A Tale of Two Medicaid Expansions: Missouri v. Oklahoma

In fishing, what one does with the rod after casting the line and hook into the water is as important to success as getting the lure in the right spot of the stream. Following through with enough wiggle and bounce to make that lure look alive is crucial to actually landing a fish for dinner. And while fishing and health policy may seem worlds apart, this same principle holds true for state Medicaid expansions.

The latest example of the importance of a successful follow through in the health policy world concerns the recent decisions of voters in Oklahoma and Missouri to expand Medicaid in their states. In Oklahoma, political leaders accepted the decision of their voters to expand coverage and worked hard to implement more affordable health plans. In Missouri, a lawsuit, legislative delays, and lack of enthusiasm to implement the new coverage has meant only a fraction of people eligible so far have signed up for the coverage voters approved.

The differences are stark. In Oklahoma, the latest enrollment estimate for their Medicaid expansion shows that 219,192 people now have health coverage.  And while estimates are that around 275,000 people in Missouri are eligible for expansion, the Missouri Medicaid program has only signed up about 16,000 people so far, even several months into the program.

Why is the fishing for Medicaid enrollees so much better in Oklahoma?

One reason Oklahoma has been so successful is that the state went actively looking for residents who could benefit from expanded health coverage, automatically enrolling nearly 100,000 people who were getting more limited benefits but who now qualified for more comprehensive coverage under the new law or who had already submitted an application. Oklahoma’s Medicaid agency is also actively targeting counties with low enrollment, working with community partner groups to reach out to residents who might not know they can now get affordable health coverage.

Other states have employed the same outreach strategies that have been so successful in Oklahoma. For example, both Kentucky and Virginia looked for opportunities to enroll people by identifying state residents through other databases who also are likely to need affordable health coverage. Recently, both these states used a state unemployment database to identify individuals who may have lost their jobs and employer health coverage during the pandemic and then reached out to this group, letting them know of the existence of Medicaid expansion coverage.

And in states like Virginia, the early success of enrollment in expansion is self-reinforcing. Virginia’s later Medicaid expansion has resulted in substantial state savings in recent budgets –with much of this savings attributable to reductions in state-paid uncompensated care and Medicaid now covering more mental health and substance abuse treatment.

In contrast to these efforts, Missouri is relying much less on state initiatives to identify potential enrollees who might be receiving services through other state programs or developing a strong, coordinated state plan for outreach. However, the need for more affordable health care remains and other organizations in Missouri are doing their best to step in and help with enrollment. And while this is no substitute for a strong, state-led outreach effort, nonprofits in Missouri are starting the hard work of doing outreach and enrolling people in the new Medicaid program.

States have had varying degrees of success in starting Medicaid expansions, but the Missouri/Oklahoma contrast is particularly striking given the similar timeframe, eligible population, and the fact the states even share a bit of their borders. Right now, the fishing is much better in Oklahoma. But perhaps observing this success will mean the folks in the “Show Me” state will adjust their Medicaid expansion follow through and show that they can keep up with Oklahoma and other states.

Adam Searing is an Associate Professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.