Oklahoma residents going to the polls June 30 have the chance to override state leaders' decadelong refusal to expand Medicaid, which would cover more than 200,000 low-income adults and bring billions of federal dollars into the state.
But advocates are concerned that turnout for the summer primary election could be hampered by fears of contracting COVID-19 at voting stations and by Republican Gov. Kevin Stitt's about-face on the issue. Since the supporters got the measure on the ballot in October, the governor has gone from opposing Medicaid expansion to announcing in January he would institute his own expansion plan beginning July 1 that included work requirements and monthly premiums for enrollees. But he turned around and surprised many in May with a veto of state funding for his own proposal.
"It's been a little nuts," said Carly Putnam, policy director of the Oklahoma Policy Institute, which supports expansion.
Jim McCarthy, CEO of Community Health Connection, a federally funded community health center in Tulsa, said the governor's plan "seemed designed to confuse people."
"There is worry about people getting to the polls," McCarthy said, noting the concerns over COVID and state's restrictions on absentee voting. "Turnout will be critical."
If successful, the Sooner State would be the fifth to use a ballot initiative to extend Medicaid under the 2010 Affordable Care Act. Idaho, Utah, Nebraska and Maine have passed similar measures. Missouri voters will decide on a Medicaid expansion initiative Aug. 4.
The election comes as the coronavirus pandemic has roiled Oklahoma's economy. More than 200,000 people in the state are out of work, many of whom are likely in need of health coverage.
As of April, Medicaid covers about 820,000 Oklahomans, two-thirds of them children. Parents are covered if their incomes are no higher than 41% of the federal poverty level, or about $8,900 for a family of three. Oklahoma is one of 14 states that offer no coverage for adults without dependent children.
Under the ACA, states were encouraged to let Medicaid cover everyone with annual incomes below 138% of the poverty level, or about $17,600 for an individual or just under $30,000 for a family of three. The expansion led to millions of people gaining health coverage and, until recently, a record-low U.S. uninsured rate. Thirty-six states and the District of Columbia have expanded Medicaid.
Clarence Powell, 62, of Oklahoma City, has been uninsured since 2015, when poor health forced him to go from working full time to part time at a hotel. Without health coverage, he's relied on the Good Shepherd free clinic for medical care and for free or low-cost medications to treat his heart and lung conditions. But seeing a specialist has been difficult without insurance.
When he went to the hospital last year for a bloody nose, he left with a bill for more than $1,000 that he has no way to pay.
"Having Medicaid would make a big difference," he said. "We will all be better off."
Conservative leaders in Oklahoma, which has the second-highest uninsured rate in the country, have balked at expanding Medicaid — even though the federal government would pay 90% of the cost for enrollees in 2020. Republicans, who control the state legislature and executive branch, repeatedly said the budget couldn't afford the state's share and they didn't trust the federal government to keep up its funding.
With his plan dead for now, Stitt opposes the ballot initiative because it would not give the state flexibility to impose restrictions on enrollees and doesn't include a plan to come up with the state's funding.
As part of his plan, Stitt asked the Trump administration to approve giving the state a set annual amount of money per newly eligible Medicaid enrollee and agree to evenly split any money the state saves on future Medicaid spending.
Such a funding arrangement would radically alter the traditional system, in which the federal government pays states an unlimited amount based on enrollment and medical expenses.
Oklahoma submitted a request to the federal government for a waiver to implement the governor's plan, but the Trump administration did not rule on it before Stitt changed his plans.
Carter Kimble, deputy secretary of Health and Mental Health and Stitt's top aide, said the governor was willing to cap federal funding for Medicaid because it would come with a deal to give the state more flexibility in using Medicaid dollars, including targeting funds for enrollees' housing and food needs. Currently, Medicaid dollars must be used for health costs.
"We have had unfettered and uncapped federal financing, and we are ranked 48th in health outcomes and 49th in health system performance," Kimble added. "So where has it got us?"
"We need innovation and change and not to keep doing the same thing," he said.
In May, the Oklahoma Legislature approved taxing hospitals to pay most of the state's estimated $150 million annual cost for its share of Medicaid expansion. Kimble said the governor vetoed the bill because he wanted multiple years of funding and the bill included only one year. Stitt has the authority to expand Medicaid on his own, though he needs the legislature to approve funding. Kimble expects the ballot measure to pass.
Several major interest groups, including the state chamber of commerce, Blue Cross and Blue Shield of Oklahoma (the state's largest insurer), and the Oklahoma Primary Care Association, which represents community health centers that treat thousands of uninsured, have not taken a position on the ballot initiative.
Community Health Connection's McCarthy said the primary care association board did not want to alienate the Stitt administration, which provides some health center funding.
The pandemic, which has led to more than 11,000 cases in the state and more than 370 deaths as of Tuesday, highlighted the need for expansion, said Patti Davis, president of the Oklahoma Hospital Association.
"The pandemic has put health care front of mind for everybody," she said. "People want to know they can get care when they need it and know they will have a hospital to care for them," she said.
Oklahoma's slumping economy, which is closely tied to oil, also fueled interest in expanding Medicaid, Davis said.
"Oklahomans are ready to do this, and with the downturn in the economy, people are even more worried about job security and helping low-wage workers get covered by insurance."