Our country is now poised through the Affordable Care Act to help millions of American families and small businesses and their employees access high quality, affordable health care coverage.  This isn’t going to happen by itself.  This is not simple.  If it were simple, someone would have accomplished it years ago.  This is complicated, but it is not beyond our grasp [..]

We are ready in Maryland to turn the corner on the healthcare costs that have been sapping our productivity as a people and as a nation.  Sapping the productivity of our businesses.  Taking from them the ability to reinvest in their own plants and their own opportunities and their own markets. Costs that force moms and dads to choose between health care and paying for groceries, or tuition, or school supplies, heat, rent, mortgage payments.  These are the big decisions that happen in the most important place – the kitchen table of every family home.

In Maryland we believe we are gaining a competitive advantage by being an early implementer [of health care reform].  Last year we had the best year of new job creation that we’ve had since the recession hit [..] Why is it that at the same time we’ve cut 7.5 billion from our state budget, we’re increasing the ranks of those who are covered by healthcare so very, very dramatically?  It’s because there is an historic truth – not a Democratic truth or a Republican truth – but an American truth and an economic truth.  In order to create jobs, a modern economy requires modern investments.

Along with the investments we make in the education of our workforce, in the innovative capacities of our people, there is also the health of our people.  That too is an economic development investment.  It’s an investment in greater productivity, greater prosperity, and greater promise.  We’ve chosen to invest in healthcare [..] Our goal was to support the health of our workforce.  So moms and dads could go to work, so they could be productive, so they wouldn’t miss days from work or searching for work because they had to take care of sick kids or to take care of themselves.  It’s very hard to put in a full day’s work if you’re sick, if you can’t go to a doctor.  You see that played out time and time again in the economies of third world nations.  A healthy workforce is a productive workforce, is a profitable workforce.

In some places in our country Medicaid expansions are kept quiet.  States worry if you let people know the uninsured are becoming covered and they might go to the doctor, that this could cost money and that that might be something our neighbors scowl at.  In fact, some of our sister states in their legal briefs to the Supreme Court are describing people signing up for Medicaid as “one of the harms brought to states” because of the Affordable Care Act.  I encourage those who make that argument to read Matthews gospel 25[..] I want to mention the tragic case of Deamonte Driver, a little 12-year old boy in Prince George’s County who died because his family could not afford to go get a toothache looked at.  That toothache led to an infection that led to his brain that took his life.  Deamonte lived just outside this nation’s capital [..]

We might want to ask [those who say they want to repeal the law] what advice they would give to the millions of Americans who don’t have health insurance.  Crossing your fingers is not really a responsible option.  Do they believe, like that debate audience, we should allow hospitals with an injured uninsured patient to just ‘let him die’?  [..] That’s not how you move America forward and that is not what the vast majority of Americans in their heart expect of ourselves or our government.

We have a responsibility to make the business case for the Affordable Care Act.  What are the opportunity costs of inaction?  When a small business is paying another fifteen to twenty percent annually, every year for health insurance, how many fewer people are they employing? How many dollars could have gone into expanding markets for their products or services?   What are the opportunity costs for families when a mom has to choose between a roof over their head, food on the table, or healthcare?

People who are sick can’t work.  Mom and Dad can’t provide for their family if all of their dollars are going to rising healthcare costs, let alone keep paying the mortgage if all of the sudden they’re wiped out by some unanticipated hospital bills.  In the private sector rising costs are eroding the quantity and quality of health benefits for American workers.  In the public sector health costs are the single greatest threat to our fiscal sustainability [..]

Peter Orzag wrote these words:

It is no exaggeration to say the United States standing in the world depends on its success in constraining the healthcare cost explosion.  Unless it does, the country will eventually face a severe fiscal crisis or a crippling inability to invest in other areas.

Truly, bending the cost curve requires innovation [..] Innovations like the health information exchange which allows the sharing of data between hospitals, labs and thousands of doctor’s offices.  This isn’t something that we’re imagining.  It’s not something that we’re hoping for.  It’s something that we’re doing [..]

