The federal government will pay for a significant portion of the cost of coverage for the newly eligible—100% in 2014 through 2016, decreasing to 90% in 2020 and thereafter—but states still face uncertainty about funding expanded healthcare coverage.

Laura Tobler


Some states are using Section 1115 waivers to implement the ACA Medicaid expansion in ways that do not follow the federal rules, but still qualify for enhanced federal matching funds for newly eligible adults.

Sen. Pam Jochum


Iowa’s compromise plan highlights personal responsibility by including cost-sharing and discounts for choosing healthy behaviors.


All the waivers that include a premium reduction for engaging in “healthy behaviors” face a substantial challenge to define and assess what those behaviors are.


New Hampshire’s bipartisan waiver is part of the state’s extensive healthcare-reform project.


South Carolina’s plan considered the social determinants of health and implemented strategies that include: payment reform, clinical integration, and targeting hotspots and disparities in healthcare access.


Social determinants of health is an emerging strategy for addressing quality, which shifts the cost curve from “paying to treat disease”  but instead invests in keeping people healthy and out of the healthcare system.

Brian S. Neale

Joseph W. Thompson

Sen. Wayne Niederhauser

Sen. John J. Cullerton

Sen. Jonathan Dismang

Sen. Susan Wagle


Many states are asking CMS for demonstration waivers. We are experimenting to find the optimal formula that solves the cost, quality, access equation. The states are the laboratory of democracy and CMS is looking to the states for effective innovations.

-- Brian S. Neale

Sen. Eduardo Bhatia

Sen. Peter Courtney

Sen. Donald Williams

Sen. John Coghill

Brian Neale

Laura Tobler

Joseph Thompson





The Affordable Care Act and
Medicaid Expansion







Healthcare is a perennial challenge and the subject of heated debate in the states. Because healthcare is a dynamically evolving area, it is frequently on the Senate Presidents’ Forum agenda. This “Issues and Insights” section summarizes the Summer 2014 Forum discussion on The Affordable Care Act and Medicaid Expansion.

The Affordable Care Act (ACA) sought to reduce the number of uninsured people and reduce the high costs of their healthcare by providing affordable coverage options through Medicaid and Health Insurance Exchanges. The ACA expands Medicaid coverage for most low-income adults to 138% of the federal poverty level (FPL) and provides subsidies for lower income individuals through the Healthcare Exchanges.

The federal government will pay for a significant portion of the cost of coverage for the newly eligible—100% in 2014 through 2016, decreasing to 90% in 2020 and thereafter—but states still face uncertainty about funding expanded healthcare coverage.

On June 28, 2012, the United States Supreme Court determined that Medicaid expansion could only be an option for the states, not a mandate. Now states face the challenge of deciding if and how to implement the ACA and Medicaid expansion.

The Forum heard specifics of different states’ approaches to Medicaid expansion from Laura Tobler, Program Director, Health, National Conference of State Legislatures (NCSL). Ms. Tobler  reported that state legislatures considered more than 2,500 bills that relate to the ACA since its passage, leading to 500+ signed into law as of December 2013 and another 1,100 bills under consideration during 2014.

Ms. Tobler noted that the ACA gave states an option to get an early start on the expansion, effective April 2010 to December 2013, at their regular federal Medicaid matching rates. Six states (California, Connecticut, Colorado, Minnesota, New Jersey, and Washington) expanded Medicaid coverage to adults after the enactment of the ACA to prepare for 2014. In addition, many states voluntarily covered pregnant women, children, and parents at higher income levels than required by the federal government.

To date, 26 states are currently moving forward with ACA-related expansion, while 21 states are not moving forward at this time and six states are using alternative methods to expand or are engaged in debate, Ms. Tobler reported.

 Current Status of State Individual Marketplace
and Medicaid Expansion Decisions

Alternative Methods: Section 1115 Waivers

Ms. Tobler described how some states are using Section 1115 waivers to implement the ACA Medicaid expansion in ways that do not meet federal rules, but still qualify for enhanced federal matching funds for newly eligible adults. These waivers must be used to “promote the objectives” of the Medicaid program, and they must be budget-neutral for the federal government, according to the Centers for Medicare and Medicaid Services (CMS).

To date, the CMS has approved waivers in three states: Arkansas, Iowa and Michigan, including provisions that allow premium assistance, charging premiums for groups at or above 100% of the FPL, removing certain benefits that are otherwise required, and using healthy behavioral incentives.

