A campaign cobbled together on a tight deadline required by Oklahoma’s strict referendum law, battled and won a narrow victory last Tuesday to amend the state’s constitution and mandate the expansion of Medicaid, overcoming the opposition of a Republican governor and legislature and major out-of-state funding for the opposition.

By a narrow but victorious margin of 50.48% to 49.52%, Oklahoma voters said they wanted their state to join the federal Medicare expansion program that was an integral part of the Obama administration’s Affordable Care Act (ACA), popularly known as Obamacare. With passage of the referendum, only 13 states, all of them Republican and located in the nation’s Southeast and Midwest, continue to refuse to expand Medicaid eligibility for their residents.

In conceding defeat, Oklahoma’s Republican Gov. Kevin Stitt announced that the government would act to implement the expansion, which will extend Medicaid coverage to an estimated 200,000 additional Oklahomans by raising the income eligibility cutoff from the current federal poverty level of $12,490 for an individual and $25,750 for a family of four to 138% of the federal poverty level, which would be $17,236 for individuals and $35,535 for a four-member family. 

Amber England, who headed the Yes on 802 campaign, told Tarbell, “Oklahomans had the courage to stand up and do what the government has been afraid to do for over a decade.” 


Executive Director of the Yes on 802 campaign, Amber England, addresses supporters of Oklahoma’s Medicaid expansion in October.

England said that the passage of the referendum measure, besides extending Medicare coverage to many people, will also save struggling rural hospitals. This is because many poor but uninsured residents of the state who until now didn’t before qualify for Medicaid but also didn’t have the money to buy even subsidized private insurance under the ACA, were having to get themselves admitted as non-paying charity patients either at local smaller hospitals or at the ER rooms of large urban hospitals that could be 50 or more miles away. Now these patients will be able to go to local hospitals and have their care funded by Medicaid.

Much of the Republican opposition in many Red states across the country to the expansion program option has been ideological. Republican members of Congress from these states had long opposed Obama’s ACA plan, and opposing Medicaid expansion was a part of that. Republican officials in Oklahoma and the other 13 states that are still denying the expanded program to their struggling residents have insisted the problem is financial, not ideological.  Under the federal expansion provisions, Washington covers 90 percent of the cost of expanding coverage, but these Republican state officials point out that their states still have to fund the other 10 percent.

But as England points out, while it’s true the state has to cover that 10 percent share of the cost of expansion, when people who could qualify for expanded Medicaid are denied that option, and cannot effort the out-of-pocket cost of seeing doctors when family members get sick, many end up getting sicker (this is particularly true during the current Covid-19 pandemic).  If, as often happens, they end up going to a hospital ER, and get taken in as charity patients, “Those costs get passed on to all insured people in the form of higher insurance premiums.”  As well, hospitals can end up being reimbursed by the states, which have to cover the deficits faced by hospitals for their charity care, lest they go bust. 

Meanwhile, England points out, without Medicaid expansion people are getting sick when they shouldn’t be because without insurance they can’t get timely care from a doctor.

England charges that Gov. Stitt’s threat made during the referendum campaign, and even following the referendum’s passage — that having a Constitutional mandate to expand Medicaid means that other state budget lines will have to be cut to make up for the state contribution to the costs of the program — is actually bogus. In reality, a number of states that have gradually overcome conservative state government opposition and adopted Medicaid expansion programs, have found themselves with a net gain in revenues because the expanded program. This is because the 90% federal funding share also funds added coverage for many disabled people, indigent veterans, and non-working parents whose costs of care had been falling on state governments before expansion. Florida, for example, reports seeing annual savings of $100  million with the expansion of Medicaid, while Ohio is projecting a gain of $1.9 billion through 2022 from its expansion of Medicaid.

“without Medicaid expansion people are getting sick when they shouldn’t be because without insurance they can’t get timely care from a doctor.”

To win this referendum, the Yes on 802 campaign, which England said will have raised and spent about $5.5 million when all is said and done, was up against a “No” campaign lavishly funded by both the Oklahoma Council for Public Affairs (a Koch Brothers operation according to England), and the national conservative organization Americans for Prosperity. After first working to obtain the required signatures from every county in the state in order to get the referendum on the ballot, Yes on 802 had only 70 days in which to campaign.

The Koch brothers, Charles (r) and the late David, control Koch Industries the second-largest privately-owned company in the United States. They have built a political network of Libertarian-Conservative donors and the brothers funneled financial revenue into television and multi-media advertising.

According to national news reports, the bulk of the yes votes for the referendum came from urban areas, with rural areas largely voting no. But England disputes this analysis, countering, “The Yes votes came from every county in the state. Expanding Medicaid was popular in every part of Oklahoma.”

This should not be surprising. Rural poverty is widespread in Oklahoma and the rest of the country, and especially now with unemployment running in double digits reminiscent of Great Depression (when many Sooners had their property confiscated by the banks and ended up driven out of the state in desperate search of work). Reliance on Medicaid is quite high in rural areas across the country, and Oklahoma, where 20% of the state’s four million residents were receiving Medicaid coverage even before the recession hit, is no exception.

The number of people in Oklahoma currently on Medicaid is 800,000, and expansion is predicted to increase this by another 200,000 people, raising total enrollment to 25% of the population. The continued recession could raise that number even further, especially if Congress lets the supplemental unemployment benefits program expire at the end of July.

“We ran a grassroots movement across the state,” says England, “because we knew that we were likely to have to fight to get the expansion implemented, even after we won.”

An advantage is that because the advocates in this case opted to use a referendum to put Medicaid expansion in the state constitution, it will be much harder for the Governor and the Republican-dominated Legislature to avoid compliance than if expansion had just been a legislative act.