Oklahoma voters took a historic step and nudged their state forward toward becoming the 38^th in the nation (including Washington, DC) to provide residents more affordable health insurance through their Medicaid program. The constitutional amendment passed by voters requires the state to open the doors to coverage no later than July 1, 2021. State leaders have been debating Medicaid expansion for years but will hopefully move quickly to implement coverage now that voters have spoken.

Estimates are that the expansion will cover at least 215,000 additional state residents with affordable health coverage. The next steps are to get a funding mechanism passed by the legislature while the Governor and relevant agencies must move forward with securing federal approval and set up plans to start enrolling those who need coverage.

However, in recent weeks, opponents of more affordable health coverage options for residents through voter-approved expansion – including Oklahoma Governor Kevin Stitt – have complained that the 10% match the state must pay to bring the 90% federal funding into the state is somehow unaffordable and unattainable. The paucity of this argument springs into sharp relief to any voter with a memory longer than Oklahoma’s beautiful state bird, the Scissor-tailed Flycatcher.

After all, just over a month ago, Oklahoma’s legislature worked with the Governor to easily pass a comprehensive funding plan for the Governor’s version of Medicaid expansion (which, changing his mind midstream, the Governor promptly vetoed). How quickly legislators have forgotten their own legislative success! Perhaps this new legislative opposition stems from the fact that now voters have approved a Medicaid expansion plan that can’t be changed or eliminated on a whim. And given the roller-coaster history of the Medicaid expansion debate in Oklahoma, voters have every right to be suspicious.

While the vote is over and Oklahoma voters have directed their elected representatives to expand Medicaid, the history of opposition to expansion provides some key points to watch going forward:

1. Given the enormous need for more affordable health coverage during the current crisis, can legislators move more quickly on financing expansion and work with the Governor to move up the start date for coverage from July 1, 2021? This year, Oklahoma’s Governor and legislature put together an expansion plan with funding in just a few weeks. This provides a strong base for the argument that funding for voter-approved expansion can be worked out quickly to allow a much sooner start date for affordable coverage.
2. Can Oklahoma’s Medicaid system quickly scale up to enroll the newly-insured? Oklahoma’s eligibility and enrollment system has been seen as a state model for years. Innovation in a “no wrong door” approach to enrollment, electronic real-time application, and post-eligibility review work well in Oklahoma. A Medicaid audit claiming some eligibility verification problems was released by the Governor just five days before the ballot vote but lacked specifics, was requested more than a year ago, and consequently was seen by many as more of a political ploy around the ballot vote than an attempt to improve the system. After years of refinements to computer systems, Oklahoma is the only state able to electronically check and process Medicaid applications within 24 hours – and has a system for double-checking their work. Overall, the state seems well-positioned to quickly and accurately provide more affordable health coverage.
3. How quickly can Oklahoma receive federal approval and implement expanded Medicaid? Other states intent on expansion have taken from just a few weeks to six months to get approval and implement their programs. For example, Virginia was able to implement enrollment in Medicaid expansion six months after final passage of the plan. Louisiana was on an even faster timeline that measured in weeks. With cooperation from the legislature, Governor and state agency leaders, it is clear that expanded coverage could be implemented on a timeline of much less than 12 months. And there are outlines of suggested actions to meet this timeline for “motivated states.”

Oklahoma voters have spoken. Now it is up to their elected representatives to make the voters’ vision a reality. Luckily Oklahoma has the tools in place to quickly move on expanding needed health care coverage. While I look forward to seeing how quickly state leaders respond to the clearly stated views of the voters, what really matters is what a difference it will make in the lives of the thousands of people who will now be able to get health care.