The CMS has denied waivers that imposed premiums for individuals at lower incomes or higher cost-sharing. It has not allowed states to waive the provision of certain benefits. Pennsylvania’s proposed waiver, which includes work requirement provisions, is still under review; however, such requirements have never been approved to date.

Several states have waivers to maintain coverage that was in place prior to the ACA, but this coverage is not eligible for the enhanced ACA matching funds for newly eligible adults. These include states implementing the Medicaid expansion, but using waivers to provide coverage or assistance to individuals with incomes above 138% of the FPL (Minnesota and Massachusetts along with New York and Vermont, two states in which waiver extensions are pending) and states not implementing the Medicaid expansion but primarily maintaining pre-ACA coverage expansions (Wisconsin, Indiana, and Oklahoma).

The Iowa Waiver

Iowa’s waiver was approved and implemented in January 2014, providing coverage for an estimated 150,000 eligible persons. Iowa’s benefit plan will be at least equivalent to the Hawkeye State’s employee-plan benefits package, and the state will provide dental benefits through a capitated commercial dental-plan carve-out.

The Iowa plan uses federal dollars to purchase private-insurance coverage in Qualified Health Plans (QHPs) for those at 100%-138% of the FPL. However, enrollees must pay part of the premium--those at 100%-138% of FPL must pay $10 a month and those at 50%-100% of the FPL pay $5 a month, beginning in year 2. Individuals enrolled can reduce their payment by participating in “healthy behavior activities.”

Iowa Senate President Pam Jochum commented that Iowa’s legislature is split, with the House having a Republican majority and the Senate having a Democratic majority, and a Governor who is opposed to Medicaid expansion. “We had to be very pragmatic and seek compromise to get a divided legislature to agree on a hybrid coalition plan.” The plan proposed a public/private insurance combination and focused on personal responsibility by including cost-sharing and discounts for choosing healthy behaviors.

Iowa’s compromise plan highlights personal responsibility by including cost-sharing and discounts for choosing healthy behaviors.

The Michigan Waiver

Michigan’s 1115 demonstration waiver, “Healthy Michigan,” was approved and implemented beginning on April 1, 2014. The waiver and associated state plan amendments provide Medicaid coverage to all adults in Michigan with incomes up to and including 138% of the FPL--an estimated 300,000 to 500,000 people.

The Healthy Michigan Plan encourages healthy behaviors and personal responsibility, helps low-income Michigan residents access affordable health coverage, and reduces uncompensated care that shifts costs onto businesses and taxpayers.

The plan requires beneficiaries to make income-based contributions to health savings accounts (2% of income). These contributions can be reduced through compliance with healthy behaviors. The CMS has required Michigan to develop and submit protocols for health-behavior incentives to the CMS 90 days prior to planned implementation.

The Healthy Michigan Plan calls for the use of existing Medicaid Managed Care Organizations (MCOs) and Pre-paid Inpatient Health Plans (PIHPs) to serve the newly eligible population. MCOs will provide acute, physical health, and pharmacy benefits, with PIHPs offering inpatient and outpatient mental health, and substance-use disorder (SUD) and developmental disability services statewide to all demonstration enrollees.

Michigan State Senate President Pro Tempore Tonya Schuitmaker reported that the required contributions to a health savings account are an incentive tool to encourage people to make informed healthcare purchasing decisions and to engage in healthy behaviors.

The Pennsylvania Plan

Ms. Tobler reported that the Healthy Pennsylvania plan, which is currently under review at the CMS, puts the focus on three key priorities: improving access, ensuring quality, and providing affordability. The plan hopes to increase healthcare access for more than 500,000 Pennsylvanians, promote healthy behaviors, improve health outcomes and increase personal responsibility, and ensure that benefits match health care needs.

The Healthy Pennsylvania Private Coverage Option for childless adults with incomes below 133% of the FPL applies federal funds to pay beneficiaries’ premiums for QHPs in the Marketplace. The plan proposes tiered benefit packages based on risk assessments when people become eligible.

The plan seeks to promote healthy behaviors and increased independence through cost-sharing and encouraging employment. Premiums are required for enrollees from 100%-138% of the FPL beginning in year 2 of $25 individual/$35 household per month. This charge can be reduced by participating in healthy behavior and work activities.

The “Healthy Behaviors” Challenge

Ms. Tobler commented that all the waivers that include a premium reduction for engaging in “healthy behaviors,” face a substantial challenge to define and assess “healthy behaviors.”

