Complications: Medicaid Expansion to Wait for Special Session, Non-IHS Provider Buy-In

Governor Dennis Daugaard explains what comes next in the IHS/Medicaid expansion plan. To his right is Secretary of Health Kim Malsam-Rysdon. Capitol press conference, Pierre, SD, 2016.02.29.
Governor Dennis Daugaard explains what comes next in the IHS/Medicaid expansion plan. To his right is Secretary of Health Kim Malsam-Rysdon. Capitol press conference, Pierre, SD, 2016.02.29.dicaid

South Dakota won’t get Medicaid expansion from this Legislative Session. We may not get Medicaid expansion this year.

Governor Dennis Daugaard held a press conference this noon at the Capitol to discuss the letter released Friday by the Centers for Medicare and Medicaid Services outlining the feds’ embrace of the Governor’s suggestion that Indian Health Service pay 100% of the cost of IHS patients’ services at associated non-IHS facilities. This new federal policy is in place now; non-IHS facilities who want to work with IHS facilities can sign a contract now to prpvide care for IHS patients referred from IHS facilities.

Here are the complications:

  1. Sanford and Avera can’t just up and take Medicaid-eligible IHS patients and get paid entirely by the feds instead of billing the feds and the state through Medicaid. Sanford and Avera have to sign complicated agreements. Governor Daugaard says existing IHS/non-IHS contracts involve “ridiculous detail.” Along with the letter, CMS sent the state a draft of a pre-approived template contract that could streamline the process, but that document still needs to be revised.
  2. Once we get non-IHS facilities on board, IHS will still not wholly replace the $67 million dollars the state currently spends paying for health care for IHS-eligible patients who seek care at non-IHS facilities. The new interpretation from CMS still requires IHS facilities to be “coordinating participants” in IHS-payable care. If an IHS-eligible and Medicaid-eligible patient in Sioux Falls goes straight to Avera for treatment, IHS won’t pay for that treatment, and the state will still foot a portion of the bill. (An important note: the CMS letter emphasizes that nothing in this new policy interpretation allows the state to require Indians to go to IHS facilities for care or to delay providing care to to Indian patients until they’ve gone to an IHS facility first.)
  3. Whatever fraction of the $67 million in current state Medicaid costs we can capture will not be captured by the state itself. It is up to our non-IHS hospitals and clinics to decide they want to sign agreements with and take patient referrals from IHS facilities. As the Governor explains it, those non-IHS facilities have no upfront incentive to participate in such deals: they get paid the same whether they bill the state and feds via Medicaid or switch to the new policy and bill the feds via IHS. The only incentive the non-IHS providers have to participate in the new IHS policy is that they will capture the dollars necessary to secure expansion of Medicaid, which would allow those non-IHS facilities to get paid for serving a whole new cadre of patients, the South Dakotans who don’t have Medicaid or any other coverage right now.

That last point is remarkable: the Governor has quite neatly thrown the ball into the hospitals’ court. South Dakota’s health care providers have been urging the Governor to expand Medicaid from when the Affordable Care Act first offered that opportunity. Having secured the IHS payment interpretation for IHS patients, the Governor can now turn to those hospitals and say, “Get us the money. Bill IHS instead of state Medicaid for an amount equal to the state’s share of Medicaid expansion, and you get expansion.”

But even if the non-IHS facilities play ball and pursue those savings, do they have any guarantee that the Legislature will pass Medicaid expansion? The Governor says the remaining two weeks of this Session are no enough to give the matter proper attention; he spoke this noon about looking for a special session this year or even waiting until the 2017 Legislature to expand Medicaid. The Governor refuses to act until all the numbers are added up and we know that implementation of the IHS payment policy can happen fast enough to generate enough savings to cover Medicaid expansion costs. Non-IHS providers will now have to put the money on the table to put naysaying Republicans (and that’s all who’s left to oppose Medicaid expansion, right? them and the Koch brothers?) on the spot and leave them with no fiscal reason to oppose Medicaid expansion.

