Monday, January 12, 2015

Expand Medicaid In South Dakota. My Column In Yesterday's Rapid City Journal

Taking A Pass On This Deal Makes No Sense
We've institutionalized irrationality in this state.  Why South Dakota hasn't grabbed this thing called Medicaid expansion for all it's worth is a study in political imperatives and social value judgements trumping a realistic and hard-headed approach to analyzing a deal that by any measure is a good one for us.  The gist of it is that by accepting federal money via the Affordable Care Act (ACA) to expand Medicaid coverage for tens of thousands (somewhere around 45 thousand seems to be the most commonly used estimate) who fall into a "coverage gap," South Dakota stands to gain huge sums of money in return for a relatively small sum that it has to put up in order to participate in the plan.  The "coverage gap" exists among those who make too much money to qualify for conventional Medicaid but not enough to afford ACA-subsidized coverage.  When people in that "gap" group need healthcare, it's usually received at local ERs and paid for by a combination of taxpayer dollars and insurance premiums adjusted to fit the cost of that care.
     What Medicaid expansion will do is shift most of the cost of that care to the federal government. And just what kind of money are we talking about?  The non-partisan South Dakota Budget and Policy Institute (SDBPI) calculated this last year and concludes that if we had been doing it since 2013, our state would stand to receive $2.1 billion (yes, billion with a "b") from Medicaid, with South Dakota kicking in a whole $157 million (million with an "m") for its share of responsibility.  
     The political imperative at play here?  You saw it morph into the anti-Obamacare pitch that characterized Senator-elect Mike Rounds' recent campaign, during which his disdain for everything about Obama surfaced as a promise to end the ACA.  I believe this contempt for Obama and his groundbreaking healthcare initiative is common throughout Republican circles in South Dakota.  But realistically, a reasonable retort to those who would reject Medicaid expansion because they think ACA will be dismantled or that the funds for it will dry up is this:  If it withers on the vine we return to the status quo, which we've been living with anyway.  And even if the program endures the many political gauntlets that it is likely to go through, SDBPI's report notes that South Dakota can always change its mind and junk the whole idea.  It’s not an irreversible decision.
     That some resistance to expansion comes from a deep-seated loathing to help out fellow South Dakotans who believe they need some help is revealed in Governor Dennis Daugaard's comments in 2012, when he told the state legislature that he didn't want to put some 48,000 "able-bodied adults" on the Medicaid rolls.  I wonder if Daugaard understands that these are working people who don't make enough money in our chronically low-wage state to qualify for subsidized health insurance. This is an observation echoed by Dan Heinemann of the SD Medical Association when he calls the potential beneficiaries of expansion "the working poor."
     Let’s expand Medicaid 

Addendum (added @1731 1/16/15:  Here's a link to an excellent column on this subject written by Rapid City physician Dr. Kevin Weiland for the Rapid City Journal a couple of years ago.  


  1. Nice article, John. Here is a link to my Forum article two years ago on expansion. It is risky not to have insurance, not just for the patient, but for the system as cost shift in caring for those without it.

    1. Thanks, Dr. Weiland. I've linked to your piece in the main body of the post.