The CMS requires states with a “Healthy Behaviors” proviso to specify the types of healthy behaviors (such as health risk assessments); include a diverse set of behaviors as well as a strategy to measure access to providers to ensure that all beneficiaries have an opportunity to receive healthy behavior incentives”; engage stakeholders and the public in developing the healthy behavior standards, show how healthy behaviors will be tracked and monitored at the enrollee and provider levels, include a beneficiary-  and provider-education strategy, and include the methodology describing how healthy behavior incentives will be applied to reduce premiums or copayments.

The New Hampshire Waiver

New Hampshire’s bipartisan waiver is part of the state’s extensive healthcare-reform project. The proposed waiver requests federal financial participation to support the Granite State’s  overall health reform strategy, including the implementation of the bipartisan healthcare expansion plan and the Medicaid Care Management (MCM) plan.

The waiver complements the state’s overall strategy of improving access to needed services, providing better health outcomes and reducing healthcare costs. It spotlights the state’s efforts to strengthen SUD interventions, mental health treatment, and population health efforts, along with a grant program to fund behavioral health workforce development with a focus on SUD.

The plan proposes an employer health insurance premium assistance plan, which will pay beneficiaries premiums for QHPs in the Marketplace starting in January 2016 and extend a current (In-SHAPE) health-promotion program for people with behavioral health disorders.

Based on evidence showing that poor oral health during pregnancy led to an increased risk of longer hospital stays after birth, low-birth-weight babies, and increased health problems in newborns, the New Hampshire plan establishes an oral health pilot program for pregnant women and mothers of children through age 4.

The South Carolina Strategy

South Carolina sought to reform Medicaid rather than expand it, Ms. Tobler said. The Palmetto State asked, “How do we most improve the health of our citizens and lower the cost of healthcare per person.” They considered social determinants of health and implemented strategies that include: payment reform, clinical integration, and targeting hotspots and disparities in healthcare access. The state’s program provides Express Lane Eligibility for children (Supplemental Nutrition Assistance Program [SNAP] and Temporary Assistance for Needy Families [TANF]).

Derived from data indicating that early inductions are associated with an increased risk of maternal and neonatal morbidity and longer hospital stays, South Carolina implemented a Birth Outcomes Initiative, which reduced early-term (before 37 weeks), elective inductions by 50%. This saved the state and federal governments a total of $6 million in the first quarter of 2013.

Social Determinants of Health

A number of states have focused on the social determinants of health. This is an emerging strategy for addressing quality, which shifts the cost curve from paying to treat disease over keeping people healthy and out of the healthcare system. Significant evidence underlies the role of social determinants of health, and numerous bills have homed in on this aspect of improving health outcomes. Among them, Ms. Tobler noted:

•  Early education and child care: 42 bills in 23 states were enacted on this topic.

•  Environmental health risks and asthma are associated with high healthcare costs: 27 bills in 18 states were ratified addressing these issues.

•  Incentives for small or minority-owned businesses have been shown to improve health status of minority members: 31 bills in 17 states were enacted to provide these inducements.

•  A focus on Tribal Health and Human Services reduced healthcare costs: 14 bills in 10 states were enacted to improve these services.

•  Increasing the minimum wage has been shown to improve healthcare outcomes for low-skilled, low-wage workers: 15 bills in 14 states were passed.

•  Unemployment benefits or retraining programs can reduce the incidence of substance abuse and depression among the unemployed: 63 bills in 27 states were enacted in this area.

In conclusion, Ms. Tobler commented that Medicaid can be positioned as a partner with the private health insurance market, and this partnership can help reduce disparities in the access to healthcare. She suggested that the CMS is more flexible than ever and this is a time of opportunity for the states to approach the CMS with innovative ideas. “The CMS wants the states to succeed with healthcare reform.”

  Medicaid Opportunities/Concerns

Introduction to The Healthy Indiana Plan

Brian S. Neale, Healthcare Policy Director for Indiana’s Governor’s Office, discussed the Hoosier State’s strategy, which is based on the existing Healthy Indiana Plan (HIP), a consumer-driven healthcare model developed in 2007 through a bipartisan agreement and a Medicaid waiver.

Indiana based its Medicaid expansion on the existing plan, which gives individuals who are Medicaid-eligible choices for coverage while stressing personal responsibility. There is a sliding scale for premiums, and participants must contribute to a Personal Wellness and Responsibility (POWER) account modeled after a Health Savings Account, from which members would pay for medical services. The Plan’s 96% satisfaction rate speaks to its success.

