dominated by conservative Republicans, and the program’s success in
halving the proportion of uninsured Arkansas residents. Part IV explains the
state’s other innovative health policy program, the Arkansas Payment
Improvement Initiative, and presents a preliminary evaluation of its first
two years’ results. This program creates new incentive structures employing
episode-based payments and patient-centered medical homes, with the
ambitious aim of transforming the state’s health care payment model from
payment-for-volume to payment-for-value. Part V concludes.
II. BACKGROUND ON ARKANSAS HEALTH STATUS, POLITICS, AND
Although its economy is aided by its status as home to the world’s
largest private employer,14 Arkansas remains a relatively poor state,15 with
below-average health status statistics.16 In 2013, before the Affordable Care
Act’s enrollment period began, 22.5% of the state’s population of about
three million lacked health insurance, compared to 17.3% nationwide.17 A
large proportion of Arkansas residents live in rural areas with provider
shortages.18 Tightly integrated health delivery systems are scarce.19 The
14. Wal-Mart, headquartered in the town of Bentonville, employs about 1.3 million full-time and part-time workers within the United States and about 2.2 million worldwide,
Walmart Facts, Walmart, http://news.walmart.com/walmart-facts/, including about 50,000
within Arkansas. Our Locations, Walmart, http://corporate.walmart.com/our-story/locations/
united-states#/united-states/arkansas (last updated Feb. 19, 2015). The company tops the
Fortune Global 500 list. Global 500 2014, FORTUNE (Apr. 13, 2014), http://
15. See State and County QuickFacts, Arkansas, U.S. CENSUS BUREAU, http://
quickfacts.census.gov/qfd/states/05000.html (last updated Mar. 31, 2015) (stating that the
capita income in 2009-2013 was $22,170, compared with the national average of $28,155).
In 2013, Arkansas had 19.4% of its population living under the federal poverty line, ranked
only ahead of Mississippi (23.9%), New Mexico (21.4%), and Louisiana (20.0%).; Small
Area Income and Poverty Estimates, U.S. CENSUS BUREAU, http://www.census.gov/
did/www/saipe/data/interactive/ (last visited Mar. 17, 2015).
16. See Arkansas Health Insurance, HEALTHCARE.ORG, http://www.healthcare.org/
arkansas/ (last visited Mar. 17, 2015) (ranking Arkansas 43rd among the states).
17. See Witters, supra note 10 (an estimated 558,000 Arkansans were uninsured before
enactment of the Affordable Care Act); Matthew Buettgens, John Holahan & Caitlin Carroll,
Health Reform Across the States: Increased Insurance Coverage and Federal Spending on
the Exchanges and Medicaid 11 tbl.2 (2011), available at http://www.urban.org/
18. Thompson et al., Arkansas’s Novel Approach, supra note 7, at 1283.
19. See ARK. DEP’T OF HUMAN SERVS., STATE INNOVATION PLAN 5 (2012), available at
df [hereinafter STATE INNOVATION PLAN] (noting state’s fragmented delivery system).