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Dems Working with Docs on Medicaid Expansion; Daugaard Open?

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?


  1. Tim 2015.02.17

    Daugaard has no problem giving away $600 million a year to business, but won't help 48,000 poor people. The people that vote in this state don't seem to have a problem with it either. How sad.

  2. Nick Nemec 2015.02.17

    Daugaard will do nothing.

  3. tara volesky 2015.02.17

    Daugaard will expand Medicaid. He owes his money masters.

  4. mike from iowa 2015.02.17

    How will expansion benefit Rounds?

  5. caheidelberger Post author | 2015.02.17

    Nick, do we need to change his name to Don't-gaard? If the health care providers and Bernie could come up with a plan that would bring those millions from DC to SD without costing the state a penny, would the Governor still say no?

  6. Francie 2015.02.17

    People like Denny Sanford and his sub-prime lending schemes subsidized by the State of South Dakota have probably put some people on Medicaid roles. Him now giving money to those folks would be a waste of perfectly good chicanery on his part.

  7. caheidelberger Post author | 2015.02.17

    Or maybe the big three hospitals need to secede, form their own state, and accept the Medicaid expansion?

  8. rollin potter 2015.02.17

    Cory, you mention SEN. HUNHOFF as our man!!!! Keep an eye out for SEN. HEINERT,D District 26!! HE appears to be a rather intelligent man with an answer who could be a sleeper in the Democratic party if he was pushed and recognized!!!!!!!!

  9. Dicta 2015.02.17

    It's a risky venture, considering Sanford is already on the hook for medicaid expansion lives in North Dakota. Keep in mind, too, that as more and more providers shift to outcomes based reimbursement, Sanford would be saddled with a TON of risk because of the nearly 70k high risk lives it would be on the line for if it took South Dakota as well. I know it's easy to crow "Hurr durr dem corporations only care about there profits," but it might be worth considering what Sanford Health would be putting on the line.

    Nope, you know what, nevermind. Screw it. Let's just make them seem like villains if they do anything we don't want. That's easier.

  10. mike from iowa 2015.02.17

    Dicta finally figured it out.

  11. Nick Nemec 2015.02.17

    Dicta, I'm having a hard time understanding your post. Are you saying Sanford Health picked up the State of North Dakota's cost of expanding Medicaid in that state?

  12. Dicta 2015.02.17

    They are the payor for the medicaid expansion lives, which are high risk lives and could cost them a lot of money.

  13. Nick Nemec 2015.02.17

    Cory, Gov. Don'tgaard will live up to his name and fail to guard the health of South Dakotans and the health of South Dakota's economy, which depends on a healthy workforce and would do better with the injection of $100,000,000 annually.

  14. Nick Nemec 2015.02.17

    Dicta, I'm sorry but I still don't understand what you are saying. Are you saying Sanford Health is picking up the bill in ND? Doesn't the State of ND pay their share of the Medicaid match and the Federal government pays the rest? Sanford Health is just one of the providers, among many, providing the care.

  15. Dicta 2015.02.17

    Sanford Health was selected as the payor (insurance provider) for the medicaid expansion lives. These are traditionally high risk lives because of their tendency to use emergency room care along with higher rates of chronic diseases that are associated with higher re-admission rates. I really don't know how to make it any clearer than that.

  16. Nick Nemec 2015.02.17

    So you're saying the way Medicaid works is that the combined Federal and State Medicaid dollars are used to purchase private health insurance, in this case Sanford Insurance, and then people are covered by the purchased health insurance? Are you sure? I thought Medicaid was similar to Medicare Part A and was its own insurance plan. A person covered by Medicaid goes to provider, provider provides service and bills Medicaid, Medicaid pays provider for service based on previously agreed upon formulary.

  17. Dicta 2015.02.17

    Don't conflate traditional medicaid and medicaid expansion lives. They aren't the same.

  18. Nick Nemec 2015.02.17

    If it is how you are saying, that's news to me, do you have a link describing this? If that's how it is and Sanford Health lowballed their bid in order to get the ND business wouldn't they have an opportunity to rebid next year?

  19. Nick Nemec 2015.02.17

    OK thanks for the link I didn't know that was how it worked. Does it work that way in every state? If the Sanford North Dakota Medicaid Expansion Plan looses money in 2015 can't they adjust their bid next year?

