In June 2020, Oklahoma voters narrowly supported expanding the state’s Medicaid program outlined in the 2010 Affordable Care Act. The vote passed with 50.5 percent in favor, enshrining the program’s funding in the state constitution. This means the state legislature must fund the program’s 10 percent cost share while the federal government pays for the remaining 90 percent.

Until 2020, the state was one of 14 nationwide that had not expanded Medicaid for those qualified by ACA standards. Oklahoma has the second highest rate of uninsured adults in the country, though that may change as the program’s eligibility expands by the 2021 deadline. Before the COVID-19 public health and ensuing job loss crises hit, the state estimated 200,000 would be eligible under the new Medicaid program. Oklahomans who file taxes as individuals making less than $17,000 a year or a family of three making less than $29,000 are now eligible. Medicaid expansion may also provide the opportunity to access expanded services not currently available.

Tribes play a unique role in Oklahoma health care and its Medicaid program.

State leaders have worked diligently in the weeks after the June 2020 vote to come up with the state government’s 10 percent cost match. Earlier in the year, the governor directed the Oklahoma Health Care Authority to submit state plan amendments to move forward with Medicaid expansion on July 1, 2020. However, in the weeks before implementation, he canceled the expansion plans. Prior to the vote on June 18, at the direction of the state’s executive branch, the OHCA issued a request for proposals from managed care organizations to run the state’s Medicaid program.

According to the Oklahoma Policy Institute, MCOs offer a streamlined and affordable way to manage health care programs, but they are not always fool proof.

“While some claim risk-based MCOs have certain flexibility and accountability advantages, they are primarily used as cost containment measures,” wrote OKPI’s Steve Lewis. “Oklahoma used this managed care model in the 1990s, and it did not work out then. The MCOs could not make a profit at the rate they were able to negotiate with the state, so they left the state. There was quite a bit of turmoil in the system, and OHCA went back to the fee-for-service model it now uses.”

Currently the OHCA oversees its management and maintains a good working relationship with tribal health care entities who serve tens of thousands of Oklahomans each year. As Oklahoma tribes well know, a positive relationship with a state entity that understands and respects the nuances of Indian Country results in a better partner. In recent decades, the growth in tribal health care services have filled in the health care gaps of rural Oklahoma, where hospitals and clinics have closed with increasing regularity. Concerns lie that an out-of-state company with little experience working with tribal health care providers may not understand the complexity that comes with the state’s tribal population. Based on a Congressional mandate, American Indians and Alaskan Natives are not mandated into MCOs. Tribes have requested OHCA allow this population to “opt in” to the MCO rather than be automatically enrolled. Tribes in states with MCOs have encountered difficulties receiving timely Medicaid payments for service or received outright denials on Tribal referrals.

Stepping in to help sort out some of these issues is State Senator Greg McCortney (R-Ada/Wanette). The former Ada mayor has been a leading voice at the statehouse to address the Medicaid issue. Senator McCortney, a citizen of the Choctaw Nation, requested an interim study for the fall of 2020 to examine tribal health and Medicaid managed care in the Senate Health and Human Services Committee.

Tribal support for Medicaid

Numerous Oklahoma tribal governments endorsed the ‘yes’ vote for the 2020 state question that pushed for Medicaid expansion. In addition to Citizen Potawatomi Nation, they included the Chickasaw Nation, Choctaw Nation, Osage Nation and Creek Nation. While health outcomes for Native Americans generally lag behind those of other groups, there were economic factors driving the support as well.

A 2019 study by the Self-Governance Communication & Education Tribal Consortium indicated that the presence of tribes can offset a significant cost to the state under the expanded Medicaid program. Under the ACA, Indian Health Service-eligible individuals can receive health care coverage paid for by Medicaid funds. According to the U.S. Census Bureau, an estimated 34,474 uninsured IHS-eligible patients in Oklahoma also meet Medicaid eligibility based on household income. If the state expanded Medicaid, the average annual per capita spent on them individually would be $7,255, which totals about $250 million. The nearly 34,500 IHS-eligible Oklahomans would not count toward the state’s funding of Medicaid support.

Like other tribal health care providers, for Citizen Potawatomi Nation, Medicaid expansion could be highly beneficial. There is often a misconception that an enrolled tribal member visiting a Tribal health clinic is the same as health insurance. That is not the case. For those members without private insurance, Medicare or Medicaid, the Nation pays for the costs of medical care. That means less money in other areas of need, whether for expanded health care facilities, services or staffing.

Uninsured AI/AN patients who may now qualify under the expanded Medicaid guidelines will continue to receive the same amount of care, and the federal government will follow federal law and numerous treaty obligations to pay the remainder of the cost.