Health Care

As Medicaid expansion supporters cite poor results, lawmakers weigh reforms

April 15, 2026

Ray Carter

When voters were asked to expand Oklahoma’s Medicaid program to provide taxpayer-funded benefits to able-bodied adults, advocates promised the expansion would dramatically improve health outcomes and hospital finances.

But after five years of expansion and billions of dollars in increased taxpayer spending, supporters are tacitly conceding, repeatedly, that Medicaid expansion has failed to deliver on those promises.

Even so, supporters continue to insist expansion should be maintained despite skyrocketing costs—based apparently on an ideological commitment to big-government solutions rather than real-world results.

This year, the Oklahoma Health Care Authority, which administers Medicaid, requested nearly half a billion dollars in increased funding, in part to cover Medicaid expansion’s runaway costs. This year’s budget agreement provides $250 million in additional Medicaid funding to cover part of that cost, and lawmakers had to draw down state savings to make that happen. Otherwise, a legislative leader has noted, the costs of Medicaid expansion would have prevented a teacher pay raise and funding for reading initiatives.

To control costs in the future, lawmakers may send a state question to Oklahoma voters that would allow the state to modify the program for able-bodied individuals added through expansion.

House Bill 4440, by House Speaker Kyle Hilbert and Senate President Pro Tempore Lonnie Paxton, would allow Oklahoma voters to remove the current ban on imposing work requirements or other eligibility standards for able-bodied adults added to Medicaid through expansion.

“The 90-year-old that is in a wheelchair that is blind gets treated exactly the same by Medicaid as the 25-year-old who is able-bodied and can work, just chooses not to,” said Paxton, R-Tuttle. “This allows that to come out of the constitution and simply let us have the management authority over the way Medicaid would work in Oklahoma.”

Medicaid-expansion supporters oppose allowing voters to consider that proposal, even though opponents have repeatedly conceded during their public comments that Medicaid expansion has not delivered meaningful results.

One expansion supporter, state Sen. Carri Hicks, D-Oklahoma City, noted that Oklahoma has “some of the worst health outcomes in the nation: high rates of chronic disease, maternal mortality, and preventable death” five years into Medicaid expansion.

She also declared, “Our rural hospitals are hanging on by a thread. Many are operating in the red.”

When HB 4440 was debated in the Oklahoma House of Representatives in March, House Democratic Leader Cyndi Munson of Oklahoma City also tacitly conceded that the program had failed to produce the results promised by advocates in 2020.

“We continue to be in a health-care crisis,” Munson said. “We still always rank somewhere between 47th and 48th in the nation for health care.”

The Commonwealth Fund’s “2025 Scorecard on State Health System Performance” report showed that multiple health outcomes in Oklahoma were worse after Medicaid expansion than before, and that Oklahoma’s outcomes were worse than outcomes in states that did not expand Medicaid.

Similarly, officials with the Oklahoma Hospital Association told lawmakers during an October 2025 legislative study that profit margins at Oklahoma’s rural hospitals are weak, ranking 35th out of the 50 states, while rural hospitals in Texas rank 11th-best nationally in total margin.

Notably, Texas has not expanded its Medicaid program to include able-bodied adults, unlike Oklahoma.

Oklahoma Hospital Association officials also told lawmakers that 53 percent of rural Oklahoma hospitals were at medium-to-high risk of closure in 2023, the most recent data available, despite the promises made when Medicaid was expanded.

Several reports have found hospitals in Oklahoma are on a more precarious financial footing today than prior to Medicaid expansion—and that Medicaid expansion is a major factor in those poor finances.

At a September 2019 legislative hearing, Jay Johnson, president and CEO of Duncan Regional Hospital, conceded that Medicaid fuels financial challenges at Oklahoma hospitals even as he advocated for Medicaid expansion.

“On every government payer, we don’t make a profit,” Johnson said. “At our hospital, whether we’re taking a Medicare or Medicaid patient, our expenses are greater than what we will get paid.”

A 2024 study from the Foundation for Government Accountability (FGA) reviewed the federal filings of more than 4,000 hospitals nationwide. In 2013, the final year before Medicaid expansion was implemented under the federal Affordable Care Act (“Obamacare”), the FGA report showed that hospitals in states that embraced expansion reported just over $10 billion in losses due to Medicaid. By 2021, those Medicaid losses had ballooned to $22.3 billion, an increase of 115 percent.

In contrast, hospitals in non-expansion states saw their Medicaid shortfalls increase by only 6 percent.

In addition to allowing the imposition of work requirements for able-bodied individuals in the Medicaid program, HB 4440 would also allow voters to remove Medicaid expansion from the Oklahoma Constitution and place it in state statutes if the federal Medicaid match for the expansion population is reduced from the current split of 90 percent federal funds to 10 percent state funds. Federal officials have repeatedly proposed changing the federal-state match for those in the Medicaid-expansion population, beginning in the Obama administration, which championed Medicaid expansion.

If the federal match is reduced and the state match increased, Oklahoma state government expenses could easily surge by $1 billion annually, depending on the size of the shift, according to estimates. Of the 41 states that have expanded Medicaid to cover able-bodied adults of working age, 38 have it in state statutes, not state constitutions, and 10 states have trigger provisions that repeal Medicaid expansion if the federal match is reduced.

State Sen. Regina Goodwin, D-Tulsa, predicted the federal match will be reduced below the current 90-10 split and that state costs will soar.

“Everybody knows that is going to happen,” Goodwin said.

She nonetheless insisted officials should do nothing to change Oklahoma’s Medicaid expansion.

State Sen. Julia Kirt, D-Oklahoma City, argued that allowing Oklahomans to vote on the Medicaid issue insults voters.

“As this bill is written, it’s about taking power away from the people,” Kirt said.

Paxton disagreed and said that giving the voters a direct say in the issue is anything but insulting.

“Sending a measure back to the people to reconsider parts of it is not disrespecting the vote of the people,” Paxton said.

If nothing is done to rein in Medicaid’s soaring costs, lawmakers noted that many other areas of government will be financially punished and experience major funding reductions in future years, including schools, because Medicaid’s costs are growing faster than the state economy.

State Sen. Julie Daniels, R-Bartlesville, warned that if voters “do not change the constitution to give the Legislature flexibility, very soon we are not only going to see education suffer,” but also “every single thing that we fund each year,” including public safety, roads and bridges, agriculture, the courts, and more.

“We are simply going to have to cut, and it’s going to be hugely painful,” Daniels said.

Paxton noted that the share of Oklahomans on welfare programs like Medicaid and food stamps (otherwise known as the Supplemental Nutrition Assistance Program, or SNAP) far exceeds the rate in other states with similar demographics.

“We’re at 25 percent. That is one of the highest percentages in the entire nation of our population that is on Medicaid,” Paxton said. “Then you go look at things like SNAP benefits. We’re at 17 percent. National average is 11. States that are poorer than us, that have a lower per-capita income than Oklahoma, have a SNAP benefit rate of around 11 percent. We’re at 17.”