  20. Dicta 2015.02.17

    I am unsure on the terms of the contract between Sanford and the state of North Dakota as far as length is concerned. I know that Blue Cross/Blue Shield of ND is dealing with its own internal issues, which may have played a factor in Sanford capturing those lives. My point is: those lives come with a lot of risk attached to them. Sanford may want the opportunity in South Dakota as well, I don't know. They would have a ton of capital on the line if they did both South and North Dakota, however.

  21. Nick Nemec 2015.02.17

    How are Medicaid and Medicaid expansion lives different? Are you saying Medicaid expansion people are sicker?

  22. Nick Nemec 2015.02.17

    If they are sicker, you don't think Sanford Health properly accounted for that in their bid?

  23. Dicta 2015.02.17

    I am unsure as to how it functions in every state, sorry. I imagine red states that recently expanded, like Indiana for example, are attempting to figure that all out. I get why the state contracted out here, though: just set aside the funding necessary and allow someone else to deal with the risk. This way, your outgoes are much more predictable on an annual basis.

  24. Nick Nemec 2015.02.17

    Isn't that a business decision for Sanford Health, or any other insurance provider to take into consideration when setting their bid? Should we provide some sort of relief from bad business decisions?

  25. Dicta 2015.02.17

    That's the point: Sanford and the state likely reached a point that was agreeable for them both, but that doesn't mean Sanford can't get smoked if it doesn't deal with these lives quickly and intelligently. There is a reason North Dakota outsourced.

  26. Nick Nemec 2015.02.17

    Do you know how many states outsourced and how many stayed in house?

  27. Dicta 2015.02.17

    Bad business decisions? That's the entire point and what kicked off this conversation! I said that I think it would be entirely reasonable for Sanford to avoid dealing with expansion lives in South Dakota, should Daugaard approve it. Sanford is on the hook for what it is on the hook for. As to your question about outsource vs. in house: I don't know. It appears the state of Minnesota has kept it in house if I am reading between the lines correctly. Outside of that, I have no idea.

  28. Nick Nemec 2015.02.17

    And I'm saying if Sanford Health ND looses money on their bid then next year they will have better data on which to base their bid. They're doing the same as any other insurance company underwriting a risk.

    Weather or not Medicaid expansion people are a higher risk than regular Medicaid patients is a question that will be answered in future years when coverage usage data is available.

    Thanks for taking the time to explain some of this to me. I didn't realize ND had gone the private insurance route. Now I'm really interested in the approaches other expansion states have taken. Federalism makes things interesting.

  29. Jenny 2015.02.17

    Nick it's 'loses'. :)

  30. Nick Nemec 2015.02.17

    Yes, sorry.

  31. Dicta 2015.02.17

    What's really weird is the way some states who are working out special medicaid expansion types due to politics (see the recent arrivals and what Pennsylvania seemed to have before the new democratic governor came in and said no, this is stupid) is this weird bastardized coverage where the state is on the hook for some lives and contracting out to private payors for others. Imagine you are a beneficiary in that morass.

  32. Nick Nemec 2015.02.17

    Jenny you're from Minnesota. Do you know if the Medicaid expansion in MN is being handled by the State or did they bid the service out like apparently ND has done?

  33. Nick Nemec 2015.02.17

    You might not agree Dicta but to me it screams out the need for a single payor system for all Americans.

  34. caheidelberger Post author | 2015.02.17

    Rollin, I hope Heinert is out helping Hunhoff twist some arms to make Medicaid expansion happens. Everybody in South Dakota wins if we take this deal.

  35. Dicta 2015.02.17

    That page makes it appear that the MN Department of Human Services is covering it and is doing so on a fee for service basis. No capitation, no outcomes based measurements as of yet. I can't find anything on MN sites inconsistent with this.

  36. Nick Nemec 2015.02.17


  37. caheidelberger Post author | 2015.02.17

    If I'm following Dicta's point, let me suggest that those folks are high-risk right now because they don't have coverage. Bring them in under Medicaid, and sure, maybe in the first year, they'll bring significantly more cost per person, but get them into the routine of using affordable public coverage, and that risk gap will shrink, until (perish the thought!) poor people may find themselves enjoying just about as good of health as middle- and upper-income people.

  38. Jenny 2015.02.17

    MN had MNSURE (state run program and the first of its kind in the nation) set up 20 some years ago for low income people that did not qualify for Medicaid but couldn't afford private insurance. MNSure was expanded and several MN health insurance companies have partnered, although one pulled out last fall (Preferred One).

