TAHLEQUAH — The Patient Protection and Affordable Care Act is being phased in across the country, providing millions of uninsured Americans the opportunity to participate in plans, and low-cost or no-cost preventive care to millions more.

Oklahoma is one of several states protesting the federal law, and the state has yet to set up an insurance exchange for its citizens, as required by PPACA.

Recently, Oklahoma Attorney General Scott Pruitt amended a federal lawsuit against PPACA, challenging procedures created to help implement the new law and the impact it will have on Oklahomans.

According to a report by the Associated Press, Pruitt, a former Republican state senator and frequent critic of President Barack Obama’s policies, said the state’s amended petition makes it the only active lawsuit challenging PPACA that seeks to hold the government accountable in how it implements the law.

“Now that the Supreme Court has deemed the ACA a tax, and therefore constitutional, the federal government must follow the law and proper procedures, and that is not being done,” Pruitt said in a statement.

The amended complaint challenges a new Internal Revenue Service Rule that will help implement the law, and seeks recognition that the state’s constitution protects citizens from mandated purchases of health care.

State legislators return to work Tuesday, Jan. 8. Some have taken a wait-and-see attitude toward implementing PPACA, pending the November elections.

Rep. Mike Brown, D-Tahlequah, said the governor has gambled on the health care law in the past and failed.

“Last session, I was under the understanding from Speaker [Kris] Steele that some form of a state health care exchange would be set up; however, political pressures seemed to have pushed hard enough to disrupt the plan,” said Brown. “For purely political purposes, Gov. [Mary] Fallin flip-flopped on her decision to accept federal dollars for the state exchange, which at the time she said we were lucky to receive. She refused these dollars and refrained from making any other effort to be in federal compliance [with PPACA]. So, here we are now – our state is short $54 million. The gamble that the U.S. Supreme Court would overturn [PPACA] failed, and now I hope our governor doesn’t gamble on Attorney General Scott Pruitt’s lone lawsuit against the federal government. It’s time to sit down and start working on some form of health care exchange that helps cut health care costs and expands access at affordable rates to all Oklahomans.”

Sen. Jim Wilson, D-Tahlequah, has term-limited out of office, but continues to follow the PPACA debate.

“I’m disappointed that AG Scott Pruitt is continuing to fight against ACA,” said Wilson. “Even Mitt Romney has backed off repeal. He’s suggested that everyone currently gets health care – at least through the emergency room. Of course, uninsured people entering the health care system for trauma have a 50 percent higher probability of dying. ACA fixes this.”

If the state fails to set up an insurance exchange, the federal government will step in and set one up for the state.

“And we’re probably better off that way,” said Wilson. “We did pass a law allowing interstate insurance activity, but put no minimum guidelines in it as required by ACA. Without guidelines, people may think they have insurance, but find it deficient.”

Wilson said despite what some may think, the state can afford to pay its share for PPACA, including the expansion of Medicare and Medicaid.

“Not only can we afford ACA, we have to stop the current insanity,” said Wilson. “I gladly spend a significant amount of time trying to get access to health care for severely ill people without insurance. ACA fixes this. Seventy percent of people who file bankruptcy because of medical bills have insurance – ACA helps prevent this.”

According to Wilson, in Oklahoma, private insurance collects about $4.5 billion in premiums, or 18 percent of the state’s health care cost. Collectively, Oklahomans spend about $25 billion annually on health care.

“The point is, the taxpayers are directly or indirectly picking up the remaining 82 percent,” said Wilson. “Insurance companies, under Oklahoma law, are allowed to spend as little as 60 percent of premium dollars on health care, with the rest going to administrative overhead. Medicare’s overhead is less than 2 percent, while Medicaid’s is between 5 and 6 percent. In addition, insurance companies pay hospitals 43 percent more than Medicare, and pay other providers 25 percent more than Medicare.”

Wilson said people should consider the cost to their families of inefficient health care delivery, excessive insurance profits and loss of disposable income because of health care inflation.

“Even if their employer is paying for health insurance, the current average cost is $15,700 for a family plan with another $4,300 out of pocket,” said Wilson. “That’s money that can’t be used for a pay raise or other expenses. About $4,000 of that for a family of four goes to care for the uninsured – whether is justified or not. Some blame the cost on tort – so we passed tort reform three years ago and the cost has continued to escalate. ACA recognizes the system is broken. It recognizes there are too many errors, too little access, many poor outcomes and too much cost. It also recognizes that state and local policymakers have no desire to fix it – or even admit there’s a problem.”

Wilson said he thinks Fallin will implement changes required by ACA to Medicaid.

“I hate to surprise anyone, [but] we have politicians in Oklahoma who pander to insurance companies and providers at the expense of their constituents,” said Wilson. “I fully believe the governor will again try to implement the Medicaid changes, because it’s the right thing to do and doesn’t cost the state any money, [but] politically, she’ll take a beating. The legislators will probably resist because they’ve spent so much energy telling everyone who will listen how bad access to health care is. I expect there will be some spin to make it look like we were forced against our will – had no choice – but have to do it.”

Rep. Doug Cox, R-Grove, is  an emergency room physician, and said he plans to introduce legislation that will help set up a network of primary-care practices.

“[This network] will implement quality improvement measures, help control costs, and most important of all, improve the health of our state,” said Cox.

“I have been working with Dr. Jim Mold at OU Health Science Center, who has received a federal grant to design our state plan. This plan is important for our state with our without the ACA. It implements many of the measures that ACA addresses. It is a very complicated read, but I am in the process of distilling it down to a short summary that will make sense to nonmedical folks.”

Cox said Oklahomans should be prepared to accept the federal health care law, but that it will most likely undergo a number of changes.

“I feel, regardless of who wins the elections, that while ACA may be modified, it is not going away, and Oklahoma must be prepared to follow the federal law,” said Cox.

“My constituents are adamantly opposed to the ACA, which they call ‘Obamacare.’ In my opinion, their opposition is based on political spin and rhetoric, rather than a true understanding of this voluminous, complicated legislation. [They] are concerned about costs not only to the state, but our nation as a whole, and many have expressed a desire that we wait and see what happens with the results of the November election, the fate of the ACA, how Congress and the White House handle the ‘fiscal cliff.’”

Like Brown and Wilson, Cox believes the state can afford to implement the ACA as it’s written, at least in the beginning.

“Feds pick up the cost initially, and then the state covers 10 percent,” said Cox. “The big question is what guarantee is there that the feds will not eventually start shifting more of the costs to the states as they face a looming federal budget crisis? We can certainly not afford a greater share of the costs without sacrificing education and infrastructure funding.”