COMMENTARY: Public opinion on Medicaid expansion, the Augean Stables, and a better future

OKLAHOMA CITY — When Oklahoma’s Republican leaders first announced opposition to Medicaid expansion and other controversial mandates in the Affordable Care Act (ACA) in 2011, I was sitting with a venerable liberal journalist.

We rarely agree but often have discussed issues amicably. He flatly predicted the GOP stalwarts would “eat their words” once average Oklahomans really understood what was in the law. 

Even now — years after the law was strong-armed into effect, a year after the Supreme Court sort of upheld it while allowing states more flexibility than the actual text of the law granted, and in wake of the most recent U.S. House “repeals” of the law — proponents of the ACA still caution pundits like me: “Just you wait and see.”

In competing analyses of what is widely deemed “ObamaCare” – even by many of its fans – there is a contingent where hope truly springs eternal. Many still believe the legislation’s mandate for dramatic expansion of Medicaid coverage will somehow, at the eleventh or even the twelfth hour, capture the popular imagination.  

Only trouble is, gee whiz: Across the nation, widespread doubts about every aspect of the bill have intensified. 

A new survey for the Liberty Foundation of America finds an absolute majority of Oklahomans believe Medicaid abuses should be fixed before expansion. Even larger numbers are fearful that Medicaid expansion can only be financed at the cost of other important programs.

I know, I know: sometimes we need a study to document that common people are capable of common sense. 

Specifically, 54 percent believe “Medicaid should not be expanded until the waste, fraud and abuse in the program is cleaned up.” (Further, 69 percent of conservatives and 89 percent of Republicans believe this.)

A similar chunk of likely voters find this argument convincing: Because we cannot count on the federal government to sustain expansion, Oklahoman’s will ultimately have to foot the entire bill. (NOTE: This argument was persuasive to 80 percent of Republican voters surveyed. … And, 20 percent of liberal voters find the “feds will fail” argument very convincing. Another 24 percent find it somewhat convincing.)

The beat goes on: 59 percent of likely voters find convincing the widespread concerns that expansion would leave less money for education, public service and environmental protection. (Yup: That was the view of 76 percent of the GOP’s members surveyed. Get the trend?)

That’s not all: Fully 70 percent of all those surveyed agree with this statement: “Because there is so much disagreement among experts on the costs of expanding Medicaid, we shouldn’t rush into any expansion until we have a better handle on the financial consequences.” (That was persuasive to 87 percent of the GOP voters.)

* * * 

It’s been a big week for Medicaid news in Oklahoma. In the Tenth U.S. Circuit Court of Appeals, Hobby Lobby, the Oklahoma City-based retailer, won at the least a right to keep fighting against the insurance mandates the owners oppose on religious grounds. In a separate case, Attorney General Scott Pruitt continues his push against what our state’s legal team considers the illegal taxing/borrowing schemes in “ObamaCare.”

And, a Leavitt Partners analysis for the independent Oklahoma Health Care Authority on Thursday (June 27) recommended Medicaid expansion … without calling it expansion.   

Jonathan Small, fiscal policy analyst for the Oklahoma Council of Public Affairs (OCPA), commented, “The goals of the Leavitt Partners report effort are noble. But unfortunately taxpayers were forced to pay for a report that recommends Obamacare’s costly Medicaid expansion, and the report ignores the chief problem in health care, which is costs and lack of transparency for consumers.”

Particularly in light of the Leavitt release, I found interesting the highlights discerned from a few hours examining the new Liberty Foundation survey. It shows ambivalence about ObamaCare, in general, and hostility to some of its provisions, particular.

Simply put, frequently heard arguments against Medicaid expansion have become embedded in the minds of Oklahomans.

* * * 

The Liberty survey from Magellan Strategies of Louisville, Colorado, found that a plurality of likely voters believe Medicaid is a flawed program (47 percent), with only 44 percent believing it is a good program. 

