Now that Gov. Mary Fallin has rejected the Obama administration's Medicaid expansion proposal, she has asked Health Commissioner Terry Cline to help her devise an “Oklahoma solution” for addressing the state's health needs.
In an interview at the University of Oklahoma Health Sciences Center, Cline discussed why state officials said no to Washington, why Oklahoma ranks near the bottom of many health indexes, and why he's ready to take on tobacco industry lobbyists when the Legislature convenes this month.
An Ardmore native, Cline has a doctorate in clinical psychology and served as President George W. Bush's director of the Substance Abuse and Mental Health Services Administration. He also is Fallin's secretary of health and human services.
Q: Why did the state turn down the Obama administration's Medicaid expansion?
A: There are people who say our health care system is a sick care system. That's the way it's structured. All of our money is going into that. If we just expand our current system, it doesn't solve the problem.
Let me give you an example. We're sitting here in the Health Sciences Center. We have the highest concentration of health care in the state of Oklahoma all around us … hundreds of doctors, hundreds of nurses, numerous hospitals. Anyone can access services here because it's a sliding-scale fee. This is a teaching hospital environment. It's already being subsidized by the state.
But if we go two blocks over, I can show you some of the worst health outcomes in the entire state. Two blocks. The infant mortality rate is twice as high as it is two miles in the other direction. If the answer is just increasing access to health care, then why do all these individuals who are living within walking distance have the worst health outcomes?
I've had my share of medical care, and I'm grateful for that. It's very important. It is one piece of the picture. But right now, it's 99 percent of the funding, and our current expansion discussions don't address the true problems with the system.
All the dollars in our system go to pick up the pieces, and frankly there's not enough money. We're ranked 49th in the country in the number of primary care physicians. If all of a sudden we give everyone in the state an insurance card, is that going to change? Not necessarily.
Q: Did you advise Gov. Fallin to reject the Obama plan?
A: She took advice from a number of individuals. And as she's prone to do, she's looking at the funding that's available to us here in this state.
We had the ability to expand Medicaid five years ago, 10 years ago. There's nothing that would have prohibited us from doing that other than the cost. ... As a state, politically and financially, we decided not to do that. That's consistent.
So what's changed is the deal from the federal government. People think that they can get a free ride. Well, there is no free ride.
We're looking at a “fiscal cliff,” which has yet to be resolved. We have a federal government that everyone acknowledges is on an unsustainable trajectory in terms of the deficit.
Q: Did you concur with the decision she made?
A: I think that's a complex question that has a complex answer. It gets boiled down to simply Medicaid expansion. I think it's a much more complicated answer than that. I can't boil it down to I concur with this or I disagree with that.
The good news in all of this is that there has been more discussion about health and health care than I have ever seen in my entire career. And that's a good thing, because we need to be talking about that. That's the only way we can really begin to change the trends and change the outcomes in this state.
Q: The governor said she would work with you to develop an “Oklahoma solution.” What will that consist of?
A: Only about 10 percent of our overall health is attributable to access to health care; 40 percent is attributable to behaviors.
Public health is at the front end of that. Prevention is better than cure. I'm all for cure, but I'm more enthusiastic about prevention. Prevention will help someone avoid having to deal with an illness altogether.
For example, if we can drive down obesity rates, we're going to be able to drive down the diabetes rate.
With this Oklahoma plan, we have an opportunity to actually create and improve our current system so it really becomes a health care system that's focused on promoting wellness.
Q: Why does Oklahoma rank so low on many health indexes?
A: One of the primary drivers is our use of tobacco. It's the No. 1 preventable cause of death, and we rank 47th. That's a bad place to start.
Many other states have more aggressively protected their citizens. They're ensuring that they have places to go in public that are free of tobacco smoke. Oklahoma has been very reluctant as a state to do that. We actually have a state law on the books that prohibits communities from getting tougher on tobacco ordinances than the state law.
Most state law is meant as a floor … But with smoking, it's actually a ceiling. For example, Oklahoma City cannot decide that it wants to go smoke-free for all indoor public facilities. It's prohibited by law. We're one of only two states left in the nation that has this level of prohibition or pre-emption. Tennessee is the other state.
Q: Have you asked the Legislature to change that?
A: We have. Two years ago, we couldn't even get it heard in committee. Last year, it passed out of the House committee, passed off the House floor, and was sent to the Senate, where it was killed. It didn't receive a hearing in committee, so it wasn't even debated on the Senate side.
There were 12 paid tobacco lobbyists that were working vigorously to kill this bill. Their interest, of course, was keeping the tobacco use rates high in Oklahoma.
Q: What about Oklahoma's high rate of prescription drug abuse?
A: Every year we have between 600 and 700 deaths from the misuse of prescription drugs. We have one of the highest prescription rates for narcotic drugs in the country.
That's a serious issue in our state, and it's something that we can do something about. A task force has been formed. The governor is going to give that a push to really drive some solutions. We really need to have a comprehensive approach to be successful in battling this.
The data shows that the majority of those drugs are actually obtained from other people's medicine cabinets. The No. 1 source is our neighbors and our friends and our own medicine cabinets.
Q: What can the Legislature do?
A: They can make sure there are opportunities for appropriate disposal. If you find that you have a large prescription rate that seems out of keeping with the number of people in the population, the Legislature could limit that either by dose or by quantity. But that gets tricky because you probably don't want the Legislature dictating the scope of medical practices.
We also have a Prescription Monitoring Program that is one of the best in the country … but it's not mandatory. They could make that mandatory.
About Oklahoma Watch
Oklahoma Watch is a nonprofit investigative team established to report on public policy issues in Oklahoma. It is funded by the Ethics and Excellence in Journalism Foundation, the George Kaiser Family Foundation, the John S. and James L. Knight Foundation and the Tulsa Community Foundation.