As you can see from the above points, the federal government did not, contrary to my first reading this weekend, just drop $67 million into South Dakota’s budget. Governor Daugaard emphasized that there is no new pot of money from which appropriators can fund teacher pay or anything else. The money isn’t there until the non-IHS providers make the deal to take payment from IHS. Those providers have no reason to do that unless they see Medicaid expansion at the end of that policy rainbow.

And we may not get to the end of that rainbow until the 2017 Session. The federal government would drop $373 million into our budget to expand Medicaid right now, regardless of where our IHS patients get their care. We could spend $12 million this year to get that pot of gold and provide health coverage to 50,000 more South Dakotans. But that’s a fiscal bridge too far for the Governor, who said in today’s press conference that he will ask Appropriations to remove from his budget proposal that $373 million in federal dollars he had asked the Legislature to authorize for Medicaid expansion.

We’ve given up three years of benefits; Governor Daugaard appears to be prepared to give up another year.

Update 2016.03.01 11:07 CST: View the full press conference here:

My questions for the Governor come at 22:00 and 32:30.


52 Responses to Complications: Medicaid Expansion to Wait for Special Session, Non-IHS Provider Buy-In

  1. You’re right – it’s complicated. Along with the large ‘not-for-profit’ hospitals that have lobbied for Medicaid expansion, there are also the for-profit operators to consider. The opportunity to eliminate most of the ‘charity care’ expenses the not-for-profits currently write off has been a major driver behind this whole issue. How are the for-profit entities affected? And what about the 2014 ‘Patient Choice’ initiative?

  2. Robin Page

    Once again, the elderly, the disabled, the working poor, will suffer without access to needed healthcare. Way to go Governor and Legislators! You just turned your backs, again, on those constituents who have the hardest time making ends meet. Shameful!!!

  3. Roger Cornelius

    I’m not buying the governor’s excuse on this one.
    It is most likely that providers and hospitals already have some kind of contract in place with IHS for payment reimbursement.
    And if there aren’t agreements in place, the next big opposition will come from providers and hospitals that do not want to participate in this plan because of the slow rate of reimbursement by IHS.

  4. I don’t think the Gov slammed the door, Robin. In fact he said he still supports expansion of Medicaid. The legislature has not yet had the opportunity to consider the plan.

  5. John Kennedy Claussen

    This is very unfortunate. Critics of health care systems which have significant government intervention often complain of rationed health care and long waiting periods before you can visit a doctor under such systems.

    But some how a conservative Governor, who often champions the free enterprise system, has figured out a way to make tens of thousands of South Dakotans have to wait yet another year for access to affordable health care.

    The Governor should extent at this time the legislative session through his constitutional powers to resolve this issue and to address the teacher pay issue through a more honest evaluation of our state budget – instead of allowing this legislative session to be a session of regressive taxation and denied health care for many harding working South Dakotans.

  6. Another Profile in (Near) Courage from GuvDD!

    Is South Dakota the only state where this is so complicated that squeamish Governor Chickenheart is getting advice to back down and wait? For what???

  7. MN uninsured down to 6.8% after Medicaid expansion. (Go Gov Dayton!)
    SD uninsured still double digits at 11.4%. :(

  8. Roger, do any non-IHS facilities act as contractual agents of IHS facilities now?

    You do raise a valid concern about delays in reimbursement. If IHS takes longer to pay hospitals than the state Medicaid office, why would the non-IHS hospitals make the switch?

    Is this whole IHS/Medicaid swap viable, or is the Governor just finding a clever way to put off passage of Medicaid expansion and shift the blame to the feds?

  9. Bill Dithmer

    IHS doesnt deal in good faith no matter where their people go. Slow reimbursement, try none at all.

