Mark Trahant
ICT
Millions of dollars are at stake on Nov. 8th when South Dakota voters weigh in on Amendment D, a ballot measure to expand Medicaid.
The big picture is that a “yes” vote for Medicaid expansion in South Dakota would bring millions of new dollars into the state and make healthcare more affordable for everyone. The Center on Budget and Policy Priorities calculates that roughly 42,500 low income people would qualify for health insurance and coverage would start July 23, 2023.
There is another way to gauge what’s at stake for Native people: A Lakota person living in North Dakota who qualifies for Medicaid is likely to get a full range of healthcare services or even referrals to specialists (what the Indian Health Service calls Purchased/Referred Care). That same person, if living in South Dakota, is limited by what’s left in the IHS budget.
Jerilyn Church, Cheyenne River, is the chief executive officer for the Great Plains Tribal Health Board. She says this is still a “huge issue” in South Dakota because there is not enough funding for IHS. But in North Dakota there is another source of money, Medicaid.
“They’re not dealing with those issues,” she said. “They’re seeing patients. Patients are getting referred out at every level.,” she said.
One aspect of that is IHS’ priority one, or “life and limb” policy where the agency will wait to spend funds until the patient’s life is at risk. But in North Dakota “ we’re not seeing the life and limb catastrophe that we still see here in South Dakota,” Church said.
This is exactly what happened in Montana when that state enacted Medicaid expansion. According to the Montana Budget and Policy Center: “Medicaid expansion revenue … enabled IHS facilities to move from a level 1, ‘life or limb’ services prioritization for PRC funds, to a level 4” or a routine level of care. This means the types of patients visits that are financially covered expanded from the likes of knee replacements to accessing behavioral health services.
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South Dakota’s Amendment D would change that and a yes vote would require the state to offer health insurance from Medicaid to adults between 18 and 65 based on their income (A family of four would need to earn less than $38,295 to qualify). Only 12 states have not expanded Medicaid.
“There’s definitely just the difference between states that have Medicaid expansion and those that don’t in terms of just the uninsured rates,” says Laura Harker, a senior policy analyst for the Center on Budget and Policy Priorities. South Dakota’s uninsured rate is higher than almost every state, except Wyoming, which has also not expanded Medicaid. “So that’s a stark difference there.”
Harker said there are some 83,000 people in South Dakota that remain uninsured, about 9.5 percent of the state. Her report says states that expanded Medicaid have seen their uninsured rate drop roughly in half between 2013 and 2019. Most of the South Dakotans who would get coverage are working in low-paid jobs or in industries where hours and earnings are more likely to fluctuate.
“In addition to providing better coverage access to Native communities, Medicaid expansion would provide an important revenue boost for facilities under the Indian Health Service, a historically underfunded federal program,” Harker’s research reported.
That works because the law says dollars from “third party billing” which includes employer health insurance or Medicaid must remain at the clinic.
“So previously under Indian Health Service, any third party billing that was generated, they pretty much had the authority to do with it as they saw fit,” Church said. That likely contributed to a lack of investment in local service units, resulting in people not getting the services that they want. But with Medicaid expansion there would be more money. “We’ll be able to expand our behavioral health, which is the number one need.”
Medicaid expansion would also boost spending for urban Indian health programs.
“So this will make a big difference for their communities as well,” Church said. “The urban programs don’t have PRC (purchased-referred care). So the families that are living in urban environments end up, you know, carrying the responsibility for that.” She said too many people won’t get care without insurance. So Medicaid expansion “will make a direct impact on people’s well-being and their overall health in the long run.”
Native Americans make up 30 percent of South Dakota’s uninsured population (compared to 8 percent of state residents).
In addition to Native communities, the Center on Budget and Policy Priorities found that rural health care will also benefit from Medicaid expansion.
“An evaluation conducted in 2022 found that people in rural areas in Montana saw improved access to behavioral health services, and rural health facilities’ costs declined by over 40 percent,” states South Dakota’s Low-Income Residents, Native Communities, and Budget Could All Soon Benefit From Medicaid Expansion report. “All but two of South Dakota’s 66 counties are rural or frontier and adults in the rural counties are more likely to be uninsured.”
However opponents of Amendment D say future South Dakota budgets will be impacted by the cost of providing low-income people with health insurance.
“Expanding Medicaid shreds our Constitution and expands services to able-bodied adults under ObamaCare,” wrote Americans for Prosperity State Director Keith Moore in the opponent section in the Secretary of State’s official ballot question pamphlet.
One additional factor is the role of the federal government. A fiscal note from the South Dakota Legislative Research Council found that 98 percent of the costs would be covered by the federal government with a total expected savings of $162.5 million covering almost all of the state’s 10 percent share of costs.
“We’re already paying for that Medicaid expansion and in other states that have expanded. We’re paying for other people’s, other states, Medicaid expansion,” Church said. “Let’s get that money back into South Dakota and take care of our own communities.”
She said this is a time for Native people to exercise their votes, their power.
“I was just talking to some of my young relatives, and just expressed how much power they actually have just by going and voting. And if everyone did that, who is eligible to vote, what a difference we could see in South Dakota, not just on Medicaid expansion, but on so many other issues that we struggle with in our communities.”
Mark Trahant, Shoshone-Bannock, is editor-at-large for Indian Country Today. On Twitter: @TrahantReports Trahant is based in Phoenix. The Indigenous Economics Project is funded with a major grant from the Bay and Paul Foundations.