The HIP Plan had already demonstrated its effectiveness, as follows:

Improved healthcare utilization

 – Inappropriate emergency room (ER) use is 7% lower than traditional Medicaid beneficiaries

  60% of HIP members receive preventive care--similar to commercial populations

  80% of HIP members choose generic drugs, compared with 65% of commercial populations

Resulted in high member satisfaction

  96% of enrollees are satisfied with HIP coverage

  83% of HIP enrollees prefer the HIP design to copayments in traditional Medicaid

  98% would enroll again

Promoted personal responsibility

  93% of members make required Personal Wellness and Responsibility (POWER) Account contributions on time.

  30% of members ask their healthcare provider about the cost of services.

The proposed HIP 2.0 Plan will be an option for people aged 19 to 64 with incomes up to 138% FPL. The plan creates a benefit structure similar to commercial health insurance plans and provides incentives to contribute to their POWER account by allowing access to the HIP Plus Plan, an enhanced-benefit plan that covers dental and vision care. Individuals who do not make contributions will maintain coverage through the HIP Basic plan. Members with incomes of more than 100% of the FPL would have access only to the HIP Plus Plan and be required to make their contributions or risk being dis-enrolled in the program.

 Healthy Indiana Plan (HIP) Plan Comparison

The plan will not raise taxes, but will be fully funded through federal Medicaid payments, Indiana’s existing cigarette tax revenue, and the Hospital Assessment Fee program. The Hospital Assessment Fee increases reimbursement to eligible hospitals for services provided in both fee-for-service and managed-care programs, and covers the Hoosier State’s percentage of disproportionate share hospital (DSH) payments. The state also created a Rainy Day Fund for healthcare by adding to its trust fund each year.

Keys to the success of the Indiana Plan included sound design, sound actuarial analysis, legislative engagement, and stakeholder engagement, Mr. Neale said. Coming to agreement took a lot of negotiation, he added, in particular with the hospitals, but eventually all stakeholders endorsed the plan, which is now being reviewed by the CMS.

Arkansas' Answer to Medicaid Expansion

Joseph W. Thompson, MD, MPH, is Surgeon General for the State of Arkansas, and Director of the Arkansas Center for Health Improvement. He presented the Natural State’s solution to Medicaid expansion, which uses federal Medicaid funds to buy private commercial insurance coverage.

Dr. Thompson reminded the Forum of the long history of healthcare reform, from 1965, when Medicare and Medicaid were established, to the Medicare Modernization Act (2003) and the Patient Protection and Affordable Care Act (2011). As these changes took place, the cost of health insurance almost doubled from $6,355 per year in 2000 to $11,816 in 2010. Today, 20% of every dollar spent by the state is for health-related care. Before healthcare reform, Arkansas had approximately 550,000 uninsured people.

 Pre-2014 Health Insurance Distribution

The unsustainable increases in health-insurance costs and the need to cover the large uninsured population led state leaders to adopt the Arkansas System Transformation Strategy for healthcare. Dr. Thompson noted that all Arkansas leaders, both Republican and Democrat, are fiscally conservative. Furthermore, approval of any new spending of state or federal dollars requires 75% of the vote. “Any new healthcare plan for Arkansas had to solve the equation of the iron triangle, balancing cost, quality and access.”

Central to the strategy is the Arkansas Health Care Payment Improvement Initiative (AHCPII), which rewards high-quality care and outcomes, ensures clinical effectiveness, promotes early intervention and coordination to reduce complications and associated costs, and encourages referral to higher-value downstream providers. The initiative requires health insurance carriers offering healthcare coverage for program-eligible individuals to assign a primary care clinician to enrollees, support the patient-centered medical home, and provide access to clinical performance data for providers.

Enrollees are served in patient-centered medical homes, where a physician “quarterback” determines whether surgeries are needed, ER use is monitored, and there are limits set on non-emergent transportation. Based on patient outcomes, a center may either receive 50% of any cost-savings accumulated, or owe money back to the state for excessive spending. The concept is to “squeeze out the excess,” Dr. Thompson noted. To date, there is a 2% decrease in trips to the ER and a 25% decrease in uncompensated hospital and ER visits.

