OKLAHOMA CITY (AP) -- Looming decisions for Gov. Mary Fallin on how Oklahoma will respond to the sweeping federal health care law are prompting an energetic, behind-the-scenes lobbying effort by hospitals, insurance companies, business and industry groups, and other constituencies that will be affected by provisions of the law.
Fallin is expected to announce within the next week her position on whether the state will move ahead with setting up a state-based online health insurance marketplace, or exchange, required under the law. Oklahoma policymakers also must decide whether the state will expand its Medicaid eligibility to provide coverage to thousands of low-income, uninsured citizens.
Fallin has yet to stake out a position on either proposal and faces a delicate political balancing act in a state where Republicans have bitterly resisted the requirements of the new federal health care law. On the one hand, hospital officials and chamber groups are pushing for both a state-based exchange and an expansion of Medicaid. But both of those ideas are fiercely opposed by tea party and other grass-roots activists who have been fighting implementation of the law since its passage in 2010.
"It's a real challenge for the governor because what it's done is put her right in between two major constituent groups inside the Republican Party," said Keith Gaddie, a professor of political science at the University of Oklahoma.
The Tulsa Metro Chamber, which represents more than 3,000 members, is among those lobbying the governor to support both a state-operated insurance exchange and an expansion of Medicaid.
"Certainly health care is one of the two largest employment sectors in Tulsa, so we're very cognizant of the jobs health care provides in our community," said Susan Harris, a senior vice president at the chamber who works on health policy. "Also, we need a healthy workforce. Healthy workers get better jobs, make more money and take care of themselves. It's better for the whole community if we've got a healthy workforce."
Fallin herself opposed the law when she was a member of Congress and even dangled a "Don't Tread on Me" flag before a tea party rally at the U.S. Capitol during the health care debate in 2010. Fallin and other Republican leaders initially hoped the U.S. Supreme Court would overturn the law, and when that didn't happen, she withheld a decision on whether to proceed until after the election, hoping Mitt Romney would be elected and either help overturn or the slow the implementation.
Oklahoma was among the states that over the law, and even after the Supreme Court's decision, Attorney General Scott Pruitt amended his lawsuit to challenge its implementation of the law.
"There is political risk in quitting resistance, but after you fail three times you really have to reassess whether or not you're going to prevail in this fight," Gaddie said. "At some point you just have to leave the battlefield and go home."
Fallin spokesman Alex Weintz said Friday the governor is still exploring the state's option as they relate to both the creation of a state exchange and the expansion of Medicaid.
"We feel like we have kept, as of right now, the doors open for the state of Oklahoma to pursue whatever we decide is the best option for our citizens," Weintz said. "We don't feel like anything has been ruled out, simply because of time restraints, at this time."
States initially had until Nov. 16 to provide federal officials with a blueprint for how the state-based exchange would work, but Health and Human Services Secretary Kathleen Sebelius said in a letter to governors Friday that they have another month, until mid-December, to submit detailed plans. Sebelius noted that she still wants to hear by the end of next week if states plan to set up a state exchange. States that don't will have a federal exchange operated for them.
Nearly 20 percent of Oklahoma citizens currently are uninsured, and an expansion of Medicaid to 133 percent of the federal poverty level would make an additional 180,000 adults eligible for Medicaid, according to the Oklahoma Hospital Association, one of the groups pushing Fallin to support the Medicaid expansion.
State health officials estimate such an expansion would result in more than $1.5 billion in federal funding to the state during the first three years when the federal government picks up the full cost of the expansion. The state's share would grow to 10 percent of the cost by 2020, which would amount to about $56 million, according to estimates from the Oklahoma Health Care Authority.
But those federal and state costs are why the Medicaid expansion is being opposed by conservative activists and Republican U.S. Sen. Tom Coburn, Oklahoma's junior senator who has railed against increased federal spending.
"I do believe our state Medicaid's program can help Oklahomans who qualify for the program," Coburn wrote in a letter to Fallin last month urging her to reject the Medicaid expansion. "But at a time when our national debt is $16 trillion and Congress is running trillion-dollar annual deficits, it is unlikely that federal promises of stable Medicaid funding are anything more than a mirage."
Sean Murphy can be reached at www.twitter.com/apseanmurphy