Oklahoma and Kentucky: A tale of two states

kentucky derby
When it come to improving health, Kentucky is off to the races

When it comes to health challenges facing their populations, Oklahoma and Kentucky are two states with strong similarities.

The latest state rankings from the United Health Foundation put Oklahoma 43rd and Kentucky 44th in overall health. Both states rank at or near the bottom in most major health categories: rates of obesity, smoking, diabetes, and physical inactivity; number of preventible hospitalizations, cardiovascular deaths, cancer deaths, drug deaths, and overall premature deaths; poor mental health and physical health days.  About 650,000 residents of each state are without health insurance.

But faced with similar obstacles, the two states have adopted very different approaches to the Affordable Care Act. In Kentucky, Governor Steve Beshear has embraced the ACA. In a New York Times op-ed titled “My State Needs Obamacare. Now.”, Gov. Beshear declared:

We’re making progress, but incremental improvements are not enough. We need big solutions with the potential for transformational change. The Affordable Care Act is one of those solutions. For the first time, we will make affordable health insurance available to every single citizen in the state.

To ensure that everyone has access to health care, Kentucky is expanding Medicaid to cover adults with incomes below 138 percent of the federal poverty level. This coverage will be 100 percent paid for by the federal government for the next three years, phasing down to 90 percent by 2020.

Kentucky has also developed its own online health insurance marketplace, KYnect, where people can go to compare and purchase private insurance plans. Amidst all the problems with the launch of the federal health insurance marketplace in October, Kentucky has stood out as a success story. Through November, Kentucky was sixth in the nation in both the number of individuals who had completed applications for coverage (151,255), and had selected a marketplace plan (13,145). In addition, 53,046 Kentuckians had been determined eligible for Medicaid, behind only California and Washington. 

Oklahoma could have been another Affordable Care Act success story. It’s important to recall that in 2011, Oklahoma was awarded a $54 million federal grant to support the development of a state marketplace, or exchange. Oklahoma was one of five states to receive an early innovator grant, in recognition of our pioneering online Medicaid eligibility and enrollment system that had earned national accolades.  The early innovator award offered us the chance to build a state-of-the-art health care marketplace best tailored to Oklahomans’ needs.

Instead, Gov. Mary Fallin rejected the grant and left Oklahoma’s exchange in the hands of federal agencies.  Through November, only one-fifth as many Oklahomans as Kentuckians had completed an application for coverage in the new insurance marketplace, and only 1,673 had enrolled in a plan, one-eighth the number as in Kentucky. While improvements with the federal website suggest that Oklahoma’s enrollment numbers are likely to catch up some over the coming months, the two initial months of technical malfunctions may have long-term effects in deterring Oklahomans from enrolling. And the federal site may never have the seamless interconnectivity with the Oklahoma Medicaid program, Insure Oklahoma, and other state health program we could have had if Oklahoma had developed our own marketplace.

In addition to rejecting the federal early innovator grant and opting not to develop a state-run marketplace, Governor Fallin has  maintained a stance of maximal opposition and obstruction to the ACA, including rejecting federal funds to provide coverage to our lowest-income adults. This means that over 100,000 Oklahomans will remain stuck in a “coverage crater“, left without access to affordable health insurance because they earn too little to be eligible for tax credits that help with the cost of coverage purchased through the marketplace. In rejecting the Medicaid expansion, Governor Fallin promised an “Oklahoma plan” to reduce the number of uninsured, but a year later, no plan has been developed or announced.

Governor Beshear reminds people that the Affordable Care Act was approved by Congress, sanctioned by the Supreme Court, and is the law of the land. “Here in Kentucky,” he writes, “we cannot afford to  waste another day or another life.” Here in Oklahoma, the stakes are just as high, but the opportunity to make progress is being wasted.   


Former Executive Director David Blatt joined OK Policy in 2008 and served as its Executive Director from 2010 to 2019. He previously served as Director of Public Policy for Community Action Project of Tulsa County and as a budget analyst for the Oklahoma State Senate. He has a Ph.D. in political science from Cornell University and a B.A. from the University of Alberta. David has been selected as Political Scientist of the Year by the Oklahoma Political Science Association, Local Social Justice Champion by the Dan Allen Center for Social Justice, and Public Citizen of the Year by the National Association of Social Workers.

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