Oklahoma Gov. Mary Fallin, right, talks with Allison Stewart, an editor at The Atlantic, during the Defining Justice event Sept. 20, 2017, in Oklahoma City. DYLAN GOFORTH/The Frontier

Oklahoma Governor Mary Fallin said she is supporting legislation that would implement work requirements as a condition for non-disabled adults to receive benefits from SoonerCare, the Medicaid state and federally-funded health care coverage program for low-income people.

And several other bills that have been introduced for the upcoming legislative session would, if passed, make additional changes to the state’s Medicaid program and the state agency that oversees it, the Oklahoma Health Care Authority.

Among those bills is legislation that would eliminate or restrict Medicaid eligibility for all non-pregnant able-bodied adults under the age of 65, increase penalties and monitoring for fraud by beneficiaries, require parents with children on Medicaid to take a parenting class and require that the Health Care Authority not contract with organizations that traffick or sell fetal body parts, likely referring to Planned Parenthood.

Earlier this month, the Center for Medicare and Medicaid Services under the direction of President Donald Trump issued a guidance letter to states inviting waiver proposals that would allow the states to put work or community engagement requirements as a condition of eligibility on Medicaid beneficiaries.

Though several states have since expressed interest in implementing work requirements, the proposal has been met with condemnation by some groups and is the subject of at least one lawsuit in Kentucky, which has already been granted a waiver but also has an expanded Medicaid program under the Affordable Care Act. Oklahoma does not have an expanded Medicaid program.

Michael McNutt, spokesman for Gov. Mary Fallin, said Fallin is interested in the work requirement concept and the Governor’s Office is supporting a bill introduced for the 2018 legislative session that would require the Oklahoma Health Care Authority to seek a waiver from the federal government to implement the work requirements.

The Governor’s Office is part of a working group that has been looking at ways to implement work requirements as a condition of Medicaid eligibility in Oklahoma, McNutt said. The group has been meeting since last summer, prior to the Trump administration’s proposal, and includes representatives from the Oklahoma Health Care Authority, the Oklahoma Department of Human Services and the Oklahoma Department of Mental Health and Substance Abuse Services, he said.

Thus far, no waiver request that would implement a work requirement on Medicaid recipients has been submitted by the state to CMS, but ideas for what such requirements mirror those currently in place for those who receive food stamps through the Supplimental Nutrition Assistance Program (SNAP) and cash assistance from the Temporary Assistance to Needy Families (TANF) program, McNutt said.

Proposals (in the working group) are rather limited in scope at this time, such as streamlining documentation of some work of job activities, and aligning Medicaid eligibility with work and job activity requirements for SNAP and TANF,” McNutt said. “The governor is looking at additional changes.”

Some of those changes to the program supported by Fallin include language in bills introduced in the Legislature beyond those implementing work requirements, including a bill that would increase the age of eligibility for college students on the Insure Oklahoma program from 23 to 26 and include technical school and career training and certification programs.   

There are a number of other new bills that have been introduced in both the House and Senate for the upcoming legislative session, which begins Feb. 5, dealing with Medicaid and the Oklahoma Health Care Authority, each of which would change the program in varying degrees. And there could be more once the session starts, as legislators amend bills or introduce language to shell bills.

Work requirement bills:

With the exception of House Bill 3557, which is currently a shell bill that Fallin said she endorsed as part of a work-requirement bill package, these bills would require the Oklahoma Health Care Authority to seek a waiver from CMS allowing the state to implement work requirements for adults who are on or applying for the SoonerCare plan.

Insure Oklahoma beneficiaries would be exempt.

The bills state that the requirements shall be similar to those currently on the TANF and SNAP programs, which requires that non-disabled adult beneficiaries work, be participating in job training and/or search for a job for an average of 20 hours per week.

According to the Oklahoma Health Care Authority’s latest figures, as of December 2017 there were more than 81,000 adult individuals signed up for the full SoonerCare program, almost all of which were under age 65 and qualified by being the parent of a child who qualifies for the program and by earning less than $943 per-month (or a little more than $11,000 per year) for a family of four.

