South Dakota
Medicaid unwinding deals blow to tenuous system of care for Native Americans • South Dakota Searchlight
About a year into the process of redetermining Medicaid eligibility after the COVID-19 public health emergency, more than 20 million people have been kicked off the joint federal-state program for low-income families.
A chorus of stories recount the ways the unwinding has upended people’s lives, but Native Americans are proving particularly vulnerable to losing coverage and face greater obstacles to reenrolling in Medicaid or finding other coverage.
“From my perspective, it did not work how it should,” said Kristin Melli, a pediatric nurse practitioner in rural Kalispell, Montana, who also provides telehealth services to tribal members on the Fort Peck Reservation.
The redetermination process has compounded long-existing problems people on the reservation face when seeking care, she said. She saw several patients who were still eligible for benefits disenrolled. And a rise in uninsured tribal members undercuts their health systems, threatening the already tenuous access to care in Native communities.
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One teenager, Melli recalled, lost coverage while seeking lifesaving care. Routine lab work raised flags, and in follow-ups Melli discovered the girl had a condition that could have killed her if untreated. Melli did not disclose details, to protect the patient’s privacy.
Melli said she spent weeks working with tribal nurses to coordinate lab monitoring and consultations with specialists for her patient. It wasn’t until the teen went to a specialist that Melli received a call saying she had been dropped from Medicaid coverage.
The girl’s parents told Melli they had reapplied to Medicaid a month earlier but hadn’t heard back. Melli’s patient eventually got the medication she needed with help from a pharmacist. The unwinding presented an unnecessary and burdensome obstacle to care.
Pat Flowers, Montana Democratic Senate minority leader, said during a political event in early April that 13,000 tribal members had been disenrolled in the state.
Native American and Alaska Native adults are enrolled in Medicaid at higher rates than their white counterparts, yet some tribal leaders still didn’t know exactly how many of their members had been disenrolled as of a survey conducted in February and March. The Tribal Self-Governance Advisory Committee of the Indian Health Service conducted and published the survey. Respondents included tribal leaders from Alaska, Arizona, Idaho, Montana, and New Mexico, among other states.
Tribal leaders reported many challenges related to the redetermination, including a lack of timely information provided to tribal members, patients unaware of the process or their disenrollment, long processing times, lack of staffing at the tribal level, lack of communication from their states, concerns with obtaining accurate tribal data, and in cases in which states have shared data, difficulties interpreting it.
Research and policy experts initially feared that vulnerable populations, including rural Indigenous communities and families of color, would experience greater and unique obstacles to renewing their health coverage and would be disproportionately harmed.
“They have a lot at stake and a lot to lose in this process,” said Joan Alker, executive director of the Georgetown University Center for Children and Families and a research professor at the McCourt School of Public Policy. “I fear that that prediction is coming true.”
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Cammie DuPuis-Pablo, tribal health communications director for the Confederated Salish and Kootenai Tribes in Montana, said the tribes don’t have an exact number of their members disenrolled since the redetermination began, but know some who lost coverage as far back as July still haven’t been reenrolled.
The tribes hosted their first outreach event in late April as part of their effort to help members through the process. The health care resource division is meeting people at home, making calls, and planning more events.
The tribes receive a list of members’ Medicaid status each month, DuPuis-Pablo said, but a list of those no longer insured by Medicaid would be more helpful.
Because of those data deficits, it’s unclear how many tribal members have been disenrolled.
“We are at the mercy of state Medicaid agencies on what they’re willing to share,” said Yvonne Myers, consultant on the Affordable Care Act and Medicaid for Citizen Potawatomi Nation Health Services in Oklahoma.
In Alaska, tribal health leaders struck a data-sharing agreement with the state in July but didn’t begin receiving information about their members’ coverage for about a month — at which point more than 9,500 Alaskans had already been disenrolled for procedural reasons.
“We already lost those people,” said Gennifer Moreau-Johnson, senior policy adviser in the Department of Intergovernmental Affairs at the Alaska Native Tribal Health Consortium, a nonprofit organization. “That’s a real impact.”
Because federal regulations don’t require states to track or report race and ethnicity data for people they disenroll, fewer than 10 states collect such information. While the data from these states does not show a higher rate of loss of coverage by race, a KFF report states that the data is limited and that a more accurate picture would require more demographic reporting from more states.
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Tribal health leaders are concerned that a high number of disenrollments among their members is financially undercutting their health systems and ability to provide care.
“Just because they’ve fallen off Medicaid doesn’t mean we stop serving them,” said Jim Roberts, senior executive liaison in the Department of Intergovernmental Affairs of the Alaska Native Tribal Health Consortium. “It means we’re more reliant on other sources of funding to provide that care that are already underresourced.”
