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South Dakota health insurance

SD gets another push for Medicaid expansion

Public health and a state’s approach to healthcare reform are significant factors that play a role in quality of life, productivity, and health outcomes. Each state has different strengths and challenges when it comes to healthcare, and healthcare reform has been a very polarizing topic for the last few years, with some states fully embracing it and others rejecting it in every way possible.
Here’s a summary of how South Dakota compares with other states in terms of overall health, access to health insurance, and the state’s approach to healthcare reform:

South Dakota health ratings

In 2014, South Dakota was ranked 12th (the same spot the state held in 2009) out of the 50 states and the District of Columbia by the Commonwealth Fund’s Scorecard on State Health System PerformanceSouth Dakota’s Scorecard provides specific details about public health in the state and how the overall score was determined.

The state ranked a little lower in the 2014 America’s Health Rankings, coming in at 18th in terms of overall health. A low incidence of drug deaths, a low percentage of children in poverty and a low prevalence of low birthweight all help the state’s ranking. But it’s lowered by factors that include a high incidence of binge drinking and occupational fatalities, and low immunization coverage among teens. From 2013 to 2014, the state saw a decrease in its childhood poverty rate, smoking and preventable hospitalizations.

Trust for America’s Health gives us another look at overall public health in South Dakota in their 2015 listing of Key Health Data About South Dakota. Their summary includes information on the prevalence of various illnesses and health outcome predictors.

If you’re interested in seeing how the counties in South Dakota compare with one another in terms of health factors and outcomes, the Robert Wood Johnson Foundation has put together this interactive map that you can use.

South Dakota and the ACA

In 2010, South Dakota’s U.S. senators were split on the Affordable Care Act. Democrat Tim Johnson voted yes, while Republican John Thune voted no. In the U.S. House, Stephanie Herseth Sandlin, a Democrat, voted yes. Sen. Thune remains in office, and Sen. Rounds did not seek re-election in 2014; he continued to make Medicaid expansion a priority as he closed out his final term. Republican Sen. Mike Round replaced him and has called Obamacare “fatally flawed.” Kristi Noem is the new U.S. representative for South Dakota, and she opposes the ACA.

Governor Dennis Daugaard is also opposed to Obamacare, and opted to let HHS run the state’s exchange. But he has been willing to negotiate on the issue of Medicaid expansion, proposing a compromise to cover only residents with incomes below the poverty level, rather than those with incomes up to 138 percent of poverty as called for under the ACA. HHS has not approved his proposal, and South Dakota has not yet expanded Medicaid. South Dakota’s state legislature has a strong Republican majority, generally opposed to Obamacare.

How did Obamacare help South Dakotans?

Before the ACA was implemented, the uninsured rate in South Dakota was 14 percent, lower than the national average. Post-ACA, 11.3 percent of South Dakota residents were uninsured at the end of June 2014 – six months after full Obamacare implementation. This put South Dakota ahead of 35 other states in terms of the percentage of the population without health insurance.

By the end of June 2015, South Dakota’s percentage of uninsured residents had dropped to 7.2 percent; however, the number could still be reduced considerably if and when the state expands Medicaid.

South Dakota enrollment in qualified health plans

In late 2013, the Kaiser Family Foundation estimated that 118,000 South Dakota residents were potential exchange customers, and that about 70,000 of them would qualify for premium subsidies. By April 19, at the end of the first open enrollment period, 13,104 people had finalized their enrollment in qualified health plans through South Dakota’s exchange, and 89 percent of them qualifyed for premium subsidies.

During the second Obamacare open enrollment period, 21,393 South Dakotans signed up for QHPs through the state’s federally facilitated exchange. However, some of them failed to make their premium payments or dropped coverage, and 18,983 remained enrolled as of June 30, 2015. Of those who retained their 2015 coverage by mid-year, 87.5 percent received advanced premium tax credits and 63.9 percent received cost-sharing reductions.

South Dakota’s exchange included plans from three carriers in 2015; however, DAKOTACARE announced it would only sell off-exchange plans in 2016. That leaves two carriers offering 2016 coverage through South Dakota’s exchange: Avera and Sanford. South Dakota’s off-exchange carriers include DAKOTACARE and Wellmark.

