LITTLE ROCK — Medicaid shutdown fatigue is starting to set in at Arkansas' Capitol.
Despite all the talk of a work requirement being key to keeping the state's Medicaid expansion alive this year, the Trump administration's approval of that new mandate wasn't the deciding factor. Instead, it was the prospect of a months-long standoff over the program.
The Arkansas Senate approved the budget for Medicaid and the expansion program, which uses Medicaid funds to purchase private insurance for low-income residents, a day after federal officials approved the work requirement. Vacancies in the 35-member chamber had created uncertainty about whether supporters had the 27 votes needed to keep the plan alive.
The yes votes included two longtime, staunch opponents of the program who said they wanted to avoid leaving the budget in limbo only to see it passed later this year after the vacant seats are filled.
"Eleventh-hour decisions, while they are necessary sometimes, really get weary every time," Republican Sen. Terry Rice told fellow senators before casting his vote.
The deciding vote came from Republican Sen. Alan Clark, who said he didn't see the sense in returning for a special session if supporters fell only one vote shy of seeing the program reauthorized.
"This time, it was simply, I still don't like the program but there's no sense in us coming back in June," Clark said.
Republican Gov. Asa Hutchinson said he thought the work requirement, which will take effect this summer, gave lawmakers "a higher level of confidence we're going in the right direction."
But the chairman of state Democratic Party said the bigger factor was how much the state and its budget depends on the expanded coverage.
"I really think they're seeing what's happening in Kansas and Oklahoma where these major tax cuts have taken place for political gain and they haven't had Medicaid dollars," state Rep. Michael John Gray said.
The Senate's approval of the expansion, and a House vote in favor of the program a day later, was the latest setback for Republican opponents who have cast it as an embrace of the federal health law Republicans regularly deride as Obamacare. The program has sharply divided Republicans since it was created in 2013 as an alternative to expanding traditional Medicaid under the health overhaul. Critics say the program is still unsustainable and too costly for the state, and is growing more expensive as the state's share of the expansion's cost increases.
"We're supposed to be a Republican, conservative-minded legislature ... and we're spending more money than any Democrat legislature or governor has even thought about," Republican Rep. Josh Miller said.
The divide even prompted Hutchinson and legislative leaders to salvage the program two years ago through a complicated maneuver that required supporters of the program to vote for its demise. Hutchinson vetoed that provision, thus keeping the program intact.
Last week's vote doesn't guarantee the program will avoid any more fights next year when lawmakers return for the regular session. Opponents of the program say they still want to push for ways to wind down or trim the program, including by capping or freezing enrollment in it.
There's also uncertainty about another restriction the state is seeking to roll back the eligibility in the program, a limit that wasn't among the proposals approved by the Trump administration last week. The proposal, which would lower the eligibility cap from 138 percent of the federal poverty level to 100 percent, would remove more than 60,000 people from the program.
The election year will determine how much of a challenge the program will face again next year. The first sign will come this week in a Republican primary runoff for a state Senate seat that has turned into a proxy fight between Hutchinson and the program's opponents.
The other unknown is just how many more restrictions Democrats would be willing to accept. Critics say the work requirement could punish many on the program, particularly in rural areas where work is not readily available, and could lead to some being stripped of coverage even though they remain eligible.
Democratic state Sen. Linda Chesterfield admitted frustration with the restriction as a tradeoff.
But, after voting for the program's reauthorization, she added: "I would be more frustrated if we didn't have anything at all."