There is no area that cries out for better choices more so than the area of containing healthcare costs, of having better preventive care.  Making our workforce healthier, making the balance sheets of our small businesses better so that they can reinvest in more jobs and more opportunities.  We need to talk about this in terms of the business case for healthcare.  There are better ways to do this, virtually every country has shown that this is possible [..]

We’ve seen what works, but we’ve been too timid to do what our parents and grandparents had the courage to do.  Which was to do it at scale, to do it in an impactful, broad way.  To realize that in our America there is no such thing as a spare American.  Everyone is needed.  Are other countries so much more innovative than us that they can figure out how to do this to scale and we can’t?  I don’t buy that [..]  There are in fact challenges so large that we can only hope to tackle them together.  Making better choices in terms of healthcare is one of them.

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One popular myth is that Medicaid costs are rising exponentially and the program is riddled with waste.  In fact, scholarly research has demonstrated that Medicaid costs about 20 percent less on average per person than private insurance, so the program is quite lean.  While it is true that health care costs are rising, it’s important to remember that they are rising across the board, not just for the Medicaid program.  The state can also take advantage of a favorable federal matching rate to leverage their health care investment.  For every $1.00 the state government invests in SoonerCare in FY 2012, the federal government will contribute $1.77.

Another common myth is that Medicaid is free healthcare for people who don’t work.  Actually, most working-age adults in Oklahoma are not eligible for comprehensive SoonerCare coverage.  Only 9.6 percent of SoonerCare/Medicaid recipients in the state are healthy working-age adults (not counting those receiving only family planning services). That’s because eligibility for an adult who is neither elderly, disabled, or chronically ill is restricted to parents at or below 37 percent of the federal poverty level.  That’s just shy of $7,000 a year for a family of three.  The vast majority of Oklahomans on SoonerCare, about 70 percent, are kids and seniors.

SoonerCare/Medicaid is also instrumental in caring for chronically ill uninsured Oklahomans.  In 2011, the program provided care to 8,430 cancer patients and treated 81,920 with heart disease or stroke.  It also plays a central role in supporting the state’s aging and institutionalized population by helping cover the costs of nursing home care:

With nursing home or institutional care coverage largely unavailable through Medicare or traditional private health insurance plans, Medicaid is the nation’s de facto financing system. SoonerCare OLL (Opportunities for Living Life) funds nearly 70 percent of all long-term care (both nursing facilities and intermediate care facilities for the mentally retarded). SoonerCare provides coverage for low-income people and many middle-income individuals who have become nearly impoverished by “spending down” their assets to cover the high costs of their long-term care.

The new federal health care law will soon usher in significant changes to Medicaid, sparking a welcome and ongoing dialogue about the cost and value of the program. Pivotal in these discussions is an understanding of SoonerCare’s safety net function – without which thousands of Oklahoma families would forgo basic health services for their children, lack necessary medical care for their disabled loved ones, and be left to shoulder alone the unsustainable burden of the long-term care of their parents and grandparents.

Click here to download ‘Medicaid 101: The SoonerCare Safety Net’

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Let’s assume that you stand on principle that it’s not the government’s role to engage the health care system.  Then we have a gravely serious problem.  We are very nearly the unhealthiest state in the country and we’re getting worse.  Individual behaviors – smoking, diet, fitness - certainly affect health, but it’s by no means certain that they’re the most important factors.  What we’re facing in Oklahoma is bigger than the sum of each individual resident’s health choices.  Acute structural defects in the state’s health care system demand solutions that are bigger than each of us and addressing them will benefit all of us.

First, we do not have enough doctors, nurses, and health care providers in Oklahoma.  If you live in an urban area, this will be hard to relate to, but it’s true.  We rank 49th in availability of primary care physicians, with only about 82 physicians per 100,000 Oklahomans.  The consequences of this fact should be obvious.  Without access to regular preventative care and treatment when you’re sick, minor health problems can become catastrophic illnesses.  Rural Oklahomans could be making healthy choices, but end up unhealthy because of lack of access to care.  We need government support for efforts that promote access to care, like schools of community medicine, graduate student loans, and incentive programs for doctors who settle in remote areas.  How can we attract modern economic development to a state where many residents haven’t ever had a doctor?