  39. Jenny 2015.02.17

    I'm sorry, the state run program that was set up a couple decades ago was call the MN Healthcare Program. MNSURE is the name of the medicaid expansion program under ACA.

  40. Jenny 2015.02.17

    This report came out today about MNSure's problematic first year. The important thing is thousands of Minnesotans now have affordable health insurance. The MN GOP will try to blast this but our pro-life governor says "the buck stops with me". Go Dayton!

  41. Dicta 2015.02.17

    MNSURE doesn't appear to be the medicaid expansion program as you stated above, rather it is the exchange the state setup for the marketplace.

  42. Jenny 2015.02.17

    Yes, you're correct, Dicta.

  43. Roger Cornelius 2015.02.17

    Daugaard will expand Medicaid once he fully understands that he has an opportunity to put profits his cronies pocket.
    Surely there are Republican doctors that want the governor to sign on to Medicaid Expansion for just that reason.
    If and when Daugaard goes for Medicaid Expansion it will have nothing to do with insuring 48,000 citizens, it will have to do with the profits to cronies and ultimately the state.
    Compassion isn't one of the governor's strong suits, Profits are.

  44. Nick Nemec 2015.02.17

    Roger's right. Sometimes someone has to point out that the king has no clothes on.

  45. Michael Dulitz 2015.02.17

    Apparently, in Tennessee, the hospitals are paying the cost of Medicaid expansion through increased state hospital assessment costs.

    According to the KFF, those eligible for Medicaid expansion, a majority are working adults, with many of those working for small businesses and agricultural related jobs. While the disabled make up a portion of the people covered under the Medicaid expansion, only 18% of individuals in the coverage gap report their health as poor or fair.
    I would encourage all to take a look at the issue briefs by the KFF for a good overview of the current Medicaid expansion landscape.

    The North Dakota Medicaid Expansion is underwritten by Sanford Health Plan in a managed care system. Thus, it is operated quite differently than the regular Medicaid system.
    North Dakota actually leads the nation in Medicaid reimbursement at 134% of the Medicare reimbursement level compared to South Dakota at 76% reimbursement.

    I can't see how this wouldn't be beneficial to the health care systems in SD. While I was working in health care, the worst statement to hear from a patient in the ER was "I don't have insurance" because you knew that they needed care, and it was going to end up being an immense burden on someone, whether the individual, the hospital, or the county government (indigent care reimbursement).

  46. bearcreekbat 2015.02.17

    Roger, perhaps that is a means to find a common ground. If we can actual help our fellow residents, even though to do so we must line the pockets of some politician's cronies, then perhaps it is worth plugging our collective noses and doing it?

  47. mike from iowa 2015.02.17

    and then we have to listen to wingnuts whine that federal programs cost too much and private for profits could do it cheaper. Wingnuts won't accept responsibility for making this stuff more expensive by stonewalling and obfuscation. The federal gubmint is broken because of us wingnuts, and we aim to keep it that way.

  48. larry kurtz 2015.02.17

    npr's julie rovner: ‏
    "White House announces (on Facebook) 11.4 million ppl signed up for health insurance in open season that ended Sunday."

  49. leslie 2015.02.17

    good discussion. thank you. what did we lose to first two years? isn't this issue the most important of all issues the legislature is "dealing" with this session?

  50. tara volesky 2015.02.17

    People owned cooperatives are the best way to go. Christian Health Care Ministries beats all for profit insurance companies owned by big hospitals that are to big to fail. Vertical integration is now what we have in SD. They own the politicians and health insurance. DD didn't expand Medicaid because he was up for re-election. He will expand it now but call it something else.

  51. Deb Geelsdottir 2015.02.17

    MN has kept Medicaid in house from the beginning. It's known as MA, or Medical Assistance. As you might expect from a state that cares about ALL its people, MN has had some type of coverage available for low income folks for many, many years. I can't give you an exact date, but when I was here in the mid 90s going to grad school MN had a program already.

  52. Jenny 2015.02.18

    Deb, you're right. MA is the largest of the varieties of healthcare programs called the MN Healthcare Programs, which is what I was referring to. There is also MN Care. I know MN retirees that end up staying in MN to get these services because a lot of other states don't have programs like these. There are definitely a lot more generous services offered, than say for instance in SD. These are not welfare programs. There are programs where the person pays what they can afford on a fee for service.

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