The 2020 referendum that expanded Oklahoma’s Medicaid program to include able-bodied adults, as allowed under the federal “Affordable Care Act” (better known as “Obamacare”), was sold on a promise to both financially enrich state hospitals and improve citizens’ health outcomes.

But a new report shows that, five years and billions of taxpayer dollars later, health outcomes in Oklahoma have actually gotten worse on major metrics, and Oklahoma ranks close to last place nationally.

In fact, health outcomes are better—and often significantly better—in nearly all states that have not expanded their Medicaid programs.

Currently, 10 states have not expanded Medicaid to add able-bodied adults in their prime working-age years to the welfare program. Those states are Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming.

The Commonwealth Fund’s “2025 Scorecard on State Health System Performance” provides a comparison of Oklahoma with all other states and shows that non-expansion states are consistently outperforming Oklahoma.

The Commonwealth Fund report showed that in Oklahoma in 2018-2019, prior to Medicaid expansion, there were 117.7 deaths per 100,000 population before the age of 75 from health care-treatable causes. By the 2022-2023 period, the most recent for which the report had data, that figure had increased to 124.6, despite Medicaid expansion having occurred.

The death rate in Oklahoma was far higher than the rates in nearly all states that have not expanded Medicaid. For example, the death rate from health-care treatable causes in Oklahoma was 51 percent greater than in Florida and nearly 34 percent higher than in neighboring Texas.

Similarly, drug overdose deaths per 100,000 population also increased in Oklahoma as Medicaid expansion was implemented, based on the data reported by the Commonwealth Fund. In 2019, Oklahoma recorded 16.7 overdose deaths per 100,000 population. By 2023, that rate had almost doubled to 32.4.

Once again, drug overdose rates were lower in most states that have not expanded Medicaid. The overdose rate in Oklahoma was 75 percent higher than in neighboring Texas.

Medicaid Helps Fuel Opioid Epidemic

The increase in overdose deaths in Oklahoma may be driven, in part, by Medicaid expansion. In 2018, a majority staff report released by the U.S. Senate’s Committee on Homeland Security and Governmental Affairs found that Medicaid was helping fuel the nation’s opioid epidemic.

The U.S. Senate report noted, “For dangerous opioids such as oxycodone, Medicaid co-pays can run as low as $1 for as many as 240 pills—pills that can be sold for up to $4,000 on the street. As one longtime local prosecutor in opioid-ravaged eastern Kentucky recounted in Dreamland: The True Tale of America’s Opiate Epidemic: ‘We can talk morality all day long, but if you’re drawing five hundred dollars a month and you have a Medicaid card that allows you to get a monthly supply of pills worth several thousand dollars, you’re going to sell your pills.’”

The U.S. Senate report highlighted nearly 300 criminal cases involving at least 1,072 defendants in which people had been convicted or charged of abusing Medicaid to obtain or sell opioids. Roughly 80 percent of those cases were in Medicaid-expansion states.

The Commonwealth Fund report showed that the rate of premature deaths from preventable and treatable causes in Oklahoma was 409.5 deaths per 100,000 people. That was a higher rate than most states, including states that have not expanded Medicaid such as Alabama, Florida, Georgia, Kansas, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming. The rate of premature deaths from preventable and treatable causes in Oklahoma was nearly 48 percent higher than in neighboring Texas, which has not expanded Medicaid.

Oklahoma ranked 48th on health outcomes and healthy behaviors, according to the Commonwealth Fund. That was worse than the ranking for outcomes in most non-expansion states, including Alabama, Florida, Georgia, Kansas, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming.

In some cases, non-expansion states ranked significantly higher than Oklahoma. Florida ranked 20th in health outcomes, while Texas ranked 27th.

Oklahoma ranked 46th in prevention and treatment. Multiple states that have not expanded Medicaid ranked higher, including Alabama, Florida, Georgia, Kansas, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming.  

Oklahoma ranked 48th on health care access and affordability. Once again, most states that have not expanded Medicaid fared better, including Alabama, Florida, Georgia, Kansas, South Carolina, Tennessee, Wisconsin, and Wyoming.

Oklahoma’s health care system was ranked 49th overall out of the 50 states and the District of Columbia. Multiple states that have not expanded Medicaid ranked higher, including Alabama, Florida, Georgia, Kansas, South Carolina, Tennessee, Wisconsin, and Wyoming.

The lack of improvement in health outcomes has become a problem for some advocates of Medicaid expansion.

During May debate on the general-appropriation bill for state government, state Sen. Carri Hicks, D-Oklahoma City, tacitly conceded that Medicaid expansion has failed to live up to the promises of advocates when she said she believed expansion “over time, will yield much improved health outcomes for Oklahoma, but we’re just getting started.”

While Medicaid expansion has done little to significantly improve health outcomes and associated rankings in Oklahoma, it has also fallen far short of advocates’ promises regarding state hospital stability.

Several reports have found that hospitals in Oklahoma are on less secure financial footing today than they were prior to Medicaid expansion. That’s not surprising since even hospital executives who endorsed Medicaid expansion have acknowledged that they lose money treating Medicaid patients because the payment received is often less than the cost of service.

Medicaid spending increased by 81 percent from $5.7 billion in the pre-expansion 2019 state budget year to $10.5 billion in the 2024 budget year. And the impact on Oklahoma’s state budget could skyrocket in the next few years.

Potential changes in the federal match for Medicaid-expansion enrollees could increase the amount of state appropriations required to maintain the expansion program by as much as $700 million per year.