Three in 10 Native American and Alaska Native people younger than 65 rely on Medicaid, compared with 15% of their white counterparts. The Indian Health Service is responsible for providing care to approximately 2.6 million of the 9.7 million Native Americans and Alaska Natives in the U.S., but services vary across regions, clinics, and health centers. The agency itself has been chronically underfunded and unable to meet the needs of the population. For fiscal year 2024, Congress approved $6.96 billion for IHS, far less than the $51.4 billion tribal leaders called for.
Because of that historical deficit, tribal health systems lean on Medicaid reimbursement and other third-party payers, like Medicare, the Department of Veterans Affairs, and private insurance, to help fill the gap. Medicaid accounted for two-thirds of third-party IHS revenues as of 2021.
Some tribal health systems receive more federal funding through Medicaid than from IHS, Roberts said.
Tribal health leaders fear diminishing Medicaid dollars will exacerbate the long-standing health disparities — such as lower life expectancy, higher rates of chronic disease, and inferior access to care — that plague Native Americans.
The unwinding has become “all-consuming,” said Monique Martin, vice president of intergovernmental affairs for the Alaska Native Tribal Health Consortium.
“The state’s really having that focus be right into the minutiae of administrative tasks, like: How do we send text messages to 7,000 people?” Martin said. “We would much rather be talking about: How do we address social determinants of health?”
Melli said she has stopped hearing of tribal members on the Fort Peck Reservation losing their Medicaid coverage, but she wonders if that means disenrolled people didn’t seek help.
“Those are the ones that we really worry about,” she said, “all of these silent cases. … We only know about the ones we actually see.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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South Dakota
Rhoden vetoes ‘misguided’ petition bill, signs off on tougher South Dakota residency law
Gov. Larry Rhoden issued his second veto while making law a slew of legislation focused on South Dakota’s elections and its citizen-led petition process.
Rhoden on Tuesday signed 20 “election bills” largely aimed at tightening the state’s residency and voting requirements.
The most notorious includes House Bill 1208. According to the bill’s language, people who claim residency at a mail forwarding address or post office “without providing a description of the location of the individual’s habitation” are not considered residents of the state and can only vote in the federal election, if eligible. The bill works in tandem with the standing requirement that prospective voters must live in South Dakota for 30 consecutive days to be considered a resident and able to vote in state elections.
Opponents of the legislation have said the bill unfairly restricts the voting rights of full-time travelers from South Dakota and the state’s homeless population.
“South Dakota continues to be an example of free and fair elections. Our election system has integrity, and these bills improve our already strong system,” Rhoden stated in a Tuesday press release. “America is founded on the principle of freedom, and I am proud that we live in a nation and a state where we can choose our leaders.”
Other bills signed by Rhoden include laws prohibiting and penalizing the use of deepfakes in an election, requiring South Dakota driver’s licenses to indicate citizenship status, and banning people who aren’t registered as in-state voters from circulating petitions on ballot measures.
House Bill 1169, brought by State Rep. Rebecca Reimer, R-Rapid City, was the only one of the batch to receive the governor’s veto brand. The bill would have required groups circulating petitions for South Dakota Constitutional Amendments to obtain no less than 5% of signatures for all 35 legislative districts in the state, based on that district’s total votes in the last gubernatorial election, in order to placed on an election ballot.
The statute as it stands only requires circulators to receive a number of signatures equal to 5% of votes cast in the last gubernatorial election for the whole state.
Rhoden stated in a Tuesday press release that HB 1169 has a “worthy goal” in raising the bar for petitioning for constitutional amendments in the state but could prove a legal problem. He explained in a letter to the State House that if a court determines the proposed law infringes on the ability to engage in free speech, it would undergo “strict scrutiny,” or the highest standard of judicial review.
“I am concerned that this bill will not withstand scrutiny in the courts. This bill attempts to change the South Dakota Constitution in statute, and I believe that approach to be misguided,” Rhoden stated.
The governor’s veto was announced after Voter Defense Association of South Dakota, a group focused on the state’s ballot process, held a Friday press conference in which they and supporters threatened to put the bill through the referendum process.
Matthew Schweich, president of VDA, told the Argus Leader the bill would have hamstrung future citizen ballot initiatives in South Dakota by implementing “the most extreme geographic distribution requirement in the U.S.”
Former State Sen. Reynold Nesiba, a Sioux Falls Democrat, planned to sponsor the referendum petition to reject the legislation.
“It will effectively end the constitutional amendment process initiated by citizens in South Dakota,” Nesiba said. “We have to remember our state motto is, ‘Under God the People Rule.’”
