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SD- South Dakota votes to expand Medicaid

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


[MM Curator Summary]: SD got expansion approved by voters 56% to 44%, but it may be the last state to push expansion through the ballot box.


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The Republican-controlled state, where lawmakers have long resisted Medicaid expansion, is the seventh in the last five years to do so at the ballot box — and likely the last to do so for some time.


“We are thrilled by this victory, which took years of work, coalition building, and organizing to achieve,” said Kelly Hall, executive director of the Fairness Project, which helped pass the ballot measure. “Citizens took matters into their own hands to pass Medicaid expansion via ballot measure — showing us once again that if politicians won’t do their job, their constituents will step up and do it for them.”

Opponents of Medicaid expansion tried to make passage of the ballot measure more difficult through a June initiative, Amendment C, that would have raised the voter approval threshold to 60 percent. That measure was overwhelmingly defeated.

Under the American Rescue Plan, the federal government encouraged states to expand Medicaid by covering an extra 5 percent of the costs of the program, in addition to the 90 percent it covers for newly eligible individuals under Obamacare.

The Kaiser Family Foundation estimates those incentives will send $110 million to South Dakota.

Opponents of Medicaid expansion, including Republican Gov. Kristi Noem, argued the measure would cost the state in the long run, force lawmakers to raise taxes, and discourage able-bodied adults from getting jobs. Proponents, meanwhile, pointed to the program’s success in the 38 other states that have implemented it over the last decade.

More than 17 million low-income Americans have gained coverage as a result of Medicaid expansion, a portion of the Affordable Care Act that was made optional as a result of a 2012 Supreme Court decision.

The South Dakota vote signals the end of an era for expanding Medicaid ballot box. Of the 11 states that still have yet to expand Medicaid, only three — Florida, Mississippi and Wyoming — have a voter-initiated ballot measure process, and none appear likely to take up the proposal in the short term.

In Florida, a 60 percent voter approval threshold makes passing ballot measures challenging. In Mississippi, the state Supreme Court effectively threw out the state’s ballot initiative process. And in Wyoming, proponents are pushing to expand Medicaid through the legislative process rather than at the ballot box.

Supporters of the measure included the South Dakota State Medical Association, the Greater Sioux Falls Chamber of Commerce and the South Dakota Farmers Union.

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New poll shows South Dakota voters are leaning toward expanding Medicaid

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


[MM Curator Summary]: Right now the yeses have it at 62%. Just in time for the PHE wind-down.



Medicaid expansion(WITN)

RAPID CITY, S.D. (KEVN) – As the November midterm elections approach, voters are focused on a wide variety of candidates and issues.

However, as one recent poll shows voters could also be looking to expand healthcare access in South Dakota.

A state-wide poll conducted in late August confirmed what officials from the American Cancer Society say they’ve known for a while.

“South Dakotans want to see Medicaid expanded and the majority of voters, 62%, plan to support Amendment D in November,” stated David Benson, Senior State and Local Campaigns Manager for the American Cancer Society.

Amendment D would amend the South Dakota state constitution and provide Medicaid benefits to people ages 18-65 with an income at or below 133% of the federal poverty level.

This would expand access to health care for thousands of South Dakotans.

“Those that may not afford health insurance on their own or they’re not provided health insurance through their provider. So, that is going to help those that are caught in the middle. They either make too much to qualify for Medicaid, traditional Medicaid, and they don’t make enough to get those subsidies to go on the marketplace,” explained Benson.

Benson added there are also financial incentives for states that haven’t expanded their Medicaid yet.

“To keep the tax dollars from going to Washington, to help for healthcare access in states like New York and California. We want to keep those tax dollars here in South Dakota to invest in our healthcare and local economy and Amendment D would do just that,” said Benson.

So why is the American Cancer Society advocating for the expansion of Medicaid?

According to Benson, thousands of South Dakotans are diagnosed with cancer every year, “and having access to healthcare and routine screenings can make the difference between a stage 1 diagnosis or a stage 4 cancer diagnosis. So, what we know from studies, the American Cancer Society has a study that shows newly diagnosed cancer patients have a better survival rate if they live in a state that has expanded Medicaid,” explained Benson.

South Dakota voters have the opportunity to vote on Amendment D this November.


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North Carolina Medicaid expansion legislation falls through

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[MM Curator Summary]: Ya don’t say?


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


As North Carolina’s legislative session came to a close, a deal that included expanding Medicaid fell through, Axios Raleigh reported Aug. 15. 

North Carolina’s House of Representatives and Senate had each passed one version of the legislation

Both the state’s Democrats and Republicans told Axios Raleigh that the failure of negotiations was mainly due to the North Carolina Healthcare Association, which aimed to block the Senate’s Medicaid plan because it would have loosened the state’s certificate-of-need laws, which the association contended would hurt hospitals’ revenues, according to the publication. 

“The House of Representatives has no intention of moving [the Senate’s bill] nor an appetite for changes to the [Certificate of Need] law,” Steve Lawler, president and CEO of the North Carolina Healthcare Association, said in a June letter to its members, according to Axios Raleigh. “Attempts to negotiate CON changes with the Senate are not only counterproductive to our messaging on our Medicaid priorities but undermine our support in the House.”

State leaders and the association are still discussing Medicaid proposals and policies. 

North Carolina is one of 12 states that has not expanded its Medicaid program since 2014. 


