Small: Medicaid expansion follies show need for initiative-petition reform

Medicaid expansion follies show need for initiative-petition reform

By Jonathan Small

In 2020, Medicaid expansion was approved by the narrowest of margins through a ballot measure placed before voters via the initiative-petition process. The proposal added hundreds of thousands of able-bodied adults to the welfare program and put taxpayers on the hook for paying the medical bills of numerous adults who were capable of gainful employment but not pursuing it.

The measure was strongly rejected by election-day voters and majorities in roughly 90 percent of counties. It passed only because of absentee votes. Yet today, Oklahoma faces a reported Medicaid shortfall of roughly a half-billion dollars that is due largely to the expansion. Every dollar going to expansion takes money away from schools, roads, public safety, or tax relief for working families.

The debacle of Medicaid expansion shows why initiative-petition reform is needed. Unfortunately, it has been relatively easy for out-of-state special interests to pour money into Oklahoma to promote badly designed and counterproductive measures that create serious long-term challenges for our state.

No sane system would prioritize medical welfare benefits for idle young men in their 20s over the needs of medically frail women and children, but that’s exactly what the Medicaid expansion measure mandated. (Obviously, backers didn’t emphasize that fact.)

Furthermore, Medicaid expansion has provided none of the promised benefits.

The Commonwealth Fund’s “2025 Scorecard on State Health System Performance” report showed that deaths per 100,000 population before the age of 75 from health care-treatable causes in Oklahoma increased after Medicaid expansion.

The death rate in Oklahoma remains far higher than in nearly all states that have not expanded Medicaid.

At an October 2025 legislative study, Oklahoma Hospital Association officials told lawmakers that profit margins at Oklahoma’s rural hospitals rank 35th out of the 50 states, while rural hospitals in Texas, which did not expand Medicaid, rank 11th-best nationally.

Fortunately, lawmakers have taken sensible steps to bring sanity to Oklahoma’s initiative-petition system. Among the most notable reforms included in last year’s Senate Bill 1027 was a requirement for initiative petitions to gather signatures from across Oklahoma. Other states with the initiative petition process have long had similar requirements for geographic diversity among those signing a petition.

Under Oklahoma’s old system, petitions could focus almost entirely on just Oklahoma and Tulsa counties, neglecting to build real support for an idea across the state, and doubled down on that strategy during a campaign, including through means such as absentee voting, which experts on both the left and right have long warned is the form of voting most susceptible to fraud.

Oklahoma’s initiative-petition reforms are being challenged in court. One must hope justices acknowledge both the wisdom and constitutionality of requiring petition proponents to gather signatures from across Oklahoma. If they don’t, this year’s Medicaid-expansion shortfall may be only a glimpse of the fiscal chaos that lays ahead.

Jonathan Small serves as president of the Oklahoma Council of Public Affairs.