How can it make sense to expand any program when there is such deep division among those who pay the bills – the taxpayers? 

When asked directly about Medicaid expansion to all uninsured state residents with household incomes up to 138 percent of the current federal poverty level, 46 percent of Oklahomans are opposed, with only 42 percent in favor. 

Passionate supporters of the ACA tend to be liberal Democrats, while passionate foes tend to be conservative Republicans. And, in Oklahoma, there are more of the latter.

Passion and commitment can mean a lot, in life as in politics, or even in ancient mythology. 

When I studied the classics, one of my favorite stories was that of Hercules and his adventures. Once upon a time, he accepted a kind of “Mission Impossible” – to clean out the mammoth stables of King Augeus. It was a dirty and smelly job, but Hercules did it. (The king betrayed him, but that’s the start of another story.) 

Here’s a caution for politicians of all stripes: Oklahoma voters don’t seem too intimidated over the idea of cleaning out the stables. Therefore, pay careful attention to what they believe, passionately, on Medicaid, ObamaCare and related matters. 

Magellan Strategies asked respondents, “Do you think that your legislators, your members of the Oklahoma state House and Senate, deserve to be reelected or do you think it is time to give some new people a chance to do a better job?” 

More than half – 52 percent – replied it was time to give a chance to “new people.” (Of those surveyed, one-third of Republicans, the party now in power, want to clean out the Capitol’s Augean stables, while 69 percent of Democrats want to do so.)

For the entire electorate, only 30 percent have a presumption in favor of reelecting the current bunch at 23rd and Lincoln in Oklahoma City. 

Turning away from stable analogies, it is not credible to say Oklahomans in general, or even politicians in particular, don’t care about the population of people served by Medicaid.

To the contrary, the Sooner State presently spends $1.6 billion a year on Medicaid. About 90 percent of the cost of expansion, as envisioned in the ACA, would be covered with federal deficit spending. However, that still would leave an additional $689 million in state spending over the next decade. 

To be clear, there are alternatives to the “pure” ObamaCare template for expansion. Florida is experimenting with regional programs of managed care; Arkansas has taken an alternative with more market discipline than found in the federal bill. 

Both those programs have gained approval from Obama administration operatives, but that’s not the case with the Sooner State’s own program of premium support funded by tobacco taxes, Insure Oklahoma (practical support for the working poor). The latter program was created in a statewide referendum.  

Any of these three approaches would be better than the financial Armageddon that unbridled Medicaid expansion will bring upon our nation – and upon the very population purportedly intended for assistance.  

The Liberty survey’s population was representative of Oklahomans, at least those who are likely voters. A little less than half (48 percent) of those surveyed identified as conservatives, with 34 percent moderate and 12 percent liberal. 

The 865 interviews for the survey took place in May 2013 and utilized automated touch-tone technology. The margin of error falls in the range of 3.3 percent. Of those surveyed, 85 percent say they are likely to vote in the November 2014 general election.

Soon, policy analysts will be sharing the polling data with government officials. They plan to dig into the meat and potatoes of the survey in the balance of the summer. 

Ronald Reagan used to say his campaigns did not conduct polls in order to decide what to believe, but to study how to approach discussion with voters, including those in the middle. Were he with us still, Reagan would be smiling because to some extent, as they seek a better way to fashion health care policy, conservatives are preaching to the choir.

The Magellan Strategies survey makes it brutally clear Oklahomans are already consumed with doubts about the wisdom and sustainability of Barack Obama’s most significant domestic policy achievement.

That is the truth, not a myth. 

Oklahoma’s political leaders can safely assume they have room to maneuver, to find state-based, market-oriented common sense solutions to the challenges of health care policy in the Twenty-First Century. 

NOTE: This is adapted from an analysis that first appeared nationally at the website, and which is forthcoming in Perspective Magazine, OCPA’s monthly magazine. 

You may contact Patrick B. McGuigan at and follow us on Twitter: @capitolbeatok.