David Montgomery left South Dakota last December for a better job in the Twin Cities. He now gets to report on Gallup numbers showing Minnesota's better rate of uninsured people:

At the beginning of 2014, just 9.5 percent of Minnesotans lacked health insurance, the fourth-best rate in the country. As of the start of 2015, that uninsured rate is now 7.4 percent, 2.1 percentage points lower.

...A previous study, conducted between September 2013 and May 2014 by University of Minnesota researchers, also showed a drop in Minnesota's uninsured rate. It used a different methodology and found the uninsured rate falling from 8.2 percent to 4.9 percent [David Montgomery, "Minnesota's Uninsured Rate Falls, Says Survey," Pioneer Press, 2015.02.24].

The uninsured rate in South Dakota dropped from 14.0% to 12.7%. Minnesota embraced the Affordable Care Act by implementing their MNSure state health insurance exchange and expanding Medicaid. South Dakota has taken neither action.

Montgomery posits no causation, but Minnesota's Democratic leaders want to give the ACA and MNSure the credit. Those DFL legislators are probably right. Take a look at this graph from Gallup showing the nationwide uninsured rate:

Gallup US uninsured 2014

Climb, climb, climb, fully enact ACA—plummet.

Then look at the Gallup state-by-state uninsured data on which Montgomery bases his report:

Gallup uninsured by state 2014

The uninsured rate went down everywhere in 2014, but the statisticians at Gallup don't hesitate to name the spade that's filling this hole faster:

While a majority of Americans continue to disapprove of the Affordable Care Act, it has clearly had an impact in reducing the uninsured rate in the U.S., which declined to its lowest point in seven years by the last quarter of 2014. This trend could be poised to continue, as 55% of Americans who remain uninsured plan to get health insurance rather than pay a fine.

States that have implemented two of the law's core mechanisms -- Medicaid expansion and state health exchanges -- are seeing a substantially larger drop in the uninsured rate than states that did not take both of these actions. Consequently, the gap in uninsured rates that existed between these two groups in 2013 nearly doubled in 2014 [Dan Witters, "Arkansas, Kentucky See Most Improvement in Uninsured Rates," Gallup, 2015.02].

The ACA is working. South Dakota should get over its Obamaphobia and help the ACA work.

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Thousands of South Dakotans are paying the price for Governor Dennis Daugaard's and the SDGOP's intransigent opposition to expanding Medicaid under the Affordable Care Act. We are all paying the cost of turning away hundreds of millions of dollars of economic stimulus that the ACA Medicaid expansion would bring our state.

Governor Daugaard is imposing additional costs on the thousands of South Dakotans who are buying insurance on the federal health insurance exchange. States could go four ways to set up ACA marketplaces: active purchaser, open clearinghouse (Minnesota's MNSure), federal partnership, or totally federal (the South Dakota model, in which we do nothing and leave all the work to Uncle Sam).

A new study in Health Affairs shows that the Minnesota model, the state-run clearinghouse, is offering customers lower premiums than the federal exchange:

Using publicly available premium data and other sources, Health Affairs found state-based clearinghouse models had lower premiums compared with active-purchaser states, partnership states and federally-facilitated states. The journal found no difference between federally faciliated exchanges and federal partnership exchanges.

Policies from all exchanges come in four levels, with the lower ones costing less in monthly premiums with higher cost-sharing when someone seeks medical care. The lowest is bronze, followed by silver, gold and platinum, which Health Affairs didn’t score because of inconsistencies in availability.

The lowest-cost bronze plans in state-based clearinghouses average $157.53 per month versus $179.49 in active-purchaser states; $196.92 compared with $225.37 for the lowest-cost silver plans; $205.30 versus $245.27 for the second lowest silver plan; and $233.96 compared with $266.91 for the lowest-cost gold plan.

Looking at differences between clearinghouse states and federal exchange states, the lowest-cost silver plan was $196.92 compared with $229.87 in partnership exchanges and $224.02 in federally facilitated exchanges [Chris Kardish, "Which health Exchanges Have the Lowest Premiums?" Governing, 2015.01.07].

Generally, the Minnesota model saves customers over $300 a year compared with the South Dakota surrender.

Governor Dennis Daugaard may think the Affordable Care Act is a lemon, but he could try a little harder to make some lemonade.

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If we were making a list of the top ten stories that did not happen in 2014, we'd probably want to include the fact that the full implementation of the Affordable Care Act did not lead to the collapse of the Constitution and a Marxist takeover in Washington, D.C. The Affordable Care Act simply started helping a few million people pay for their health insurance while helping millions more keep insurance that, a few years ago, insurers would have eagerly taken away to protect their bottom lines.

KELO-TV reports that more than 8,800 South Dakotans have signed up so far in the second open enrollment period on HealthCare.gov, the federal health insurance exchange. That's about 1% of the state. A similar proportion of Minnesotans (59,000 as of last Friday) have signed up for insurance on MNSure, the state-run exchange.

