A tale of two Medicaid expansions: Oklahoma jumps in, while Missouri lags

Reviewed by Emily Henderson, B.Sc.Dec 3 2021

Temp worker James Dickerson applied for Medicaid because it will be cheaper than his current health plan. Home health aide Sharon Coleman looks forward to having coverage that will cover a hospital stay. Incoming medical student Danielle Gaddis no longer worries a trip to the doctor will leave her in debt.

All three are among the roughly 490,000 people newly eligible for Medicaid after Oklahoma and Missouri voters in 2020 approved expanding the federal-state public health insurance program for people with low incomes. In both states, people who earn up to 138% of the federal poverty level — about $18,000 per year for an individual — can now get the free coverage even if they don't have disabilities.

But the experience of the newly eligible in those two states — an estimated 215,000 people in Oklahoma and 275,000 in Missouri — has differed dramatically. Oklahoma has enrolled over 210,000 people, while Missouri has enrolled fewer than 20,000.

The difference comes down to the approaches taken by the two states, both of which are Republican-led and resisted expanding Medicaid for years.

Once Oklahoma voters approved the expansion, it was quickly embraced: The legislature appropriated $164 million in the state budget to fund it. Applications opened this June, one month before the program began, and within a month, 113,000 people had been approved.

In August, Oklahoma Secretary of Health and Mental Health Kevin Corbett told state lawmakers about one of those enrollees: a 62-year-old woman able to schedule appointments with a doctor and dentist for the first time in 20 years.

"Truly life-changing," Corbett said. "We feel very good about what we're being able to do."

Other states that expanded Medicaid in recent years saw enrollment swell in the first month. Louisiana's combined Medicaid and Children's Health Insurance Program rolls grew by over 255,000; Virginia's increased by almost 184,000; Idaho added about 45,500 enrollees, roughly half of the anticipated number of newly eligible people; and Montana added over 23,000, 51% of its expected total. Missouri, on the other hand, has enrolled only about 7% of newly eligible people in Medicaid.

"You can expand Medicaid on the books, but there are a lot of ways that you can throw up barriers to keep people from getting enrolled," said Sidney Watson, director of the Center for Health Law Studies at Saint Louis University.

Expansion has been a slog in Missouri. The legislature refused to fund the voter-approved program, prompting Republican Gov. Mike Parson to announce in May that the state would "withdraw" its expansion plan. Then, in August, a judge ordered the state to start accepting applications, which it did. But Missouri could not begin processing them until Oct. 1.

That whiplash means many newly qualified Missourians are likely unaware they could be covered by Medicaid, according to University of Missouri-Kansas City law professor Ann Marie Marciarille.

Marciarille said that the state has a responsibility to get the word out about the program and that Missouri has done little more than what was legally required by the August court order. The critique has been echoed by others.

Heather Dolce, a spokesperson for the Missouri Department of Social Services, which oversees Medicaid, said the department had publicized the Medicaid expansion by updating its website, emailing participants in its family support programs and posting on social media. The department's Facebook and Twitter accounts show a handful of posts about the expansion, including two tweets posted the day after the publication of a KCUR article that noted the state's outreach efforts had been slow.

Oklahoma's efforts, meanwhile, included outreach events, TV interviews, plus a video and social media campaign.

In Missouri, without robust advertising by the state, much of the outreach has fallen to clinics like Affinia Healthcare in St. Louis. James Dickerson saw a flyer about the Medicaid expansion on the front door of an Affinia clinic when he went to see a doctor about an ear infection.

The 59-year-old, who works various jobs through a temp agency, was eager to sign up. He had a good experience with Medicaid in 2014 when he was covered while getting spinal surgery for a workplace injury.

At Affinia, Dickerson met with a certified application counselor, Sunni Johnson, who within about five minutes got all the information she needed to send in his application. Most clinics like this have specialists who can help patients enroll in health insurance and other assistance programs.

By federal law, Missouri is required to determine whether an applicant is eligible for the program within 45 days. But Michelle Davis Reed, the lead eligibility and enrollment coordinator at Northwest Health Services, based in St. Joseph, Missouri, said in November that some applications she had filed in August were still not processed.

Dolce said the state had 32,000 Medicaid applications pending as of Nov. 17. She did not respond directly to a question about the number of staffers processing the applications but said overtime was being used.

In Oklahoma, 144,000 of the 210,000 Medicaid expansion enrollees previously lacked insurance. The remainder were enrolled when the state evaluated whether people who had applied to other benefit programs were also now eligible for Medicaid.

One Missouri program that could be a candidate for such reprocessing is Gateway to Better Health, a temporary insurance program that Sharon Coleman uses in St. Louis. Gateway covers about 16,000 residents of the city of St. Louis and St. Louis County who earn up to 100% of the federal poverty level.

Angela Brown, CEO of the St. Louis Regional Health Commission, which administers Gateway, said she believes that at least 90% of its participants would qualify for Medicaid under expansion but that bureaucratic hurdles made encouraging patients to sign up for Medicaid directly simpler than the process necessary to move them into a new system. Gateway sent a text message to Coleman and other recipients urging them to apply.

After getting the alert, Coleman, 60, who provides in-home care to older adults, went to Affinia specifically to enroll in Medicaid. She has high blood pressure, but her health is otherwise good — she said she hasn't been to a hospital since her son was born 40 years ago. Coleman was relieved to know that if she had to go now, her bills would be covered by Medicaid. Gateway covers only primary, specialty and urgent care.

"I can go to the emergency room now and not worry about them sending me bills I can't pay," Coleman said after visiting with Johnson, the enrollment specialist.

In Oklahoma, 26-year-old Danielle Gaddis had been uninsured for two years. She was reluctant to see a doctor during that time, fearing the medical bills. So she was thankful to be enrolled in Oklahoma's Medicaid program when she got sick recently. Like Dickerson and Coleman, Gaddis applied for Medicaid with the help of a specialist at a health clinic, Mary Mahoney Memorial Health Center in Oklahoma City.

"Because of covid, a cold could be the end of the world, so you freak out," said Gaddis, who will start medical school in August after deferring for a year.

Gaddis said she's keeping the experience of being uninsured front of mind as she begins her medical training.

"No one should ever have to worry about, 'How long am I going to have to ride this out before I go to see what’s wrong?'" Gaddis said. "That’s how things get worse."