthcare program, it’s not like this thing goes away. This makes no common sense. I certainly understand the pros and cons of it politically. But this makes no common sense whatsoever.

These are 100 percent federal dollars coming in to our state [for the next three years; 90 percent federal match in 2020 and beyond]. An analogy I have used is, my brother and I have been in the ready-mix concrete business in Blytheville, Arkansas since 1970. When that airbase closed in 1992, a dramatic difference took place. Those federal dollars that came in to that community that were spent and re-spent through restaurants and service industries…it was dramatic when those federal dollars stopped to that air base. It changed that entire community up there. The economic development of the area suffered for many years.

I think that’s a good analogy to tell you what federal dollars can mean. Here we’re [talking about] turning down 100 percent federal dollars. Then we are creating problems with our budget. … The legislature understood, Democrats and Republicans alike understood, the 100 million dollar tax cut came directly from the savings on health care [via the private option]. .. I hope that the legislators that are proponents of not funding the private option will not get amnesia about the need to figure out how we fill that gap that’s created.

I think this is politically driven, I don’t think this thing is policy driven. That’s two tremendously different things. 


My expectation would be that the Democrats would hold together and provide that significant support that’s necessary for the private option to even have a chance of sustaining.

I asked Sabin about the strategy of keeping relatively quiet last year, referenced above by Leding.

The dynamic will be similar although I wouldn’t couch it as Democrats being quiet. It’s just that all of the drama has taken place on the Republican side. The Democrats have been solidly in support of expanding health insurance to those who need it across the state. We see the great logic that’s applied when you consider the impact of the federal funding on the entirety of the state budget. We certainly have had a lot to say about it. I would say that a lot of the focus, whether that’s from the media or otherwise, hasn’t really been on what Democrats think because it’s simply not as dramatic or theatrical — or ultimately, to some degree, relevant — because in this particular case because of the way our constitution requires a three-quarter vote for an appropriation. It allows a very vocal minority to drive the debate. We represent a substantial number of people across the state. We have 48 votes in the House. Our voice is strong. Our constituency is huge. I think that we deserve to be heard. But again, when you need 75 votes you’re really focused on those handful of people who are going to provide the margin of victory. 

Does he have concerns about a precedent demanding a supermajority for any policy.

I do have serious concerns about the process going forward. I think it’s a product of an evolving political culture in the state. The closest parallel is the filibuster in the U.S. Senate, which had existed for many, many decades but only recently was abused to the point where no legislation would get through the Senate unless it had a filibuster-proof 60-vote majority, which, again, empowered the extreme elements of the minority to hold up a lot of legislation there. We have a similar threshold [for appropriations]—75 votes in the House and 27 votes in the Senate. The process worked for a long time when the culture was one of compromise and responsible policy making and now we have a situation where even if you pass the policy, ultimately you can’t enact policy without appropriations. Whoever pulls the strings financially really gets to dictate how policy is enacted in Arkansas. These groups are going to utilize that going forward and I do think it’s going to be a problem we’re going to experience a lot in the future. 

I asked about whether “tweaks and adjustments” to the private option in order to gain Republican votes might go too far.

I do think that’s a concern. I think that if the private option is tweaked to the point where it doesn’t accomplish its intended purpose, which is to expand healthcare to those who most need it and those who can least afford it, then I think there is going to be a serious risk of losing that foundational support that Democrats are providing. Also there are certain requirements that we have to abide by because ultimately this is a federal program, and we’ve already achieved waivers on a couple of issues. There are certain issues that have come up [such as an asset test for beneficiaries] — it’s already been testified in front of committee that are unlikely to receive waivers or permission form the federal government if they were attempted. And I think that we do run the risk somewhat of creating a situation where we have thrown the baby out with the bathwater and we haven’t really attempted to seriously implement the policy… .I’m concerned that if we’re going to re-litigate this policy every year through the budgetary process and by any other means that are at the disposal of the minority of people who oppose the policy, it just jeopardizes its chances of success. 

If a small group of Republicans block the appropriation, would Democrats counter by blocking any appropriation without the private option?

I certainly think that’s a scenario that could come into play. If all options are going to be on the table, then all options are on the table. We have to consider what’s in the best interests of the state of Arkansas. I think there’s no way to evaluate that until we’re in a particular situation if the option’s in front of us. We’re going to have to look at where we are at that point. Certainly we’ve indicated a willingness to compromise and a willingness to be flexible. That is not unlimited. There has to be a point at which — what’s going to be in the best interests of the people of Arkansas, the best interests of people who’ve already signed up and enrolled in the private option? What’s the impact on the budget overall? Especially since we have enacted these tax cuts and these other policies already? Compromise is about meeting in the middle. We certainly demonstrated that we can do that from our end. Other people have to come to the table as well. At some point, if you give in at every juncture, you’re really not serving the interests of your constituents or the population overall.

We have to come together and we have to address this and we have to do it a responsible way. That isn’t just about making the point about one particular issue. We’ve already passed the private option. Almost 100,000 people have already enrolled in it. We know that if you don’t go forward with it, we’re going to have to cut 89 million dollars from other parts of the state budget. We know that hospitals and healthcare providers are going to be seriously impacted. We know that businesses from all sides are going to be seriously impacted. People are going to be without access to affordable health care. These are really serious issues and they demand a serious approach, and not one that’s just rooted in campaign politics or other considerations. 


