According to the latest U.S. Census figures, 565,000 Oklahomans, or 15.8 percent of the total population, were without health insurance in 2007-2008. The uninsured rate is just under 10 percent for children but over 20 percent for adults ages 18-64.

The Oklahoma Legislature has made several efforts in recent years to chip away at the number of uninsured by expanding eligibility for Insure Oklahoma, a program that provides public subsidies towards the purchase of employer-sponsored coverage for employees of small businesses or a public product for those without access to employer coverage. Eligibility for Insure Oklahoma goes up to 200 percent of the federal poverty level ($44,000 for a family of four) and is available to employees of businesses with up to 250 employees.

Back in 2007, the Oklahoma Legislature passed the All Kids Act (SB 424), that aimed to expand access to health insurance coverage for children in low- and moderate-income working families.  The bill offered subsidized coverage in the Insure Oklahoma program for children 18 years of age or younger with family income between 185 percent of the federal poverty level – the current income threshold for the Medicaid program – and 300 percent .  The bill included an $8 million  set-aside from Insure Oklahoma revenues to help pay for coverage for an estimated 20,000 children. In 2007 and 2008, the Legislature also approved expansions of Insure Oklahomans to new categories of adults, including those with incomes up to 250 percent of poverty, employees of businesses up to 500 employees, and foster parents regardless of the size of their employer.

All that was left to do was for the Oklahoma Health Care Authority secure federal approval for the amendments to the state’s SoonerCare and Insure Oklahoma waivers that would allow for the expanded coverage. How long could that take, right? As it turned out, it wasn’t until this past December, after two-and-a-half long years of negotiations, discussions, revisions, and waits,  that CMS (the Centers for Medicare and Medicaid Services) finally informed OHCA that the amendments had been approved to the applications for both children and adults.

Despite the delays associated with the lengthy approval process, OHCA has indicated that it intends to implement the expansion slowly and gradually.  Beginning in October, enrollment in Insure Oklahoma will be opened to children between 185 and 200 percent of the federal poverty level whose parents are already enrolled in Insure Oklahoma. OHCA estimates that 3,000 children could gain coverage during this initial phase.  No date has been set to open up enrollment for children above 200 percent of poverty or to those with parents not enrolled in Insure Oklahoma. Similarly, OHCA has not set a timeline for expanding enrollment for adults in categories that have now received federal approval for coverage in Insure Oklahoma.

The cautious approach is explained as due to both systems implementation issues and to uncertainty about the ongoing availability of funding to cover the expansion. Insure Oklahoma is funded through a portion of the increased tobacco tax collections approved by voters in 2004. In FY ‘09, OHCA was allocated $45 million for Insure Oklahoma. For several years, the program accumulated large surpluses as enrollment lagged. However, enrollment nearly doubled in 2009; with 30,314 participants as of February 2010, the program is approaching the level where annual revenues will only match expenditures on an ongoing basis. At that point, OHCA anticipates imposing a cap and waiting list on new enrollment.

The agency’s cautious approach to expanding eligibility without additional revenues is understandable, especially given the fraught fiscal outlook for the state as a whole, and the Medicaid program in particular, over the next few years.  The problem is really one only the Legislature can resolve. Expanding coverage to new categories of uninsured children and adults was the right commitment to make. Now it’s time to fund the commitment.

According to an e-mail that went out late last Friday afternoon from Nico Gomez, the Deputy CEO for External Relations and Communications of the Oklahoma Health Care Authority (OHCA), the agency will recommend to its Board this week that it make up for shortfalls in its FY ‘10 budget by adopting a cut of 2.5 to 3 percent in the rates it pays all its providers. Read the rest of this entry »

Every year or two, I get an e-mail from my former housemate in France asking me to help make sense of some raging American political issue – impeachment, the electoral college, superdelegates – that is getting regular coverage abroad but which is largely unfathomable if you’re not fully immersed in our political system. On Christmas Eve, after the Senate’s passage of the health care bill, the latest e-mail came from Maxime.  If I had a few minutes (ha!), could I help him understand the stakes in the health care reform debate, especially the public option?  My response oversimplified and only touched on a small portion of the legislation, but tried to explain the crux of what the House and Senate bills would do in ways a non-expert can follow. Assuming this may be of some value to a few Americans as well, here is a slightly modified version of what I wrote him:

