Arkansas’ Medicaid expansion is endangered. Again.

The U.S. Supreme Court’s ruling that summer left up to states the decision on whether to expand Medicaid to more low-income people under the Affordable Care Act. And the decision faced an especially uphill climb in Arkansas, with a three-fourths vote needed to pass the budget bill for Medicaid.

It was a threshold that was difficult enough to get for “motherhood and apple pie,” as then-Gov. Mike Beebe often quipped. Clearing that hurdle and convincing Republicans to embrace a key part of Obamacare seemed improbable.

Yet that’s exactly what happened, with Arkansas becoming the first state in the South to expand Medicaid and the first in the nation to use private insurance to do so. 

A new decision by the Trump administration has injected more uncertainty for the program and the thousands of Arkansans who rely on it for health coverage.

Arkansas’ expansion has gone through multiple names and governors, but the recurring theme of its 13-year history is improbability. The program has repeatedly survived multiple attempts to kill it and has been credited with cutting the state’s uninsured rate and the costs hospitals pay for treating patients without coverage.

There’s been no shortage of legislative drama surrounding the program over the years, including marathon voting sessions in each chamber. One year, the House speaker asked State Police to retrieve a member who wasn’t present to vote. Republican lawmakers who supported the program have been targeted in heated primaries by opponents on the right.

The expansion survived one year through a bizarre procedural move that required supporters of the program to back a bill calling for its end, a provision that then-Gov. Asa Hutchinson struck through a line-item veto. 

But the Trump administration’s decision not to renew the state’s premium-assistance approach has put the expansion — now called ARHOME — back in familiar, endangered territory. And supporters of the program face a tougher political climate as they hope to find a way to retain coverage for more than 200,000 low-income Arkansans. Health providers and experts already are warning of disastrous consequences if the coverage ends. 

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It’s unclear what will happen to people using ARHOME when the expansion program expires at the end of the year. The state has requested a two-year temporary waiver, which would tee up a new debate over the future of Medicaid when the Legislature meets next year.

Arkansas policymakers are left with two primary options for replacing the hybrid model the state uses. They could move those on the program to fee-for-service Medicaid or could look at moving them to managed care.

Either approach faces its own political risks before a predominantly Republican Legislature that struggled at times to reauthorize Arkansas’ expansion. 

Moving enrollees to fee-for-service may face opposition from conservative Republicans who already worry Medicaid’s rolls are too large. Democrats and some Republicans may resist managed care because of the impact it could have on services for enrollees.

Health experts say the only option that shouldn’t be on the table is letting thousands go without any insurance coverage. Doing so would send shockwaves through a healthcare system that’s already under the strain of low reimbursement rates and rising costs that have prompted some hospitals to cut back services.

But finding a way out may be much more difficult than when Arkansas adopted expansion 13 years ago. The state has become even more polarized, with many Republicans aligned with Trump and his push to cut Medicaid.

Finding a way forward isn’t impossible, but the odds seem stacked against it. Another fight for survival is fitting for a program that few would have bet on in the first place.