Because the state has not played a role in educating consumers about the state’s health insurance exchange, federally funded navigators affiliated with community outreach and advocacy groups are trained to help consumers in South Dakota.

South Dakota Medicaid/CHIP enrollment

The Supreme Court ruled in 2012 that Medicaid expansion was optional for the states. However, as the ACA was written, exchange-based subsidies are only available for people with incomes between 100 and 400 percent of the federal poverty level. Below that range, federal lawmakers anticipated Medicaid coverage would kick in for everyone.

South Dakota is currently one of 20 states that has not expanded Medicaid under the ACA and has no imminent plans to do so. Unfortunately, in states like South Dakota, coverage is only available based on the pre-ACA eligibility rules. For South Dakota, there’s no Medicaid coverage available for non-disabled childless adults, and parents with dependent children are only eligible if they have a household income that doesn’t exceed 58 percent of poverty.

As a result, in 2015, approximately 13,000 South Dakotans remained in the coverage gap with no access to Medicaid or exchange subsidies. Their only option is to pay full price for a private plan, which is not possible for most households with incomes below the poverty level.

The state had tried to reach a compromise with HHS in 2014, but the two sides were not able to agree on an acceptable path to Medicaid expansion and the process stalled. Gov. Daugaard and Republicans in the South Dakota legislature had proposed expanding Medicaid, but only up to 100 percent of poverty, rather than 138 percent as called for in the ACA.

Governor Daugaard’s proposal would have provided Medicaid to people currently in the coverage gap – everyone with incomes up to 100 percent of poverty level – but would have kept the current system of exchange subsidies for people with incomes between 100 percent and 138 percent of poverty level (about 22,000 people in South Dakota). Medicaid is less expensive for the federal government than exchange subsidies, but exchange subsidies don’t cost the states anything, while the states will eventually be on the hook for up to 10 percent of the total cost of Medicaid expansion.

In September 2015, South Dakota officials announced that their latest proposal to expand Medicaid had received “an initial ‘go ahead’” from HHS. Proposal details had not been made public, but Gov. Daugaard’s office predicted the expansion would extend program eligibility to 48,500 additional South Dakotans. The governor’s senior advisor, Kim Malsam-Rysdon, noted that while the plan is still preliminary, it appears promising.

Despite a lack of Medicaid expansion, 3,214 South Dakotans enrolled in the program from 2013 to July 2015, a 3 percent increase. Medicaid enrollment lasts year-long.

South Dakota and high-risk pools

Before the ACA reformed the individual health insurance market, coverage was underwritten in nearly every state, including South Dakota. This meant that pre-existing conditions could result in an application being rejected altogether, or a coverage offer with significantly higher premiums or policy exclusions. The South Dakota Risk Pool was created in 2003 to give people an alternative if they couldn’t purchase individual health insurance because of their medical history.

Implementation of the ACA and the switch to a guaranteed issue individual market made high-risk pools largely unnecessary starting in January 2014, and the South Dakota Risk Pool stopped enrolling new members as of December 31, 2013. The plan remained operational for existing members until June 30, 2015.

SD state-based health reform legislation

South Dakota’s legislature tackled a few different healthcare issues in 2014, including passing a bill that calls on the federal government to repeal or defund the ACA.

Medicare in the state of South Dakota

South Dakota Medicare enrollment is about 17.1 percent of the Mount Rushmore State’s total population, compared with 16 percent of the U.S. population. The state’s enrollment breaks down to 86 percent who qualify based on age alone and 14 percent who qualify due to disability.

South Dakota’s per recipient spending is among the lowest in the nation, at $8,148 per beneficiary each year. The state ranks 46th in total spending on Medicare with $1.1 billion annually.

If they want additional benefits, Medicare beneficiaries in South Dakota can choose private Medicare Advantage plans instead of Original Medicare In 2014, 15 percent of South Dakota Medicare recipients did so. 47 percent of the state’s Medicare beneficiaries chose a Medicare Part D plan, a figure that matches the national average.