In the US, there are three main ways that people get health insurance. According to the US Census Bureau:

* about three in five (59 percent) are covered through private insurance provided through their employer or the employer of a family member;
* about one in three (29 percent) are covered through the government – primarily through Medicare, a program for the elderly, or Medicaid, a program for the poor;
* about one in ten (9 percent) buy insurance for themselves on the individual market. Read the rest of this entry »

With Oklahoma in the midst of what is certain to be a severe and extended fiscal crisis, protecting core public services in every area of state government from deep and painful budget cuts poses a great challenge. However, protecting the budget of Medicaid, the main health insurance program for low-income children, seniors, pregnant women, and persons with disabilities, will present policymakers with special difficulties.

As noted in a recent fact sheet from the Kaiser Commission on Medicaid and the Uninsured, state Medicaid budgets face two distinct dilemmas: “the crunch” and “the cliff”. The crunch refers to the surge in Medicaid enrollment and spending associated with the economic downturn, as those losing jobs and access to employer-based coverage turn to Medicaid for coverage. Nationally, the Kaiser Commission found that total Medicaid spending growth averaged 7.9 percent across all states in FY 2009, the highest rate of growth in six years. As we reported in our last Numbers You Need bulletin, Oklahoma’s SoonerCare (Medicaid) enrollment climbed 8.9 percent between August 2008 and August 2009 and shows no signs of letting up. Read the rest of this entry »

From time to time we publish guest blog posts that help illuminate a policy issue or advance the discussion of public policy in Oklahoma (see our guest blog guidelines). This post was written by Laura Dempsey-Polan of Life Senior Services, a Tulsa senior service care provider. Laura may be reached at (918) 664-9000 X267 or LDPolan@LIFEseniorservices.org. The opinions stated below are not necessarily the opinions of OK Policy, its staff, or its board. This blog is a venue to help promote the discussion of ideas from a variety of different points of view.

Oklahomans and their families prefer in-home supports over institutionalization and we know these supports offer marked savings with much better outcomes. Over two decades, Oklahoma developed five in-home support Medicaid programs (i.e., 1915C Waivers) now serving 31,000 eligible citizens, and 2 more are in the works. Yet, in-home programs are increasingly squeezed by nearly eight years of stagnant reimbursement. Read the rest of this entry »

As the national health care reform debate continues to heat up, most of the controversy has centered on such hot-button issues as the public  option, individual and employer mandates, and paying for expanded coverage. One issue that is of considerable significance to states and low-income advocates in particular, but that has received far less attention, concerns the Medicaid program, the existing state-federal health care program for certain low-income individuals and families.

Poverty, poor health, and inadequate access to health insurance coverage are strongly correlated.  Adults living in poverty are one of the largest segments of Oklahoma’s uninsured population. According to the Kaiser Family  Foundation, 55 percent of poor adults were without health insurance in Oklahoma in 2006-2007, the fifth highest rate in the nation. There were 194,410 uninsured adults below the poverty level in 2006-07 ($22,050 for a family of four in 2009). This group represents almost two-fifths (38 percent) of all uninsured adults and just under one-third (30 percent) of the entire uninsured population in Oklahoma.

Few adults in poverty are covered by private insurance, either because they are not working or are not offered or cannot afford employer-based coverage. Some believe that if you’re poor, you automatically qualify for public health insurance.  But that’s not the case. Until recently, most adult Oklahomans living in poverty were ineligible for any public health insurance programs unless they were pregnant, elderly or had a disability. Medicaid in Oklahoma covers only parents of dependent children up to 50 percent of the federal poverty level ($763 per month in 2008 for a family of three). Parents of children with income above 50 percent of poverty, as well as childless adults under age 65, were ineligible for coverage.

With implementation of the Insure Oklahoma program, adults below the poverty level became eligible for subsidized coverage either through their employer or the state-administered Individual Plan. However, participation in Insure Oklahoma requires the enrollee to pay a portion of premiums and other cost-sharing expenses up to a maximum of 5 percent of family income. These cost-sharing obligations appear to create a huge barrier to participation in Insure Oklahoma among those living in poverty. While the program has now grown to cover over 20,000 individuals, just one in four participants has income below the poverty level.

