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Oklahoma’s Medicaid Expansion Continues to Shatter Enrollment and Spending Estimates—And the Worst Is Yet to Come

Key Findings

  • In 2020, Oklahoma took the ObamaCare bait and expanded Medicaid via ballot initiative.
  • Voters were misled by false and faulty estimates of total enrollment and cost.
  • Just three years after Medicaid expansion was implemented, SoonerCare enrollment continues to shatter those enrollment and spending estimates.
  • As the state Medicaid program grows, other budget priorities are crowded out.
The Bottom Line: The SoonerCare Program is still facing an enrollment and budget crisis.

Overview  

The Medicaid program was designed to provide a safety net for truly needy individuals—such as seniors, pregnant women, low-income children, and people with disabilities.1 But over time, and with the passage of the Affordable Care Act—more commonly known as ObamaCare—the program has shifted toward able-bodied adults.2

Under ObamaCare, states were given the option to radically change their Medicaid programs by expanding eligibility to a new class of individuals—able-bodied adults, most of whom do not have children and are not working.3-4 Unsurprisingly, states that have expanded Medicaid have experienced massive cost overruns driven by skyrocketing enrollment.5

Oklahoma shares a similar story with many states nationwide. Since expanding Medicaid in 2020, the state has seen enrollment overruns, increased costs, and a crowding out of other
budget priorities.6

Expansion enrollment is still outpacing projections

In 2020, after years of standing strong against the expansion of welfare, the Oklahoma legislature was circumvented as out-of-state groups funneled money into the state to pass Medicaid expansion through a ballot initiative.7 Similar tactics were used in 2018 when the state legalized medical marijuana.8 

Unfortunately, voters were given false promises and faulty information instead of facts.9-10 For example, the Centers for Medicare & Medicaid Services (CMS) projected that 190,000 able-bodied adults could be expected to enroll in Oklahoma’s Medicaid program if the state were to expand.11 The left-leaning Kaiser Family Foundation (KFF) also produced inaccurate estimates, claiming that 204,000 able-bodied adults could be expected to enroll.12 Based on the experiences of other states that had previously expanded, it was clear these estimates understated the expansion, but advocates continued to push for expansion relying on these artificially low projected figures.

The deficiency of those projections has become increasingly clear. In January 2024, there were 251,263 able-bodied adults enrolled in SoonerCare—nearly 24 percent of the state’s entire Medicaid population. Total expansion enrollment in Oklahoma is now 32 percent higher than CMS’s projections and 23 percent higher than KFF’s projections—just three years into expansion, which was implemented in June 2021.14-15

Even worse, as these able-bodied adults have jumped to the front of the line, the truly needy are suffering. In Oklahoma, there are more than 3,000 individuals with intellectual or developmental disabilities who are languishing on a waiting list and have been shoved to the back of the line.16

Medicaid expansion costs are soaring

For taxpayers, the news only gets worse. As the SoonerCare program has been flooded with able-bodied adults, the cost of Medicaid expansion has continued to rise. 

According to KFF, Oklahoma’s expansion should cost taxpayers around $1.1 billion annually—and carries a 10-year price tag of $10.8 billion.17-18 Similarly, the Oklahoma Hospital Association (OHA) estimated that expansion would cost the Sooner State nearly $8.5 billion over a five-year period—with annual costs increasing with each fiscal year.19

These projections have also proven to be inaccurate. According to CMS, actual expansion spending in Oklahoma was $1.5 billion in fiscal year 2022 and $2.7 billion in fiscal year 2023.20 Combined, that is $4.2 billion in expansion spending—in just two years.21

By KFF estimates, total expansion spending for this period should be just above $2 billion.22-23 Similarly, the OHA projected that expansion spending during this time would cost $3.6 billion.24 But unfortunately for taxpayers, actual expansion spending is 94 percent higher than KFF projections and 17 percent higher than OHA’s projections.25

SoonerCare is consuming the state budget

As Medicaid enrollment continues to soar in Oklahoma, so do the financial obligations required to keep the program operational. Unsurprisingly, SoonerCare’s growth has led to other budget priorities being crowded out.