Schweich also challenged the bill from a practicality standpoint by sharing concerns that petition gatherers would need to carry multiple versions of their petitions and clipboards for voters that may not live where they’re encountered. He also said the bill would make South Dakota’s petition process more vulnerable to outside influence, as smaller groups would be unable to financially support a statewide campaign that some out-of-state groups could still afford.
Rhoden echoed this in his letter to the State House.
“The additional burden of collecting signatures from each of the 35 senatorial districts, each on a separate petition sheet, risks creating a system where only those with substantial financial resources can effectively undertake a statewide petition drive. This undermines the bill’s intent by putting South Dakotans at a disadvantage to dark money out-of-state groups,” Rhoden wrote.
Other bills signed by Rhoden on Tuesday include:
- SB 68: Requires an individual be a citizen of the United States before being eligible to vote and to provides a penalty therefor.
- SB 73: Requires that an individual registering as a voter when applying for a driver’s license be a resident of the state for the purposes of voting.
- SB 89: Repeals the requirement that judicial officers be listed on a separate nonpolitical ballot.
- SB 91: Revises the requirements for a petition to initiate a measure or constitutional amendment or to refer a law.
- SB 92: Requires that the director of the Legislative Research Council and the secretary of state review an initiated measure and determine if the measure embraces more than one subject.
- SB 173: Revises the process by which a recount may be requested.
- SB 185: Amends provisions pertaining to the process by which the qualifications of a registered voter are verified.
- HB 1062: Amends provisions pertaining to the maintenance and publication of the statewide voter registration file.
- HB 1066: Revises residency requirements for the purposes of voter registration.
- HB 1126: Modifies provisions pertaining to the compensation of a recount board.
- HB 1127: Requires that notice of a county’s canvass, post-election audit, and testing of automatic tabulating equipment be posted to the secretary of state’s website.
- HB 1130: Provides permissible dates for municipal and school district elections.
- HB 1164: Revises the process for nominating candidates for lieutenant governor.
- HB 1184: Amends the deadline for filing a petition to initiate a measure or constitutional amendment.
- HB 1256: Requires the inclusion of certain information on a candidate’s nominating petition or on a ballot question petition.
- HB 1264: Requires the disclosure of an outstanding loan balance on a campaign finance disclosure report.
State House and Senate lawmakers will convene in Pierre on Monday. Both chambers will need a two-thirds majority of legislators to override Rhoden’s veto.
South Dakota
'Nature Is Nonpartisan' launches in South Dakota, seeking environmental narrative change
A new national nonprofit wants to redefine the environmental movement.
‘Nature is Nonpartisan’ launched its efforts in Belle Fourche, South Dakota, the geographical center of America.
According to a press release by the group, ‘Nature is Nonpartisan’ wants to become the nation’s most influential environmental organization by creating a large-scale, cross-partisan movement dedicated to practical, long-lasting solutions. It’s kicking off its first effort called ‘Make America Beautiful Again.’
SDPB’s Lee Strubinger spoke to the group’s founder, Benji Backer, on Thursday. The interview has been shortened for clarity. Backer said the group wants broad investments in conservation.
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How will that work in this like particular political moment?
I think the polarizing moment that you’re alluding to is exactly why we exist and exactly the problem, right? Americans want efficiency and effectiveness from all energy sources. They’re not against solar and wind, they’re not against hydropower, they’re not against nuclear, they’re not against natural gas. They don’t want to have, you know, winners and losers chosen. The response to this administration is because of the pro solar wind only idea that has been pushed for a while and that wasn’t right either. So I think the answer truly lies between those two, similar on the timber issue.
But the problem is there hasn’t been the balance in the discourse. It’s either cut everything down or don’t touch it. It’s just solar and wind or just oil and gas and neither of those are productive conversations.
How do you plan to manage this coalition and what does that coalition look like?
We’re going to build coalitions around whatever push we’re doing at that time. So right now we’re pushing, you know, this administration to buy into a package that we’re calling make America beautiful again. And so we’re leveraging left and right leaning voices to push the administration to do that. That will be different than what we do in two or three years.
What we’re being really intentional about is that for every liberal person or every liberal group or every liberal board member we have on board, we also have a conservative and that’s the whole point. It’s for us to bring uncomfortable conversations there. I’ve hired an evenly split political team, our board is that way, it’ll never change. That’s how our coalitions will work and we’re going to make sure that we’re resembling the bulk of America and everything that we do.
Sounds like a tightrope.
Somebody’s got to do it and we’re going to be the ones to do it is because there’s proof in the past that this was possible.
Look at cultural transformation on issues like criminal justice reform or gay marriage or some of these other topics. Those are way harder topics to build consensus around. A love of nature, there’s a reason why almost 80% of Americans self-identify as environmentalist in 1990. We can get to that again and we have to rebuild that or the group to do it.
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