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.