In 2020, the year before expansion was implemented, the Medicaid program accounted for 22 percent of the total state budget—requiring nearly $6 billion in funding.26 But by 2023, the Medicaid program’s share of the budget ballooned to 34 percent of the total budget—a whopping 55 percent increase in less than two years of expansion being implemented—and spending soared to more than $8 billion.27

Meanwhile, education and transportation have seen their share of the budget dwindle. Both K-12 education and transportation’s share of the budget have decreased since expansion went into effect.28-29 And while total spending in these areas has increased during this time, their slice of the state budget is continuing to get smaller as there are fewer funds available.30

This highlights a concerning trend that has persisted for years. Over the last decade, Medicaid spending in Oklahoma has skyrocketed by 63 percent.31-32 Meanwhile, spending on elementary and secondary education has failed to keep pace with Medicaid, and transportation spending has essentially remained at a standstill.33

Despite the many claims and assurances made by expansion advocates, Oklahoma lawmakers knew the truth—when one program grows at a massive rate, other priorities will shrink.

Rather than prioritizing public education and building a robust infrastructure, lawmakers have been forced to expand welfare instead.

The Bottom Line: The SoonerCare Program is still facing an enrollment and budget crisis.

Despite objections from state lawmakers, out-of-state groups funneled money into the state to pass Medicaid expansion through a ballot initiative less than four years ago. Fast forward a few years and Oklahoma lawmakers have been proven right. The advocates and proponents of expansion used false and faulty information to make their case.

Today, state taxpayers and the truly needy are facing the consequences. SoonerCare expansion enrollment is far outpacing projections, and the Medicaid program is growing so rapidly that other priorities are seeing their share of the budget shrink. And as more able-bodied adults flood the state Medicaid program taxpayers are on the hook, and the truly needy are shoved to the back of the line.

