An ongoing series on efforts in Oklahoma to extend health coverage to thousands of uninsured people through Medicaid expansion or other approaches. The coverage is enabled by a grant from the Anne & Henry Zarrow Foundation.

Oklahoma is poised to become the next battleground in a Medicaid expansion fight that has poured tens of millions of dollars into campaigns in other states.  

A proposal to extend subsidized health coverage to more than 200,000 uninsured low-income adults is expected to be decided next year. Oklahoma officials announced last month that supporters turned in enough signatures for the question to go to a statewide ballot. 

Oklahomans won’t be the first to push a ballot initiative in an effort to go around lawmakers who have resisted the Obama-era Affordable Care Act policy.  

Medicaid expansion plans have made it on the ballot in five states: Maine, Utah, Idaho, Montana and Nebraska. All passed, except in Montana.

If those states are an indicator, Oklahoma can expect see a multimillion-dollar public campaign with supporters and opponents from within and outside the state’s border working to sway public opinion.  

An Oklahoma Watch review of campaign finance data compiled by the National Institute on Money in Politics shows that about $40 million was spent in those five states. About two-thirds came from out-of-state groups.  

Amber England, executive director of Oklahomans Decide Healthcare, the group leading the Yes on 802 coalition, said she expects the spending trend in Medicaid expansion campaigns to continue in Oklahoma.  

Although she declined to disclose the group’s internal fundraising targets, England said money already is being raised for what could be a heated campaign.  

“We are prepared to run a modern campaign and to raise and spend whatever it takes to win,” she said. “This issue is too important to leave up to chance.” 

The Money Race 

Among the five states that voted on Medicaid expansion, Montana saw the most expensive campaign.

The 2018 battle differed from those in other states, however. Montana’s ballot measure asked voters to continue its existing expansion program that was set to expire the next year.

It was also tied to a $2-per-pack cigarette tax increase to help pay for the state’s share of the cost.

That prompted opponents – funded almost entirely by tobacco giants The Altria Group and Reynolds American – to spend about $17.5 million to defeat the measure. Supporters, meanwhile, put in about $9.8 million, including $7.1 million from the Montana Hospital Association.

The proposal failed, with 53% of voters opposed. But five months later Montana lawmakers passed a measure to continue the state’s existing expansion program with some changes, including adding a work requirement.

In the other four states with Medicaid expansion votes, supporters significantly outspent their opponents and the measures passed by margins ranging from 53% to more than 60% of the vote.

Pro-expansion groups spent about $3.8 million in Utah, $3.3 million in Maine, $3 million in Nebraska and $2.9 million in Idaho. Opposition groups in those four states spent about $3.6 million combined, or an average of $893,000 per contest.

Bankrolling the Efforts 

Oklahoma Watch’s review of campaign finance records shows that individuals contributed just a fraction of what was spent in support and opposition in those states – about $1.5 million of the nearly $40 million.  

Outside of tobacco money in Montana, the Fairness Project has been the largest national group to spend money on the ballot measures. 

The Washington, D.C.-based nonprofit advocacy group has given a total of $6.5 million to pro-Medicaid expansion groups in Utah, Idaho, Maine, Montana and Nebraska since 2017.  

The group was founded in 2015 by the president of the Service Employees International Union-United Healthcare Workers West, which represents more than 97,000 health-care workers in California. It is often labeled a “dark money” group because it is not required to disclose its donors. 

A Fairness Project spokesman declined to say whether it will contribute to Oklahoma’s Medicaid expansion initiative. But in a statement emailed to Oklahoma Watch, the group’s executive director, Jonathan Schleifer, indicated its support for Oklahoma’s proposal.  

“The Fairness Project supports working families all over the country who are fighting for change, and we support the efforts of voters in Oklahoma to put Medicaid expansion on the ballot,” he said. “When it comes to health care, voters should get the chance to decide what’s best.” 

The bulk of the rest of the contributions to pro-expansion groups came from hospital associations, individual hospitals or health systems, and left-leaning state-level interest groups or nonprofits.

Anti-expansion efforts, meanwhile, largely have not seen that type of institutional support. Other than tobacco money in Montana, only one other organization has given more than $50,000 to any group opposing an expansion ballot initiative. 

Americans for Prosperity, a dark-money nonprofit founded by brothers David and Charles Koch, spent $125,000 to oppose Utah’s Medicaid expansion plan, which passed with 53% of the vote.

Amber England, executive director of Yes on 802, speaks to supporters of Medicaid expansion at the Secretary of State’s office on Oct. 24, 2019, when the group submitted more than 300,000 signatures to add a state question on expansion a ballot in 2020. Whitney Bryen/Oklahoma Watch

Will Money Matter in Oklahoma? 

Jennie Pirkl, who led Maine’s first-in-the-nation Medicaid expansion ballot initiative as organization director for the Maine People’s Alliance in 2017, said it’s not clear if they needed the $3.3 million they spent. The measure passed with nearly 60% of the vote.  

But she said being able to get their message out and bring together a diverse coalition of health-care, business and patient advocate interests was critical.  

“Whenever you are trying to pass any big thing like this, it’s really important to do that work and try to get as many people involved,” Pirkl said. 

Nebraska Appleseed Project Manager James Goddard similarly helped lead Nebraska’s Medicaid expansion campaign, which was approved with 53% of the vote. 

Although there was little organized resistance, Goddard said it still required a good amount of work to reach voters in a GOP-led state like Nebraska. His group used TV ads, social media, public forums and one-on-one campaigning to promote their message.

“So I think this is winnable in places like red Oklahoma because we can show that is a good deal and because people need this help,” he said. 

In Idaho, Fred Birnbaum said he thinks the 2018 Medicaid expansion vote might have failed if supporters hadn’t outspent opponents by a nearly 3-to-1 margin. 

Birnbaum is the vice president of the Idaho Freedom Foundation, one of the few groups that spent money opposing Idaho’s expansion, which passed with more than 60% of the vote. He said many groups and businesses opposed to the measure ended up “sitting on the sideline because they didn’t want to ruffle feathers.” 

“I don’t think it was a fair fight,” Birnbaum said. “The supporters had way more money and were able to run a bunch of ads and get all the support of the media.” 

It remains to be seen how much supporters and opponents will raise in Oklahoma. 

Jonathan Small

Jonathan Small, executive director of the Oklahoma Council of Public Affairs, said he anticipates a “broad coalition” to come together to oppose Oklahoma’s ballot initiative. His group has led the charge against Yes on 802, including unsuccessfully challenging the petition’s language during the signature-collecting phase.  

But even if opponents don’t raise money on the same level as supporters, Small said he’s optimistic the ballot initiative can be defeated.  

“Normally, the big spending operations have more money on their side and they can spend anywhere from two, three or four times what the opposition spends,” he said. “They can still lose because once voters have enough information about what (the proposal) actually does, it doesn’t end up mattering in the end.” 

Reach reporter Trevor Brown at

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