About 200,000 low-income Arkansans are about to find out what a paperwork rule can do to a doctor's appointment.

The Trump administration has told Arkansas officials it will not renew the state's 13-year-old Medicaid waiver — the agreement that lets Arkansas run its Medicaid expansion the way it does. The reason federal officials gave, reported by Phil Galewitz of KFF Health News, is that the waiver doesn't comply with new "budget neutrality" rules taking effect in January.

Those rules exist because of a law. And that law had Arkansas fingerprints all over it.

What Arkansas is about to lose

Arkansas did something unusual when it expanded Medicaid in 2013. Instead of putting newly eligible adults into traditional Medicaid, the state got a waiver to buy them private Affordable Care Act marketplace plans. Arkansas calls it the "private option," and a Democratic governor and a Republican legislature built it together.

The point of doing it that way was access. Some doctors won't take traditional Medicaid, because it pays less. Private coverage pays more, so more doctors say yes. The state's uninsured rate dropped by nearly half.

If the waiver goes away, Arkansas officials say they will keep covering the same people — but through regular Medicaid instead. State officials have acknowledged that could leave enrollees with access to fewer doctors and other health providers.

Same person. Same income. Fewer places that will see them.

The state asked for a five-year renewal. CMS told Arkansas that wasn't happening. Arkansas is now asking for two years.

Where the rule came from

Here is the part that matters for anyone deciding how to vote in November.

CMS is citing authority granted under the 2025 Republican budget bill — H.R. 1, the "One Big Beautiful Bill Act." Before that law, the federal government checked retroactively whether a state's waiver had kept its budget promises. In June, the administration announced it would no longer approve or renew any waiver unless CMS certified up front that it wouldn't increase federal costs.

The agency's own guidance says the new waiver rules are expected to reduce federal spending.

Robert Nelb, policy director at America's Essential Hospitals, said that when the bill passed, he and most experts believed it was merely writing existing CMS policy on budget neutrality into law. The administration has instead read it as a tool to restrict how states use waivers at all.

Nicole Huberfeld, a health law professor at Boston University, was blunter:

"What we have here is a sneaky way to cut Medicaid expansion and the Medicaid program."

Huberfeld also made the point that ought to worry the people who voted for this most: because the changes run through obscure regulatory machinery, Medicaid enrollees who lose coverage won't know whom to blame.

So let's make that easy.

The votes

On July 3, 2025, the House passed H.R. 1 by 218 to 214. All four of Arkansas's Republican congressmen voted for it:

• Rick Crawford — Aye
• French Hill — Aye
• Steve Womack — Aye
• Bruce Westerman — Aye

Two days earlier, the Senate had passed it 50 to 50, with the vice president breaking the tie. Tom Cotton voted yes.

A 50–50 Senate and a four-vote House margin mean every single one of those votes was decisive. Arkansas's delegation didn't go along with a done deal. They made it a done deal.

This is the same delegation whose record we laid out in what Arkansas's Republicans in Congress are costing you — a state already ranked 49th of 50 on the measures we track, whose own members voted to cut the programs propping it up.

What the governor's office is saying

Sarah Sanders' administration is now trying to negotiate a temporary extension. Her spokesman Sam Dubke said the goal is "to ensure impacted Arkansans maintain access to quality, affordable healthcare during this transition period."

Then he said this:

"Looking ahead to the next legislative session, CMS has provided the state with an opportunity for bold, conservative healthcare reform, and the governor will work with her partners in the legislature to build a sustainable model that maintains the same high quality of care and saves taxpayer dollars."

Read that again. The federal government just refused to renew the program covering 200,000 Arkansans, and the governor's office is calling it an opportunity. "Saves taxpayer dollars" is doing a lot of work in that sentence — the taxpayer dollars in question are what pays for those people's coverage.

It gets worse from here

Arkansans on Medicaid expansion were already headed into a rough winter before any of this:

• Starting in January, they must prove they work or qualify for an exemption to keep coverage, under the same law.
• One of the two private insurers in the program, Centene, announced in July it is pulling out at the end of the year.
• And Arkansas has already lost 14,441 people off its Obamacare marketplace coverage since the premium tax credits lapsed.

Now add the waiver.

Arkansas is not alone. It is one of a dozen states whose waiver expires December 31. Georgia, which has added about 18,000 people to Medicaid under its waiver, and California, which uses its waiver to cover food and housing services, are both still negotiating with CMS. Indiana, Michigan, New Hampshire and Iowa all expanded Medicaid using waivers too.

The overall law cuts Medicaid spending by about $900 billion over a decade. About a third of the nearly $600 billion the federal government spent on Medicaid and CHIP in 2024 went to programs created by waivers.

That's the size of the lever the administration just picked up — handed to it, on a 218–214 vote and a tiebreaker, by people who are on the ballot this year.

Source

Phil Galewitz, KFF Health News, republished by the Arkansas Advocate: "Trump Team's Use of Arcane Budget Rule Threatens Medicaid Coverage." Photo: Arkansas Advocate.