OKLAHOMA CITY — With the threat of a citizen-led ballot initiative looming on the horizon, lawmakers admit they’re working behind the scenes this session to try to develop an Oklahoma-centric plan that would expand health insurance access for the state’s working poor.

But after nearly eight years of continued failure to develop a plan, some say lawmakers’ time to act may be running out as voters’ patience runs thin, health care outcomes worsen and rural hospitals collapse.

There’s a strong sense that if the Legislature continues to buck calls to expand insurance coverage to the working poor, a group of health care providers, civic foundations and business organizations may try to bypass the Legislature entirely, said David Blatt, executive director of the liberal-leaning Oklahoma Policy Institute. He said supporters would circulate a Medicaid expansion petition asking voters to force the Legislature’s hand at the ballot box in 2020.

Such a maneuver is modeled after successful efforts in three other very conservative Republican-controlled states — Idaho, Nebraska and Utah — where voters last year forced their elected officials to expand Medicaid, he said.

“It has been a long, long wait,” Blatt said. “We’ve had eight years for this to happen, and the Legislature has been unable to get this done, so I think there will be a serious consideration of a ballot initiative.”

Blatt said lawmakers are cognizant that voters have forced their hands on other stalled issues — namely medical marijuana legalization and criminal justice reform. So the threat of Medicaid expansion ending up on the 2020 ballot is increasing pressure on the Republican-controlled Legislature to act.

‘Support is growing’

State Sen. Greg McCortney, R-Ada, said the threat of a ballot initiative should be ratcheting up pressure on his colleagues.

“I think more are looking at other states and seeing that there are some very red states, Utah in particular, that passed Medicaid expansion through the ballot,” he said. “As we deal with the fallout from the marijuana ballot initiative, I think we all agree we don’t want to expand Medicaid in that type of hodgepodge fashion.”

McCortney authored legislation that could have allowed Oklahoma to accept billions in federal health care dollars meant to help states expand health insurance access under the Affordable Care Act. But under his plan, state leaders would have asked the federal government to allow them to care for the state’s Medicaid population in a different way than what the Obama-era policymakers envisioned.

The measure would have created a premium assistance program for households whose income falls below 138 percent of the poverty line. Individuals would receive private health insurance that would primarily be subsidized with federal dollars. Able-bodied participants would be required to work and pay up to 5 percent of their premium, he said.

Under the plan, more than 200,000 uninsured Oklahomans would have been eligible for insurance and about $1.2 billion in federal health care dollars would flow into the state, supporters said. Oklahoma would be responsible for paying a 10 percent match — about $140 million.

The measure stalled in the Senate, though McCortney said he’s hopeful it could be resurrected during the budgeting process later in the session.

“I feel like support is growing, especially as we get more of those details hammered out,” he said. “I think the plan is coming together, and I think it’s a plan that a lot of people can support.”

‘Not quite ready

for prime time’

State Sen. Roger Thompson, R-Okemah, who serves as appropriations chair, said he remains interested in moving something forward, but McCortney’s measure, Senate Bill 605, “was not quite ready for prime time.”

Still, he said he’s not influenced by the threat of a ballot initiative.

“I don’t make any judgments based on what somebody else may do,” he said. “I’m just trying to do my job right.”

Patti Davis, president of the Oklahoma Hospital Association, said Oklahoma ranks second, behind Texas, in the number of uninsured.

Clearly, the No. 1 priority for members is decreasing the number of uninsured, and her group continues to be involved in legislative discussions to increase insurance access, Davis said.

“We all pay for that care currently through cost-shifting,” she said.

Her group is also involved in conversations about a potential ballot initiative.

“Clearly, we know that people care about what happens to rural health care, so we certainly think it’s worth looking at,” she said.

Since 2016, five rural Oklahoma hospitals have closed.

State Rep. David Perryman, D-Chickasha, said he doesn’t anticipate a solution until voters force lawmakers to act.

“We just can’t get people to come around and realize the economic benefits and health benefits,” he said. “It’s very frustrating. That’s probably … the greatest detriment that this political rhetoric at the Capitol is having on the state of Oklahoma. It makes no sense whatsoever to leave federal funds on the table.”

Perryman said over the years, ideas similar to McCortney’s have gone nowhere. Meanwhile, he said health outcomes are declining, and rural hospitals are providing an increasing amount of uncompensated care for uninsured, poor Oklahomans. Those patients work but can’t afford insurance, and their employer doesn’t offer it.

“I think because of the rhetoric every time one those comes forth, every time there’s an idea that’s potentially workable for uninsured, working Oklahomans, it’s knocked down by conservative think tanks and the political rhetoric,” Perryman said. “Until Oklahomans step up, maybe a state question or voters wake up and push their elected officials to do what’s necessary, we’re not going to have a solution.”

Janelle Stecklein covers the Oklahoma Statehouse for CNHI’s newspapers and websites. Reach her at jstecklein@cnhi.com.