 Potential Health Insurance Distribution

A second pillar of the Transformation Strategy is the Health Care Independence Program (HCIP), an alternative approach to Medicaid expansion, commonly called the “Private Option,” which uses Medicaid funding to purchase private coverage through the Health Insurance Marketplace for those below 139% of the FPL. The majority of newly insured people are placed with private carriers, with qualified high-value silver-level policies offered to all. Participants at 50%-100% of the FPL are required to share costs through health savings accounts.

Arkansas’ plan is a marriage of Medicaid and private insurance, based on state insurance rules rather than federal Medicaid rules, Dr. Thompson said. He reported that by buying commercial plans paying commercial rates, the discrepancy between Medicaid and private insurance payments to providers was eliminated.


Sen. Wayne Niederhauser (UT): In the Arkansas plan, who pays the Hospital Assessment Fee (HAF)? What has been the response to that fee?

Dr. Thompson: Federal healthcare funds can be matched by the state only if they are provided across a broad base. This levels the playing field for hospitals with different populations. The hospitals pay the fee because it gains them higher reimbursement rates. Most hospitals benefit by getting higher payments.

Sen. John J. Cullerton (IL): Did the Arkansas plan require special legislation? Was it a popular plan or is it under attack? Have there been efforts to repeal it?

Dr. Thompson: Arkansas statutes require a 51% majority vote for the enabling legislation, but a 75% vote to allocate the funds. With a coalition of Democrats, Republicans, and the community, the 75% vote is reachable. However, there is a group of polarized conservatives who present a risk to the 75% vote.

Sen. Jonathan Dismang (AR): Arkansas faced a $300-million shortfall in Medicare funding before the ACA was enacted. Medicare cuts are funding Medicaid expansion. One Arkansas hospital currently receives the most Medicare funding in the country. The hospitals will not be able to make up for the Medicare cuts, so the ACA will hurt small rural hospitals the most.

Sen. Susan Wagle (KS): Do you have an out if the federal government backs off on its commitment to fund 90% of the program costs from 2020 on?

Dr. Thompson: Arkansas’ legislation built in a poison pill to shut the program down if federal funding is cut.

Mr. Neale: Indiana specifies an automatic termination of the waiver if that happens.

Sen. Susan Wagle (KS): What was the legislative involvement in the process of developing these plans?

Sen. Jonathan Dismang (AR): The Arkansas plan orginated in the legislature. We wanted a healthcare plan that was predictable and sustainable. We didn’t trust the federal legislation and wanted to create a plan that was as conservative as possible. We followed Indiana’s strategy, requiring personal responsibility through participation in a healthcare savings account. Our goal is to return Medicaid to the program it is supposed to be, which is to take care of the neediest of the needy.

Dr. Thompson: Coming to agreement on the healthcare plan required intensive communication among all sectors. The State Health Departments act as the convener and the translator, and each month, sponsor a 4-hour meeting of all stakeholders, including the Chambers of Commerce, the self-insured, hospitals, and all other stakeholders. We recognize that our goals and objectives are common, but the language each sector uses is different. We have been able to find common ground.

Sen. Eduardo Bhatia (PR): What portion of healthcare spending is for patients and how much goes to administration? It seems that administration costs are too high.

Dr. Thompson: That is a challenge because we do not know the real costs of various procedures. We need greater transparency to determine what those costs are.

Sen. Peter Courtney (OR): The logistics challenges of the ACA are daunting. We have 971 million Oregonians on Medicaid. More than 300,000 were added after the January Medicaid Expansion, and they had to be entered into the database by hand. The online enrollment systems are not working.

Mr. Neale: Most states have struggled with an online system. We have not yet added this functionality to the Indiana system. The federal system isn’t ready either.

Dr. Thompson: Arkansas used known eligibility criteria to automatically enroll people. Anyone who qualifies for Food Stamps is automatically enrolled, thereby eliminating the whole enrollment process.

Sen. Donald Williams (CT): Premium assistance may create unintended consequences in the future. Over time, premiums will go up. We saw a similar issue in the 1990s when Connecticut enacted gas-tax cuts to help consumers. Instead, gas prices continued to rise, and the retailers pocketed the cost savings, not the consumers.

Sen. John Coghill (AK): Can consumers roll over their healthcare savings accounts (HSA) from year to year? How are you addressing the challenges of consumer education about the program?

Mr. Neale: Education is key. It is essential for influencing consumer behavior so that they make choices that reduce costs. We want to create cost-conscious consumers.  In Indiana, consumers can roll over their POWER accounts and the residual funds reduce the next year’s required contribution.