However, there is a feeling among some legislators that many of the able-bodied adults on the state’s Medicaid roll as a parent or caregiver of a child on SoonerCare should be working.

“There’s a movement right now at CMS looking at states to do work requirements,” said Sen. Josh Brecheen, R-Coalgate, who is the author of one of the bills. “It’s this population that the Trump Administration is saying ‘states if you want to put in work requirements, go for it.’”

Brecheen said the reason for the bill is that the parent/caregiver group in the Medicaid population, nationally, has both changed and grown from 20 years ago.

“Used to, you would look at this population of caretakers and see single moms,” Brecheen said. “That’s not the case anymore. We’re talking about men able to work.”

Sen. Josh Brecheen, R-Coalgate

Brecheen said he was willing to amend his bill to include certain exceptions, such as women who have given birth to a child in the past year, but he is adamant that many of the able-bodied parent/caregiver population on the state program should be working to provide their own insurance coverage so that the money can go to the aged, blind or disabled.

“I’m agreeable to amendments on this front, but the men who we know are increasing the Medicaid rolls, who are able to work, that’s a growing population we must take into account if we’re going to be able to afford to fund the Medicaid AdVantage waiver for those who are in need and fall through the cracks,” Brecheen said.

Brecheen pointed to the work requirements enacted for TANF and SNAP beneficiaries as similar, successful efforts that have ended dependency on government programs and helped people better their situations.

“I’m open for amendments, I’m open to suggestions because I have no desire to be hard-hearted,” Brecheen said. “I have no desire to come across that way. I know there are people who find themselves in difficult circumstances. What I do want to do is make sure we have a social safety net, not a hammock. “

Though the only state thus far to enact a work requirement for adult able-bodied Medicaid recipients is Kentucky — a state that expanded its Medicaid system to include low-income adults, Brecheen said the work requirement waiver is for all states, regardless of whether they expanded the program.

“That change would not just be for states that have done Medicaid expansion,” Brecheen said. “It’s for states that have done Medicaid expansion and states that have not done Medicaid expansion.”

However, many of the people who would be affected by the work requirements already work and can’t afford insurance or are in a situation where they are not able to work such as caring for a sick child or elderly parent, said David Blatt, executive director of the Oklahoma Policy Institute.

“We’re talking about a small population, most of whom already work,” Blatt said. “Just because somebody isn’t working doesn’t mean you put in a work requirement and presto, they’re going to find jobs.”

Even if they do find jobs, it doesn’t mean they will be able to afford insurance or qualify for the insurance exchange, said Craig Jones, president of the Oklahoma Hospital Association.

“We’ve removed somebody from the rolls, but you may have someone who has lost coverage and become an uninsured when they have to go to the hospital or another provider,” Jones said. “Or you’ve created a situation where some of their basic needs that were being met by the Medicaid program are now not being met because their employer is not providing the coverage or they can’t afford it.”

Eligibility restriction/expansion bills:

The language in House Bills 2932 and 3344 are the same — all non-pregnant, non-disabled individuals under age 65 would be ineligible for Medicaid, regardless of income level. However, Rep. Glen Mulready, R-Tulsa, said his bill, House Bill 2932, is actually meant to be a work requirement bill.

“That’s not what it’s supposed to be. I will not be doing that, no,” Mulready said. “We may have gotten some old language somehow and I didn’t catch that. The intent of my bill, I can tell you, is to have a work requirement on able-bodied adults.”

Rep. Glen Mulready, R-Tulsa

Senate Bill 1030, by Brecheen, would restrict adults who qualify for SoonerCare because they have a child who qualifies from earning 40 percent of the federal poverty level to 20 percent in order to qualify.

For a family of four, that would mean an adult who would qualify now by earning $9,840 per year would have to earn about $4,920 in order to qualify.

“My goal, with the able-bodied population — able to work, not blind, not disabled — is for this population instead of being dependent on the government, which we know to creates an atmosphere of dependency for those who are able to work, then you take an opportunity, in my opinion, for them to be able to increase their status and their income levels,” Brecheen said.

