As Gov. Mary Fallin approached crucial decisions about health care reform in Oklahoma in the past two years, members of her staff routinely relied on advice from conservative political groups bent on destroying Obamacare.
More than 50,000 pages of emails released by the governor's office are notable for a lack of debate over the merits of various policy options. Instead, in document after document, the governor's staff frets over political messaging, responding to reporters and cajoling legislators.
At the beginning of Fallin's term in early 2011, the governor's aides were seemingly caught off guard by the virulent opposition in Oklahoma to anything related to the 2010 Patient Protection and Affordable Care Act, also known as Obamacare.
That experience, which led to a major defeat for the governor's attempt to use federal money to build a state marketplace for health insurance policies, seemed to guide the administration's approach to the key decisions in 2012 after the U.S. Supreme Court's opinion upholding portions of the health care law and leaving other parts up to states' discretion.
The emails released by the governor's office show top aides regularly participated in briefings with the Republican Governors Association and solicited information from that Washington-based political group as it moved toward decisions on whether to expand Medicaid coverage for the poor and create its own health care marketplace. Aides also used talking points from conservative think tanks and news publications.
Oklahoma Attorney General Scott Pruitt's lawsuit against key provisions in the health care law also weighed on discussions.
There is little evidence, however, of outreach to key stakeholders such as physicians, hospitals, insurers and even average people with stories to tell about the health care system. The governor's staff called a meeting last July that included, among others, the Oklahoma Hospital Association and lobbyists for some health insurers. But it's not clear from the emails if or how top aides incorporated that input into their thinking.
The governor's office gathered detailed information from the Oklahoma Health Care Authority about the potential costs of Medicaid expansion, but did not fully understand this information before announcing opposition to this expansion.
Fallin's own input in shaping the decisions she announced is unclear. There are relatively few emails from her among the thousands released.
Fallin's chief of staff, Denise Northrup, said in an interview last week that Fallin was engaged in serious policy discussions about the state's approach to the federal health care law and its impact on Oklahomans, but that she didn't do that through emails.
“The bulk of the conversations we have with the governor are in person, in staff meetings, where we can all sit around a table and have that discussion,” said Northrup, whose voice is among the most prevalent in the emails released by the governor's office.
The emails among Fallin aides sometimes discuss the need to “prep” Fallin for interviews and other public appearances.
In one instance, just days before Fallin announced key decisions in November, Northrup asked Marie Thomas Sanderson, the policy director at the Republican Governors Association, for advice on what Fallin should say to U.S. Health and Human Services Secretary Kathleen Sebelius.
Sanderson gave Northrup a blueprint for state concerns about setting up health care insurance marketplaces, known as exchanges.
“Further, she could say it concerns her that Utah has a fully functioning exchange — a state with one of the lowest costs of care and highest quality,” Sanderson wrote. “Governor Herbert is very concerned that his exchange won't qualify under PPACA (the health care law). That gives Governor Fallin a lot of heartburn to move forward with an OK state based exchange.”
That day, Northrup also sought information from Sanderson about what other states had decided.
“Would be helpful for my gov I know ... ,” Northrup wrote.
The Republican Governors Association was all about uniformity when it came to Obamacare. In the days leading up to the Supreme Court decision last summer, an association official invited governors' aides to participate in a conference call “to discuss GOP messaging on health care.”
“Given the high stakes impact of the decision and its political repercussions, it is essential that all of our governors be on the same page message-wise, especially in the critical 24-72 hours following the decision,” he wrote.
Northrup said last week that Fallin's administration may have “arrived at the same position” as the Republican governors group, “but it wasn't necessarily because of the same things.”
Ultimately, the governor carried out the wishes of Oklahomans who voted overwhelmingly in favor of a state question in 2010 to opt out of the federal health care law — and reminded her of it through thousands of calls, letters and emails over the past two years.
On Nov. 15, four days before Fallin announced she wouldn't expand Medicaid or create a state exchange, her office received a record 1,818 phone calls, a pace of four per minute, running nearly 2-to-1 against Obamacare.