Second, we have hundreds of thousands of households living in poverty.  Poverty affects a person’s health in innumerable ways that are beyond their control.  Not being able to afford medical care, even if you have a doctor nearby, can be an insurmountable hurdle to well-being.   Children living in poverty are especially vulnerable, as their health choices are totally dependent on caregivers who are already struggling to meet other basic needs like food, clothing, and shelter.  The state and federal governments, through the SoonerCare/Medicaid program, currently subsidize medical care for 472,111 Oklahoma children who might otherwise go without.  If you don’t think that government has a role to play in the overall health of our citizens, then you’d better be prepared to count those children out.

Other structural conditions, many perpetuated by living in poverty, also contribute to poor health:

• Lack of medical care, malnutrition, and second-hand smoke as an infant or during early childhood has lifelong effects on health.
• Limited access to healthy groceries coupled with abundant access to fast food in urban areas (‘food deserts’) significantly constrain household diet choices.
• Poor air quality exacerbates chronic conditions like asthma and other respiratory disorders.
• Fewer gyms and public parks in low-income areas make consistent exercise more challenging.
• Insufficient income to purchase nutritious food coupled with lack of knowledge about healthy eating stacks the deck against low-income households.

Government can and should invest in improving the structural conditions that destine impoverished people to a lifetime of poor health outcomes. There is no other alternative.  Oklahoma households cannot continue to work, save, and invest as more and more of their labor and income is taken up caring for ailing parents and grandparents.  The economic development goals of the state cannot be met with an ever-sicker, ever-poorer workforce.  Individual health problems eventually become public health problems that the state must address.  If we don’t come to terms with the grim reality of our health care situation on the ground, we cannot expect the state to enjoy continued, broad-based prosperity.

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Julie is an Associate Professor and Assistant Director of the Anne and Henry Zarrow School of Social Work.

The number of uninsured individuals in Oklahoma has reached approximately 600,000 individuals. Almost half of Oklahoma’s uninsured are between the ages of 19-34. Despite this high number, little is known about why these young adults are underinsured or what strategies might encourage them to obtain coverage.

A state-wide survey and focus groups were designed to capture the opinions of young Oklahomans ages 19-34 regarding access to and the use of Oklahoma’s health care system in the absence of health insurance. Although it has been suggested that the young adults believe that they do not need health care coverage, results of the survey suggest otherwise.

Only a very small percentage of those without insurance reported that they did not have insurance because they did not need it. Further, those without insurance reported worrying about their health significantly more than those with insurance. Overwhelmingly, the main barrier for uninsurance status was cost: 85 percent of those survey indicated that cost was a significant barrier for obtaining health insurance. Many young adults also believed that they would not qualify for state insurance programs or were not employed, or employed at jobs without health coverage.

When those young adults without insurance were asked what they considered to be an affordable monthly premium, 97 percent reported that they could only afford a premium under $100.00.

Another assumption about young adults is that they are a fairly healthy group, with fewer and lower medical costs. Results from this study reveal a different picture. Young adults struggle significantly with medical costs; more troubling, 60 percent of uninsured young adults report having medical debt and 57 percent report that they have used pay day lenders to assist with covering medical costs. Debt among Oklahomans is a a major problem, and health care costs are a significant portion of this debt.

Further, young adults without insurance coverage report poorer health and over half report having long term and ongoing medical problems that require regular care as well as health related limitations.

Improving coverage for young adults is an important policy problem for Oklahoma, so what could be done?

• Address the affordability of coverage.
• Expand access to affordable care for Oklahoma’s young workforce. If we promote pathways to higher education and training for young adults, better paying jobs will mean better health insurance coverage.
• Educate young adults about state programs. Many young adults believe they are not eligible or are aware of state programs designed for adults without health insurance (e.g. Insure Oklahoma).
• Consider marketing campaigns aimed at young adults. On the precipice of health reform in Oklahoma and the development of health exchanges, young adults will require information specific to their needs. Social media campaigns that explain health care changes and options will increase knowledge and enhance decision making. Targeting young adults who are particularly at risk for underinsurance is also important (e.g. those without access to Cobra coverage through parents, lower income or minority young adults).