Proposals emerging out of committees in both the U.S.  House and Senate would require states to expand Medicaid eligibility to cover all adults up to 100 percent or 133 percent of  the federal poverty level.  In the Senate Finance committee version, states would have three years to phase in eligibility to 100 percent FPL; the federal government would provide an increase in federal funding for the new eligibility categories for five years and then phase down to the regular state match.

The proposal poses some genuine challenges that will need to be addressed by Congress and the states, including the increased obligations this could place on state budgets, finding effective ways to ensure that those who are Medicaid-eligible actually enroll in the program, and ensuring adequate access to services for Medicaid recipients. Still, expanding Medicaid seems like the right approach. It is an established program that provides cost-effective coverage at low or no expense for participants and offers a comprehensive benefits package, which is especially important for the poor, who frequently have chronic and complicated health problems.

There is little doubt that having access to consistent, affordable care will help keep low-income adults healthier, creating a foundation that will help lift families out of poverty and towards economic security. If health care reform can succeed in covering most of the sizable uninsured below-poverty population through Medicaid, that will be one its worthiest accomplishments.

This week we released the July edition of Numbers You Need, our monthly bulletin of key economic and budget trends.  The monthly report contained some glimmers of good news, as the state’s unemployment rate rose by a relatively modest 0.1 percentage point to 6.3 percent in May, while rising energy prices (of benefit to Oklahoma) contributed to a modest increase in the Consumer Price Index. However, if we step back and compare where we are now to our situation 12 months ago, we get a sense of the extent of the  economic downturn’s toll on the state’s economy and population. Compared to 12 months ago, we find (numbers compare May 2009 to May 2008, except where otherwise noted):

• 39,900 fewer Oklahomans employed;
• A 77 percent increase in the number of unemployed;
• More than three times as many Oklahomans receiving Unemployment Insurance benefits;
• Over 51,000 more people receiving food assistance (Supplemental Nutrition Assistance Program, formerly food stamps) benefits and almost 26,000 more people on Medicaid (April 2009 vs. April 2008);
• State General Revenue collections down 30 percent (June 2009 vs. June 2008)

The weak economy continues to place great strains on both our private and public safety net support systems.  Fortunately, the federal stimulus bill included increases in both Unemployment Insurance and food assistance benefits, as well as help for states to protect Medicaid health insurance coverage and avoid layoffs of teachers and other public sector employees. This  provides crucial help to families in need and keep dollars circulating through the economy at a time when state resources are declining.

We hope you’ll check out Numbers You Need and post a comment sharing your thoughts.

As we’ve discussed in various blog posts and issue briefs, most state agencies received basically flat funding or were dealt budget cuts of 5 to 7 percent for the new fiscal year beginning July 1st, even as inflation leads to increased operating expenditures and the cost of employee health care and retirement contributions continue to mount. The result is that most agencies are being underfunded for the basic functions and missions that they are expected to accomplish, whether that is operating schools or parks, regulating environmental quality or nursing homes, protecting at-risk children, or preserving  public safety.

But what does this situation mean for the agencies, departments, and school districts that operate public services? We usually don’t hear stories about the impact of underfunding unless and until there is a crisis. Yet the reality is that many public agencies at all levels of government, especially regulatory and administrative agencies, are perpetually underfunded.  Resources are always scarce, and even in good budgetary times, most legislators prefer to fund programs that provide direct benefits to their constituents than those that do the unglamorous work of  licensing, inspecting, investigating, and adjudicating. This is especially true here in Oklahoma, where we are among the bottom five states in the amount we spend per person on state and local government

Recently, the journal Health Affairs published an interview with Kerry Weems, who served as Interim Director of one of those unheralded but vital regulatory agencies, the Centers for Medicare and Medicaid Services (CMS), during the last 18 months of the Bush Administration. CMS is charged with overseeing expenditures of almost $700 billion annually in the two major public health care programs. In particular, it has the responsibility for preventing and investigating waste, fraud and abuse in these programs. But in Weems’ view, one that is shared by many others, CMS is not staffed at levels necessary for it to fulfill its mission. Here’s how he describes the impact that a shortage of resources has on his former agency: Read the rest of this entry »