Oklahoma’s Medicaid Expansion Vote Wasn’t As Simple As Urban Versus Rural

Six Oklahoma counties voted for State Question 802, including those home to the state’s largest cities. Map using Oklahoma State Election Board data, compiled by Catherine Sweeney.

Back in June, Oklahoma voted to expand Medicaid through State Question 802. That vote determined that Oklahoma would open its Medicaid program, SoonerCare, to more adults. About 200,000 Oklahomans are expected to qualify for enrollment under Medicaid expansion.

StateImpact Oklahoma’s health reporter, Catherine Sweeney, reports that there was a common misconception immediately after the vote. Those who saw election results broken down by county observed that urban areas, like Oklahoma and Tulsa counties, voted for the measure and rural counties voted against it.

The Oklahoma Policy Institute, a non-profit think tank, did a deep dive into voting trends on State Question 802 and reached the conclusion that the urban versus rural breakdown was a myth. Sweeney interviewed Oklahoma Policy’s Carly Putnam about the institute’s report.

Sweeney: Everybody was talking about how rural voters voted against it. At the precinct level, you could see that there was a lot more variation than there was at the county level. But you guys found, even further, that if you look at the actual votes, it was a lot closer than it might seem. Right?

Putnam: Right. So I think basically what we found was – this is going to sound like a cliche. We found that every vote counted. So complicating that black and white narrative, rural Oklahoma did not overwhelmingly reject it. There were rural Oklahomans who voted in favor of expansion. In three out of four precincts, the margin was less than one hundred votes. And I want to be clear that a lot of those are very small precincts. And so there may not have been a lot of votes to pull from. But even in very small areas, just one or two people making a different choice was enough to significantly affect the outcome.

Sweeney: That’s really interesting. Your story also looked like where people did vote for Medicaid expansion. It looked like tribal areas were pretty in support of it.

Putnam: Yeah, we felt as we were, again, sort of watching the results come in and then the press about the results come in, that one of the stories that really wasn’t being told was the effect that Oklahoma’s American Indians had on this vote. Local tribes have for a long time, I think, been incredibly aware of what Medicaid expansion could do for Oklahoma, both in terms of the health care facilities that the tribes operate. And then also just knowing how important Medicaid is for their members and for the federal trust responsibility for the U.S. to provide health care. And so we thought it was really interesting when we started looking at counties and the share of people who self-reported as being American Indian or Alaska native. There was a pretty significant positive correlation there. In Cherokee County, which is the seat of the Cherokee Nation, State Question 802 passed by more than a thousand votes, which only happened in five other counties. And so we wanted to make sure that when people were sort of shaking out what did or what didn’t work, what the factors were in this campaign, that this was a piece that was being brought into the picture.

Sweeney: Another indicator, it looks like, was income. How did that play into the votes?

Putnam: Yes. So I don’t want to overstate the correlation. It’s not an incredibly strong one, but it is significant that lower income counties were somewhat more likely to vote in favor of expansion than higher income counties, which functionally means that areas that were more likely to benefit or somewhat more inclined to vote for Medicaid expansion. And we’re looking at this really from the perspective of, you know, the narrative is always that people have voted against their own self-interest, which is irritatingly simplistic way of looking at a really complicated issue. One of the things that we wanted to dig into was: To what extent was that true? And it’s not incredibly strong correlation, but it is there.

Sweeney: That makes sense. Were there any other surprises that you guys found or anything that I should’ve thought to ask you about?

Putnam: I just think that I’m really glad that we’re having this conversation. Because it’s not often that we get to talk about nuance in elections. And so to the extent that we can, being able to really emphasize that every single vote counts, I think is really my my top line takeaway from this. And the thing that I’m definitely going to keep in mind as I’m looking at other results in other elections going forward.

This report was produced by Catherine Sweeney for Oklahoma Engaged, an election project among Oklahoma’s NPR member stations with major support from the Inasmuch Foundation and the Kirkpatrick Foundation.