Strategies such as the above could prevent some of the serious health and financial consequences that young Oklahomans experience without health insurance coverage. Secure coverage would afford them both health and future economic stability.

This blog summarizes some findings of a collaborative state-wide survey of young, uninsured Oklahomans by the University of Oklahoma–Anne and Henry Zarrow School of Social Work and the Oklahoma Insurance Department. For the full report, please contact  jmcribbs@ou.edu

The opinions stated above are not necessarily those of OK Policy, its staff, or its board. This blog is a venue to help promote the discussion of ideas from various points of view, and we invite your comments and contributions. To see our guidelines for blog submissions, click here.

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Jeffrey Alderman, M.D., is an associate professor in the Department of Internal Medicine at the University of Oklahoma School of Community Medicine in Tulsa.

With Medicaid cuts looming and the federal government entertaining efforts to shift the costs of Medicare and Medicaid on to states and individuals, the future of health care reform and reimbursement seems murkier now than ever. But gaining little attention is the issue of physician workforce. In other words – with the size and scope of our health care provider pool now shrinking, how will we meet increasing patient demand with our current available workforce?

Despite our best efforts, we simply cannot attract new physicians to the state, and a large percentage of our OU/OSU graduates leave to work outside of Oklahoma. This helps to explain why in 2009 the Commonwealth Fund ranked Oklahoma 50^th in the nation for health status and health system performance. Similarly, a 2007 American Medical Association report found that Oklahoma ranks last in the US in physicians per capita, perhaps revealing why there is a 14-year difference in life expectancy between some north and south Tulsa communities.

Therefore, we depend upon a pool of providers that is ever shrinking – and an even smaller pool of doctors who are willing to practice primary care AND will accept Medicaid insurance. If deeper cuts to providers are made, the urban and rural poor, disabled, pregnant and aged patients will be forced to seek care in the only places where doctors will continue to accept SoonerCare (at higher contracted rates): the universities and the Federally Qualified Health Centers (FQHC’s.)

This is highly problematic, because many Medicaid patients have difficulty securing transportation to such far-flung facilities. Moreover, attracting physicians to work in these settings is challenging – especially when a physician can earn two to five times more income working in the private sector.

We need to graduate and retain doctors in Oklahoma who feel a sense of mission (like the innovative Dr. Jeff Brenner of Camden, NJ – who was recently featured in ‘The New Yorker.’) This line of thinking led OU-Tulsa and the George Kaiser Family Foundation to launch ‘The School of Community Medicine’ – with its emphasis on improving health status through retooling medical education.

The school’s new curriculum is designed to train medical students not just to focus on meeting the health care needs of individual patients, but on whole communities as well. Yet, when medical students are now graduating with over $200K in debt, it’s easy to see why we have a surplus of highly paid specialist physicians, such as urologists and orthopedists, opening practices in wealthy Tulsa and Oklahoma City enclaves. It is also easy to see why we have very few primary physicians throughout Oklahoma that will accept Medicaid.

Of course, the biggest losers in the new paradigm are low-income patients, who will face ever-decreasing access to medical care. In essence, we’re waiting for Superman to open a primary care practice in Oklahoma – but I worry he may have just moved to Texas to become a Neurosurgeon.

The opinions stated above are not necessarily those of OK Policy, its staff, or its board. This blog is a venue to help promote the discussion of ideas from various points of view, and we invite your comments and contributions. To see our guidelines for blog submissions, click here.

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Why was Oklahoma one of only six states selected for this grant?  There are two programs that uniquely position Oklahoma as an innovator of health care information technology:  Insure Oklahoma (IO) and SoonerCare online enrollment (OE).  Online enrollment for SoonerCare, the state’s Medicaid program, went live in September 2010 and has already dramatically improved the efficiency of the application process.  Applicants input required information on family members, income, etc. into a web-based interface, and their eligibility is determined in real-time (subject to verification). Three months after online enrollment launched, only 7 percent of SoonerCare applications were paper.  OK Policy blogged about the launch of online enrollment and the resulting national accolades this past December.