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GA- Kyle Wingfield: Expanding Medicaid isn’t the silver bullet

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[MM Curator Summary]: Its good for you to hear from people you disagree with from time to time.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



Are we really doing this again?

Another election year, another opportunity to pretend Medicaid expansion is a cure for Georgians. Both the working poor and rural hospitals are pitched as beneficiaries of enrolling more people in America’s safety-net program.

If it were actually that simple, Georgia might already have capitulated to the Affordable Care Act’s enticements for expanding Medicaid. As proponents are quick to point out, that offer includes federal taxpayers picking up the entire tab for the expansion’s earliest years.

But rather than starting with the financial aspects of Medicaid expansion, let’s look first at the people affected.

It’s increasingly hard for Medicaid patients to find a doctor. The State Health Access Data Assistance Center (Shadac) reports that, from 2011-2013, only 71.6% of Georgia doctors accepted new Medicaid patients. From 2014-2017, that number fell to 69.4%. The Georgia Board of Health Care Workforce, using a different survey, reports that in 2019-2020 the number was 60%.

In each case, more doctors accepted new privately insured patients — over 90% in both periods of time Shadac studied.

There are financial reasons for this. But before we get into those, let’s think through what this means.

For those who would gain coverage, it means the promise of receiving care is somewhat illusory. If it’s hard to find a doctor, many patients will go without care until they wind up in the emergency room. In other words, they’ll behave the same as when they were uninsured.

For those already on Medicaid — in Georgia, that means the truly vulnerable: children, pregnant women, the aged, blind and disabled, and the truly destitute — things will get worse. Suddenly, they would be competing with hundreds of thousands of additional people for a relatively small number of doctors appointments.

That’s a grim outlook for both groups.

Why is this so? Bureaucratic hassle is a major reason: Although proponents of single-payer (read: taxpayer-financed) healthcare love to bash insurance companies, and not wholly without reason, Medicaid isn’t so easy to work with, either.

And — finally we come to money — Medicaid’s payments can be not only slow, but skimpy. The latest data from the Georgia Hospital Association indicate Medicaid reimburses providers at 88% of cost. While that’s markedly better than for uninsured patients (22%), it’s still a loss.

We’ve already seen how hard it is for Medicaid patients to find doctors. But let’s forget that for a moment, and entertain expansion proponents’ arguments that new enrollees will receive more services. If that’s true, then might not a larger volume of loss-making patients offset the higher reimbursements?

This is the dilemma rural hospitals face. Yes, they would benefit from more cash flow. But those who understand the industry — including some hospital executives, in their unguarded moments — acknowledge this is a short-term fix. Losing less money per patient, especially if this spurs more volume, is a poor business strategy.

Rural hospitals struggle for two basic reasons. One is having too few people nearby: A rule of thumb is that you need a population of at least 40,000 to sustain a local hospital, and 110 of Georgia’s 159 counties don’t meet that threshold. That includes more than 50 counties with hospitals.

The other is their “payer mix.” Having uninsured patients who could be on Medicaid is less of a problem than having too few privately insured patients. Private insurance pays more than the cost of services, offsetting losses from other patients. If a hospital has too few privately insured patients, Medicaid expansion isn’t going to save it.

That’s one reason Gov. Brian Kemp’s Medicaid “waiver” plan held promise.

Although fewer Georgians would be subsidized than under the ACA expansion, many of them would have joined their employer’s insurance plan. That would afford them greater access to care, while offering more reimbursement for providers and limiting taxpayer exposure.

It’s easy to simply say “expand Medicaid.” Maybe that soothes some people’s consciences. Unfortunately, it doesn’t solve the problems many patients and providers in Georgia face.

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Medicaid expansion faces hurdles in South Dakota

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[MM Curator Summary]: The 2 ballot initiatives have been consolidated, but a pesky $456M annual state funds additional costs estimate still hangs out there.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



Facade of South Dakota Capitol building in Pierre.

Paul Brady Photography / Shutterstock

(The Center Square) – Zach Marcus of South Dakotans Decide Healthcare is confident South Dakota voters will approve Medicaid expansion in November. 

Ask him why and he will quote numbers he says were given to him by the state’s Legislative Research Council. 

“Forty-two thousand, five hundred South Dakotans are currently stuck in the coverage gap, right?” Marcus, the campaign manager for the organization, told The Center Square. “They’re working hard but still they’re stuck making too much money to qualify for Medicaid, not enough money to actually afford health care.”

And there’s another number. Medicaid expansion would bring back $1.3 billion in federal funding to the state, Marcus said. 

Until earlier this week. South Dakotans Decide Healthcare and Dakotans for Health both had Medicaid expansion measures on the ballot. The groups have joined forces in a grassroots effort to get the measure passed. 

“We are grateful to the 24,000 South Dakotans who signed our petition, and the hundreds of South Dakotans who worked tirelessly to get Initiated Measure 28 on the ballot,” Rick Weiland, co-founder of Dakotans for Health, said in a news release. “After conversations with South Dakotans Decide Healthcare members, we have agreed that the best path forward to accomplishing this goal is to join efforts behind one campaign.”

The groups have an adversary in Gov. Kristi Noem, who has staunchly opposed Medicaid expansion. Noem’s administration did not immediately return a message seeking comment. But when lawmakers discussed passing Medicaid in February, a member of Noem’s administration said it would be costly. 