The enrollment figures look relatively good. I think they probably would have been a little better if we had had some advertising dollars. In general, the demographics of the [private option] rollout group is very positive. Most of them are under 40. That certainly changes the actuarial tables to look better for the insurance companies

Ferguson has been vocal in her criticisms of the reimbursement rate cuts imposed by Blue Cross Blue Shield to specialists for patients on the Arkansas Health Insurance Marketplace, including the private-option beneficiaries.

The bottom line, it’s really about patients and access to care.

As part of the ACA next year they’re actually required to have the same reimbursement schedule for their marketplace as they do for their traditional insurance plan. What they’re doing now wouldn’t be allowed next year.

The other thing that aggravates me about the whole thing: Every person per month is paying a $5.25 reinsurance fee as a risk adjustment, as protection against risk for the insurance companies. They’re protected against loss for three years because they knew that trying to predict this actuarial group would be difficult. They have their risk mitigated…I really think looking at the demographics of the group, considering they had this risk mitigation — I think they’re going to end up making money. They’re getting millions of dollar in federal dollar premiums. I would much rather pay that to providers, hospitals and doctors, than to return that to CMS for premium reimbursement.

I understand they’re private insurance. It’s new ground for them as well, because it’s the first time our tax dollars are paying the premiums. Unlike Medicaid where we have we some legislative oversight, we really don’t have any legislative oversight with their reimbursement. We can complain and make suggestions, but in terms of having any legal authority we don’t. I would hope, because Blue Cross is 80 or 85% of the market, that they would listen to legislators’ concerns. Unfortunately the only hammer we have is to not vote for the private option.

I think Blue Cross will be reasonable in the end. After our meeting with them, I feel like they will make some adjustments in the reimbursement schedule, which is…they’ve never reimbursed by that method. It’s unprecedented even for them.

I’m hopeful, I think in the end they’ll do the right thing.

If there wasn’t a satisfactory resolution to the Blue Cross issue, would Ferguson vote to block the private option?


I think you can mark me undecided at this point. 

On the possibility of incorporating cost-sharing below the poverty line to the private option.

I certainly support personal responsibility and we all want that. But purchasing health care is very different than purchasing something at Walmart. We’ve had co-pays in AR Kids for years and it’s essentially no-pays. You can’t make them pay and you’re not going to not see them if they don’t pay, so it’s sort of double-edged sword. It sounds good and I understand it. It is unfortunate that this whole group of people has no cost sharing and … that said, we do have to do something to encourage them not to use the ER. 


Like Ferguson, Magie, an ophthalmologist, has been vocal in his criticism of the Blue Cross reimbursement cuts. However, he has been clear that the issue would not keep him from supporting the private option. 

We’ve had several meetings with Blue Cross and discussed with them some of the concerns we have about it. … If it had been fair across the board — if everybody takes a fifteen percent cut…most physicians would look at that and they might mumble and grumble about it, but they’d say well that’s fair. Everybody is sharing in the pain and we want to provide the services for the patients. What they did was singled out specialty care and really made it unfair between physician groups. Now when a specialist sees a patient for even a primary care service, they get paid less. So for instance, if a cardiologist sees a patient in their office for a congestive heart failure follow-up visit, he gets paid 15 percent less than what a primary-care or family-practice doctor would see to see that same patient in their office for the same service. … it’s not a fair method of reimbursement to pit one group against another in terms of their reimbursement when they’re providing the same service.

Now the argument they make, well you’re still getting paid more than you got paid in the past because before you weren’t getting paid anything. That’s true. That is true. But I just think it has to be fair. We’ve talked with them at length about that.

It really is not a legislative or government issue. Because the legislature has no — and shouldn’t have — powers over a private company and telling them how to set their rates. … We can certainly express our displeasure. One of the things we want to do, many of us who support the private option, and I support it, we want to make sure there’s not bumps in the road that give people pause.

It won’t keep me from voting for the private option. There’s just too many people in the state that need access. And the whole thing about the private option is, if you do away with the private option, you’ve just taken the poorest, least advantaged segment of our population and said to them, sorry, you’re just not getting any help. You’re talking about one of the most vulnerable segments of the population. … I can’t do that. I can’t do it. That’s not the right thing to do. … In terms of taking care of patients, we need to advocate and do what we can to make sure that people have access to healthcare.

From a medical standpoint, it’s all about the patients and getting the patients the care that they need. I really think the private option, if you really set back and look at it, it is a completely different way to deliver healthcare to a segment of our population that needs it. It’s taking federal dollars and buying private insurance for those people. … We’re not creating the whole huge bureaucracy of Medicaid. We’re actually completely rethinking and changing the way that we think about how we provide care and provide financial care of patients. And I think this thing, if it goes and it’s successful, it has a chance to really change the way healthcare is financed and delivered across the country. People are looking at Arkansas and I have a hard time believing that someone on the other side of the aisle wouldn’t vote for it.

There are 48 Democrats. The day that everyone pushes their button to vote, I expect there will be 48 Democratic votes for it. I just can’t imagine that anyone would not.