In 2005, Insure Oklahoma (IO) became the state’s first premium assistance program.  IO currently offers coverage to employees of small businesses through employer sponsored coverage, and directly to individuals who are unemployed, self-employed, or working for an Oklahoma business that doesn’t offer insurance.  The IO program is the first step to establishing a state-wide exchange, when coupled with advances in online enrollment automation, Oklahoma is years ahead of other states in readiness to launch an insurance exchange.

One of the first tasks for the Early Innovator grant will be a ‘gap analysis’, an assessment of the capacity of the state’s current technology infrastructure.  Once current capacity is mapped, it will be measured against what the state needs to build and operate an effective Exchange.  For instance, OHCA already operates a call center to handle inquiries for IO and SoonerCare, but the capacity of the call center will need to be expanded to handle the call volume of a new insurance Exchange that will serve hundreds of thousands of additional consumers.

The goal is for the Exchange to serve as a one-stop shop for all of a household’s health care needs.  A single web-based portal for citizens to access affordable private insurance and determine their eligibility for public assistance like breast and cervical cancer screening, services for persons with disabilities, or dental care for children.  Currently, those programs listed are provided by three different state agencies.  When the insurance Exchange goes online in 2014, they will be accessible through one internet site, alongside an insurance marketplace where private plans can be bought and sold.

Building this single portal is no easy task, especially when you consider the constantly changing needs of each household.  As citizens move from job to job, get married, have children, and age, their health care needs and eligibility for public assistance changes too.  The Exchange IT system must be interoperable and integrated so consumers can easily make changes, i.e. switch from Medicaid to private insurance or vice-versa.

In addition, the Exchange will be built with the security needed to protect consumer information, obstruct fraud, and comply with the Health Insurance Portability and Accountability Act (HIPAA).  The online provider directory used by IO and SoonerCare will be upgraded to a universal provider directory, a state-wide database of doctors searchable by location, gender, and specialty.  For the full Early Innovator grant proposal including all the proposed system upgrades, click here.

Once the basic infrastructure upgrades are made, there are innumerable and creative ways that businesses, consumers, providers and state agencies can use these tools to improve care.  For example, North Carolina has used upgrades to their Medicaid information system to help doctors make wiser patient treatment decisions.  As doctors and hospitals submit claims information to the state, they receive periodic reports back from the system that reveal how their treatment and prescription choices compare to other doctors treating the same kinds of patients right down the street and in other parts of the state.  Providers can use that information to make sure they are not falling behind, or getting ahead, of the standard of and cost of care in their specialty area and geographic location.

Improving the quality of health care, and reducing long-term costs for the consumer, require large up-front investments in infrastructure.  This money represents an opportunity for Oklahoma not just to be a leader and example for other states, but to facilitate relationships between consumers and private sector providers that will guarantee the long term health of its citizens and the profitability of its businesses.

For more information, check out our ongoing series examining the Affordable Care Act, including previous posts on long term care and consumer protections for preexisting conditions. You can also visit the health care reform page on our website for more resources and information.  If you have thoughts on health care reform, we encourage you to comment below or contribute a guest blog.

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One of the most important provisions of the federal health care reform law, officially known as the Affordable Care Act (ACA), is the requirement that states establish private insurance marketplaces, or ‘Exchanges’, to sell plans to individuals and small groups in their state.  Health insurance exchanges were written into the law to ensure that these particularly vulnerable segments of the market – individuals and small groups – could obtain affordable coverage.  What is unique about these segments?  Well, consider how insurance works for a large group employer:  every employee is covered regardless of medical history and all employees pay roughly the same premiums.  This is possible, and perhaps more importantly profitable, because the risk of covering the sicker/costlier employees is offset by the ease of covering healthier/cheaper employees.