The Department of Social Services would need an additional $456 million a year in ongoing taxpayer funding, said Laurie Gill, the department’s secretary. The department would need an additional 64 full-time employees, she said.

“This growth of the program is out of line with our charge to be fiscally responsible,” Gill told the South Dakota Senate Health and Human Services committee

The Medicaid expansion effort has broad support from South Dakota’s health care community. Among the groups backing the amendment are the American Cancer Society Cancer Action Network, AARP South Dakota, South Dakota State Medical Association, Avera Health, Monument Health, Sanford Heal and the American Heart Association

South Dakota is one of 12 states that has not expanded Medicare. 


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South Dakota Medicaid expansion groups join for constitutional amendment

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[MM Curator Summary]: They were able to convince the other guy to fold his initiative in with theirs. They being Big Hospital who needs to ensure the win.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.




SIOUX FALLS, S.D. (AP) – A pair of South Dakota campaigns trying to expand access to Medicaid through the November ballot will join efforts to focus on passing an amendment to the state constitution.

The announcement from the two organizations – South Dakotans Decide Healthcare and Dakotans for Health – puts to rest a potential rivalry between the two campaigns.

Both brought separate ballot proposals to require the state to make Medicaid government health insurance available to people who live below 133% of the federal poverty level.

South Dakotans Decide Healthcare is sponsoring Constitutional Amendment D and is backed by the state’s health care industry. It says that Dakotans for Health will join its coalition rather than push its own proposal for a voter-initiated measure.


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KS- Gubernatorial candidates at odds on approach to Medicaid expansion in Kansas

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[MM Curator Summary]: Those pesky politicians want to tie work requirements to expansion for able-bodied adults who can work and don’t meet the normal low-income requirements.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



Derek Schmidt, a Republican gubernatorial candidate for governor, would not support Medicaid expansion in its current proposed form, said Katie Sawyer, his running mate, during a candidate forum in June.


TOPEKA – Katie Sawyer, Republican gubernatorial candidate Derek Schmidt’s running mate, said neither she nor the attorney general would support Medicaid expansion in its current proposed form.

Sawyer made the remarks at a candidate forum in Salina the last weekend of June in response to a question from an audience member who asked if Schmidt would support a plan to expand KanCare, the state-run Medicaid program. The audience member also questioned former Gov. Sam Brownback’s stance against expansion, arguing the state lost billions of dollars by not expanding.

“I can’t speak to what Gov. Brownback did,” Sawyer said. “What I will say pretty clearly is, as it stands right now in its current proposed form, Derek Schmidt would not be supportive of expanding Medicaid.”


CJ Grover, campaign manager for Schmidt, said the attorney general could not support current proposals because they would assist able-bodied Kansans without children without a work requirement. No matter who is governor, Grover said he did not believe the Legislature was likely to pass Medicaid expansion.

Overall, he said Schmidt considers himself an “open-minded skeptic” on the issue.

“Should the Legislature one day reconsider and decide to advance a proposal, there are requirements AG Schmidt believes must be met,” Grover said. “First, the state share of the expansion cost must be honestly paid for, second there must be a work or job training requirement to ensure expansion is not a welfare program but instead a way to help able-bodied Kansans who are working to support themselves, and third there must be a clear and enforceable prohibition of any taxpayer funding for abortion coverage.”

According to the most recent Kansas Health Institute estimates, expansion in January 2023 would lead to 148,000 newly enrolled Kansans. Nearly 88,000 adults who currently fall in the “Medicaid coverage gap” would gain coverage if Medicaid were to expand.

The April estimates indicate an increase of 36% from the pre-pandemic monthly average KanCare enrollment, but only a 1.4% increase in spending. In addition, KHI estimated that the American Rescue Plan Act would create $418 million in savings for Kansas over two years if KanCare were expanded to low-income adults.

“None of the non-expansion states have adopted expansion since ARPA was enacted,” the brief notes in conclusion. “In the meantime, Kansans who remain in the coverage gap have few alternatives for comprehensive affordable health insurance.”

KHI estimates include indirect effects of expansion enrollment for children and currently eligible adults.

Alliance for a Healthy Kansas estimates the state has lost out on over $5.6 billion without expansion and 150,000 Kansans fall in the Medicaid gap.

Proponents of expansion also highlight concerns with rural hospital closures. Since 2005, nine rural hospitals in the state have closed, and of the 105 rural hospitals in Kansas 75 are currently running at a loss and are vulnerable to closure, according to a Center for Health Care Quality and Payment Reform study.

Madison Andrus, a campaign spokeswoman for Gov. Laura Kelly, said the governor would continue to strongly support expansion.

“It will expand quality health care for 150,000 hardworking Kansans and create 23,000 jobs,” Andrus said. “That’s good for rural Kansas, good for the Kansas economy, and good for Kansas health care workers – and it will remain a top priority in her second term.”


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State budget goes to Gov. Cooper

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[MM Curator Summary]: The Good Guvn’r has to decide whether his year’s long fight for Medicaid expansion is worth throwing the whole state in disarray.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



Gov. Roy Cooper will now have to decide whether to veto the budget, which does not include Medicaid expansion. Cory Vaillancourt photo

Both chambers of the North Carolina General Assembly approved the state’s $28 billion fiscal year 2022-23 budget last week, but as Gov. Roy Cooper nears the halfway point of his final term, he’ll now have to decide whether or not to veto the proposal, which does not include what’s become his signature issue — Medicaid expansion.