  1. Centers for Medicare & Medicaid Services, “CMS’ program history,” U.S. Department of Health and Human Services (2021), https://www.cms.gov/About-CMS/Agency-Information/History#:~:text=Though%20Medicare%20and%20Medicaid%20started,affordable%20health%20care%20they%20need.
  2. Jonathan Bain, “How millions of Americans will be kicked off private insurance if the remaining states expand Medicaid,” Foundation for Government Accountability (2024), https://thefga.org/research/how-millions-americans-kicked-off-private-insurance.
  3. Medicaid and CHIP Payment Access Commission, “Overview of the Affordable Care Act and Medicaid,” Medicaid and CHIP Payment Access Commission (2023), https://www.macpac.gov/subtopic/overview-of-the-affordable-care-act-and-medicaid.
  4. Sam Adolphsen, “To help the truly needy, lawmakers should fix the welfare pit—Not the imaginary welfare ‘cliff,’” Foundation for Government Accountability (2023), https://thefga.org/research/lawmakers-should-fix-the-welfare-pit.
  5. Jonathan Bain, “How millions of Americans will be kicked off private insurance if the remaining states expand Medicaid,” Foundation for Government Accountability (2024), https://thefga.org/research/how-millions-americans-kicked-off-private-insurance.
  6. Jonathan Bain, “The Sooner State showdown: How able-bodied adults and ineligible enrollees have flooded Oklahoma’s Medicaid program,” Foundation for Government Accountability (2023), https://thefga.org/research/ineligible-enrollees-flooded-oklahomas-medicaid-program.
  7. Jackie Fortier, “Oklahoma votes for Medicaid expansion over objections of Republican state leaders,” National Public Radio (2020), https://www.npr.org/sections/health-shots/2020/07/01/886307241/oklahoma-votes-for-medicaid-expansion-over-objections-of-republican-state-leader.
  8. Oklahoma Medical Marijuana Authority, “About OMMA,” Oklahoma Medical Marijuana Authority (2024), https://oklahoma.gov/omma/about/about-omma.html#:~:text=Oklahoma%20voters%20authorized%20the%20state’s,passed%20by%20the%20Oklahoma%20Legislature.
  9. Jackie Fortier, “Oklahoma votes for Medicaid expansion over objections of Republican state leaders,” National Public Radio (2020), https://www.npr.org/sections/health-shots/2020/07/01/886307241/oklahoma-votes-for-medicaid-expansion-over-objections-of-republican-state-leader.
  10. Jonathan Bain, “The Sooner State showdown: How able-bodied adults and ineligible enrollees have flooded Oklahoma’s Medicaid program,” Foundation for Government Accountability (2023), https://thefga.org/research/ineligible-enrollees-flooded-oklahomas-medicaid-program.
  11. Centers for Medicare & Medicaid Services, “Oklahoma’s Medicaid expansion will provide access to coverage for 190,000 Oklahomans,” U.S. Department of Health & Human Services (2021), https://www.cms.gov/newsroom/press-releases/oklahomas-medicaid-expansion-will-provide-access-coverage-190000-oklahomans.
  12. John Holahan et al., “The cost and coverage implications of the ACA Medicaid expansion: National and state-by-state analysis,” Kaiser Family Foundation (2012), https://www.kff.org/wp-content/uploads/2013/01/8384.pdf.
  13. Oklahoma Health Care Authority, “SoonerCare fast facts January 2024,” Oklahoma Health Care Authority (2024), https://oklahoma.gov/content/dam/ok/en/okhca/docs/research/data-and-reports/fast-facts/2024/february/Total%20Enrollment01_24.pdf.
  14. Author’s calculations based on actual SoonerCare expansion enrollment as compared to projections from CMS and KFF.
  15. Oklahoma Health Care Authority, “Medicaid expansion,” Oklahoma.gov (2023), https://oklahoma.gov/ohca/about/medicaid-expansion/expansion.html.
  16. Kaiser Family Foundation, “Medicaid HCBS waiver waiting list enrollment, by target population and whether states screen for eligibility,” Kaiser Family Foundation (2023), https://www.kff.org/medicaid/state-indicator/medicaid-hcbs-waiver-waiting-list-enrollment-by-target-population-and-whether-states-screen-for-eligibility/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
  17. John Holahan et al., “The cost and coverage implications of the ACA Medicaid expansion: National and state-by-state analysis,” Kaiser Family Foundation (2012), https://www.kff.org/wp-content/uploads/2013/01/8384.pdf.
  18. Nic Horton and Jonathan Ingram, “How the ObamaCare dependency crisis could get even worse—And how to stop it,” Foundation for Government Accountability (2018), https://thefga.org/research/obamacare-dependency-crisis-get-even-worse-stop.
  19. Ann K. Peton et al., “The economic benefits of state question 802 (2020-2024),” Oklahoma Hospital Association (2020), https://www.okoha.com/Images/OHADocs/Advocacy/State/2020%20Legislative%20Session/2020%20Oklahoma%20Economic%20Impact%20report%20-%20statewide%20for%20web.pdf.
  20. Author’s calculations based on expenditures provided by CMS in quarterly expenditure reports that range from FY22 through FY23.
  21. Ibid.
  22. John Holahan et al., “The cost and coverage implications of the ACA Medicaid expansion: National and state-by-state analysis,” Kaiser Family Foundation (2012), https://www.kff.org/wp-content/uploads/2013/01/8384.pdf.
  23. Nic Horton and Jonathan Ingram, “How the ObamaCare dependency crisis could get even worse—And how to stop it,” Foundation for Government Accountability (2018), https://thefga.org/research/obamacare-dependency-crisis-get-even-worse-stop.
  24. Ann K. Peton et al., “The economic benefits of state question 802 (2020-2024),” Oklahoma Hospital Association (2020), https://www.okoha.com/Images/OHADocs/Advocacy/State/2020%20Legislative%20Session/2020%20Oklahoma%20Economic%20Impact%20report%20-%20statewide%20for%20web.pdf.
  25. Author’s calculations based on expenditure data provided by CMS as compared to projections provided by KFF and OHA.
  26. Brian Sigritz et al., “2020 state expenditure report,” National Association of State Budget Officers (2020), https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b750-0fca152d64c2/UploadedImages/SER%20Archive/2020_State_Expenditure_Report_S.pdf.
  27. Brian Sigritz et al., “2023 state expenditure report,” National Association of State Budget Officers (2023), https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b750-0fca152d64c2/UploadedImages/SER%20Archive/2023_State_Expenditure_Report-S.pdf.
  28. Brian Sigritz et al., “2020 state expenditure report,” National Association of State Budget Officers (2020), https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b750-0fca152d64c2/UploadedImages/SER%20Archive/2020_State_Expenditure_Report_S.pdf.
  29. Brian Sigritz et al., “2023 state expenditure report,” National Association of State Budget Officers (2023), https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b750-0fca152d64c2/UploadedImages/SER%20Archive/2023_State_Expenditure_Report-S.pdf.
  30. Ibid.
  31. Brian Sigritz et al., “2013 state expenditure report,” National Association of State Budget Officers (2014), https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b750-0fca152d64c2/UploadedImages/SER%20Archive/State%20Expenditure%20Report%20Fiscal%202012%202014%20S.pdf.
  32. Brian Sigritz et al., “2023 state expenditure report,” National Association of State Budget Officers (2023), https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b750-0fca152d64c2/UploadedImages/SER%20Archive/2023_State_Expenditure_Report-S.pdf.
  33. Ibid.
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