What’s the news: Oklahoma voters approved expanding Medicaid, leaving only a baker’s dozen worth of states who have chosen not to do so.

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The Oklahoma measure expands Medicaid eligibility to all adults ages 19 to 64 years old making up to 133% of the Federal Poverty Level no later than July 1, 2021. This will provide coverage for individuals making up to $16,970 or $34,846 for a family of four.

At 14.2%, Oklahoma’s percentage of uninsured is second only to Texas at 17.7%, according to 2018 U.S. Census data. Medicaid expansion is expected to provide coverage for some 200,000 Oklahomans and this number could grow by another 50,000 as COVID-19 leads to people losing their jobs and employer-based insurance.

Oklahoma is the first state to approve Medicaid expansion during the COVID-19 pandemic, which has led to dramatic growth in unemployment. Around 47.5 million people are at risk of losing their employer-based insurance nationwide because of the pandemic, according to a study cited in a recent JAMA Health Forum report.

The margin of victory was slim: 50.5%-49.5% with the question decided by 6,688 votes. But it made Oklahoma the fifth state to approve expansion by voter referendum. Unlike Idaho, Maine, Nebraska and Utah, Oklahoma’s expansion is now part the state’s constitution.

The AMA supports Medicaid expansion and believes health system reform efforts must ensure that Medicaid is a viable and effective program to provide health insurance coverage to low-income individuals, seniors and the disabled.

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Read the AMA’s recommendations for strengthening Medicaid.

“We continue our call for Medicaid expansion because we know it improves access to care and the health of our patients,” then-AMA President Patrice A. Harris, MD, MA, said this past January at the AMA State Advocacy Summit in Bonita Springs, Florida.

The Oklahoma State Medical Association strongly endorsed the ballot question and stated that it “supports the acceptance of additional federal dollars redirected back to the state which are dedicated to expanding access to Medicaid health care services to Oklahomans in need.”

Why it’s important: More than 14.7 million people have gained coverage through Medicaid expansion under the Affordable Care Act since 2013 and this coverage has been linked to greater access to care, more preventive care and improved chronic disease management, according to research cited in a 2019 JAMA “Viewpoints” column.

Prior to the referendum, Oklahoma Gov. Kevin Stitt sought approval from the Centers for Medicare & Medicaid Services (CMS) to make changes to Oklahoma’s expansion program under a demonstration called “Soonercare 2.0.” If approved, federal funding for the program would be subject to a per capita cap, certain benefits would be limited, and eligibility for certain Medicaid enrollees would be conditioned on participation in mandatory work, community engagement, education or volunteerism hours. The approved ballot measure, however, now prohibits the state from imposing eligibility restrictions on the expansion population that are more burdensome than those imposed on other Medicaid-eligible populations.

The AMA opposes Medicaid work requirements and caps on Medicaid spending and urged CMS to reject both.

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“Artificially limiting the growth of Medicaid expenditures will hinder Oklahoma’s ability to address the health care needs of its most vulnerable citizens,” AMA Executive Vice President and CEO James L. Madara, MD, wrote in a letter to CMS Administrator Seema Verma, regarding the per capita caps included in the SoonerCare 2.0 proposal.

Regarding work requirements, Dr. Madara noted that the work requirements in the Arkansas Medicaid plan didn’t lead to employment growth—but did lead to 18,000 people losing their coverage.

“We believe that such requirements will negatively affect access to care and lead to significant negative consequences on individuals’ health and well-being,” Dr. Madara wrote. “As physicians, we are especially concerned about interrupting the continuity of care for our patients who are subject to the requirements.”

Arkansas instituted Medicaid work requirements in 2018, but they were struck down the next year by a federal judge.

What’s next: The Oklahoma Health Care Authority has three months to submit a plan and all other necessary documents to CMS for expanding the state’s Medicaid program.

Missouri voters will decide Aug. 4 whether to amend their state constitution to include Medicaid expansion. If approved, expansion is expected to provide coverage for about 300,000 Missourians.

The Missouri State Medical Association favors expansion.

“MSMA supports Medicaid expansion because physicians want their patients to have access to the best health care options possible,” the organization states on its website. “Increased access to health care is linked to better health outcomes in patients of all ages. In particular, access to preventative health care can help prevent or delay the onset of much more costly and devastating chronic health care problems for patients.”

Once Oklahoma’s expansion program is implemented, there will be about 4.6 million people who still could gain coverage if the remaining 13 states adopt Medicaid expansion, according to Kaiser Family Foundation estimates.

The AMA continues to seek opportunities to improve the Affordable Care Act and expand options to those who do not qualify for subsidized coverage. Learn about the AMA vision on health care reform.

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