Now consider how insurance works in the individual and small group market:  currently, when you shop for insurance for yourself, or a handful of employees, you pay a much higher premium and have fewer plan options.  Why?  The insurance company does not have that larger pool of people to spread out the risk that you or your employees will be the sick/costly type.  This is exactly the problem exchanges are designed to remedy.  Exchanges enable individual and small group consumers in a state to pool their buying power and create a marketplace to negotiate with insurers for higher quality lower cost coverage, just like a large employer.

Exchanges, available in 2014, will provide information to consumers about each participating plan’s benefits, pricing, and eligibility.  It’s important to note that most of the plans offered on the Exchanges will be sold and administered by private insurers – the state’s role is to host and regulate the marketplace. Participation in the insurance exchange is voluntary; consumers can still choose to buy directly from an insurance company, through a broker, or through their employer, when available.  However, for those income-eligible for premium subsidies, the online Exchanges are expected to serve as the primary venue for determining eligibility and accessing those subsidies to buy insurance.

The states have significant discretion in setting standards for a plan’s inclusion in the online Exchanges, although the federal government has set minimum requirements.  For instance, insurance policies must cover ‘essential health benefits’, defined by the ACA to include at least the following:

ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

The ACA also requires that Exchanges be equipped with consumer-friendly features like a web portal, a toll-free assistance hotline, and an online coverage cost calculator.  Insurers must offer specified tiers of coverage presented in a standardized way to maximize comparability.  The Department of Health and Human Services explains how this requirement builds on existing online private insurance infrastructure:

All or virtually all of the information needed for the web portal is standard information that is already made available to individuals, insurance agents, or existing IT contractors with pricing engines and other entities that sell or otherwise provide health insurance to individuals and small groups. For example, information on deductibles, coverage, cost-sharing, and catastrophic protection limits is routinely available on all or virtually all insurance available to individuals or small groups. Nothing in this rule requires preparation of entirely new information. In essence, we simply require that relatively comprehensive information be provided in standardized formats so that plan comparisons can be automated in ways that present comparable information in comparable levels of detail to facilitate consumer understanding of available choices.

The Oklahoma Department of Mental Health & Substance Abuse Services received a $1 million dollar planning grant to begin developing Oklahoma’s Exchange.  The second Oklahoma Health Insurance Exchange public stakeholder meeting was held in late January in Oklahoma City.  The Exchange Project Managers are soliciting participation from stakeholders and have set up seven work groups, each tasked with a different aspect of exchange planning, including Governance & Administrative Structure; Enrollment; Eligibility Process & Infrastructure; Information Technology (IT); Carrier & Plan Selection; Financial Management & Premium Development, and Education and Marketing.

Considerably more funding for developing the Exchange may be on its way – Oklahoma is in contention to be one of five states that will receive an Early Innovators Grant, a grant to reward states that demonstrate leadership in developing cutting-edge technologies for insurance eligibility and enrollment.  The Oklahoma Health Care Authority (OHCA) has requested $54 million for a two-year project – the Oklahoma Health Infrastructure and Exchange Project (OHIEP) – to invest in developing the states health insurance technology infrastructure.

Even as legal and political challenges have left the future course of health care reform implementation in question, Oklahoma, like most states, seems determined to press ahead with putting a health insurance Exchange in place.  In addition to the grants received and work being done on Exchanges by OHCA, Senator Bill Brown (R) has introduced SB 960, “to create a health insurance exchange to facilitate the purchase of individual and small group health coverage within the state.”  In large part, Oklahoma policymakers are motivated by the knowledge that if states do not create their own exchanges, the ACA enables the federal government to step in and run a non-compliant state’s Exchange for them. Oklahoma policymakers seem committed to retaining control over the important policy choices involved in designing and operating the exchanges – even if that means that the hostile rhetoric about the new law coming from some elected officials ends up at odds with the real and important implementation work that is underway at the administrative level.

