An effort to send Medicaid expansion back to Oklahoma voters, following demands from the governor and a request for a nearly $500 million budgetary increase from the Oklahoma Health Care Authority, has come to a close. But the legislature or governor could still call a special session.
None of the four state questions proposed by lawmakers made it to the finish line before they adjourned last week.
Leaders in both chambers said they were disappointed they did not succeed in sending a question to voters amid disagreements over language and opposition from Senate Democrats and Freedom Caucus members.
How has the effort to address Medicaid expansion evolved?
In 2020, voters approved a ballot initiative expanding Medicaid eligibility to adults making up to 138% of the poverty level, or $22,025. Today, that includes 233,530 low-income Oklahomans. That eligibility cannot be adjusted without another vote of the people, because Medicaid expansion is enshrined in Oklahoma's constitution. It’s one of three states where that is the case.
Republicans have expressed concerns about the budget – especially amid the state Medicaid agency's increased request – and argued expansion should be transferred to statute, where lawmakers could make changes to address spending.
Approximately $42.3 million of the Health Care Authority’s ask accounted for Medicaid expansion growth and utilization increases, according to an agency spokesperson. The agency is set to receive only half of its initial request.
At first, lawmakers planned to run a ballot measure in August and another in November if the first measure failed. They proposed House Bill 4440 by Speaker Kyle Hilbert, R-Bristow, and Senate Pro Tem Lonnie Paxton, R-Tuttle, and House Joint Resolution 1067 by Rep. Ryan Eaves, R-Atoka, and Sen. Julie Daniels, R-Bartlesville. But August ballot efforts were blocked by Senate Democrats and Freedom Caucus members.
To avoid two November state questions, language from both proposals was combined into House Joint Resolution 1067. It would have asked Oklahomans to decide whether to remove Medicaid expansion from the state constitution and add it into statute, where it can be amended or repealed, if federal financial participation drops below 90%.
Currently, the federal government covers 90% of the costs of Medicaid expansion, and states fill in the remaining 10%. If a change in that match occurred, public officials would have had 15 days to update the state constitution and statutes.
The measure would have also removed the portion of Oklahoma's constitution saying the Medicaid expansion population cannot face additional restrictions on eligibility than other enrollees.
The language garnered the necessary signatures to advance out of conference by the House Rules Committee, but it didn't receive enough Senate signatures to move forward.
When the Senate didn’t meet May 6 and 7, Hilbert said the only way to get the sought-after state question on the ballot before they adjourned was to add it to a Senate resolution that was in their chamber.
That turned into Senate Joint Resolution 50, which the House passed May 7. The only major difference from HJR 1067 was it offered protections for Medicaid-eligible American Indian and Alaskan Native Oklahomans. The federal government’s share of Medicaid expenditures is 100% for the population when Indian Health Service and tribal facilities provide the care.
On Thursday, when the Senate reconvened, it did not take up the measure. Instead, Paxton filed an amendment to replace language in House Joint Resolution 1077 with a mostly similar, but slightly shorter, version of SJR 50. The original language in HJR 1077 sought to divert $1 billion from the Tobacco Settlement Endowment Trust Fund to establish the “For Oklahoma’s Future Trust Fund.”
That maneuver required a suspension of Joint Rule and four Senate rules. A motion to do so by Daniels failed to receive the necessary two-thirds vote — with 24 in favor, and 23 against — preventing the measure from moving forward. Objectors again included Freedom Caucus members and Democrats, among some additional Republicans.
House and Senate leaders respond
During a Thursday press conference, Hilbert said he was concerned by the language in HJR 1077 and the requirement to get rules suspended to move it forward. HJR 1077 did not include the provision requiring public officials to update the state constitution and statutes within 15 days.
“When [HJR 1077] failed today, I assumed at some point they would take up SJR 50, and then ultimately never did. I don't understand that decision,” Hilbert said. “But we are where we are at this point. I do think Medicaid is going to continue to be a big part of the conversation.”
Hilbert expressed concerns about the portion of the state's constitution saying the Medicaid expansion population cannot face additional restrictions on eligibility than other enrollees, including those on traditional Medicaid who are aged, blind or disabled.
“There's no other levers that the legislature or OHCA can pull when those populations are tied together,” Hilbert said.
Hilbert didn’t deny the possibility of a special session but said it would be up to the governor.
“I think we're going to take a moment and celebrate the fact we're at Sine Die and got past another great session,” Hilbert said.
Paxton, however, said during a Friday press conference, he doesn’t see a need for a special session.
He expressed frustration with the Freedom Caucus for disrupting efforts to address Medicaid expansion.
“Over and over and over, the Freedom Caucus sided with Democrats and voted for Obamacare,” Paxton said.
Daniels joined Paxton during his press conference and said she believes the language she wanted to add to HJR 1077, in consultation with Eaves, was clearer for voters.
Paxton added the language was worked on with the Oklahoma Hospital Association. He thought everything else they considered was “too confusing.”
“At some point, you just say, ‘This is not going to happen this time.’ I'm very disappointed that we're at that spot, but what I don't want to do is put something on a ballot for the voters to try to figure out what it is,” Paxton said. “Because, if it's not clear and concise, they're going to do what I would do in the same situation and vote no on it. And if we vote no on it, then there's probably not a chance to go do that again.”
“I would rather wait two years and try this again and do it the right way than put something on the ballot that would, I think, ultimately fail.”
Senate Minority Leader Julia Kirt, D-Oklahoma City, said she was surprised Republicans did not move a state question on Medicaid forward.
“I think what we saw was a real disagreement about what that final product should be,” Kirt said.
Cherokee Nation Principal Chief Chuck Hoskin Jr., who has been vocal in his support of Medicaid expansion as the measures were considered, applauded lawmakers for adjourning without passing a Medicaid expansion measure in a statement.
He said it is a lifeline for the Oklahomans it covers and pointed to the economic impact Medicaid expansion has had on the Cherokee Nation’s health system. He said it generates $222 million annually and supports 1,400 jobs.
“Every version of the proposed legislation under consideration represented a retreat from what Oklahoma voters decided in 2020. The proposals were based on both the speculation that Medicaid expansion will require a larger future proportionate investment by the state and based on a defeatist attitude that future funding could only be sustained by weakening the program,” Hoskin said.
“Weakening or destroying Medicaid expansion would weaken our state by stripping people of health coverage and destroying health care jobs.”
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