Uncertainty in Washington about how the debate on health care will play out impacted budget decisions last month at the Oklahoma Health Care Authority.

Providers who rely on SoonerCare reimbursements — the state's Medicaid program — will see the fallout from those decisions this time next year. That's because agency officials balanced this year's budget by pushing three billing and payment cycles into fiscal year 2019, delaying reimbursements to providers. 

Jo Stainsby, director of public information at OHCA, said two factors led to that decision: The agency's state-appropriated funds for the year were $35 million less than requested, and there are unknown variables regarding congressional reauthorization of the Children's Health Insurance Program.  

Medicaid and CHIP provide health coverage to more than a third of the children in the United States — the vast majority of these children are covered through Medicaid. Those numbers are even higher locally, according to the Kaiser Family Foundation, with 55 percent of all children in Muskogee County — 54 percent in Cherokee County and 58 percent in McIntosh County — securing health care coverage through one of the two programs. 

Stainsby said the match rate for CHIP enrollees in Oklahoma presently is made at an enhanced rate of 94 percent, compared with the normal match rate of 57 percent. She said the higher match rate was made possible by the Affordable Care Act even though state officials declined to expand its Medicaid program made available by the same federal law.  

"We didn't know what we were going to get in our budget, so we accounted for just the straight Medicaid match," Stainsby said, citing a $50 million difference between the enhanced and normal match rates. "Our No. 1 goal and our mission is to operate the program and maintain rates to ... keep an adequate number of providers who can provide services to our members."

These uncertainties with CHIP may be small compared with Medicaid cuts that could occur if either of two bills Republicans are pushing as a way to repeal and replace the Affordable Care Act become law. The Congressional Budget Office and independent analyses of the bills predict the cuts could be devastating for an estimated 45 million U.S. children who rely Medicaid and CHIP coverage.

CBO estimates the American Health Care Act of 2017, which House Republicans narrowly passed on May 4, would cut Medicaid spending by an estimated $834 billion during the course of a decade. The CBO's analysis of the Better Care Reconciliation Act, which has yet to be put to a vote in the Senate, projects Medicaid funding would be cut by 35 percent during the next two decades.

Medicaid funding cuts, according to the CBO analyses and examinations by the Kaiser Family Foundation and Robert Wood Johnson Foundation, would be achieved with the termination of the enhanced match given to states that accepted Medicaid expansion funds made available through the ACA the program, and per capita-based caps on future Medicaid payments.

U.S. Rep. Markwayne Mullin, who represents Oklahoma's 2nd Congressional District, lauded the May 4 passage of AHCA. The Westville Republican said the House bill would take "health care out of the hands of Washington, D.C., bureaucrats" and put it "in the hands of patients," and Medicaid reforms would shift power back to the states.

Patricia Gulager, regional vice president for Jordan Health Services and CIMA Hospice, expressed doubts about whether the GOP proposals would improve Medicaid in Oklahoma. Gulager, who has 41 years of nursing experience in 22 states, said Oklahoma never has administered "a Medicaid system that works."

"This is nothing new — it's been this way since I became a nurse," said Gulager, who was invited to Washington by the National Hospice and Palliative Care Organization to discuss that sector's concerns with the GOP proposals. "I always thought Oklahoma was one of the luckiest states, because we have Indian Health Systems that can step in to help, but I believe even those systems will be hurt under these bills."

Gulager's concerns appear to bear out by a Kaiser Family Foundation analysis, which found Native American communities benefited by Medicaid expansions that offered health care options beyond those provided by Indian Health Service. IHS and tribal facilities reportedly were able to expand as a result of increased Medicaid revenue, and about 13 percent of IHS funds came from Medicaid reimbursements in 2016. 

"The result of what Congress is doing will be that our emergency rooms will fill up, and what these hospitals will end up taking on will be a whole lot more debt," Gulager said. "Our rural hospitals can't take on more debt — we already have an issue with our rural hospitals closing down — these Medicaid cuts will make that worse."

Statistics provided by the OHCA, which administers the state's Medicaid program, show SoonerCare enrollment in May totaled 822,563 participants. Children made up 67 percent of program participation with more than 547,160 members, and 275,400 adults made up the remaining 33 percent.

Stainsby said the agency has assembled a “working group” to look at the impact the GOP health care proposals might have on the state's Medicaid programs. According to the CBO analysis, the proposals would increase the number of uninsured by 22 million to 23 million while repealing or delaying taxes on high income workers, and reduce the federal deficit from $119 billion to $321 billion during the course of a decade.

Reach D.E. Smoot at (918) 684-2901 or dsmoot@muskogeephoenix.com.

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