Could Medicaid expansion happen this year? South Dakota has already given up two of the best years of the federal government's offer under the Affordable Care Act to cover most of the cost of putting 48,000 low-income South Dakotans on affordable public health insurance. But John Tsitrian notices that Governor Dennis Daugaard is hinting at a shift from his ideological excuses to an openness to accepting some form of the Medicaid expansion.

And Democrats are working hard to make that possible. AP reports that our man Bernie (that's Senator Hunhoff, D-18/Yankton) is working behind the scenes with health care providers to bring some sort of Medicaid expansion to South Dakota.

Hmm... just a thought: if health care philanthropist T. Denny Sanford can kick in $25 million to match state funds and launch Governor Daugaard's scholarships for welders, might we be able to persuade Sanford to spend a fraction of that money each year to bring hundreds of millions in the Medicaid economic stimulus to South Dakota?

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Governor Dennis Daugaard is lining up millions of dollars to expand vo-tech scholarships and railroads. He still hasn't announced his willingness to spend a fraction of such money to expand Medicaid.

Alaska's new Independent Governor Bill Walker is not so blind:

...for Walker, it's a no-brainer: Around 40,000 low-income Alaskans would receive health benefits under Medicaid expansion; most of those affected would be childless adults. The federal government would pay 100 percent of the costs until the end of 2016, and after that the state's share would only slowly increase to 10 percent by 2020.

Plus, Walker points out, Alaskans already pay taxes that fund the expansion.

"I always will default back to what is best for Alaskans," he says, "and it's best for Alaskans to have the health care coverage we've already paid for" [Annie Feidt, "Alaska's Governor Eager to Expand Medicaid," NPR, 2014.12.16].

Tennessee's Republican Governor Bill Haslam is at least working with the feds to create a Medicaid expansion alternative:

The plan would provide two private-market choices that would make payments to providers based on outcomes and give participants incentives to take personal responsibility for their health. The goal: to have participants make a transition eventually to commercial health coverage.

The Healthy Incentives Plan would be a redesigned part of the state's Medicaid program. The Volunteer Plan would issue vouchers to be used to offset expenses in the health insurance plans of participants' employers [David Boucher, "Tennessee's GOP Gov to Expand Medicaid Program," USA Today, 2014.12.15].

Alaska's Walker and Tennessee's Haslam join the majority of governors who have figured out that accepting federal dollars to provide more citizens health insurance is a good idea. Governor Daugaard, get off your political high horse and do the right thing.

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How does a practical Republican react to an underperforming state economy and Governor Dennis Daugaard's blasé budget proposal? John Tsitrian says drop the political posturing, prioritize practical economics, and expand Medicaid:

Given Daugaard's cautiously reactive tone when discussing the upcoming budget, I wondered why our Governor couldn't be a bit more pro-active in his approach to energizing the economy. Daugaard is either overlooking or ignoring an obvious boost to our near-static growth rates--Medicaid expansion.

...[C]onsider the total outlays by SD through 2022 vs. the revenues from the federal government: SD pays out $157 million and gets back $2.1 billion, yes billion with a "b." Are we as a state too stupid to grasp what a good deal this is? [John Tsitrian, "With SD's Economy Drifting into the Doldrums, Expanding medicaid Makes More Sense than Ever," The Constant Commoner, 2014.12.11]

Even if you think the Affordable Care Act won't last, it's time to get out the Mickelson bucket and catch some of that federal money while it's raining.

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South Dakota is spending less money on Medicaid than expected this fiscal year. Whether this unexpected underspending is related to the record low rate of growth of health care spending under the Obama Administration is open to discussion. Whatever the cause, Governor Dennis Daugaard has proposed amending the FY 2015 budget to reduce Medicaid funding by $2.648 million.

Those lower-than-expected Medicaid expenditures are part of $11.8 million in budget savings Governor Daugaard says we can write into our current budget. Those savings neatly cover the $10.8 million in lower-than-expected state revenues for this year. But the Governor is also proposing $26.1 million in new "emergency" expenditures that will go on the FY 2015 budget. The biggest chunk of that emergency money will come from cashing out a $16-million Medicaid reserve fund that Daugaard created earlier but now says is unnecessary.

Nowhere in Governor Daugaard's emergency expenditures or FY 2016 budget is a proposal to expand Medicaid, which in the coming budget year would cost us $2.1 million, or just an eighth of the Medicaid reserve fund that the Governor is spending on other projects. As the federal cost share drops from 100% to 90%, Medicaid expansion would cost South Dakota $38.6 million a year by 2020, but the billion-plus we'd get from Uncle Sam over a decade of expansion would create 29,500 jobs, boost our economy, and add tens of millions to our tax receipts. (Oh yeah, and we would save lives.)

Governor Dennis Daugaard has over $18 million he could use as a down payment on Medicaid expansion, one of the biggest, easiest health and economic stimulus programs he could enact. Legislators, let's turn the budget ship in that direction.

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Here's the tough call of the morning. Jonathan Ellis reports that South Dakota implemented a new rule on September 1 requiring Medicaid patients to get authorization from the state to seek medical treatment more than 50 miles from South Dakota (with the exception of folks headed to Bismarck for service, which makes perfect sense for folks all along lonely Highway 12). The rule is a reasonable cost check, used by many states as well as private insurers. The state hasn't been wielding it too avidly: Ellis says in the first two months of the rule, the Department of Social Services denied only 14 of 483 requests for out-state care.

Enter Nicole Cook, 31, mom of six, from Madison:

Cook originally went to Mayo in August after repeated doctor and hospital visits in Madison and Sioux Falls, she said. She was rapidly losing weight, was exhausted and in pain.

