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 healthcare 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 2014, 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 46th 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 a 35 percent decrease in the number of children in poverty.
But the state has considerable challenges, including a limited availability of primary care physicians and low immunization rates for children. Nearly a third of adults in Oklahoma are obese, and 33 percent are physically inactive.
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 Boren has since been replaced by a Republican, and the entire U.S. congressional delegation from Oklahoma is Republican.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 Oklahoma Gov. Mary Fallin is also a Republican. There’s a small Democratic majority however, in the demographics of the state population. Gov. 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 2014 study from Georgetown University. The state defaulted to a federally run exchange and has refused to expand Medicaid.
How did Obamacare help Oklahoma residents?
Before the ACA was implemented, the uninsured rate in Oklahoma was 21.4 percent, making the state one of 14 that had more than a fifth of their population without health insurance in 2013.
By the end of 2014, that number fell nearly three percentage points; 18.5 percent of Oklahoma residents were still uninsured, six months after full ACA implementation. That number dropped to 17.7 percent uninsured, less than one percentage point, by mid-2015 – 3.7 percentage points from 2013.
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 qualified health plans
Early in the first open enrollment period, the Kaiser Family Foundation estimated that 446,000 people could potentially buy coverage through Oklahoma’s federally facilitated 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 qualified health plans through the Oklahoma exchange, with 79 percent receiving premium subsidies.
At the end of the 2015 open enrollment period, 126,115 Oklahomans had selected qualified health plans. Some of them failed to make their initial premium payments or dropped coverage, lowering that number to 108,614 enrollees as of June 30 – 80 percent had a plan with an advanced premium tax credit, and 59.7 percent received cost-sharing reductions.
Those who shop Oklahoma’s exchange will notice fewer carriers than in years past. There were six for 2014 open enrollment and four for 2015. For 2016 open enrollment, there will be two carriers offering individual plans on the exchange: Blue Cross Blue Shield of Oklahoma and UnitedHealthcare, which is new to the exchange but offered off-exchange coverage in past years. Premiums for Oklahoma’s benchmark plan rose an average of 36 percent for 2016, the largest increase among the 37 states using the federal Health Insurance Marketplace.
Oklahoma Medicaid/CHIP enrollment
Oklahoma is currently one of 20 states that has not yet expanded Medicaid and has no pending plans to do so. The ACA would have expanded Oklahoma 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, as the state has done.
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.
The Oklahoma exchange enrolled 17,374 people in existing Medicaid by mid-April 2014. From November 15, 2014, to February 22, 2015, there were 12,946 Oklahomans who enrolled in Medicaid or CHIP through HealthCare.gov. Overall, from 2013 to 2015, average monthly enrollment grew 3 percent. Open enrollment for Medicaid and CHIP lasts year-round.
Because the state has not expanded Medicaid under the ACA, enrollment for 2016 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).
If the state expanded Medicaid, an estimated 173,000 people would be eligible for coverage. Oklahoma has 91,000 people 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.
Oklahoma’s Medicaid expansion alternative
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 2016. 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 17,923 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.
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, and the Oklahoma Health Insurance High Risk Pool ended operations as of December 31, 2014.
State-based health reform legislation
Here’s a summary of recent Oklahoma bills related to public health and healthcare reform:
Oklahoma lawmakers have been looking for ways to reign in Medicaid spending growth and, as part of this effort, passed HB1566 in May 2015. This bill directs the state to implement a pilot program to evaluate the managed care model for Medicaid enrollees and gather proposals from private insurers.
Medicare enrollment in the state of Oklahoma
About 17 percent of Oklahoma’s population is enrolled in Medicare, which is consistent with 17 percent nationwide. Oklahoma Medicare beneficiaries qualify for benefits as follows: 79 percent of individuals are eligible due to age alone, while 21 percent are eligible as the result of a disability.
Medicare spends about $9,999 annually per enrollee in the state of Oklahoma, which ranks 27th in overall spending on Medicare with $5.9 billion per year.
Oklahoma’s Medicare recipients can select Medicare Advantage plans instead of Original Medicare. Some choose to do so in order to receive additional benefits. Of Oklahomans enrolled in Medicare, 17 percent have selected a Medicare Advantage plan. Half (50.7 percent) are enrolled in Medicare Part D, slightly higher than the national average for enrollment in stand-alone Medicare prescription drug plans, which is 47 percent.