Oklahoma has quietly released details of Gov. Kevin Stitt’s Medicaid expansion plan, with the state’s own report saying the plan “will likely depress enrollment” by thousands of Oklahomans compared to a traditional Medical expansion plan.

An ongoing series on efforts in Oklahoma to extend health coverage to thousands of uninsured people through Medicaid expansion or other approaches.

As state and federal leaders focused their attention on the coronavirus pandemic, the Oklahoma Health Care Authority posted on its website Monday the state’s waiver application and a notice of the start of a 30-day public comment period. The application is part of the federal Healthy Adult Opportunity program, which allows states to seek multi-year waivers to traditional expansion.

The 66-page application lays out new details on the second phase of Stitt’s SoonerCare 2.0 health plan. Those include how the state would charge some premiums and co-pays and place work requirements on the new Medicaid expansion population.

Stitt’s first phase is already underway. The state has submitted a state plan amendment to allow Oklahoma to expand Medicaid through the traditional model that dozens of other states have followed.

According to state projections, about 220,000 low-income Oklahomans – adults under age 65 earning up to 138% of the federal poverty level – would be newly eligible for subsidized health coverage through Medicaid starting July 1 if lawmakers find $150 million for the state’s share of the costs.

Once that’s in place, Stitt wants to use a federal waiver to would allow Oklahoma to add cost-sharing provisions, work requirements and other provisions, including moving to a block grant model for the expansion group. The waiver application seeks to launch these changes by July 1, 2021.

Stitt first unveiled the plan’s framework in late January in Washington, D.C., alongside Trump administration officials.

He billed it as a more flexible and tailored alternative to State Question 802, a proposed constitutional amendment that would accept the expansion without conditions.

Stitt, who opposes the ballot initiative, has yet to set a date for the state question. But it’s expected to be on the June primary or November general-election ballot.

What’s in the Plan?

For the first time, the federal waiver application spells out many details of how Stitt’s plan would differ from traditional expansion.

A big difference is how many people will be covered.

The application states that although it is difficult to estimate, “based on other state experiences,” Oklahoma could see 5% fewer enrollees than if the state enacted a traditional expansion model without the cost-sharing or work requirements.

That would mean nearly 7,600 fewer Oklahomans covered during the first year of its implementation, according to state projections.

Another big change would make more than half of projected new enrollees in the expansion group pay monthly premiums – a feature not included in most other states’ expansion plans.

Depending on their salary and household size, enrollees in SoonerCare 2.0 could pay up to $10 a month if they are the only enrolled adult in a household or $15 a month if two or more adults in a home are enrolled.

The application also states that all households will be responsible for paying copayments for their services up to the 5% out-of-pocket household maximum. In addition, there will be an $8 copay for “non-emergency” use of emergency room visits.

The state’s proposal also calls for members of the expansion group to work, volunteer or attend classes unless they are exempt. They would have to work an average of 80 hours a month to keep their enrollment following a phased-in grace period. Recently released incarcerated Oklahomans would get an extended grace period.

Other details include eliminating retroactive eligibility that would have covered unpaid medical bills up to three months before a beneficiary applies for Medicaid and moving to a managed care system for the expansion group.

The application is largely silent on how the state would transform Medicaid into a block-grant program for low-income adults in the expansion group and set caps on Medicaid spending.

Terry Fife, a volunteer for Yes on 802, carried part of the petition to send Medicaid expansion to voters at the Secretary of State’s office on Oct. 24, 2019. (Whitney Bryen/Oklahoma Watch)

Opponents Blast Timing, Plan Details

Release of the application and starting the 30-day comment period comes only days after Stitt, and governors nationwide, announced a state of emergency because of the coronavirus epidemic.

Carly Putnam, a health policy analyst with the left-leaning Oklahoma Policy Institute, called the decision to proceed with the waiver application during the crisis “shameful.”

“We know what works with Medicaid expansion, and that is putting as few barriers between people and their care as possible,” she said. “And under the guise of doing something innovative, the state is suggesting failed policies like charging premiums and work requirements.”

Putnam said concerns that thousands will lose their jobs or be forced into unpaid leave for weeks or months because of the coronavirus is another reason why Stitt’s plan will further strain the financial resources of low-income Oklahomans and make getting care more difficult.

“Saying we’ll cut off coverage if people don’t pay a symbolic premium when all of the bars are closing and all the restaurants are eliminating their wait staff right now, is just incredibly tone deaf,” she said.

Minority Leader Rep. Emily Virgin, D-Norman, said the state’s focus right now should be on combating the COVID-19 pandemic, adding there will be time in the future to talk about “how unnecessary” Democrats believe the work requirements are.

The governor’s office did not respond with comments Tuesday. But the state’s application addresses many of the criticisms directed at the plan.

The document, for instance, notes that Medicaid “is intended to be a temporary stepping-stone for many low-income adults” and cited a 2016 study out of Indiana that showed that having Medicaid enrollees there pay premiums resulted in better health outcomes.

It also said the work requirements would “promote upward mobility, greater independence, and improved quality of life among individuals.”

What’s Next

Oklahoma is still far from getting the application approved and implemented.

Residents can voice their thoughts on the plan during the comment period through April 15 by visiting the Health Care Authority’s SoonerCare 2.0 page. The authority originally scheduled two in-person public hearings.

But concerns of the spread of the coronavirus prompted state officials to move the first meeting (scheduled for 3 p.m. Wednesday) to an online meeting and add another online hearing for 3 p.m. Friday. Another hearing, planned for March 24 in Tulsa, was still tentatively scheduled to go on as of Wednesday afternoon. That meeting will also be broadcast online.

The state hopes the waiver will be approved by November, allowing the state to implement the changes by July 1, 2021. But many factors could complicate the timetable.

The National Health Law Program sent a letter Tuesday to Centers for Medicare and Medicaid Services Administrator Seema Verma, urging her to immediately postpone the public hearings and extend the public comment period until the coronavirus crisis has ended.  The legal group, which calls itself progressive, noted the cautions against public gatherings and said many Oklahomans may not be able to attend by person or video.

Democrats and health advocates have vowed to challenge state waivers in court that include the block grant or work requirements. It’s also likely that if Democrats retake the White House this November, the new president would reverse Trump’s guidance encouraging states to apply for the waiver.

Oklahoma voters could also stop Stitt’s plan. If SQ 802 were to pass, it would supersede any changes that Stitt or the Legislature want to make.  

This story was updated at 1:30 p.m. Wednesday to include changes the state made to the scheduled public comment meetings.


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