Hurry up and wait: Even with federal approval, Oklahoma coverage expansions left on hold

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.