Ms. Tobler: Michigan allows consumers to roll over their HSAs or use the funds to purchase private insurance. Educating people and doing adequate outreach is the most critical element for success.  Iowa, for example, has done a great job of outreach through a newsletter and their website.

Mr. Neale: Many states are asking the CMS for demonstration waivers. We are experimenting to find the optimal formula to solve the cost, quality, access equation. The states are the laboratory of democracy and CMS is looking to the states for effective innovations.

Speaker Biographies

Brian Neale

Brian Neale serves as Health Care Policy Director for Governor Mike Pence, where he is responsible for developing and overseeing the implementation of health care policy for the State of Indiana’s health-related agencies, including the Family and Social Services Administration, Indiana State Department of Health, and the Indiana Department of Insurance. In this role, Neale helped design the new Healthy Indiana Plan Medicaid expansion alternative that would provide consumer-driven healthcare options to over 350,000 uninsured Hoosiers.

Before joining the Pence Administration, Neale served as Congressman Mike Pence's Legislative Director and Counsel in Washington, D.C., where he held a policy portfolio consisting primarily of health care, financial services, and judiciary issues. Prior to joining the Pence office, Neale served an appointment as Advisor to U.S. Small Business Administrator Sandy Baruah. A native Hoosier, Neale holds degrees from Indiana University's Kelley School of Business and McKinney School of Law.

Laura Tobler

Laura Tobler is a nationally recognized expert on state health care policy issues.  Laura serves as a Program Director for the Health Program at the National Conference of State Legislatures managing the work on policy issues related to Medicaid, health care workforce, primary care and rural health.  Laura has authored many papers, articles, books, and issue briefs on a variety of health topics.  She received her Bachelor of Science from Pennsylvania State University and her Masters of Public Policy from Rutgers University.

Joseph Thompson

Dr. Joe Thompson’s work is centered at the intersection of clinical care, public health and health policy. He is responsible for developing research activities with robust data collection, health policy and collaborative programs that promote better health and health care in Arkansas. Dr. Thompson works closely with and often serves as a bridge between the Governor’s office, the Arkansas legislature and public and private organizations across the state to develop relevant health policy initiatives.

Dr. Thompson has led vanguard efforts in planning and implementing health care financing reform, tobacco- and obesity-related health promotion and disease prevention programs. He has worked with Governor Mike Beebe, Arkansas’ legislative leadership and the U.S. Department of Health and Human Services to develop a creative alternative to Medicaid expansion under the Patient Protection and Affordable Care Act. In addition, Dr. Thompson is guiding Arkansas’ innovative initiatives to improve health system access, quality and cost including a systematic, multi-payer overhaul of Arkansas’ health care payment system.

Previous accomplishments include serving as the lead architect of the Tobacco Settlement Act of 2000 and instituting the Arkansas Health Insurance Roundtable. Under his leadership, Arkansas Center for Health Improvement helped pass the Clean Indoor Air Act of 2006, documented the state’s success in halting progression of the childhood obesity epidemic, and passed a tobacco excise tax increase to provide funding for more than two dozen health initiatives.

Dr. Thompson has been at the forefront of both Arkansas’ leading-edge efforts against childhood obesity and in national efforts to reverse childhood obesity as the former Director of the Robert Wood Johnson Foundation (RWJF) Center to Prevent Childhood Obesity.

He currently serves on the Arkansas Board of Health and is past President of the Arkansas Chapter of the American Academy of Pediatrics. Nationally, Dr. Thompson serves on the board of the Campaign to End Obesity and of AcademyHealth. He is author of numerous articles and publications that reflect his research interests in the areas of health and health care.

Dr. Thompson earned his medical degree from the University of Arkansas for Medical Sciences and Master of Public Health from the University of North Carolina at Chapel Hill. He served as the RWJF Clinical Scholar at the University of North Carolina at Chapel Hill, the Luther Terry Fellow in Preventive Medicine advising the U.S. Assistant Secretary of Health in Washington, DC, and the Assistant Vice President and Director of Research at the National Committee for Quality Assurance in Washington, DC. In 1997, he served as the First Child and Adolescent Health Scholar of the U.S. Agency for Healthcare Research and Quality (then the U.S. Agency for Health Care Policy and Research) before returning to Arkansas.




The Affordable Care Act and Medicaid Expansion

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