Health and Human Services' December enrollment report shows that out of 4.38 million applicants determined to be eligible to buy insurance on the federal exchange, 3.56 million, 81%, are eligible to receive financial assistance in the form of the premium tax credit. (The percentage is about the same in South Dakota.) Most folks who carried exchange insurance this year have already received that credit—or, more accurately, their insurance companies have already received that credit. When they signed up in 2013 for coverage in 2014, exchange customers provided an estimate of their income for 2014. HealthCare.gov calculated the premium tax credit based on that estimate and, in most cases, sent that money straight to the insurance provider, allowing the customer to pay the lower premium up front. Customers could choose to pay the full premium and reclaim the premium tax credit on their 2014 tax return when they file in the next few months. But most people have already spent that credit; they'll see the number on some line of their 1040 this tax season, but they'll see it zero out, with adjustments based on any difference between the income they estimated when they bought their exchange insurance last year and what they actually earned in 2014. Tax preparers, study up!

Those millions of Americans receiving premium tax credits could get grinched by the selfish conservatives who are suing to overturn the credit for customers of the federal exchange. The Supreme Court hears King v. Burwell on March 4 and probably won't rule until the end of June. Still, if you got a premium tax credit, it wouldn't hurt to file your taxes early and make sure your refund is in your pocket before the Roberts gang has its say... just in case!

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An eager reader reminds me that the Supreme Court has agreed to hear King v. Burwell, the selfish conservative effort to sabotage of the premium tax credits offered under the Affordable Care Act. (Recall that King v. Burwell was the case the federal government won in circuit court. Companion case Halbig v. Burwell, which selfish conservative jerks won, was vacated and will be heard by the full Fourth Circuit this week.) At stake is nothing less than exploding costs for policyholders and chaos in the health insurance market in the 36 states that have not set up their own health insurance exchanges:

If the IRS rule is invalidated — and absent effective contingency planning — a state that has declined to create its own exchange probably won't be able to stave off the immediate destabilization of its insurance market. The Court will probably release its opinion in late June; its decision will take effect 25 days later. At that point, if the challengers prevail, the U.S. Treasury will probably have to stop issuing tax credits to users of federal exchanges. Enrollees who are unable or unwilling to pay the full cost of their insurance premiums could see their coverage terminated, perhaps as soon as 30 days after they fail to make a payment. Those who retain insurance are likely to be sicker than those who drop coverage, which will skew the risk pools and expose insurers to large, unanticipated losses [Nicholas Bagley, David K. Jones, and Timothy Stoltzfus Jost, "Predicting the Fallout from King v. Burwell—Exchanges and the ACA," New England Journal of Medicine, 2014.12.10].

Republicans could nudge the Court closer to impaling the ACA on its own wording by crafting real replacement legislation to minimize the impact of overturning King v. Burwell. Republicans may slobber over the prospect of killing Obamacare, but they surely don't want to price millions of Americans out of their health insurance and hit their insurance company friends with heavy losses.

A good Supreme Court, however, will not let any political maneuvers push it closer to a naked political power play and a ridiculous ruling against the common good.

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Regrets? Ha! Thanks to the Affordable Care Act, South Dakota just saved $9.1 million.

Because of the failure of the free market, South Dakota created a high risk pool in 2003 to provide health insurance for people the death panels private insurers wouldn't insure. By eliminating the right of insurers to refuse coverage to folks with pre-existing conditions, the Affordable Care Act rendered high risk pools superfluous. South Dakota stopped taking applicants to the high risk pool on January 1, 2014; we pull the plug on our program at the end of this fiscal year.

Governor Daugaard is thus able to include this line in his proposed budget:

Decreases of $450,965 in federal fund expenditure authority and $9,060,356 in other fund expenditure authority are due to the end of the Risk Pool [South Dakota Bureau of Finance and Management, "Summary of Recommended Budget Adjustments," 2014.12.02].

From that $9,060,356 in state savings, Governor is asking for $2.42 million in one-time money to salt the general fund.

Gordon Howie, keep your pen ready: in March, when the Legislature passes this budget, every legislator who supports this one-time money will be casting one more vote in favor of the Affordable Care Act, which is saving South Dakota millions of dollars. Thank you, Mr. President!

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As the federal health insurance exchange launches its open enrollment period, the New York Times reports that the private insurers participating in the exchange may be jacking up their rates by as much as 20%. Policyholders wanting to keep their premiums down will have spend their valuable time shopping around, comparing deductibles, benefits, and provider networks. And this differs from the pre-Affordable Care Act system how?

NYT's Upshot finds one important difference—lower premium increases than pre-ACA averages:

That competitive pressure appears to be working in most markets, andparticularly in large cities. Over all, we found that if you compared the cheapest plan in the most popular category from 2014 with the cheapest plan in that same category for 2015, the price rose modestly, by 3.4 percent.For comparison, price increases in the individual market before the Affordable Care Act were in the neighborhood of 10 percent a year, and premiums for employer plans grew by 3 percent last year.