The crux of Fallin's argument against expanding the Medicaid program in Oklahoma was that it would add significant costs to the state, despite the federal promise of paying for most of the newly eligible people.
Though an expansion would clearly be expensive, Fallin's aides inflated the amount by adding the cost of people who already are eligible for Oklahoma's Medicaid program, but are not participating.
According to emails, the inflation wasn't deliberate at first but resulted from a lack of understanding. Despite having weeks to study the issue, Fallin's aides didn't grasp the crucial nuances in the numbers generated by the Oklahoma Health Care Authority.
On Nov. 19, the day Fallin announced the state would not expand its Medicaid program under the health care law, she said the expansion would cost $475 million through 2020, when the expansion cost itself was less than half that amount.
Patti Davis, executive vice president of the Oklahoma Hospital Association, which had been pushing for the expansion, asked Fallin's policy director, Katie Altshuler, in an email where the number had come from.
Altshuler responded that the figure came from the Health Care Authority. After Davis responded that she had never seen the figure, Altshuler emailed Nico Gomez, a Health Care Authority official, who told her the figure included administrative costs and “woodwork,” a term for the people who already were eligible for Medicaid and would come out of the woodwork to sign up.
Altshuler then emailed Davis that “The 475 figure includes administrative costs and woodwork.”
The next day, amid email exchanges with a reporter from The Oklahoman about the same question, Alex Weintz, Fallin's communications director, emailed Gomez before crafting a statement to the paper about the distinction between people already eligible for Medicaid and those who would be newly eligible.
Weintz then sent an email to the governor, who was about to appear on a national news program to talk about health care reform.
“The following is an important point for tonight's interview and moving forward that I was not 100 percent clear on until now: Additional Medicaid expenses to the state of Oklahoma with a full Medicaid expansion as outlined under ObamaCare will be $475 million between now and 2020,” Weintz wrote to Fallin.
“However, additional Medicaid costs to the state will STILL be $254 million even WITHOUT the Medicaid expansion. This is because people who are currently eligible for Medicaid but not enrolled are going to be pushed towards enrollment by the individual mandate aka tax under ObamaCare.
“This is important for two reasons. From a messaging standpoint, it means that we are NOT saving the state $475 million by not expanding Medicaid. We are saving the state about $200 million dollars; we will still be on the hook for about $275 million.”
Weintz's revelation wasn't followed by a corrected news release, and the administration now is citing a higher figure — based on a nonpartisan study — again without making a distinction between those automatically eligible for Medicaid and those who would be newly eligible if Medicaid were expanded.
Besides the obvious mistake in interpreting the numbers, the episode suggested that the administration apparently didn't know they would be facing higher Medicaid costs whether they expanded the program or not.
The email exchange between Altshuler and the hospital association's Davis also raised questions about whether key members of the administration realized how some parts of Obamacare interacted — specifically how hard state hospitals would be hit by Medicare cuts without expanded Medicaid to offset those reductions.
While policy intricacies are often missing from the emails, there is much talk in the emails of political messaging, the trendy term for public relations. News releases were drafted and sent around for approval. Reporters' questions were batted among several people.
Weintz and his assistant, Aaron Cooper, fielded numerous requests for interviews with the governor and weighed the benefits through emails.
Two years ago, when a national radio program requested some of the governor's time, Northrup asked Weintz whether it was “worth her getting stressed and prepped.”
Weintz responded: “She said she wanted to do it. It's 6 mins of ObamaCare bashing.”
Prep stress seems to be a recurring theme. In November, when a local television channel requested an interview, Northrup wrote Weintz, “Just depends on what she's doing tonight and how stressed she will be in preparation.”
As the time drew near for Fallin to announce her decisions about Medicaid and exchanges, Weintz wrote up the news release and sent it to a tight group of aides and administration officials for review.
“This is really long … but it is two big issues that we are trying to look thoughtful about so maybe that's ok,” he wrote.