Just spoke with Senate President Pro Tempore Jonathan Dismang, who — along with House Speaker Jeremy Gillam — wrote a letter to Gov. Asa Hutchinson asking him to skip the Medicaid managed care question during this week’s special session on health care because there was not a consensus to move forward. 

The governor proposes using managed care for two high-cost populations in the Medicaid program: the developmentally disabled and those with severe and persistent mental health issues. The proposal has been met with fierce resistance from providers’ allies in the legislature, who this afternoon released a brief summary of their own alternative proposal for care management for those populations, known as DiamondCare, which would protect the fee-for-service payment system for providers rather than using managed care companies. 


Dismang, a supporter of the governor’s bill, said that the issue was not inadequate support for the managed care bill per se, but that members have not had enough time or information to make a decision. 

“Members still have a lot of questions about what it means, what it does, who it impacts, and it’s going to be difficult for them to take that matter up and feel certain about their vote,” he said. He pointed out that the governor’s bill was released last week and has undergone significant revisions. “That’s added to some confusion about what those changes do and who they impact,” he said.


The existence of two competing plans (the governor earlier said that his special session should consider only his bill, and not DiamondCare) is another factor pushing members to seek more information, Dismang said. “DiamondCare has not been released yet so members haven’t had a chance to look at it, minus a select few,” he said. 

Let’s be clear here: the leadership in the House and Senate clearly does not believe that they have the votes to pass managed care. Managed care proponents have suffered a major setback today. What Dismang is arguing is that the short vote count is less a matter of “hard no” members than “I don’t know” members.


“They’re trying to get more information to make sure they understand what they’re voting for,” he said. “And I’ve talked to a number of members who are comfortable with the proposal but just have a few more questions.” Dismang is a supporter of the bill himself, so take that with however many grains of salt you’d like. 

Given that there’s not an organized faction in the legislature suggesting to do nothing at all, I asked Dismang whether there was a possibility for a compromise between the DiamondCare group and the governor’s office. Both proposals aim at the same broad slate of reforms.  

Dismang said that members generally had interest in a compromise solution, but he argued that the governor had already made significant concessions “both to the actual bill and concessions that haven’t yet made it into bill form. Those have been rejected by the folks leading the charge on the DiamondCare proposal.”

At a meeting with DiamondCare backers on Friday, Dismang said that the governor floated the idea of establishing provider organizations, known as “risk-bearing provider organizations,” that would operate under managed care but theoretically give providers more clout. DiamondCare backers appeared cool to the idea and have not responded. 


I asked what was next — if the traditional Medicaid savings question wasn’t going to be tackled at the special session, when? 

Not during the fiscal session, if Dismang gets his way. “I would like to limit the fiscal session only to budget items,” he said, and added that the two-thirds requirement to consider non-budget items during the fiscal session would complicate matters. Unless a consensus is reached this week, Dismang suggested that the best bet was another special session after the fiscal session (either the one already happening for highways and other matters, or possibly another one altogether). 

The timing of waiting until after the fiscal session is at least logistically doable. It will likely take a significant amount of time to ramp up to managed care in any case, so it does not necessarily need to be included in the Medicaid budget for this fiscal year. 

However, what about the politics of the private option? The PO (or “Arkansas Works” as the governor now calls the state’s privatized Medicaid expansion) should pass easily in the special session, but it faces a tough re-authorization fight in the fiscal session that follows, when it needs 75 percent support. The governor’s managed care plan has nothing to do with the private option, but he has tried to link them together. Could he lose votes for the continuation of the PO if the traditional Medicaid savings plan is in limbo? Note that this could complicate things on both sides: some managed care backers don’t believe that DiamondCare will work and of course many DiamondCare backers are diehard opponents of managed care. Are there some potential PO voters who will threaten to block the Medicaid appropriation unless they get their way on the managed care question?

Dismang said that he did not think that the potential limbo would complicate the ability to get the supermajority for the private option. Well, we’ll see. Health insurance for more than a quarter million low-income Arkansans hangs in the balance. 

I asked Dismang whether he would support DiamondCare if the governor’s managed care plan ends up failing to get majority support whenever it’s finally taken up. He said he would be willing to take a look at it, but that he couldn’t comment on legislation that he hasn’t seen.

The DiamondCare legislation is expected to be released tomorrow. The Health Reform Legislative Task Force will meet to discuss it tomorrow afternoon. 

Support for special health care reporting made possible by the Arkansas Public Policy Panel.