But people who just stay in the plan that was cheapest — and most popular — in 2014 are looking at much bigger increases. The average rate increase for those plans across the country is 9.7 percent [Margot Sanger-Katz and Amanda Cox, "Why Shopping Is So Important in Health Enrollment," New York Times: The Upshot, 2014.11.14].

You shop, you save. You cruise, you lose.

Competition matters: NYT finds the premium hikes are sharpest in places with fewer insurers participating in the exchange. Ah, competition—how much nicer it would be if the federal government would add some competition to the program by implementing the public option of Medicare for Everyone. Yes, Medicare, solid, reliable insurance with the least overhead and coverage pretty much everywhere—why aren't we enhancing the competition we already see working under the ACA?

Gallup finds another important difference between policies on the exchange and other insurance. In a survey conducted over the last three weeks, Gallup finds that folks who bought policies through the exchanges are about as satisfied with their insurance as folks who get coverage elsewhere, but exchange participants are more satisfied with the cost of their policies. I assume Gallup will survey that satisfaction again after this open enrollment period.

Premiums aren't going up everywhere. Most South Dakota counties will see cheaper plans on the exchange. According to this NYT interactive map, the cheapest silver plans out in West River will cost $46 less per month, a 15.2% drop. A slaunchwise tier of East River counties from Sully to Yankton will see a $31 decrease, down 10.9%. The rest of East River sees the lowest premium stay about the same or creep up a two to five bucks. South Dakota has the same three providers this year: Avera, Sanford, and Dakotacare.

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Rep. Kevin Killer is fighting for re-election in District 27. He's leading the mighty get-out-the-vote charge on the Pine Ridge Reservation that could tip the balance in the U.S. Senate race.

And on top of that, he's proposing a big tribal sovereignty idea: let South Dakota's tribes leapfrog the state and set up their own health insurance exchange and expansion!

“If I am re-elected I plan on introducing a bill that would ask the state to delegate their authority to tribes on the reservation under the Affordable Care Act and allow for tribes to set up their own healthcare exchanges and to expand Medicaid to tribal citizens,” said Killer.

...“If the state of South Dakota wants to opt out of certain parts of the Affordable Care Act based of principle that is their right. What I want to do is to allow for tribes to partner with each other to set up these exchanges to help with economic development and to provide coverage to their members,” said Killer [Brandon Ecoffey, "Indian Lawmaker Kevin Killer Makes Big Plans," Indianz.com, 2014.10.27].

But what about the Indian Health Service? Ecoffey explains that Congress has hamstrung the IHS and Bureau of Indian Affairs budgets, leaving tribes reaching for alternatives. Medicaid and private insurance revenue can keep IHS facilities running. Plus, IHS doesn't cover everything that Medicaid and private insurance do. Let the tribes extend those benefits, and tribal members get access to better health care.

But would our ACA-averse Republican Legislature let the tribes exercise their sovereignty to take advantage of federal services that the SDGOP has denied the rest of South Dakota?

It sounds like a heck of an idea, Rep. Killer! I look forward to your testing your colleagues' commitment to tribal sovereignty and health care this winter.

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South Dakota Magazine continues to live dangerously, allowing me to grace its genteel online pages with my political polemics. This week I offer my Leftist voting guide for the 2014 general election.

On candidates, I offer one simple criterion: check the one-party regime in Pierre by electing qualified alternatives to Republicans wherever possible. No surprise there. I offer a few more specifics about the application of that criterion in South Dakota Magazine.

On the three ballot measures, I offer the following advice:

Initiated Measure 17, requiring health insurers to include any willing and qualified provider in their networks: Opponents have characterized IM 17 as “another mandate with more government control over health care.” However, IM 17 doesn't lay a mandate on anyone other than insurers, who have to accept any physician who meets their standards into their networks. You, Mr. and Ms. South Dakota, get more control over which doctor you see. IM 17 may save you money and a trip to Sioux Falls. Vote YES.

Initiated Measure 18, raising South Dakota's minimum wage: The labor and liberty of even the lowest-skilled worker is worth more than $7.25 an hour. Be moral, help workers pay their bills, and stimulate the economy. Vote YES.

Amendment Q, allowing roulette, keno, and craps in Deadwood: No part of a noble constitution should include the word crap. Schoolkids will giggle. Besides, I hear the high-rollers from Asia want to play baccarat. Send this amendment back to the drafters and demand an amendment giving this picayune authority to the Legislature. Vote NO [Cory Allen Heidelberger, "The Leftist's Guide to Election 2014," South Dakota Magazine, 2014.10.29].

I'm not convinced liberty hangs in the balance on Amendment Q. But the other issues and candidates on the ballot offer you real chances to improve economic security, liberty, and governmental integrity for lots of South Dakotans.

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