    “Bennett County Hospital almost closed their doors because of it.
    However, it was a short-term fix, and the hospital is at the brink again. The problem is twofold, hospital CEO George Minder said: Medicaid reimbursements from the state have dropped in recent years, and Indian Health Services refuses to reimburse the hospital for most treatment of tribal members.”

    http://www.nativetimes.com/index.php/life/health/6939-struggling-south-dakota-hospital-faces-insolvency

    The Blindman

  10. It is called the eunuch shuffle. Daugaard fooled us into thinking that he had a pair, but we all can see the emperor without clothes. The hospitals would go for it if the fed would cover the reimbursement as in Medicaid right now and not depend on the IHS to do that part of it as it would require a lot more bookkeeping to handle the transactions. More bookkeeping, more delays in payments. Daugaard knows that by keeping things the way they currently are, the natives continue to get screwed and the rest of the working poor do so as well a win win in right wing circles. Their is a solution to all of this, Medicare for all Americans from birth to death. Vote Bernie Sanders.

  11. Eve Fisher

    Once again, screw the poor. Ignoring the fact that Medicaid coverage will save more money than it will spend, because finally people will have access to health care and will not be in the emergency room with septicemia or strep or pneumonia – all of which emergency room visits are covered by the rest of us. Ignoring the fact that maybe a number of people won’t die. Ignoring the fact that… Oh, why bother.

  12. I’ve heard that Daugaard is pissing a lot of GOP legislators off right now with the proposed sales tax increase and not signing the potty bill right away.
    The GOP is thinking that Dauggard has turned left on them.

  13. Douglas Wiken

    Daugaard and cohorts have had three years to get prepared for this. Not doing this now is inexcusable. If this were a corporation proposing to spend $67 million on a facility, the governor and legislature would go into special session to get it done as soon as possible.

    This GOP diddling makes no sense. Hospitals, government and paying patients are already paying for costs they should not have to bear. Daugaard and team should be ready to go with this tomorrow instead of next year.

    Hospitals with IHS contracts may or may not get paid as they should. IHS is second provider for them. The IHS should be first provider for all Native Americans. The state is getting stuck for part of the medicare-medicaid bills right now. What is Daugaard’s problem other than this might be part of Obama’s plan?

  14. I think you are hitting it correctly Mr. Wiken. As long as everyone else is cool about paying higher premiums to Wellmark (45% rate increase) and Dakotacare (60% rate increase) all is good. The bottom line for the insurance companies is doing fantastic as the rubes are willing to continue to foot the phony bill. Daugaard and his team are team players for the insurance moolah! You win big when you speak tea party mantra while fleecing the crew. What bunch of grifters.

  15. PlanningStudent

    Bill Dithmer / Blindman 2016-02-29 at 15:13
    IHS doesnt deal in good faith no matter where their people go. Slow reimbursement, try none at all.

    “Bennett County Hospital almost closed their doors because of it.
    However, it was a short-term fix, and the hospital is at the brink again. The problem is twofold, hospital CEO George Minder said: Medicaid reimbursements from the state have dropped in recent years, and Indian Health Services refuses to reimburse the hospital for most treatment of tribal members.”

    You just cited the very problem the Governor just had addressed. Bennett County Hospital is not an IHS facility, therefore it wasn’t getting reimbursement for tribal members. Now they can sign a contract with the IHS and the State (I’m not clear on who the contract is between) and start receiving reimbursement through IHS. Some hospitals figured out what Bennett County didn’t, just submit for tribal members through medicaid not IHS. In Bennett County the Hospital was eating the cost and else where the state is eating the cost through Medicaid. Now the Governor has gotten the Federal government to address this, and not just in SoDak but in every state with this problem.

    IHS and Medicaid / Medicare reimbursements are submitted through the same computer system maintained by the state. This should be pretty easy to implement, check a different box and the reimbursement will come from a different federal agency. Of course after the contracts are worked out.

    Ya’ll shouldn’t act surprised or duped. Or that the Governor is screwing over poor ppl. The Governor said he needed to see the green from IHS before committing the green for Medicaid. Cory states in his post that its clear the Governor now knows he can’t see the green before the end of this session, therefore he’s not moving on the Medicaid expansion. I still believe that if the governor can be satisfied that the state is saving around 67 million/yr from getting things right with IHS he will promote the Medicaid expansion. I don’t trust the governor because I support his politics, I guess i genuinely believe he will do what he says. After all, he just did.

