private insurance market is quite concentrated: two insurers, Blue
Cross/Blue Shield and QualChoice,20 dominate with an 80% market share.21
Politically, Arkansas was the last of the southern states, except perhaps
for Florida and Virginia, to turn red. Arkansas voters’ general conservatism
is evident from the fact that the Republican presidential candidate has won
every election after 1968, except when the Democratic candidates (Carter
and Clinton) were southerners.22 Nevertheless, for the opening decade of
the 21st century Democrats dominated state politics. Both U.S. senators and
three of four congressmen were moderate Democrats, as were the governor
and a majority of both houses of the General Assembly.23 In the 2010 and
2012 elections, however, as public reaction against “Obamacare”
intensified, a pronounced red shift began.24 President Obama was trounced
in Arkansas in 2012, as he was across the South.25 The Republicans gained
not only a Senate seat and two House seats in Congress; most importantly,
Republicans won a narrow majority in both houses of the Arkansas
Two features of Arkansas law deserve mention here: one concerning
state finances and the other concerning legislative rules. First, the Arkansas
Revenue Stabilization Act requires the state budget to be balanced every
biennium.27 State government is prohibited from running a deficit.28 This
20. QualChoice was acquired in 2014 by Catholic Health Initiatives, which operates St.
Vincent’s Hospital in Little Rock. See Catholic Health Initiatives, QualChoice Agreement
Finalized, available at https://www.catholichealthinit.org/documents_public/news%20
releases/2014-05-01_QualchoiceFINAL.pdf (last visited April 2, 2015).
21. Joseph W. Thompson et al., Arkansas Payment Improvement Initiative: Private
Carriers Participation in Design and Implementation, HEALTH AFF. BLOG (Oct. 15, 2014),
carriers-participation-in-design-and-implementation [hereinafter Arkansas Payment
22. United States Presidential Election Results, DAVE LEIP’S ATLAS OF U.S.
PRESIDENTIAL ELECTION RESULTS, http://uselectionatlas.org/RESULTS/ (last visited April 5,
2015). (To view presidential election results in Arkansas since 1968, click Arkansas on the
left tab and navigate the various elections via the “by year” tab at the top of the page.)
26. See Arkansas Elections, 2012, BALLOTPEDIA, http://ballotpedia.org/Arkansas_
elections,_2012 (last visited Apr. 5, 2015) (click on “State Senate” and “State House” tabs
for General Assembly results).
27. 1945 Ark. Acts 311 (original enactment, renewed in each regular legislative session
since), codified at ARK. CODE ANN. §§ 19-5-101 to 1254. For a brief analysis of the law’s
history, rationale and functioning, see Revenue Stabilization Act, THE ENCYCLOPEDIA OF
ARKANSAS HISTORY AND CULTURE, available at http://www.encyclopediaofarkansas.net/
encyclopedia/ entry-detail.aspx?entryID=7840 (last visited May 15, 2015); see also Arkansas
State Budget and Finances, BALLOTPEDIA, http://ballotpedia.org/Arkansas_state_budget_
and_finances (last visited Apr. 15, 2015) (explaining Arkansas’s budget process).
28. See Hooker v. Parkin, 235 Ark. 218, 230, 357 S. W.2d 534, 542 (Ark. 1962) (“The