“North Carolina is emerging from the pandemic stronger than before, and we will sustain that only if we invest in a strong foundation for our people: A quality education, good jobs and infrastructure, and access to affordable healthcare,” Cooper said  in a May 11 press release attached to his own budget proposal, which included Medicaid expansion. 

The House and the Senate each passed their own proposals for expansion, but ultimately could not agree on which to advance. 

Expansion aside, the proposed budget  represents a 7.2% increase from the previous biennium, increasing the rainy-day fund’s balance to nearly $5 billion and setting aside an additional $1 billion in anticipation of a recession. 

State employees will see a 3.5% pay increase, teachers 4.2% and non-certified public school employees either 4% or a raise to $15 an hour, whichever is greater. Entry-level teachers will also see an increase in starting salary. Overall, education spending is up nearly 7%. 

In the wake of the mass shooting at Robb Elementary School in Uvalde, Texas, North Carolina legislators pushed for a dramatic increase in school safety spending, including an additional $32 million in grants to support safety equipment and training as well as students in crisis. School resource officer spending will increase by more than $40 million, and an additional $15 million has been earmarked for elementary and middle school SROs. 

A series of threats to the state’s Historically Black Colleges and Universities this past February, including Fayetteville State University and Winston-Salem State University, prompted an additional $5 million in funding for cybersecurity and bomb threat prep at the state’s HCBUs. 

More than $880 million has been set aside for water and wastewater infrastructure projects, alongside $250 million to cover possible project cost overruns due to inflation. There’s also a small $5 million increase in the GREAT grants program for rural broadband. 

One element of Cooper’s proposed budget did make it into the General Assembly’s proposal, a $1 million appropriation to the Economic Development Partnership of North Carolina to identify megasites that could host advanced manufacturing facilities. 

Public safety spending is also on the rise, increasing nearly 4% over the last budget. An additional 13 magistrates, 11 assistant district attorneys and more than 130 judicial support and clerk positions will be funded if the budget’s approved. 

On the local level, there was much anticipation over how much state funding Haywood County and the Town of Canton would receive to aid in the recovery from historic flooding  that took place in August, 2021. 

The scale of the damage was initially estimated at more than $300 million, including private property. The Town of Canton suffered catastrophic losses to major infrastructure including police, fire and town hall. 

Given the town’s relatively small annual budget, replacing the multi-million-dollar facilities would have resulted in substantial property tax increases, however Haywood County’s Rep. Mark Pless said in a release that he’d worked to secure more than $23 million. 

At least $8 million will go toward repairing damaged buildings and the town’s playground. The appropriation is separate from a $9 million previous allotment intended for repair of water infrastructure damaged un the flood. 

Another $5 million is set for use on debris removal, mostly outside the town’s municipal boundaries. 

Yet another $5 million has been lined up to help farmers affected by the flood, which came just as many summer crops were ripening in the fields; famously, thousands upon thousands of green peppers littered streets and riverbanks from just south of Canton through Clyde. The money will be administered through the state’s Agricultural Crop Loss Program. 

There’s also another $5 million for bridges and roads destroyed in the flooding. The funding is earmarked for private roads and bridges not covered by previous reimbursements from the Federal Emergency Management Agency. 

Unrelated to the flood, an additional $5 million was appropriated to a separate crop loss program for a freeze that affected crops last April, and $150,000 has been allotted for baseball and softball facilities in Bethel. 

As part of the state’s overall public safety spending, Pless said that some of the funding would result in an additional assistant district attorney for the 43rd prosecutorial district as well as another assistant clerk for the Superior Court in Haywood. Since 2020, the judicial system has been hobbled by a backlog of cases due to COVID-19 shutdowns in the court system. 

Pless also secured $3 million for a wastewater treatment plant in Yancey County. 

“Our office is pleased with the appropriations for these important projects and positions,” said Pless. “We have been working hard this session to listen to the needs of the district and secure funding based on those needs and suggestions. While we did not secure all of our requests, we will continue to advocate for them in future budgets.” 


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SD- Concerns arise as dueling ballot measures both seek to expand Medicaid coverage in South Dakota


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[MM Curator Summary]: One measure is trying to amend the state constitution; the other is a simple ballot initiative.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.



“It’s unfortunate that this life-saving issue has turned into a political bogeyman that people can use as a scare tool.”


SIOUX FALLS — Some advocates for Medicaid expansion in South Dakota are concerned that two ballot measures with different language and separate backers but the same goals may confuse or diffuse voters, reducing the chances of success in the November election.

The goal of each campaign is to provide health care coverage to more than 40,000 additional low-income South Dakota residents by broadening Medicaid insurance criteria as established by the Affordable Care Act, with the federal government covering 90 percent of the cost. Unlike Medicare, which provides coverage for the elderly, Medicaid focuses on low-income individuals and covers services such as hospital visits, preventative care, X-rays and family planning.

The ACA in 2010 expanded Medicaid to include nearly all adults with incomes up to 138% of the federal poverty level, which currently translates to an annual salary of about $18,000 for an individual (or $36,500 for a family of four). But the Supreme Court ruled in 2012 that states could reject the expansion and still get federal funding for traditional Medicaid costs, which all states currently receive.