  16. wth???

    I do not trust our gov

    should we big time lobby (loosely!) for the special session and dive into this thing deep and find out where the traps are .

    dd has condition after condition after condition….

  17. Kim has been enabling the posturing

  18. she’s the governor’s expert, right?

  19. The difference between this blog and the second-rate press release blog is that Cory offer’s analysis and commentary. PP cuts and pastes from social media without anything more. No wonder Republicans come here to find out what’s really going on. I think PP is burned out and just doesn’t care anymore. He’s just (barely) going through the motions.

  20. You got that right, Ror. I miss Professors Blanchard and Schaff. Everyone would learn more if the blogosphere had more ambitious conservative voices offering their own counteranalysis.

  21. Planning, I’m still puzzling over this whole thing. As I understand it, non-IHS facilities would sign a contract with an IHS facility. They would not need to include the state on that deal; they just wouldn’t submit their claims to the state via Medicaid.

    But if I understand the Governor correctly, no hospital gains anything financially by switching from billing the state to billing IHS.

  22. Leslie, if entrenchment = expertise then I guess yes. But there is history here of battles with the Feds on IHS reimbursement, even lawsuits. So the motivation to expand Medicaid was likely coming from an old axe to grind mentality which over shadowed even the anti Obama petulance.

  23. Planning 2016-02-29 at 19:27

    “You just cited the very problem the Governor just had addressed. Bennett County Hospital is not an IHS facility, therefore it wasn’t getting reimbursement for tribal members. Now they can sign a contract with the IHS and the State (I’m not clear on who the contract is between) and start receiving reimbursement through IHS. Some hospitals figured out what Bennett County didn’t, just submit for tribal members through medicaid not IHS. In Bennett County the Hospital was eating the cost and else where the state is eating the cost through Medicaid. Now the Governor has gotten the Federal government to address this, and not just in SoDak but in every state with this problem. ”

    I work for Bennett County Hospital and did back then as well. We would have loved to submit to Medicaid. But most of the IHS patients we see are not eligible for Medicaid. Most are male between the ages of 19 and 60. They usually don’t have Medicaid. IHS is all they are eligible for. But they live closer to us and need healthcare.

    We would love to have a contract with IHS for payment. Back then, IHS didn’t even really want to discuss that, saying they don’t sign contracts for healthcare with non-IHS facilities. Maybe this will help us now.

  24. As Mike J notes, Medicaid expansion offers benefits for Indian patients as well.

  25. SDPB has posted video of yesterday’s press conference to Youtube. I have embedded the video as an update to the original post above. My questions for the Governor come at 22:00 and 32:30.

  26. Roger Cornelius

    Cory,
    Whether IHS has contracts with hospitals and providers I don’t really know.
    What I do know that Indians living in Rapid City and on the Rosebud and Pine Ridge are routinely referred to outside hospitals and providers that Sioux San or IHS facilities can’t handle.
    That would include trauma care and specialty doctors and clinics.
    Another interesting note on this debacle is that when you go to an IHS facility and have Medicaid, Medicare, or state insurance those agencies are billed for services.
    Like Bennett County Hospital, IHS facilities have also had to suffer from slow or no payment from Medicare and Medicaid.

  27. Hi everyone, just wanted to let you know that MN uninsured went down to 4.8% since the expansion of Medicaid and the implementation of MN sure. This is one of the lowest percentages in the nation. Yay for MN, ranked a leader once again! Come on SD
    insure your poor, MNs rooting for you!

    http://www.postbulletin.com/news/local/report-rate-of-uninsured-in-minnesota-drops-to-record-low/article_5a6b44dc-a390-55e5-9a02-b7c6333b4c1e.html

  28. Actually MN uninsured is 4.3% not 4.8%.

  29. This will work well to keep native Americans on the reservation for treatment when they have nowhere to go.
    http://www.argusleader.com/story/news/2016/03/01/feds-deal-blow-rosebud-ihs-hospital/81152530/
    The loss of Medicare dollars is a huge blow, as it is their best and most consistent payer. Hospitals are going to close, people will die, institutional racism will continue. Instead of fully funding to allow for prevention, we go at a fraction, and we have to spend that money putting out very expensive fires.
    It is going to be impossible for Daugaard to bring his idea forth if the IHS continues to be in such flux. For now, it will be a good scapegoat for the status quo.