“My goal for this population is to help them find more income so their entire family can be financially enhanced,” he said.

Such a move, Brecheen said, would save around $60 million for the state’s Medicaid program and several other states have similar income restrictions on the caregiver/parents group. Those savings can be put toward helping those on the program who are aged, blind or disabled, he said.

“There are people right now in Oklahoma who are childless and fall into the same income category but yet aren’t on Medicaid,” Brecheen said. “The question is — how can we justify for one subgroup with income eligibility that they’re not Medicaid eligible, however for this group you are. The real issue comes down to — these are able-bodied adults.”

However, the state’s Medicaid system already has one of the lowest costs per-person and there is a concern that the restrictions could be more about cutting costs and less about creating a healthy state, OHA President Jones said.

“I’m sure that has some legislators and state officials are concerned when the state is spending more dollars when the state’s overall budget is in a doldrum,” Jones said. “But if you say wait a minute, yes we’re spending more dollars, but if the dollars we’re spending are pretty efficient dollars, then it appears your only objective is to reduce the amount of money the state is spending. And if that ends up being the primary objective, there’s no way to avoid the fact you are going to adversely impact people’s ability to maintain health care services.”

The state should be trying to expand the number of people with health coverage, not restrict it, said Susan Savage, CEO of Morton Comprehensive Health Services, a Tulsa-based Federally Qualified Health Center that does primary care for low income individuals.

“I will support any bill that leads to improved health outcomes in Oklahoma,” Savage said. “I will strongly oppose any bill that seeks to eliminate an already restrictive field benefits for sick people who need access to health care. We are a poor and sick populace.”

Further restricting eligibility could create more uninsured people, Savage said, which not only harms patients but providers as well.

“One of the unintended consequences of some of this is if you restrict Medicaid eligibility more than it’s already been restricted, you potentially drive uninsured people to hospital emergency rooms where they will seek their primary care,” Savage said.

House Bill 3219 would expand Medicaid eligibility to students who are in technical school, Career Tech or job training and increase the age limit from 23 to 26. McNutt said Fallin is endorsing House Bill 3219.

House Bill 1437 would eliminate the Soon-to-Be a Sooner program, which provides prenatal care to pregnant immigrant women, regardless of their legal status.

Fraud, abuse and cost-saving bills:

Senate Bill 1282 by Brecheen would direct the Oklahoma Health Care Authority to study ways to reduce costs of the Medicaid program.

The rising cost of health care has been difficult for a state already struggling with its budget, Brecheen said. Over the last decade health care costs for the state — including Medicaid, state employee insurance, and other health care expenses — have increased by more than $1 billion, Brecheen said.

“This is one of the largest drivers of why Oklahoma is struggling to fund core government,” Brecheen said.

Brecheen’s Senate Bill 975, which would require that Medicaid enrollment forms have a perjury clause in them, Senate Bill 1177, which would create a division in the Attorney General’s office to prosecute Medicaid fraud by enrollees, and Senate Bill 1326, which would increase the fines for Medicaid fraud by enrollees to three times the amount of assistance received, are all part of a package to more aggressively go after Medicaid fraud by enrollees, he said.

Brecheen said he has heard numerous anecdotal stories throughout his years in government of Medicaid fraud by users, but there are relatively few cases of enforcement by oversight agencies and even fewer cases of prosecution

Brecheen said the bills are not targeting those who may have accidentally exceeded Medicaid eligibility requirements, but those who are actively defrauding the system for tens of thousands of dollars by being paid or operating a business in such a way that their funds are not being reported to the IRS as income.

“That person — we’ve got to stop that. We’ve got to stop the permissiveness, we’ve got to stop the no consequences,” Brecheen said. “We have to take this seriously and there has to be a message sent to the public — Oklahoma will not tolerate you stealing from the disabled population who is truly in need of these funds.”

Brecheen said it is not his intention to try and make things difficult on poor people.

