Oklahomans voted Tuesday to alter their state constitution to expand Medicaid over nearly a decade of opposition by Republican governors, making their state the first to widen the safety-net insurance program as the coronavirus pandemic steals jobs and health benefits.
The expansion’s approval, by a slender margin, means that an estimated 250,000 additional Oklahoma residents will be eligible for the public insurance, including nearly 50,000 who have lost coverage as unemployment has soared this year.
The decision in a Republican-leaning state is rich in political significance. Oklahoma becomes the fifth state in which voters have passed ballot initiatives to expand Medicaid by employing a tool to circumvent the will of GOP governors and legislatures. Another Medicaid-expansion vote is pending in Missouri early next month.
The 50.5 percent vote in favor of Oklahoma’s ballot question, announced late Tuesday night, shows that, even in red states, voters are significantly less hostile to the Affordable Care Act than President Trump, whose administration is trying to invalidate the law in a case before the Supreme Court. The ACA is the law that gives states the ability to expand Medicaid, a program run jointly by states and the federal government that originated out of the 1960s’ War on Poverty. With Tuesday’s vote, all but 13 states have decided to allow adults without children at home and those with slightly higher incomes into the program.
‘‘It’s important for the country to know what happened in Oklahoma last night,’’ Amber England, campaign manager for Yes on 802, the grass-roots group leading the effort to pass the measure, said Wednesday. ‘‘In the middle of the pandemic, Oklahomans stood up to deliver health care to our friends, families and neighbors.’’
Question 802 was the number of the initiative on the state’s primary ballot. She said volunteers collected 313,000 signatures — a state record —- to get the question before voters, and hosted Zoom happy hours instead of house parties in this pandemic spring. Both proponents and opponents ran ads.
The vote results do not expand Medicaid in the Sooner State immediately or automatically. Under the wording change to the state constitution, the expansion will start in one year. The state is required within 90 days to submit to federal health officials a request to make the change to its Medicaid program. And the state legislature would need to agree to pay for the state’s portion of funding for the expansion, at least 90 percent of which is covered by federal money under ACA rules.
Approving the change ‘‘is huge, but it’s also just the start,’’ said Carly Putnam, policy director of the Oklahoma Policy Institute, which favors the expansion. ‘‘We are finally at the point where we can do the hard work to get this implemented.’’
Republican Oklahoma Governor Kevin Stitt immediately made his opposition clear.
‘‘Our Oklahoma legislators now have the difficult job of deciding where we will find an estimated $200 million in funding to support this constitutional mandate,’’ Stitt said in a statement Wednesday.
With states’ finances eroded from shutting down large parts of their economy to help protect people from the coronavirus, Stitt said, ‘‘we are currently looking at a $1 billion deficit for this upcoming year, and the options on the table are raise taxes on hard-working Oklahomans or cut finding to core services, such as education, roads and bridges, or public safety.’’
In Oklahoma, the Medicaid vote occurred against a complicated backdrop. The state is the only one so far that had taken the Trump administration up on an offer to abandon the program’s traditional status as a federal entitlement, in which each state is paid a fixed amount for each person who qualifies. Instead, the administration has said it is willing to free states from a lot of federal rules if they switch to a per-person cap — or a block grant, in which a state’s federal money would be fixed in times of economic crisis, such as a pandemic, when more people would qualify. Oklahoma applied for such a switch this spring, and it is unclear how the expansion vote will affect that.
According to the federal Bureau of Labor Statistics, Oklahoma’s unemployment rate for the civilian labor force shot up from 3.2 percent in February to 14.7 percent in April.
Stitt cited the sharp rise in unemployment — and a bigger pool of residents who now qualify for Medicaid — in May when he vetoed a bill that would have provided money for the first phase of the Medicaid transition to a block grant the governor has asked federal officials to approve.
In embracing a more expansive version of Medicaid, residents of Oklahoma — a state in which about two-thirds of voters supported Trump in the 2016 election — fit within a broad political shift. A May poll by the Kaiser Family Foundation, a nonpartisan health research organization, showed that two-thirds of people in states that had not expanded Medicaid thought their state should do so. That preference was even more common (72 percent) among adults in those states who said they or someone in their home had lost pay or a job during the pandemic.
Oklahoma’s Medicaid ballot initiative was different from the four others, because it called for a change to a state constitution rather than state laws. Others have hit snags after the vote. Maine passed a ballot initiative in late 2017, but Medicaid did not expand there until a Republican governor was succeeded by a Democrat in early 2019. Political wrangling ensued in Utah and Idaho before the expansions began there. Like those two states, Nebraska approved an expansion in November 2018, but it is not scheduled to take effect until this fall.