  30. The stinking fish goes back to the Medicaid Expansion as a whole. The governor can dance around this all he wishes, but the facts are stubborn, without Medicaid Expansion, nothing gets paid, including Bennett County. Now with the terrible issues at Rosebud and IHS in general, we see more unnecessary suffering regarding lack of care. As we do not have any kind of congressional representation on the federal level, probably the only thing for Natives to do is to lobby the United Nations for the same kind of recognition that they are giving Palestine. There is a parallel here regarding that.

  31. Medicaid expansion debate is dying. don’t let daugaard let it slide!!!!!!!!!!!!!!!!!

  32. Bill Dithmer

    $13.00 an hour, thats what a CNN gets at BCH. For that money, why dont people want to work?

    Just got of the ph with my daughter. She has worked for BCH for over four years. In that time, she has been there when she was suposed to, and she did her job despite having to drive 30 miles one way in every conceivable condition you could imagine. In that time she has worked many 12 shifts by herself, and in the last six months she has worked two 24 hr shifts, one by herself, because people just wouldnt show up.

    The problem isnt lack of CNNs, there are plenty of them. The problem is that those other CNNs only want to work when they want to work. I’m just guessing here, but I think they have lost a valued employee after this weekend. If that hospital doesnt get help that is dependable it will have a lawsuit that will close it anyway.

    My question is this. Why wont the native CNNs do the jobs they were hired for? And why dont they loose their jobs after blowing the hospital off so many times?

    In that part of the country, $13 an hr is a pretty good wage. Yet the CNNs that live in Martin cant, or just plain wont go to work every day. Isnt that just part of having a job?

    A workhorse will stop working if they are pushed hard enough. That is what is happening at BCH.

    There are some jobs out there, the trouble is that nobody wants to work.

    The Blindman

  33. It may be that the IHS will need to build a new facility there in Martin. That is what some speak of anyway. $13.00 an hour is about the same you can get for clerking in a convenience store in Wall. How can that wage justify your expense for an education? The reason most do not want to work is that they cannot afford to. If you consider what the cost of day care is and that 30 mile road trip to and from your job site, you had better have the wages that justify the misery. To purchase a 4 wheel drive pickup in these days, you have to lave about 50 K out on the line. At Harry K in Winner, they advertise a 66,000.00 dollar pickup that has been reduced by 12 thousand as a real deal. It is all relevant. That hay burner workhorse still needs grain to keep the pace.

  34. Bill Dithmer

    Jerry, my daughter drove those miles, the others lived in and near Martin. She is also a fulltime nursing student and has three boys in school. Why is she able to “get er done,” and those other p e ople only come to work if they feel like it?

    A job is only a job if you show up every damn time your supposed to.
    The Blindman

  35. Good for your daughter Blindman. My point is that the wages you think are adequate may not be as you think. In my view, they should be much higher for the work performed and as you note, your daughter is a nursing student with 3 boys in school. The cost of school must be factored in as well as someone responsible to watch the kids while you work. When you do all of that, the wage needs to be higher. You can drive down the interstate like I do and see the request for help at the stores. That is about what they pay for clerks not to say anything bad about clerks, but a nurse has gone to school for their degree and they have to pay that back.

    Look, it all else fails, there are many immigrants who would love to have the job and would do the work without question. They could recruit them from Huron or many other places to come there for the job. Or they could see about a higher wage along with better working conditions to have more folks like your daughter that would be willing to drive further than 30 miles to go to work. Working in a hospital or nursing home is no picnic that is for sure. There are some jobs in those places that are delegated to those who maybe are not in the favor of who ever is running the shift. 13 bucks an hour is not enough in healthcare.

