Since the passage of the Affordable Care Act in 2010, Oklahoma has made headlines by fighting against the law – resisting implementation in Oklahoma, and challenging the law in the federal court system. Public health and realistic, affordable access to health care are significant factors in long term health outcomes and quality of life, but Oklahoma faces health challenges across the board.
Here’s a summary of Oklahoma residents’ overall health, access to health insurance, and the state’s approach to healthcare reform:
Oklahoma health ratings
Oklahoma ranked very close to the bottom of the list on The Commonwealth Fund’s Scorecard on State Health System Performance in 2014. The state came in 49th (up one spot from 50th in 2009) out of the 50 states and DC. The Oklahoma Scorecard provides details showing how the rating was determined.
In 2013, America’s Health Rankings placed Oklahoma slightly higher than the Commonwealth Fund – but still squarely in the bottom 20 percent – giving the state a ranking of 44th out of the 50 states in terms of overall health. The state’s rating is helped somewhat by a low incidence of binge drinking and pertussis, and also by moderate per capita public health funding (although even that has decreased by 40 percent over the past two years).
But the state has considerable challenges, including a high rate of drug deaths, low immunization rates, and relatively few primary care physicians. Nearly a third of adults in Oklahoma are obese, and more than 28 percent are physically inactive. 23 percent of the adult population uses tobacco, and more than 27 percent of Oklahoma children are living in poverty, which presents a particular public health obstacle.
Trust for America’s Health has summarized a variety of public health data pertaining to Oklahoma in their 2014 edition of Key Health Data, which includes information on specific diseases and health factors. The Robert Wood Johnson Foundation has also analyzed public health data on a county level, ranking the counties in Oklahoma against one another on this interactive map. In general the counties in the northwest part of the state fare better than those in the southeast.
Oklahoma and the Affordable Care Act
In 2010, both of Oklahoma’s U.S. Senators, Republicans Thomas Coburn and James Inhofe, voted no on the ACA. In the U.S. House, one Democrat, the second district’s Dan Boren, voted yes, while four Republican Representatives from Oklahoma voted no. Boren has since been replaced by a Republican, and the entire U.S. congressional delegation from Oklahoma is Republican.
At the state level, there’s a strong Republican majority in both the House and Senate, and the Governor is also a Republican. There’s a small Democratic majority however, in the demographics of the state population. Governor Mary Fallin is strongly opposed to the ACA, and supported her Attorney General’s lawsuit against the ACA.
Oklahoma is one of five states considered “diehard hold outs” against Obamacare, according to a January study from Georgetown University. The state defaulted to a federally-run exchange, and has refused to expand Medicaid.
How did the ACA help Oklahoma residents?
Before the ACA was implemented, the uninsured rate in Oklahoma was 21.4 percent, making the state one of fourteen that had more than a fifth of their population without health insurance in 2013. That number has since fallen by nearly four percentage points; 17.5 percent of Oklahoma residents were still uninsured as of June 30, six months after full ACA implementation.
Oklahoma leadership’s opposition to the ACA and refusal to expand Medicaid means that a primary feature of the law’s ability to reduce the uninsured rate is not being utilized. The ACA has benefitted the nearly 87,000 people who enrolled in coverage through the exchange (in existing Medicaid/CHIP as well as private plans) during the first open enrollment, but there’s still a long way to go.
Oklahoma enrollment in QHPs
Early in the first open enrollment period, the Kaiser Family Foundation estimated that 446,000 Oklahoma residents could potentially buy coverage through the exchange, and that 256,000 of them would be eligible to receive premium subsidies. By the end of the first open enrollment period, 69,221 people had finalized their enrollment in the Oklahoma exchange, with 79 percent receiving premium subsidies.
Six carriers are offering plans in the Oklahoma exchange: Aetna, Blue Cross Blue Shield of Oklahoma, CommunityCare HMO, Coventry Health and Life, Coventry Healthcare of Kansas, and Global Health. The vast majority (roughly 60,000) of the enrollees during the first open enrollment period selected a plan from Blue Cross Blue Shield of Oklahoma.
Oklahoma Medicaid/CHIP enrollment
Oklahoma is currently one of 22 states that has not yet expanded Medicaid and has no pending plans to do so. The ACA would have expanded Medicaid to cover all legal residents with incomes up to 138 percent of poverty, but in 2012 the Supreme Court ruled that states could opt out of Medicaid expansion, and Governor Fallin has so far chosen to do so.
Most experts believe states like Oklahoma will eventually expand Medicaid for financial reasons – it’s a question of when, rather than if. But in states where political leadership is strongly opposed to Obamacare, Medicaid expansion could still be several years away.
As an alternative to expanding Medicaid, Oklahoma received an extension from the federal government to continue running their Insure Oklahoma program through the end of 2015. Insure Oklahoma uses tobacco taxes and federal matching funds to provide private health insurance subsidies for people earning up to 200 percent of poverty level.
The program’s participation has declined from about 30,000 people to about 19,000 this year, because members with incomes above the poverty level are eligible for subsidies in the exchange. Insure Oklahoma continues to provide assistance to people with incomes below the poverty level, but only a small fraction of the 144,000 people in the Oklahoma coverage gap are being helped by the program.
The Oklahoma exchange enrolled 17,374 people in existing Medicaid by mid-April. Because the state has not expanded Medicaid under the ACA, enrollment in 2014 is still contingent on Oklahoma’s existing strict eligibility guidelines: Non-disabled adults with no dependent children are not eligible for Medicaid regardless of income, and parents with dependent children are only eligible if their household income doesn’t exceed 42 percent of poverty (about $692 a month for a family of three).
Because the state refused to expand Medicaid, Oklahoma has 144,480 people – about 28 percent of its uninsured population – in the coverage gap, with no access to financial assistance with their health insurance. There are currently no realistic insurance options available for people with incomes below the poverty level who do not qualify for Medicaid under the state’s existing guidelines.
Even though Medicaid eligibility guidelines have not changed in Oklahoma, the state’s Medicaid program was facing a budget shortfall this year, and announced a 7.75 percent cut in reimbursement rates for providers in an effort to shore up the programs finances.
Does Oklahoma have a high-risk pool?
Prior to 2014, individual health insurance was underwritten in nearly every state, including Oklahoma. This meant that pre-existing conditions could prevent an applicant from getting coverage, or could result in significantly higher premiums or policy exclusions.
The Oklahoma Health Insurance High Risk Pool (administered by Blue Cross Blue Shield of Oklahoma) was created in 1995 to provide an alternative for people who were ineligible to purchase individual health insurance because of their medical history.
Implementation of the ACA and a guaranteed issue individual market have eliminated the need for high-risk pools, but the Oklahoma Health Insurance High Risk Pool will remain operational until the end of 2014. Oklahoma House Bill 3282, which was signed into law in early June, called for the risk pool to cease new sales as of June 1, 2014 (with no effective dates available later than July 1), and to terminate all coverage as of December 31, 2014.
Remaining members will be able to transition to a private plan in the exchange – with premium and cost-sharing subsidies if they’re eligible – and can have continuous coverage as long as they apply for a new plan by December 15.
State-based health reform legislation
Oklahoma had quite a bit of additional legislation related to healthcare during this year’s session. Here’s a summary of recent Oklahoma bills related to public health and healthcare reform: