Sooner, not later, Medicaid Expansion is upon us

Baseball legend Yogi Berra, whose simplistic nostrums masked an underlying wisdom about things, was describing the shortest route to his house when he told a reporter, “When you come to a fork in the road, take it.”
On an important matter, Oklahoma has to decide which fork in the road to take.
Whether it’s called managed care or co-ordained care, the process Oklahoma Governor Kevin Stitt wants to pursue for Medicaid Expansion is a conservative path.
It is not a perfect conservative path, but as a noted policy analyst puts it, the “least-worst” option for the array of issues resulting from last summer’s narrow voter approval for Medicaid Expansion.
Rather than reinventing the wheel, Stitt is building on models that have worked “good enough, on time” in many states. But coincidentally, those models allow for at least some regular incorporation of lessons learned from actual experience, rather than the dictates of alternative-reality liberalism.

Already a pivotal player in state policy debates, over this past week Jonathan Small, president of the Oklahoma Council of Public Affairs, immersed himself even more deeply into the Managed Care fray, in defense of the Stitt approach.

In an alert to OCPA supporters, Small commented, “Efforts are underway to block Governor Kevin Stitt’s plan to reform Oklahoma’s Medicaid program and help manage the rising costs of the medical welfare program. A handful of members in the Oklahoma House of Representatives, as well as a number of special interest groups, are working to stop Gov. Stitt from implementing ‘managed care’ for Oklahoma’s Medicaid program.”

During a Zoom meeting this week, Small pointed out that the powerful status quo in Oklahoma health care – you know, “non-profit” hospitals and their allies – spent an astounding $7 million on last year’s ballot initiative to compel Medicaid Expansion.
Advocates of the status quo state health care program, as Small said in that session, want to implement a new welfare program with, however, real controls over the cost-escalations that are expected. They assert that adding over 100,000 more recipients to expand an existing welfare program will flow smoothly without creating undue budget pressures or human stress.
Having expanded a welfare program (Medicaid) without a financing source for the state’s share of growth, they assail anyone who offer that “least-worst” option Oklahomans now have:
That is, take the fork in the road to establish the best possible plan.

With this ‘least-worst’ path, as Small said this week, the governor and his allies are trying to avoid the nightmare of a ‘worst’ path – the soaring and out-of-control costs now unfolding in Arkansas.
This sensible Oklahoma-based plan is based on practices in 40 of the 50 American states – models trying to improve health and bring sensible restraint on rising costs.
As for those rising costs, from 1999 to 2019, the system’s expenditures increased (in inflation-adjusted dollars) from $2.3 billion-plus to $5.6 billion-plus – and that’s before the imminent voter-mandated expansion. (See chart above.)

State officials believe the expansion itself will cost taxpayers an additional $164 million to $246 million every year. But wait, that’s not all:
The state House of Representatives’ plan embodies Senate Bill 131 (crafted by Rep. Marcus McEntire, R-Duncan) for an in-house managed care plan would cost $263-277 million, according to a legislative staff projection, and add 1,200 more government employees, to boot.
The McEntire path will take years to implement, whereas Stitt’s path will be ready for implementation – on time.

No doubt, some employees of the Oklahoma Health Care Authority (OHCA) – responsible for management of SoonerCare and the new “SoonerSelect” expansion – desire that projected surge in state government employee numbers.
But OHCA’s management, those at the agency who are on the governor’s team, envision a path built on the operating models in the aforementioned majority of the states.
The OHCA narrative points out, “There are clear approaches to transition from Medicaid Fee-for-Service (FFS) supplemental payments to ‘directed payments’ under Medicaid Managed Care (MMC) that have been approved by CMS (Centers for Medicare and Medicaid Services) in other states to preserve supplemental payments in a managed care model.”

The healthcare Feds (those who in any case must approve a managed care structure) are familiar with what the governor wants to do. For policy reasons and because of the 2020 voter mandate, the state must move forward – and it must do so this summer and fall.
One newspaper editorial of recent days suggested the state should wait, let things play out for a year or two, and then decide whether or not Managed Care is truly needed. But in truth, another old saying applies: This is one of those moments when those who hesitate will be lost.

In an OHCA compilation of frequently asked questions, the point is well-stated:
“Oklahoma ranks near the bottom on virtually every indicator of health outcomes. Among the measures in which Oklahoma is in the bottom tier of states include infant mortality, immunization rates, suicide, cancer deaths, smoking, obesity and cardiovascular deaths. The current Medicaid program is not working to improve the health of Oklahomans. It’s time to try a different approach. Managed care organizations will work with their members to improve outcomes and will be incentivized and held accountable for improving the health of their members.”
The thing about government contracts with Managed Care Organizations (MCOs) is that the feds do allow incentives for MCOs – linking contract renewals to explicit guidance to managers, seeking ways at least to flatten the curve of accelerating costs and improve health outcomes.
It’s reasonable to ask why a Republican governor faces so many legislators who profess conservatism but have formed a tight alliance with non-conservatives.
Perhaps it’s not surprising that a businessman new to the Capitol precincts is having trouble with the permanent political class. 

What Stitt faces is not healthy bipartisanship, it’s a truth that dare not speak its name:
Too many legislative Republicans have abandoned the conservatism of hard choices and embraced the faux conservatism of convenience. These personalities won’t be around to deal with the ‘out years’ impact of untrammeled growth in Medicaid costs, but many want to be around to benefit from the short-term benefits of bashing the governor and insurance companies.

It is easier for some in Oklahoma’s political class to ally themselves with those who deride Stitt’s approach as a “health care holdup.”
One wonders if they are blind to the real theft which will come over the next half-decade — when money required for Medicaid could compel cuts in other areas of desired government spending(schools, safety, roads and bridges, etc.).

When that reality bites, the Legislature can “hold hearings and decry problems,” as the late M. Stanton Evans, a legendary conservative journalist, used to remark about the U.S. Congress. To the detriment of us all, the divisiveness and lack of long-term thinking under the dome at N.E. 23 and Lincoln in Oklahoma City looks more and more like Washington, D.C. every day.

The back-and-forth on many important issues is both interesting and vital at this moment in state history.
Medicaid Expansion is going to happen, and Managed Care is the best path forward.

Still, policy analysis aside, sometimes it’s good fortune to come across a common person (man or woman) with common sense to help distill into everyday terms an issue like this.
One Southwest Oklahoma citizen-philosopher remarked to this reporter, “Do you have health insurance through your employer or yourself? If so, you have managed care, someone who stands between your doctor and an unfettered amount of money. Perhaps we all need more ‘managed care’? 
We spend 17.7 percent of our GDP on health care yet we are 35th healthiest. … 
“Oklahoma is 12th in the country for diabetes. More and more of us are spending more on healthcare than we pay in. I say this as an overweight, fat guy with kidney issues who continues to drink soda and tea. Shouldn’t smokers pay more? Shouldn’t people who don’t manage their healthcare pay more?”
Another way to say it: Shouldn’t those who pay the bills (taxpayers) be able to nudge beneficiaries toward better behavior?

And, not forgetting the related “big picture” of public policy, shouldn’t a chief executive be able to behave like an executive?
Stitt’s approach is the best possible.

Millions and Millions have become Billions and Billions.
It’s real money, and this is the real world.
Managed. Care. Now. Each of those words is important.

NOTE: This analysis first appeared in The Southwest Ledger, May 13, 2021 print edition.