  36. Bill Dithmer

    Jerry, there are no excuses for not going to work except health and a death in the family. $13 an hour might not be enouvh, but its what they are paying. Im not bitching about how much they are getting, it that employees dont want to do the jobs they agreed to do when they were hired. This seems to be a common denominator on and near the rez.

    Why does it have to be that way? There are no high paying jobs unless you are willing to work. If what a CNN does is beneath what natives want to do, the answer isnt to hire aliens, its teach work ethics to those that already have the jobs. No excuses!

    The Blindman

  37. Of course, there are excuses for not going to work, they are called strikes. In a right to work state, you do not have that as they can fire you. So there is that. What happens when the worker is fired and why is that not considered? Could it be that no one wants the job at all and that they have to take what comes? I am thinking so, bad help is better than no help at all. In the real business world, these things are taken into consideration and a remedy is found. Most generally working conditions must improve along with wage considerations. I found your statement that “there are no high paying jobs unless you are willing to work”, amusing. That was more or less what was on the sign at Dachau “Arbeit macht frei” (work sets you free)

  38. Bill Dithmer

    Stop trying to make excuses Jerry. If you take the job, do the job. If you dont want to work quit. Yes its that simple.

    They arent on strike, they dont w a nt to work.

    The Blindman

  39. Make excuses for low wages? on the contrary, I am merely pointing out that the wage for the work does not equate. At one time, I worked with autistic children, that is work and was paid crap to do it. Had it not been for my girlfriend at the time, I never would have done such work. The wages paid for healthcare workers are not that good and they should be higher for the amount of stress and hard physical as well as mental requirements for the job. If the employer is unhappy with the workers, they should terminate them immediately and hire someone else to fill the job. To make sure that they are not the problem, the employer should try to raise the wages to see if that makes a difference. No excuses, just solutions.

  40. Roger Cornelius

    The IHS hospital in Pine Ridge is one of the largest employers on the reservation with employees traveling greater distances than 30 miles to get to work. I know a Native American mid-wife employed by IHS in Pine Ridge that lives here in Rapid City and travels to the reservation everyday. That is nearly a 200 mile commute daily.
    On the reservation Native Americans travel from all districts to work at the hospital.
    My question would be since the Bennett County Hospital has long standing problems, are they all caused by Native Americans either for equal pay issues or poor treatment by their employees?
    If the management of the hospital continues to have conflicts with employees, he may have problems with his management style.
    If there are ALL these Native Americans not showing up or performing poorly it is the problem of the administration. He has a responsibility to terminate bad employees and replace them with good employees
    Hospitals and healthcare is a critical need for all our communities, if the administrator is under performing he should be replace immediately, he has become a danger to the publics health.
    Of course in Dithmer’s world, ALL white employees in every business Always show up for work.

  41. I can tell you that Mr. Dithmer is right on one count. People need to work harder and whine less.

  42. Indeed Mr. Grudznick “Arbeit macht frei” Indeed

  43. Bill Dithmer

    Just more excuses Roger.

    The Blindman

  44. Roger notes something very interesting regarding travel to and from work. He notes a mid-wife that makes the 200 mile round trip for her job. I am thinking that maybe if there were some kind of change in management at the hospital in Martin to go along with higher wages, then there may be more of a desire to work in that environment. As Roger has a history with healthcare, I am sure that he has heard may reasons or excuses on why something does not work and has probably seen the need for changes to be made to make the work situation function as was its intent.

    As the problem created by the Rounds-Daugaard cabal to deny Medicaid Expansion is as it is, they now see fit to blame it on the Natives for having the audacity to need healthcare. To me it could be as simple as calling for a special secession to hammer it out. Of course, that does not fit into the right wing scheme of things as Daugaard and company wait to see if the Donald should get the nod or the Reconstructionist, Ted Cruz. If Clinton or Bernie wins, then this issue will be solved quickly.

  45. Roger Cornelius

    You’re an excuse Dithmer, a sorry one.

  46. Roger Cornelius

    Jerry,
    The choice to go to work or be employed is always and individual reason or excuse.