“The easy thing on this is to go ‘you hate poor people,’” Brecheen said. “No. To love justly, to love justice, to walk in mercy is absolutely part of what I want to do here. Part of that loving justice and walking in mercy is when I see justice being perverted by those who are stealing — have the ability to provide for themselves, taking away from the disabled who are falling through the cracks, my job as an elected official is to say we need to do something about this.”

House Bill 3677 by Rep. Kevin Calvey would implement the HOPE Act, a piece of model legislation that would increase eligibility reporting requirements not just for Medicaid, but TANF and SNAP as well. Similar legislation last year and during the first special legislative session did not pass.

Calvey did not return a phone message from The Frontier seeking comment on the HOPE Act.

Blatt said that the bill would put a number of cumbersome burdens to prove eligibility on beneficiaries, and is intended to reduce the number of people on Medicaid who are eligible for the program, rather than root out fraud.

“It’s unlikely that we’re going to find many people who are ineligible for benefits or lose their eligibility,” Blatt said. “We’re going to have some people who are eligible who have their benefits cut off because the system has problems or they can meet the new verification standards. There’s a real risk with all of these that people who are genuinely eligible will end up losing benefits.”

Management bills:

Senate Bill 1094 would eliminate the Oklahoma Attorney General’s Office from appointing an administrative law judge to conduct overpayment appeal hearings for providers, while Senate Bill 1284 would require the Health Care Authority to conduct administrative hearings within 30 days of a request by Medicaid recipients or applicants.

Senate Bill 1243 would require the governor to appoint a chief financial and budget officer to review all proposed expenditures by the Health Care Authority.

Senate Bill 1415 and House Bill 3582 would both move administration of the AdVantage Waiver Program from the Department of Human Services to the Health Care Authority. Senate Bill 1418 would require the Health Care Authority to contract with outside companies to determine eligibility for the AdVantage program.

Sen. AJ Griffin, author of Senate Bills 1415 and 1418 are both intended to streamline the system, since many of the other Medicaid functions are handled by the Health Care Authority.

House Bill 2934 by Mulready, would eliminate the Oklahoma Health Care Authority Board and replace it with a single administrator appointed by the governor.

Senate Bills 1285 and 1331 would establish the Legislature’s intent to change Medicaid to a managed care system.

OHA president Jones, said he opposes changing the system to managed care because it has been tried in the past and failed.

Other bills:

Senate Bill 896 would allow the Medicaid program to tap into the Tobacco Settlement Endowment Trust funds to pay for services, while Senate Bill 970 would prohibit the Health Care Authority from reducing payment rates to certain providers and facilities if they are operating efficiently.

Meanwhile, Senate Bill 1372 would allow providers to bill the Health Care Authority for services rendered to Medicaid patients up to a year after those services are provided.

Senate Bill 1267 and House Bill 3679 would prohibit the Health Care Authority from contracting with organizations that have either sold or trafficked in fetal body parts. This bill is likely aimed at Planned Parenthood.

Finally, House Bill 3484 by Rep. John Paul Jordan, R-Yukon, would require parents who have children enrolled in Medicaid to take parenting classes.

Jordan said the bill is a work in progress and only supposed to cover parents of children enrolled in the SoonerCare program. The intent, he said, is to lower the amount of children taken into state custody because of abuse or neglect.

Rep. John Paul Jordan, R-Yukon

Data on children taken out of the home shows that many of the children are signed up for SoonerCare, Jordan said, and many of the parents in those cases are young and do not have a large degree of knowledge or experience in caring for a child.

“In some instances, kids are getting taken out of the home, and it’s a case where it’s babies having babies, they’re young parents,” Jordan said. “They just don’t know, they weren’t raised where some of the things you would consider acceptable behavior or things you should do with a child, it’s small things like that that add up to a big consequence.”

Jordan said the details of who would pay for the parenting class have not yet been worked out, and intent is not to go after the poor or those on SoonerCare.

“It’s trying to make sure some of these young parents know how to take care of their kids so they have better home lives,” Jordan said.