South Dakota is one of just 12 states that hasn’t expanded Medicaid, making it an outlier even among neighboring Republican-led states such as North Dakota, Iowa and Nebraska. But expansion proponents are optimistic after seeing voters reject Amendment C – which would have made ballot measures involving state spending more difficult to pass – in the primary election June 7 with 67 percent of the vote.

Constitutional Amendment D, which is sponsored by South Dakotans Decide Healthcare and will appear on the November ballot, seeks to expand Medicaid by changing the state constitution, viewed traditionally as a more iron-clad method of initiating new policies. Amendment D is supported by the state’s major healthcare systems and the Fairness Project, a national advocacy group that assists in ballot measure campaigns.

The second Medicaid ballot measure, Initiated Measure 28, is spearheaded by former Democratic U.S. Senate candidate Rick Weiland, a frequent supporter of ballot measures who successfully campaigned to increase South Dakota’s minimum wage in 2014. Weiland’s group, Dakotans for Health, initially presented its measure as a way to give voters another option in case the 60-percent voting threshold was passed into law by the June primary vote.

“Historically, initiated measures have fared better than conditional amendments,” said Weiland. “There are groups of voters who just don’t like to mess with the constitution and could see Medicaid expansion as more appropriately accomplished by statutory measure.”

Since Amendment D had a later filing deadline to the Secretary of State’s office, the fiscal note from the Legislative Research Council includes additional offsets extended by the Biden Administration as part of the American Rescue Plan, showing the state’s share over the first five years of Medicaid expansion to be a total of $3.8 million. That information is not reflected in IM 28’s fiscal note, nor does that measure specify an implementation date.

These differences – plus the significant financial backing of South Dakota’s “big three” health systems: Sanford, Avera and Monument – lead state Sen. Reynold Nesiba, a Sioux Falls Democrat who supports Amendment D, to call for Weiland to pull Initiated Measure 28 off the Nov. 8 ballot to create a unified statewide effort.

“Rick Weiland and the people bringing the initiated measure need to withdraw it,” Nesiba told News Watch. “It’s got an inferior fiscal note attached to it, it doesn’t have an implementation date, and the constitutional amendment will have a more definitive impact.”

Weiland, whose efforts to coordinate a petition-led campaign to pass Medicaid expansion date back to 2019, chuckled when informed of Nesiba’s remarks.

“Give me a break,” said Weiland, who served as an advisor to former U.S. Senator Tom Daschle. “The language in both these initiatives accomplish the same thing, and the implementation date is written into state law. As for voters being confused, there are only three measures on the ballot (the two Medicaid proposals and IM 27, which would legalize recreational marijuana). I don’t think that’s going to be too overwhelming for people.”

If both ballot measures pass and have the same intent, state law dictates that “the initiated measure or amendment receiving the greatest number of affirmative votes at the election shall be given effect.”

That provision could be construed as the measures competing against each other, though their aim is the same. The deadline to voluntarily remove a ballot measure is 120 days before the election (July 12 in this case), but so far both groups are holding firm.

“We are fully focused on campaigning for and passing a constitutional amendment that will expand Medicaid in South Dakota,” said Zach Marcus, a spokesperson for South Dakotans Decide Healthcare.

Erin Hislaw walks her son, Jairus, into the Indian Health Service clinic in Fort Thompson for a checkup in this 2017 file photo. This IHS branch was visited Monday by an investigator from the IHS regional office in Aberdeen.

Mitchell Republic file photo

General agreement on intent

One thing the factions agree on is that chronically underfunded Indian Health Service facilities and rural health clinics and nursing homes will receive a boost from federal Medicaid reimbursements if more low-income patients are covered. In addition to the 90% federal matching rate, states that implement expansion also see an increase in funding for traditional Medicaid populations under COVID-related American Rescue Plan provisions.

In South Dakota, the total cost of expansion over the first five years would amount to about $1.5 billion, of which the state’s share would be $166.2 million, according to the Legislative Research Council. Since total savings to the general fund – from federal matching and incentive funds and fewer reimbursement payments to hospitals for treating uninsured patients – is estimated at $162.4 million over that five-year period, the state’s net financial obligation would be $3.8 million.

“It will cost us less to expand Medicaid than it cost to buy the governor a new airplane,” said Nesiba, referring to the state’s $4.5 million purchase of a 2015 Beechcraft King Air 350 last year. “The failure of South Dakota to take this step is one of the most short-sighted economic decisions we have ever made.”

Under South Dakota’s current (non-expanded) Medicaid system, two-thirds of the roughly 130,000 enrollees are children who meet poverty level guidelines, while eligible adults include pregnant women, elderly or disabled individuals and parents of minor children up to 52 percent of the poverty level (for a household with three people, that means an annual salary of about $11,300).

Childless adults without a disability are ineligible for Medicaid coverage in South Dakota regardless of income level, and many don’t qualify for ACA subsidies to help obtain private coverage unless their income is at least 100 percent of the poverty level.

The number of these residents who “fall through the cracks” of health insurance coverage is estimated at 42,500 in South Dakota, just under 5 percent of the total population. Nearly 40 percent of them are estimated to be Native American, according to Georgetown University’s Health Policy Institute, compared with about 9 percent of the general population that is Native American.

The federal government pays 58% of the cost of standard Medicaid coverage, with slight increases made during the COVID-19 pandemic. Under Medicaid expansion, the federal government share increases sharply, especially with incentives added as part of the American Rescue Plan.