    The Lakota have no universal excuse or reason not to work, maybe they choose not to work a Bennett County Hospital.
    Bennett County has had a long history of racism and conflict with the Lakota.
    With the exception of buying my vehicles from a local auto dealer because of our friendship, I refused to do business in the town.

    There is little tolerance for chronically late or not showing up for work in the healthcare industry, all their jobs are vital to patient care. In the health clinics I was involved with that kind of behavior would not have tolerated regardless or race. If it is a continue problem the hospital or clinic would and should be terminated.

  47. Roger, That is exactly what I see as well. As an example, I have worked with a lot of companies that are as diverse as healthcare facilities. From what I have seen, regarding healthcare is that if your work environment is healthy and managed fairly and you pay a wage that makes workers have a feel of being a part of something bigger than themselves, you have success with less turnover. Some of the assisted living facilities that I have been associated with have a lot of turnover as the work is difficult and they are underpaid for the incredible jobs they do. I have been in other assisted living facilities that you can see a remarkable change in that regard. All you have to do is shoot the cool breeze with the workers and you get the idea they feel a part of the place.

    In my opinion, when Medicaid Expansion is finally fulfilled here in our state, it will make a big difference in how all of these facilities are run. Management will have to be reevaluated to keep up with the times and workers will be more appreciated as they will want to be compensated for their efforts to keep the facility on line. As the IHS has a different set of pay guidelines and expectations, I am sure you would agree that if more funding came into the system, that health delivery system would improve dramatically. I think that all healthcare providers in the state including the IHS system would agree that by not having the Medicaid Expansion in place, it does nothing but harm citizens health wise as well as the taxpayers bottom line. Why should local taxpayers be burdened even further for funds when those funds would come from a nationwide taxpayer system exactly like how the rest of subsidized healthcare comes from. Daugaard is penalizing the states taxpayers for his ideology.

  48. bearcreekbat

    Jerry nails it – “if your work environment is healthy and managed fairly and you pay a wage that makes workers have a feel of being a part of something bigger than themselves, you have success. . . .”

    People who feel appreciated tend to love (or at least enjoy) their jobs and will show up for work. People who are treated like commodities naturally dislike their jobs and find ways to avoid work. I don’t think this has anything to do with a person’s culture, rather, it has everything to do with the working environment and how that environment contributes to the employee’s sense of value and self worth.

    My spouse disagrees and argues that the need to support your family trumps a hostile work environment, so my spouse is all aboard the Blindman train while I am taking a ride on the Roger train.

  49. Hey, Leslie—you note that Medicaid expansion is dying before us, with the Governor effectively using the delay in the feds’ response (or maybe more accurately, the delay in his request to the feds for this unnecessary complication) to keep the real Medicaid debate out of this session. Democrats held their fire on the teacher pay package, not pushing their plan way hard, dutifully helping the Governor pass his plan. Is it time now for Democrats to ask for something in return? Is it time for Democrats to bring the Session to a screeching halt and vow to block passage of the budget and anything else left on the calendar this week unless the spending authority for federal Medicaid expansion funds is included in the budget?

  50. Bill Dithmer

    At least I’m telling the truth Roger, you all are still making excuses for people noyt djoing their job.

    Oh ya Roger, you are a racist and there is no excuse for that.

    The Blindman

  51. Bill Dithmer

    Of course in Dithmer’s world, ALL white employees in every business Always show up for work.

    Where did I say that Roger? Stop trying to make excuses for not going to a job.

    The Blindman

  52. Cory, I would like to add that Democrats owe it to their state to fight for people’s rights as only a Democrat would. The Democrats should indeed band together with the few and the proud and say enough. Enough of the punishment of the working poor, pass Medicaid Expansion! Enough of our hospitals and providers having to think of closing their doors due to lack of reimbursement for services rendered, pass Medicaid Expansion! Enough of pushing these unnecessary charges onto the backs of South Dakota taxpayers, pass Medicaid Expansion!

    Democrats Unite! Hold the governor and his budget hostage until the Medicaid Expansion passes! You can do this Democrats! Show your will!