What's the Matter With Arkansas?

On Saturday, the senior senator from Arkansas, Blanche Lincoln, was the last Democrat to tell Harry Reid she'd vote yes on a motion to allow the Senate to consider his health-care-reform bill. Her 11th-hour acquiescence was dramatic, particularly considering that she was consenting only to let the Senate debate the issue. She doesn't support the bill as it stands; her central objection is over the inclusion of a public option. In holding out as long as she did on this initial vote, she's sending a clear signal to the leadership that they'll need to work hard to secure her vote for final passage.

In D.C., most observers assume her hesitancy to support her party's reform package is directly related to her reelection bid in 2010. But that doesn't tell the full story. To be sure, Lincoln is facing an uphill battle. Her approval ratings have slid over the past year, and now hover in the low 40s. A recent Rasmussen poll had her trailing four potential Republican candidates, and rumors of a primary challenge from the left abound. But will health-care reform be the issue that breaks her? Janine Parry, director of the Arkansas Poll, is doubtful. Parry's polling suggests that 75 percent of Arkansans aren't even really following the health-care debate. According to Parry, "history is with her. I'm not sure she needs to be so timid."

Politically, most of the country pays attention to Arkansas only on election night, when it appears as one of the reddest of the red states on the electoral map. Last year John McCain walloped Barack Obama there, beating him by 20 points. But beyond presidential elections, Arkansas is a Democratic stronghold. Both its U.S. senators are Democrats and, with the exception of one lone GOP senator who was promptly ousted after one term, it's been that way since Reconstruction. The state legislature is currently 70 percent Democratic. Gov. Mike Beebe, who has sky-high approval ratings, is a Democrat, as are the other seven statewide elected officials. Parry points out that in the most recent Arkansas Poll, 40 percent said they'd vote for a Democratic candidate for Lincoln's Senate seat in 2010, compared with 34 percent who said they'd vote Republican. Parry says it's possible that the state might be open to voting for a Republican. But the GOP has a relatively anemic infrastructure there, and in the past it has had trouble recruiting and financing serious challengers for statewide races. In the 2006 elections, the Green Party fielded more candidates for state office than the Republicans. "The Democratic Party is still the name brand in Arkansas politics," Parry declares.

But that political landscape doesn't necessarily make health-care reform an easy sell for Lincoln. Arkansas Democrats are a very different breed than Northeastern ones. They tend to favor smaller government and limited spending. They're deeply uncomfortable with budget deficits. Even though the Congressional Budget Office estimates that the Senate health-reform bill would reduce the deficit, and tax increases would not be shouldered by the middle class, many Arkansans perceive reform as a costly expansion of government that may raise taxes or deficits over the long term.

Arkansas is one of the poorer states in the Union. Average household income is about $52,000 for a family of four, which is well below the national average of about $70,000. Not coincidentally, Arkansas has enormous health-care challenges. In the most recent edition of America's Health Rankings, an annual state-by-state assessment of the nation's health conducted by the United Health Foundation, , Arkansas ranked No. 40. It has a strikingly high incidence of chronic disease, most notably obesity, which affects 29.5 percent of its population. Kevin Ryan, the executive associate director of the Arkansas Center for Health Improvement, says there are 2 million cases of chronic disease in Arkansas, which has a population of just 2.9 million. (Note: individuals may have more than one chronic disease—both obesity and type 2 diabetes, for example—so the case number does not equate to 2 million individuals.) Three quarters of a million people are currently insured with the government's low-income provider, Medicaid, which covers 60 percent of the state's children and about half its pregnant women. But access to Medicaid is tougher in Arkansas than it is in many states. The most recent figures show Arkansas has almost a half million uninsured people, although Ryan says that number may be higher, as it doesn't take into account the impact of the economic downturn. His research indicates that the Senate health-care-reform bill would likely extend coverage to about 250,000 people in Arkansas.

The state also has serious problems with physician access, particularly in rural areas, where almost half its population resides, and it has a hard time enticing doctors to fill the considerable number of vacancies because of the high numbers of Medicare, Medicaid, and uninsured patients. Doctors simply don't make much money working with those populations. With the bill's measures including an expansion of insurance coverage, public-health experts like Ryan hope the legislation will alleviate that problem to some extent, but the impact will depend on the scope of the final bill.

What's not clear, then, is why people in a state with such serious health-care deficiencies would encourage their senators to be so lukewarm about reform. The Arkansas Poll suggests Arkansans are unconvinced that reform will enhance their current health care, with 44 percent saying they think the quality of their care will get worse as a result of reform. Only 15 percent think it will improve, and 30 percent say it will stay about the same. "Sentiment for especially the public-option component of the reform is really a mixed bag in Arkansas," says Prof. Glen Mays, a health-policy expert at the University of Arkansas. The Arkansas Poll puts support for it at just 39 percent, while a Research 2000 poll, which likened the public option to Medicare in its question, found 56 percent of Arkansans in favor of it, likely indicating that approval for reform hinges on the framing of key issues.

Progressives see numbers like those and sense an opportunity for Lincoln: if a prominent political figure championed the bill, then Arkansans would be more likely to accept arguments about the benefits of reform, such as expanded coverage and competition. (Arkansas is virtually a one-insurer state, with Blue Cross Blue Shield dominating the market.) According to Parry, Arkansas liberals are asking themselves, "Where's the statesmanship? Where are the people encouraging voters to act in the best interests of their community?" Meanwhile, there are pockets of strong support for the bill: the currently uninsured and those at the lower end of the socioeconomic scale. But Mays notes that like many other states, those constituents have less political capital and their voices are marginalized.

Expecting Lincoln to step in and fill a pro-reform leadership void might be a bridge too far. Her race is the only political game in town next year, and she's living under a white-hot spotlight. Health care aside, widespread unease about the president's agenda is being channeled into Lincoln's race. Arkansas is no friend to Obama, and the Senate ballot box is the only place Arkansans can express their displeasure next year.

That leaves Lincoln in a middling position. "Isn't it possible that she's not being risk-averse, but that she actually really just has strongly conflicted views about the issue?" asks Parry. Perhaps Lincoln's position accurately mirrors that the ambivalence of many Arkansans, whom Parry says want to do something about health care but just aren't sure whether the current plan is the right path to head down. "We're confused about how to proceed," she says. "You can make the case that she is representing Arkansans in an intellectually honest way." But holding out on even the procedural vote to allow debate to begin indicates she's acting strategically too. She knows that her potential opponents are already fundraising and, smartly, she's reluctant to, as Parry puts it, hand them a bat and ask them to bludgeon her with it.