A study of state budgets from 2014-2017 by the Commonwealth Fund, a nonprofit that supports research on health policy reform, found that Medicaid expansion was associated with a 4.4% to 4.7% reduction in state spending on traditional Medicaid while also reducing the cost of uncompensated care, such as when the state reimburses hospitals for services provided to uninsured individuals.

Deb Fischer-Clemens, Avera Health senior vice president for public policy and a supporter of Amendment D, said that expanding coverage to uninsured residents helps not just those individuals or families but also entities that might incur those costs down the line, including state or county government, non-profit health systems or taxpayers.

“There’s a lack of preventative care when you don’t have insurance,” said Fischer-Clemens, a former state legislator who also serves as president of the South Dakota Nurses Association. “When you don’t have a lot of money, you’re using it all to pay for rent or groceries or gas, meaning you’re not getting that preventative colonoscopy. And when you find out there’s something wrong with you, instead of a couple thousand dollars, it’s tens of thousands of dollars, and a lot of time away from work and a lot of debt. The big picture of this is taking care of individuals who don’t have the resources to access care at the appropriate time.”

Medicaid expansion opponents, including GOP Gov. Kristi Noem and Republican Senate President Pro Tempore Lee Schoenbeck, counter that able-bodied individuals, such as currently uncovered childless adults, should be able to work and are not entitled to free health care. They also point to uncertainty about the state’s share of expenses once COVID-related incentives from the Biden administration phase out and the nation’s public health emergency expires, which is expected later this year.

Schoenbeck, who declined an interview request, made his position clear when asked about Medicaid expansion during a Senate primary event in May.

“I don’t happen to support more welfare,” he said.

Gov. Dennis Daugaard delivers a budget address before lawmakers at the South Dakota State Capitol in this file photo.

Mitchell Republic file photo

Expansion talks fizzle in state government

In 2016, two years after being re-elected as South Dakota governor with more than 70% of the vote, Dennis Daugaard undertook an effort to expand Medicaid despite lingering rancor toward “Obamacare” among most of his fellow Republicans.

The fiscally conservative Daugaard saw it as a good deal for South Dakota, since the state was already paying in part for Native American residents who couldn’t receive care at reservation IHS facilities because of lack of services or availability. The U.S. Health and Human Services Department agreed to an arrangement where those treated outside IHS facilities would be covered by federal Medicaid matching funds.

The problems Daugaard faced were not procedural but political, as state Republicans balked at expanding the ACA, the outgoing Obama’s signature achievement, and voiced their concerns about government handouts for adults who were able to work and fend for themselves.

The governor convened a Health Care Solutions Coalition, which produced a 2016 report that found the state spent $182 million on health care for Native Americans in fiscal year 2015, about $97 million of which was federal funds and $85 million was state funds. The report noted that “$85 million is more than enough to cover state costs for expansion.”

With legislative action stalled, Daugaard tried unsuccessfully to negotiate a work requirement provision with the federal government. Donald Trump’s victory in 2016 – along with Trump’s proclaimed goal to repeal the ACA – ended what little momentum had occurred, especially after Daugaard met with then-Vice President MIke Pence and discussed the new administration’s repeal strategy, which ultimately failed in Congress.

Fischer-Clemens, who served on Daugaard’s coalition, joined with other hospital officials and health associations to consider a new course, especially after Noem took office following the 2018 election and declared her opposition to Medicaid expansion. Advocacy groups in states such as Nebraska, Oklahoma, Missouri, Utah and Idaho had found success by taking the issue straight to voters with petition-fueled ballot measures, and that became the strategy.

“After seeing so many bills fail in committee over the years, we knew we couldn’t do it with legislative movement,” said Fischer-Clemens. “The philosophy in the Legislature is basically, ‘We’ve done enough with Medicaid, and if the federal government takes dollars away, then it’s going to lead to higher taxes.’ There was nowhere else to go.”

Voters cast their ballots inside the Mitchell Career and Technical Education Academy in this Republic file photo.

Mitchell Republic file photo

Taking issues straight to ballot

There were some early discussions with Weiland, who was well-versed in the ballot measure process and knew of its pitfalls. After his successful effort to raise the state’s minimum wage in 2014, state legislators voted to exempt workers under age 18 from the required wage, so Weiland and other Democrats referred the law back to voters and won with 71 percent of the vote.

Two years later, Weiland spearheaded an electoral victory for IM 22, which revised lobbying and campaign finance laws while establishing a state ethics commission. But Republican legislators sought a preliminary injunction and later repealed the measure with an emergency clause that ensured it could not be sent back to voters.

Those South Dakota efforts against initiated measures, and delays in Nebraska as Gov. Pete Ricketts sought to restrict the implementation of voter-approved Medicaid expansion for several years, convinced South Dakotans Decide Healthcare and the Fairness Project that a constitutional amendment was the most logical course.

They used paid petition circulators to speed the process and submitted 47,000 signatures last November with the Secretary of State’s office, announcing in January that the proposal had qualified for the November 2022 ballot officially as Amendment D.

“We had seen some of the things that the legislature does with initiated measures,” said Fischer-Clemens. “Then some of us watched what was happening in Nebraska and basically said, ‘We don’t want to go through that – we’re not going to live that long.’ In the end we were more confident that we could reach our goal with a constitutional amendment.”