Testing at Mayo determined that she has a lung tumor, scarring in her lungs, bone lesions and other health problems. She was scheduled to return to Mayo in October with the hope that doctors there could find a cause for her maladies.

But this time, she was unable to go because the Department of Social Services would not authorize payment for the visit [Jonathan Ellis, "Medicaid Rule Drives Woman from S.D.," that Sioux Falls paper, 2014.12.01].

Cook says the state says South Dakota doctors can provide the care Cook needs. But South Dakota doctors evidently couldn't provide the diagnosis Cook needed. Nicole's husband Ryan says on his fundraising page that Nicole's local doctor actually dropped her, saying her case is too complex for him. One can thus understand her lack of confidence in her local docs and her preference to seek treatment from the Mayo docs. According to Ellis, Cook's Sioux Falls doctors are recommending Mayo for treatment.

But who gets to pick the piper: the patient or the payer? Cook or us, the taxpayers?

Cook is relieving us of that choice. She is moving to Minnesota and applying for Medical Assistance. As far as I can tell, Minnesota has no rules against moving primarily to qualify for public benefits. Minnesota's residency rules say that once she's physically present in the state and made clear her intention to stick around, she can qualify.

So how do we feel, South Dakota, about driving away someone who needs help?

p.s.: Cook's fundraising page shows about $4,800 raised toward a $150,000 goal. Please don't tell me that private fundraising is an effective way to pay for everyone's medical bills.

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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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That Sioux Falls paper is dribbling out a new Mason-Dixon poll that finds South Dakotans want to expand Medicaid under the Affordable Care Act. The poll finds 45% in favor, 37% against. Hey, if that margin is enough to elect a U.S. Senator, it should be enough to make a policy decision.

That's a remarkable drop from a January 2014 poll, conducted by GOP pollster Glen Bolger, that found 63% of South Dakotans favoring the Medicaid expansion. Perhaps so close to an election, a large chunk of voters can't help noticing the cognitive dissonance between their thoughtful values and their ingrained, automatic, inertial reach for the "R" on the ballot, and they resolve that psychic tension by following their leaders. Sigh.

Jon Walker's report notes that fiscally, the numbers add up in Susan Wismer's favor:

Susan Wismer, the Democratic candidate for governor, said the state is leaving a fortune on the table by dragging its feet on expansion. Wismer, a state legislator from Britton, argued in a debate in August that South Dakota hospitals are losing more than $250 million a year from federal money that would flow into the health care system if Medicaid were expanded here. Daugaard said in the same debate that expansion would be a new $95 million burden on the state budget from 2017 to 2020 [Jon Walker, "Poll: More S.D. Voters Back Medicaid Expansion," that Sioux Falls paper, 2014.10.25].

Notice that even reaching out for four years of budget impact doesn't come close to beating one year of the fiscal boost South Dakota would get from Medicaid expansion. Let Governor Daugaard have all the "No more free stuff for poor people!" voters quoted in Walker's report (one from her lofty perch at Dakota Dunes). Even the modest support shown in the Mason-Dixon poll is one more bit of evidence that South Dakotans would elect Democrats if they integrated their policy thinking into their voting.

Related Reading:

  1. The lagging Republican Senate candidate in North Carolina is U-turning his position to welcome the Medicaid expansion.
  2. The only problem with Nevada's expansion is a doctor shortage and a high percentage of already scarce doctors refusing to see Medicaid patients (because, you know, health is for the rich, kind of like how I should only teach kids whose families are big tippers).
  3. Republican Ohio Governor John Kasich still wants to repeal the Affordable Care Act, but not the Medicaid expansion. Kasich told AP the opposition to Medicaid expansion in the Ohio statehouse "was really either political or ideological.... I don’t think that holds water against real flesh and blood, and real improvements in people’s lives."
  4. In nine states that have expanded Medicaid under the ACA and where Democratic governors face strong Republican challengers, none of those GOP challengers have advocated repeal of the ACA's Medicaid expansion.
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The Affordable Care Act is improving and saving lives by expanding Medicaid:

Charles McClinon, a 50-year-old Ohio resident who lives with epilepsy, told ThinkProgress, “The peace of mind is worth more than anything. I could be a millionaire, but if I don’t have peace of mind, what good is it? And that’s one thing this type of insurance is good for. I know I can get the kind of care I need.”

In 2010, McClinon’s epileptic seizures intensified, making it too difficult for him to hold down a job or complete the university classes in which he was enrolled in at the time. To make matters worse, his student health policy dropped him under a pre-existing condition clause. After that, McClinon struggled to afford the treatment he needed, especially after his medications started to give him debilitating side effects. He eventually became homeless.

After Ohio’s governor became one of the first Republican leaders to accept the Medicaid expansion, however, McClinon gained coverage in February. He can now afford the multiple medications he needs to manage his condition — and this summer, he also had a cutting-edge surgery that will hopefully prevent his seizures and eliminate the need for all the drugs he currently takes. Thanks to his Medicaid coverage, he didn’t have to pay for that procedure out of his own pocket.

McClinon, who worked his whole life before his seizures worsened, is looking forward to feeling like his old self again. “It’s not even just about medical care — it’s also been helpful for me on the mental health side,” McClinon said, referring to his newfound peace of mind. “I don’t know what I would have done if I lived in another state” [Tara Culp-Ressler, "Meet The People Whose Lives Have Been Transformed By Medicaid Expansion," ThinkProgress, 2014.10.16].

Read Culp-Ressler's full article, then remind why anyone is voting for the South Dakota Republicans like Mike Rounds, Kristi Noem, and Dennis Daugaard who want to take such health and peace of mind away from their fellow South Dakotans.

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