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.