Weiland, however, points to Amendment A, the South Dakota recreational marijuana effort that passed with 54% of the vote in 2020. Noem’s administration challenged the measure, saying it violated the state’s requirement that constitutional amendments deal with just one subject, and won a 4-1 decision at the South Dakota Supreme Court that prevented legalization from taking place.

That single-subject clause had been a response to IM 22, meant to discourage sweeping voter-based changes to state law. When it became clear that Medicaid expansion would be on the ballot in 2022, Sen. Schoenbeck tried to orchestrate a preemptive strike with Amendment C, which was backed by the Koch Brothers-funded Americans for Prosperity and would have required a 60% vote for ballot measures that raise taxes or spend $10 million in general funds in their first five years.

The resounding failure of Amendment C was viewed by some as a message from voters to lay off the petition process, which Weiland interpreted as a potential buffer for initiated measures as well. He noted that state Sen. Wayne Steinhauer, R-Hartford, who chairs the Senate Health and Human Services Committee, led an effort during the 2022 legislative session to endorse or prepare for Medicaid expansion, a proposal that fell short but indicated a desire to get out in front of voter-backed measures. Steinhauer did not respond to an interview request.

“I think state legislators realize that they’re on thin ice when it comes to messing around with the will of voters,” said Weiland, whose group’s measure was certified June 9 by the Secretary of State’s office with 17,249 valid signatures (the threshold is 16,961). “We have a chance to hold their feet to the fire, because they mis-stepped on minimum wage, they mis-stepped on corruption, they mis-stepped on cannabis and they’re getting tired of mis-stepping. This whole notion that the only way to get things done is through constitutional amendment is not really the case anymore. I hope they both pass. We’re encouraging people to vote for both.”

The South Dakota Department of Tribal Relations says this map is meant as a general guide to where tribal lands are located but does not wholly represent tribal lands or reservations as they are today.

Map courtesy of the South Dakota Department of Tribal Relations

Finding support for Native populations

One of the most persuasive arguments for expanding Medicaid is its ability to address long-standing health care concerns that plague tribal communities in South Dakota, which has the fourth-highest percentage of Native American residents in the country.

A 2021 study by the Health Policy Institute at Georgetown found several predominantly Native counties (Buffalo, Oglala Lakota, Todd) with at least four times the national average of uninsured non-elderly adults.

Remi Bald Eagle, a member of the Cheyenne River Sioux Tribe who is part of the Dakotans for Health group, pointed to the limitations of IHS services on reservations and noted how Medicaid expansion could improve the level of care.

Some Native residents don’t live close to an IHS facility, or they require services that aren’t provided. Expanding Medicaid would allow those patients to be referred to other hospitals or clinics, which would then be reimbursed. Currently, referrals are determined by a “triage” system, meaning cases are prioritized by level of medical severity.

“IHS facilities have a capped budget they operate under,” said Bald Eagle, a former Democratic candidate for public utilities commissioner. “If a person’s condition is not seen as high priority, that person might not get referred.” He added that third-party billing through Medicaid expansion could potentially help IHS facilities expand services or upgrade medical personnel.

Among Native Americans with IHS access, Medicaid enrollment increased by 45% in expansion states and 25% in non-expansion states from 2010 to 2018, according to the IHS Tribal Self-Governance Advisory Committee.

Montana, which approved Medicaid expansion in 2016, saw more than 15,000 tribal members newly enrolled in Medicaid in the first two years, according to the state Department of Public Health and Human Services. The tribal and IHS facilities on the Blackfeet Reservation in northern Montana saw an additional $13.6 million for services reimbursed by the federal government during that time.

Bald Eagle supports the initiated measure but said both proposals are encouraging to many in South Dakota – not as government handouts, but as ways to address problems that low-income residents and health providers have faced for a long time.

“It’s unfortunate that this life-saving issue has turned into a political bogeyman that people can use as a scare tool,” he said. “The more people you have using these services, the more it helps everyone, not just Indian Country, but South Dakota as a whole.”

— This article was produced by South Dakota News Watch, a non-profit news organization online at


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NC- House passes Medicaid expansion study bill

MM Curator summary

[MM Curator Summary]: NC legislators commissioned the Medicaid agency to work with CMS to negotiate a Medicaid expansion with work requirements. Whelp.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


The N.C. House passed a bill Tuesday evening 101-6 that would direct the state’s health agency to come up with a Medicaid Modernization Plan. The bill lays out the fiscal requirements that members would require in order to vote to expand Medicaid to an estimated 600,000 new enrollees.

Those policies outlined in the Rural Healthcare Access and Savings Plan Act
(Senate Bill 408) include work requirements for enrollees, $1 billion earmarked for behavioral health and substance abuse, expansion of health care to rural areas, and a requirement that the state withdraw from Medicaid expansion if the federal government reverses its promise of covering 90% of the costs.

 “I feel confident that this plan has been set up in a way, with fiscal accountability and responsibility in place, if the secretary can meet that,” said Speaker Tim Moore, R-Cleveland, on the House floor Tuesday evening. “I’m certainly going to support it and encourage my colleagues to support it, because it’s the right path forward, with these guardrails in place.”

Six months to strike a deal

The bill authorizes Department of Health and Human Services Secretary Kody Kinsley to work with the federal Centers for Medicare and Medicaid Services (CMS) to come up with a plan specific to North Carolina and gives him until Dec. 15 to present it to lawmakers. A vote would then be held on that plan.

