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.

Oklahomans will decide on Tuesday whether the state will expand its Medicaid program and give subsidized health coverage to more than 200,000 Oklahomans.

State Question 802 will be the only statewide ballot measure on the state’s upcoming primary election.

But the impact on the state budget and the health of thousands of residents will be directly impacted by the vote. Here are some things to know before you vote.

Who is eligible with and without the expansion?

Oklahoma’s current Medicaid program, known as SoonerCare, is only open to low-income residents who are children, parents with children under 19, pregnant women or blind, disabled or elderly residents. The latest report from the Oklahoma Health Care Authority shows that about 20 percent of Oklahoma’s population – including 263,800 adults and 526,600 children – is enrolled.

Those eligibility requirements were generally standard across the nation until the Affordable Care Act passed in 2010 and a U.S. Supreme Court decision two years later decided that states could decide whether to accept federal funds to expand Medicaid.

State that accept the expansion can now cover adults under 65 who make up to 138 percent of the federal poverty level, which would be up to an annual salary of $17,236 for an individual or $35,534 for a family of four.

The Oklahoma Health Care Authority estimates 215,000 new Medicaid enrollees would sign up if the state question passes.

When would the expansion take effect?

The state question requires the state to implement the expansion no later than July 1, 2021. There is nothing stopping the state from starting it earlier, but lawmakers would need to convene a special session to fund the measure.

Where is the ‘expansion population’?

The Census Bureau reports that in 2017, the latest year with available data, Oklahoma had the second highest uninsured rate in the country (only ahead of Texas) with 14.2% of the population lacking health coverage.

But the data is more striking when looking at the potential Medicaid expansion population.

Almost 26.4% of low-income Oklahomans under 65 who make up to 138 percent of the poverty level lack insurance, according to the Census Bureau. And in rural Oklahoma, particularly in the panhandle and northwest corner of the state, the number is higher, with uninsured rates at or over one-third of the population in several counties.

Which states have accepted the expansion?

Oklahoma is one of 14 that have not accepted the expansion, as of Aug. 1, according to a tally from the Henry J. Kaiser Family Foundation.

The states that haven’t adopted expansion are mostly Republican led states in the southeast and the Great Plains. Of the states bordering Oklahoma, only Arkansas, New Mexico and Colorado have accepted expansion.

But voters in states that haven’t accepted expansion have increasingly tried to pass the proposal by popular vote. Last year, Medicaid expansion made the ballot in Idaho, Montana, Nebraska and Utah. It passed in each of the states except Montana.

Like Oklahoma, Missouri will also be voting on a ballot measure to accept the expansion this year. Voters in that state are set to vote on the measure Aug. 4.

Who pays for the expansion?

States and the federal government split the cost to cover the traditional Medicaid population with some states, including Oklahoma, receiving more than others though a calculation determined by the Federal Medical Assistance Percentage (FMAP) rate, which is based on state’s per capital income compared to the national capita income.

Oklahoma’s FMAP rate last year was about 58%, meaning the federal government contributed $1.43 for every $1 the state spent. That the state spent $1.27 billion and the federal government spent about $3 billion in Oklahoma Health Care Authority program costs in 2018.

The funding split for the expansion population, however, operates differently.

The federal government initially covered all the costs to cover the newly eligible population in state that accepted the expansion during the first two years after the health care law took effect in 2014. That rate has been phased down over the years so the federal government will cover 90% of the expenses in 2020 and all subsequent years.

The Oklahoma Health Care Authority estimates that 215,000 will enroll, costing a total of nearly $1.4 billion with Oklahoma needing to pick up $164.1 million of that amount.

A report commissioned by the Health Care Authority estimated that the state’s share of the costs would range from $137 million to $157.9 million if Medicaid expansion took effect in 2021. But the report anticipates a net cost of $48.6 million to $81 million when anticipated savings in existing programs across state government are taken into account.

Can the expansion be changed?

SQ 802 is proposing a constitutional amendment requiring the state to provide coverage to the expansion group. That means that the governor and the Legislature alone couldn’t repeal or change the eligibility requirements unless they put it to another vote of the people.

How would Oklahoma pay for the plan?

The ballot language on SQ 802 is silent on where the funding would come from, so it would be up to the Legislature to either use savings, find new revenues or make cuts to pay for the state’s share of the costs.

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