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This chart (which is based on DHS monthly statistical bulletins available here) shows monthly participation for both programs going back to January 2008: Both programs reached all-time participation highs in March. The 575,898 food stamp recipients that month represented an increase of 28 percent compared to 12 months before and an astounding 40 percent increase compared to March 2008. The growth in Medicaid beneficiaries was slightly less dramatic – the 690,055 Oklahomans covered by SoonerCare in March was a 15 percent increase from June 2008. The two programs now serve between one in five and one in seven Oklahomans, including an especially high percentage of children.

We would expect that as the economic recovery gains steam, these enrollment numbers will begin to level off, as more people regain employment that provides them enough income to cover their basic needs and offers private health insurance. However, we shouldn’t anticipate any swift or sudden drop in participation. Even in healthier economic times, a substantial portion of Oklahoma’s population relies on the public safety net for adequate food and medical care. And even with public programs and a vigorous network of non-profit agencies and faith-based groups, some families still fall short or fall through the cracks. But during these hard times in particular, the support provided  by programs like SoonerCare and food stamps is making the difference in helping hundreds of thousands of economically vulnerable Oklahoman households just make it through from one month to the next.

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SoonerCare has undergone many changes over its history. Perhaps most significantly, the program’s initial experiment of serving Medicaid recipients in the urban catchment areas of Oklahoma City, Tulsa, and Lawton through fully-capitated HMOs was abandoned at the end of 2003 after the program was unable to retain an adequate number of managed care organizations. Since then, all SoonerCare clients statewide have been served through a partially-capitated primary care physician (PCP) model, with OHCA itself assuming many of the case management and coordination functions previously contracted out to the HMOs (Medicare dual eligibles, foster care children, and other select populations remain in the traditional fee-for-service program).

The report is valuable reading for anyone looking to understand the recent history of the state’s Medicaid program. While identifying ongoing problems, Mathematica unambiguously asserts that “SoonerCare has contributed to improvements in access to care for low-income Oklahomans”.  The program is applauded for improving coverage for children (although the Legislature played a key role in expanding coverage to 185 percent of the poverty level in 1997, along with subsequent expansions),  restraining costs, growing the Medicaid provider network, and delivering customer satisfaction. OHCA itself is applauded for developing a culture of  innovation and strategic planning,  emphasizing performance monitoring and reporting, and displaying a commitment to public reporting and accountability (through such mechanisms as its monthly Fast Facts). The evaluators are more critical of OHCA’s success in collaborating with other public agencies and communicating with the Legislature.

Perhaps the most interesting finding of the evaluation (p. 16 of the Executive Summary) concerns what happened when OHCA assumed responsibility for managing the care of SoonerCare recipients who had previously been enrolled in commercial HMOs. The state, it turned out, was able to provide care at less cost with no decline in quality of care:

With sufficient resources and leadership commitment, state Medicaid agencies can manage care at lower costs than MCOs and with similar outcomes. Annual per-member costs in Oklahoma have been significantly below the national average for every year between 1996 and 2005, and in most cases below the average of states operating MCOs. Given the cost trajectory of Oklahoma’s MCO contracts, and the limited competition that existed between companies at the time that the Plus [fully-capitated managed care] program was terminated, it seems likely that SoonerCare would have been more costly to operate during the past four years had those contracts been maintained. Evidence from this evaluation suggests that provider participation and member outcomes have not been adversely affected as a result of the statewide expansion of SoonerCare Choice and termination of the MCO contracts, though we did find some evidence that preventable hospitalizations for diabetes and asthma may have increased. In states such as Oklahoma, where managed care penetration is low and turnover among MCOs is relatively high, MCOs’ key advantage — utilizing resources more flexibly – may have limited effectiveness in achieving better outcomes….The growing concentration of Medicaid managed care interest and capabilities in a relatively small number of multi-state private MCOs has prompted many states to look at state-managed PCCM, care management, and disease management programs as potential alternatives. Oklahoma has demonstrated that such programs have the potential to produce results that are as good as those produced by private MCOs, and perhaps better, if state Medicaid agencies have the necessary resources and a commitment to truly manage care.

As the national debate on health care reform heats up, with particular controversy focused on whether to provide consumers the choice of a publicly-operated product competing with private insurance plans, Oklahoma’s experience may have national relevance.

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