By Steve Brawner
© 2016 by Steve Brawner Communications, Inc.

Voting for the private option was hard for many Arkansas Republican legislators, and every month – every dang month – it becomes harder to keep supporting it.

That’s because every month the number of Arkansans being served by the program continues to rise – past the 250,000 that was originally forecast, and now, as of the end of September, past 324,000 who are either enrolled or have been deemed eligible, or have been placed in traditional Medicaid because they were considered “medically frail.”

The private option is the health care program created by the Legislature in 2013 after the U.S. Supreme Court ruled the Affordable Care Act – that’s Obamacare – was constitutional but that states were not required to expand government-run Medicaid to serve individuals with incomes up to 138 percent of the poverty level. Given the choice, most Republican-leaning states said no to a lot of federal dollars, but Arkansas said yes, with a twist: Instead of simply expanding Medicaid, it bought those folks private insurance.

By many measures, the private option has been a success. Arkansas is a national leader in reducing its uninsured population. Without it, most beneficiaries would not have health insurance, but some still would have health problems, which they would wait to address until they were very sick by showing up at emergency rooms and being treated for free. Meanwhile, the huge pool of private option customers has kept insurers in the state and competing against each other, holding down rates for other individual buyers.

But all that government-paid health care isn’t free. The federal government is sending the state $1.6 billion in taxpayer dollars this year and paying 100 percent of the cost. Starting next year, the state chips in 5 percent, a number that rises to 10 percent by 2020.

For Republicans who have supported the program, it’s been a conundrum. Most if not all would say government benefit programs invariably create ever increasing numbers of beneficiaries – which is exactly what has happened. They went against their own instincts to vote yes because Arkansas is a poor state that needed the money, and local hospitals can’t keep providing all this free emergency room care. Also, frankly, there aren’t a lot of better ideas out there. Health care is hard.

Each legislative session has hinged on whether enough legislators could be found to overcome the objections of diehard opponents. The program barely passed in 2013 and barely passed again in 2014. It survived 2015 because Gov. Asa Hutchinson promised changes in the form of Arkansas Works, his renamed version that requires higher-income recipients to contribute $13 to their monthly premiums and makes other minor changes. Hutchinson wanted more, including a work requirement, but the Obama administration didn’t agree. So he took what he could get hoping the next administration will be more flexible.

Now here we are at 324,000 counting those deemed eligible but not yet enrolled, which is 7,000 more than last month and 16,000 more than the month before that. Department of Human Services Director Cindy Gillespie says there’s still a backlog of applications. Each month, the diehard opponents get a fresh chance to say “I told you so” (without offering much of an alternative), and each month the state draws nearer to when it must pay part of the cost. For Republican supporters, it’s like Chinese water torture: drip, drip, drip.

When the Legislature meets in 2017, those Republican lawmakers will face the same difficult choice they’ve faced every year since 2013: Keep a program that’s growing unsustainably, or … what?

Eventually, those supporters will become opponents unless the next administration gives states more flexibility. For them to keep voting yes, recipients must have more skin in the game. The rules will have to push recipients into jobs, and then into better paying jobs, and eventually out of the program entirely. And if able-bodied recipients don’t move along that path, then they’ll have to lose their benefits.

Of course, doing that – or getting rid of the private option entirely – would put us right back where we were before it existed: sick, uninsured people showing up at the local hospital seeking care, and then what should be done? Treat them for free and then shuffle the costs around, or turn them away because they don’t have insurance?

Did I mention health care is hard?