South Dakota Medicaid expansion proposal faces hurdles

Dec. 20--Since South Dakota Indian Health closed in Aberdeen in August 2013, American Indians in town have had to travel at least 100 miles for care provided by Indian Health Services.

Gov. Dennis Daugaard's move to expand Medicaid might save patients the hassle of driving to either Sisseton or McLaughlin and the state a considerable amount of money.

Daugaard's proposal essentially asks for a trade -- South Dakota would expand Medicaid if the federal government would fully cover care for American Indians in every instance.

Under the present system -- Federal Medical Assistance Percentages, or FMAP -- the federal government reimburses about half the cost when American Indians who qualify for the Indian Health Service go to non-IHS facilities. The other half of the bill is covered by the state.

Daugaard would be willing to expand Medicaid if the federal government would take on the cost of providing care for all who qualify for IHS, even if they go to medical providers that aren't currently contracted.

That should open up more health care options and eliminate travel for some American Indians who need medical care.

Medicaid is a government-funded insurance program for income-qualifying people. Today in South Dakota, it covers the children who are members of low-income families; long-term care for those who are 65 and older and those who are disabled. There's also prenatal coverage for low-income pregnant women.

The IHS is the health care system for federally recognized American Indian and Alaska Natives in the U.S.

Now, there are an estimated 55,000 South Dakotans are without health care coverage because they don't qualify for Medicaid or IHS, nor do they have the income necessary to pay for their own coverage through the general market. Of the 55,000, state Rep. Steven McCleery, D-Sisseton, said he has seen an estimate that 15,000 are American Indians.

Were Medicaid expanded in South Dakota, an additional 48,500 people, including 13,000 American Indians, would be covered, according to a letter Daugaard wrote to South Dakota tribes.

The current system has left South Dakota shouldering about $67 million, Daugaard said, and service providers shouldering more. So far this year, Avera Health has provided $112 million in care to people who are unable to pay, said Deb Fischer-Clemens, senior vice president for public policy at Avera Health.

When a state expands Medicaid to cover income-qualified residents, the federal government initially covers 100 percent of the cost, but the portion states pay slowly increases. By 2021, South Dakota's anticipated cost is $57 million, or about 10 percent of the expense, Daugaard said.

Indian Health Service

When the Sisseton Indian Hospital, an IHS facility, closed in 2007, visits to the emergency room at the town's Coteau des Prairies Hospital increased from 500 per year to over 6,500, said Coteau des Prairies CEO Michael Coyle.

The substantial increase required that a new seven-treatment room emergency department be built and staffed 365 days a year, 24 hours a day, he said. Previously, the hospital staffed its two treatment rooms in the ED.

"As a volume standpoint, it's been good," Coyle said.

He also noted that IHS pays at a slower rate, which creates a little financial burden.

According to Coyle, Medicaid currently pays 30 cents on a dollar. He wonders where the 100 percent will come from.

"Some other program is going to be impacted," he said. "It's great to have those dollars in as long as it doesn't impact dollars where we need them.

"We're going to provide care regardless. It just changes how we get paid," he said.

According to its website, the Great Plains Area IHS provides services to approximately 122,000 American Indians who reside within 19 service units, 10 of which are in South Dakota, and 6,000 additional American Indians who reside outside of the unit areas, but meet the IHS eligibility criteria.

"The largest concentrations of the nonservice eligible (in South Dakota) are found in Aberdeen and Sioux Falls," the website states.

No explanation

When IHS closed its Aberdeen clinic in August 2013 after 36 years of serving American Indians and others, the board and administration chose not to comment on why, according to American News' archives. Those who qualify and want to receive IHS services have since had to travel, with the closest IHS providers in Sisseton, 102 miles northeast, or McLaughlin, 131 miles northwest.

Now, travel is most common for routine care like seeing a dentist, said Sara DeCoteau, health coordinator at Sisseton-Wahpeton Oyate Health Care.

Sisseton, on the Lake Traverse Reservation, is home to the Sisseton-Wahpeton Oyate tribe.

The list of services available at the Woodrow Wilson Keeble Memorial Health Care Center, formerly called theSisseton-Wahpeton Oyate Health Care Center, includes behavioral health, dental, pharmacy, physical therapy, well child care, weight loss/nutrition and diabetes care, among others, according to the IHS website.

Priority levels

Yet, those qualifying for IHS will sometimes not find all the care they need at an IHS location. And not all health care services meet the priority level of care guidelines for contract health services, which can limit referrals.

For contracted health care, most IHS facilities are limited to the highest priority of medical services -- Level 1 -- which the Sisseton-Wahpeton Oyate Health Care system refers to as "life or limb."

If that level of priority is not met, the patient cannot be referred out and bills cannot be paid,DeCoteau said. And if a person without insurance seeks services that do not meet IHS guidelines, the provider does not get paid, she said. Patients will be billed if they go to non-IHS providers on their own. However, if they are referred from IHS, it is against the law for patients to be billed.

While traveling patients can receive direct care, they are also not eligible to be referred DeCoteau said. Contract health services state that, in order to be referable, the patient must live on or near a reservation.

"So people that move away are no longer eligible," she said.

The Affordable Care Act included permanent reauthorization of the Indian Health Care Improvement Act, which extended the law and authorized new programs and services within IHS. However, Congress did not appropriate any money to carry it out, according to DeCoteau.

"If it comes to pass, what they've found in other states is that (expansion) has doubled Medicaid collections of the facilities," she said. "And that's money that can be used to pay for more services."

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By the numbers

102: Miles from Aberdeen to the nearest Indian Health Service center near Sisseton.

55,000: South Dakotans without health insurance, estimated by Gov. Dennis Daugaard.

15,000: Uninsured American Indians in South Dakota, said Rep. Steven McCleery, D-Sisseton.

$66.5 million: In state funds paid for Indian Health Service care provided by non-HIS providers in fiscal year 2015, according to Daugaard.

$57 million: The estimated cost for Medicaid expansion for South Dakota for fiscal year 2021, according to Daugaard.

6,000: More emergency room visits per year at Coteau des Prairies Hospital in Sisseton since Sisseton Indian Hospital closed in 2007, said CEO Michael Coyle.

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