Democrats in the chamber Tuesday expressed concern that the bill’s plan requirements would be difficult to meet, asking the speaker if House leaders have designed to set it up for failure.

“Are these criteria such that they are almost impossible to meet?” asked Rep. William Richardson, D-Cumberland.

Moore assured him that Kinsley has agreed to the terms of the bill and believes they can be met.

“If I wanted this bill to fail, the easiest thing to do is to say we aren’t going to take it up, but that’s a lot of trouble to go through and a lot of hours spent for this to ultimately fail,” said Moore. “The beauty of this, though, is that instead of us giving that blank check out, we actually have the final say once the product comes back here. I believe these benchmarks will be met.”


House Minority Leader Robert Reives, D-Chatham (Image from YouTube)

House Minority Leader Rep Robert Reives, D-Chatham, encouraged Democrats to vote for the bill.

“I’m going to support this because I’d like to keep the conversation moving forward,” said Reives.

“The people who are being left out right now are people who are working. They are working, they are trying, and they are in a terrible gap,” he added. “If there is a human being out there who will say, ‘Hey, I got Medicaid insurance, now I’m going to quit my job,’ I’d like that person to come by my office because that would mean you would be homeless, you wouldn’t have any food. If you are homeless and you go without eating or drinking, the health insurance can’t save you.”

During the break between official legislative sessions, a study committee of members, chaired by Rep, Donny Lambeth, R-Forsyth, examined Medicaid expansion, talking to health care groups and officials from other states that have expanded the federal entitlement program. However, the committee’s report was never completed before the state Senate passed an outright Medicaid expansion bill in May.

Senate members have been pressing the House to take their bill up, but House leadership said they wanted a clearer view of the costs and to have their requirements met before they would agree. The House bill gives N.C. DHHS six months to hammer out the details to get a vote.

“If the secretary did bring back something that did not meet the criteria, there would probably be a lot of folks on this side who would vote no, and I don’t know if it would pass,” said Moore.

Some House Democrats wanted the body to take up the Senate’s bill, too, before adjourning. Gov. Roy Cooper has also called for Medicaid expansion since taking office in 2017.

“It’s no secret that the governor didn’t like the fact that there would be votes in December,” said Moore. “I made it very clear to the governor that if there was not a second vote in December on this bill, it would go nowhere in the House. So it was either this way or no way, just to be candid.”

In other states that have expanded Medicaid under the Affordable Care Act, experts generally underestimated the size of Medicaid expansion enrollments, underestimated its cost, and overestimated its health benefits.

What is in the bill

The bill lays out some additional requirements of NCDHHS’ proposed expansion plan including that, “Individuals who are not United States citizens shall not be covered except to the extent required by federal law.” DHHS is also required to establish a system of reporting back on enrollment numbers, whether enrollees are using preventive care, and how it is impacting health outcomes. 

Work requirement waivers to allow states to put work/volunteer requirements or a small co-pay into expansion plans were offered by the Obama administration to encourage states to expand the program back when the Affordable Care Act passed. Under the Trump administration, states that expanded Medicaid had their work waivers approved, but the Biden administration has put a stop to them. Kinsley will now be required to negotiate with CMS to pass them.

The House bill also requires that $1 billion be spent on opioid, substance abuse, and mental health crisis in North Carolina, “using savings from the additional federal Medicaid match available under the American Rescue Plan Act.” ARPA is the $1.9 trillion plan passed by Congress in 2021 that economists are blaming for the nation’s historic inflation rate.  

Under the House legislation, a DHHS-created task force of leaders in the faith community, law enforcement professionals, mental health experts, and addiction specialists would be required to guide the $1 billion in spending on drug and mental health issues.

The plan also has specific proposals to increase access to health care and preserve hospitals in rural areas of the state. Lambeth said North Carolina ranks 43rd out of 50 states for access to health care and that 11 rural hospitals have closed since 2005, with 19 currently at risk of shutting down.

“Members, we have universal care in this state and in this country. It’s called the emergency room,” said RIchardson Tuesday evening on the floor.

“The is a great step forward,” he added. “I urge you to vote for it, and in December I urge you to vote to put North Carolina as part of this plan so that our people can get adequate health care, so they can work and not live in the emergency room.”

What is NOT in the bill

The directives for DHHS in the House bill do not include some of the industry reform measures that the Senate offered in its bill, including the SAVE Act, which would address needs in rural areas and giving nurses more independence, and partial repeal of some certificate-of-need requirements.

Rep. Gale Adcock, D-Wake, a registered nurse, stood on the floor to object to the omission of the SAVE Act (House Bill 277) in the House Medicaid bill. It would allow nurses to work up to the level of their training, even if a doctor was not immediately available.  It is intended to address labor shortages in rural hospitals.

“I know that at least half the members of this chamber signed on as co-sponsors of the SAVE Act,” she said. “The SAVE Act does really important things for this state economically.”

Adcock announced on the House floor that she wanted to file a discharge petition to get the SAVE Act heard before lawmakers leave Raleigh.

Ultimately only six members of the House voted against the bill, with 101 voting in favor. It now goes to the Senate for approval.

“I believe that this will be successful, that we will have a product back that we can all be very proud of when we vote on this in December,” stressed Moore.

The legislature is driving to wrap up business and adjourn the short session by Saturday afternoon, July 2.


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