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Oklahoma must be doing something right. The state has managed to find a way to look after a large percentage of its uninsured children and pregnant women. While the average state averaged a 2% increase to its insured rolls between June 1997 and December 1999, Oklahoma powered to the head of the class with a 39.1% tally.
It’s a big accomplishment, one that others obviously find difficult to match.
So what has Oklahoma done that everyone else can only envy? Analysts and officials say Oklahoma had the advantage of many variables falling into place at one time, a feat nearly impossible to plan in advance and one in which the way the chips randomly fall plays a large role.
What could cause aged and disabled enrollment to shoot up 3.4% or enrollment in families, children, and pregnant women categories to swell by 61.5%?
Success, it’s often said, occurs when preparedness and opportunity meet. Preparedness is the variable that is most controllable in this equation for success. Oklahoma had it nailed down.
"They did a bunch of the right things at the same time. They were ahead, for example, of everyone on eligibility," Julie Hudman, associate director of the Kaiser Commission on Medicaid and the Uninsured tells State Health Watch. "They had a bill ready to go before CHIP [the Children’s Health Insurance Program] passed. Other states were much slower."
During the early 1990s, leading up to CHIP’s coronation in 1997, policy changes paved the way for a change in Medicaid. During that ramp-up period, Oklahoma outpaced its 49 competitors, edging out its nearest competitor, the commonwealth of Massachusetts, which posted an increase of 32.5% in its enrollment. The bottom dweller, in a ranking by the Kaiser Foundation, was West Virginia, whose enrollment dropped by 12.1%. (See the total Medicaid enrollment list, p. 3.)
"In 1999, the total number of uninsured individuals in America decreased for the first time after steadily increasing over the past decade. Both the booming economy and expansions of public programs contributed to this decline," the Kaiser Foundation notes in its report Medicaid Enrollment in 50 States. "From December 1998 to December 1999, national Medicaid enrollment increased by 1.1 million individuals, or 3.6%, with 43 states and the District of Columbia experiencing growth."
Oklahoma’s legislators and policy-makers saw the big picture of the process and did lots of streamlining in its drive to the top.
"We were way ahead on CHIP. The state legislature in 1997 passed Title 19 expansion prior to creation of the federal CHIP program," Nico Gomez, of the Oklahoma Health Care Authority in Oklahoma City, OK, tells State Health Watch. "The legislature also raised the [for enrollment] to 185% of the poverty level, including children under age 18."
Another key element of Oklahoma’s success, according to Mr. Gomez: the state’s decision to expand its Medicaid program, creating SoonerCare, instead of starting its own separate CHIP division.
"That helped our total number of children enrolled," he says. "After Medicaid expansion, our number was then 275,685 children. We then began an aggressive outreach program. We had legislation in place that gave us the opportunity to do things the state needed in order to address pregnant women. That increased access and lowered barriers."
The majority of states have expanded their Medicaid programs and CHIP, on top of that, making enrollment easier.
Other states followed Oklahoma’s lead but with less success, not because there weren’t enough people to fill the rolls of the uninsured but because fewer people came in through the door to sign up for help.
So how specifically did Oklahoma get the attention of those qualified for the program?
"Oklahoma made some key simplifications. They changed the application from 17 to two pages and got rid of the asset test. By dropping the asset test, that makes the process easier to enroll in, it saves time," says Ms. Hudman.
Mr. Gomez likes to point out a key phrase for the asset test: It is not a two-page form, he says, it is one page, front and back. Processing time for paperwork also was slashed to 20 days from 45.
One of the most important changes Oklahoma officials made, Ms. Hudman adds, was the creation of the self-declaration-of-income form.
"That’s where you say how much you make per month or year, then the state goes and checks it," Ms. Hudman says. "That took the place of the face-to-face interview. Now you can enroll in Medicaid through the mail or over the telephone. Before, the burden was on the family, and that has changed."
Another step in the right direction from SoonerCare: Simplifying the methods used to keep the uninsured from falling off the rolls.
"We’ve reduced the application days. A case does not automatically terminate in six months," Mr. Gomez says. "Now it is proactive. We do a redetermination and make contact with the participants and redetermine their eligibility. Before that, to stay on the rolls, they came to us."
From December 1998 to December 1999, nine states saw double-digit growth in their total enrollment in Medicaid, according to the Kaiser Foundation.
Those states are, alphabetically:
• Alaska: 19.6%
• Indiana: 12%
• Kansas: 12.7%
• Louisiana: 15.9%
• Maryland: 23.4%
• Missouri: 20.2%
• Oklahoma: 23.3%
• Rhode Island: 15%
• Wisconsin: 11.1%
Total Medicaid enrollment rose 3.6% during the same period, hitting 31.99 million from 30.89 million. The states showing decreases in their rolls were, alphabetically:
• Arkansas: -4%
• Georgia: -4%
• Iowa: -.02%
• Montana: -2%
• New York: -1%
• Pennsylvania: -.7%
• Texas: -1.6%
• West Virginia: -2.5%
There is still plenty more work to be done. Nationally, there are about 2.5 million children who are eligible for the CHIP program who are not included on its rolls. In Oklahoma, Mr. Gomez says statistics show that more children are steadily being added to the ranks of the insured.
"I don’t think it has leveled off yet," he says. "Oklahoma still, as the national trend will tell you, has a large number of children who have not been enrolled."
Nearly 379,000 low-income residents of Oklahoma are uninsured. In the next two years, Oklahoma officials will be studying eligibility requirements to see if further adjustments are needed.
"There may be an increase in provider rates," Mr. Gomez says. "We will see what is effective for other states, especially in outreach." One of the largest hurdles to overcome, in Oklahoma and nationally, is overcoming the negative stigma of being on Medicaid rolls, he adds.
[For more information, contact Julie Hudman at (202) 347-5270, fax: (202) 347-5274; and Nico Gomez at (405) 522-7484.]