The Health Care Solutions Coalition meets this week Wednesday (1 p.m. at the Pierre Ramkota). Their mission: figure out if South Dakota can finally expand Medicaid under the Affordable Care Act without spending one more penny of state money. Their magic trick: move Indians off Medicaid and back to IHS care, thus freeing up money to expand Medicaid to the 48,000 South Dakotans waiting for Governor Daugaard to stop backhandedly calling them lazy and let them get public health coverage.
Let’s compare this 31-member Medicaid-expansion task force with another sprawling task force convened by our Governor, the 26-member Blue Ribbon Task Force on Teachers and Students.
If I understand the public documents the Health Care Solutions Coalition makes available online, the state hatched the Medicaid-IHS-offset plan back in March 2015. Here’s the introduction to the concept paper that the state discussed with the Centers for Medicare and Medicaid Services on March 6, 2015:
Eligible South Dakota Native Americans are served by the Great Plains Indian Health Service Unit. However, actual access to Indian Health Services is limited in all areas of the state, and IHS contract care budgets do not meet the demand for healthcare beyond even limited emergency services. As a result, Native Americans eligible for IHS services use non-IHS services at high rates, and often at higher cost than if they were able to access care earlier and closer to home.
The state Medicaid program pays almost twice as much for health care for Native Americans by non-IHS providers as IHS providers. For Native Americans eligible for IHS services and also Medicaid eligible, health care expenditures provided through IHS are reimbursed at 100% federal funds through Medicaid. Health care expenditures for Medicaid eligible Native Americans by a non-IHS provider are reimbursed at the state’s regular FMAP (51.62% federal/48.38% state in state fiscal year 2016). For this reason it is fiscally beneficial to the state to help eligible Native Americans get care from IHS instead of non-IHS providers. Given the capacity issues with IHS, the state is looking for innovative ways for eligible Native Americans to get care that qualifies for 100% federal funding as it would if IHS were able to provide it.
The state, in collaboration with IHS and non-IHS health care provider, is specifically seeking to implement different strategies to significantly augment services that can be provided to Medicaid eligibles through 100% federal funding authority through a variety of strategies. Examples include using health care specialists available through non-IHS providers to serve patients at IHS sites via telehealth or specialty clinic arrangements. Other examples include use of telehealth emergency room services to reduce non-emergency transfers of patients from IHS to non-IHS providers in the state and the provision of clinic services in non-reservation population centers to better serve IHS eligible Native Americans. For these strategies to work there would need to be flexibility in how IHS services are defined in terms of providers and locations of services for the purposes of Medicaid reimbursement. That means CMS would pay the same match rate (100% federal) as they would today for IHS services to Medicaid eligibles, but for more services than the current IHS system can accommodate. These strategies would benefit both the current Medicaid population and the Medicaid expansion population eligible for services from IHS.
To be clear, we are not asking for fundamental changes of funding for IHS, but for CMS to work with the state to provide needed Medicaid services that can be billed at the IHS federal rate for IHS eligible individuals.
The result of increasing access to services to individuals eligible for IHS would include better health outcomes for South Dakota Native Americans. With an increase in IHS funded services through Medicaid at 100% federal funds, state general funds used now to pay for services to this population would be redirected to offset the costs of expanding Medicaid in South Dakota. That would result in coverage for 48,000 additional people in South Dakota, more than a quarter of whom are Native American [State of South Dakota, concept paper, March 2015].
Following up on a call with Health and Human Services in May, the state provided figures showing $133.3 million in state Medicaid expenditures in FY2014 for American Indian residents that could have been delivered through IHS. A January 2013 analysis from the South Dakota Budget and Policy Project showed that South Dakota could have covered ten years of ACA-Medicaid expansion for $157 million. The annual state cost by 2022 will be $36 million.
That May follow-up also identified two key policy actions for making the Medicaid-IHS shift possible: implementation of a Community Health Worker model used in 41 other states and expansion of telehealth services.
With a pot of money and two key policy interventions identified, the Health Care Solutions Coalition is now meeting every two weeks to turn this plan into reality. The task force seems to have started meeting on October 7. They meet this week on October 21. They meet again on November 4 and 18 and December 2 and 16.
Meanwhile, the Blue Ribbon K-12 panel, conceived by Governor Daugaard last February, held three months of public listening sessions from April through June and has subsequently convened for four monthly meetings. They have one meeting left on October 29. The Blue Ribboneers have yet to coalesce around any firm proposal for increasing revenue for K-12 schools that could galvanize the Legislature into action.
The Governor appears to have come around on Medicaid expansion. His administration appears to have found a two-bird-one-stone solution that may improve health care for South Dakota’s Indians and the uninsured working poor. And the Daugaard Administration appears to have handed this firm plan to his Medicaid expansion task force and said, “Get it done!” I see no similar definitive direction or urgency on K-12 funding.
I’m not saying that I’m disappointed that Governor Daugaard has finally come to Jesus on ACA-Medicaid expansion. Nor am I saying that I want Governor Daugaard to step in and write the Blue Ribbon K-12 funding plan for us.
I just wish the Governor were driving the Blue Ribboneers to find a solid plan for raising teacher pay with the same verve and focus that appears to be behind the Medicaid expansion task force.
IHS and the VA should be merged.
So? When an atheist uses a reference to God, is that a Freudian slip?
If words have meaning, if we are to comply with the strict politically correct mandate imposed by the Left, and you are true to your professed belief in nothing.. it should have read “Daugaard has finally come to nothing..”
;-D
Is anyone surprised? Big govt loving Chicago lawyer Denny Daugaard embracing more govt? Whatever the big govt loving Chamber of Commerce and the big hospitals want..
DD, I swim in the linguistic soup of my community. You understood my meaning, right? But if Chicago lawyer Daugaard really is a big-government guy (please hit the campaign trail with your local Dems next year, DD, and help us make that point to defuse SDGOP sloganeering), why did it take him this long to embrace this particularly lucrative, moral, and effective bit of big government?
(By the way, I do not dispute the existence of a carpenter from Nazareth who was put to death by the Roman Empire for stirring up trouble. My kind of guy… except for the getting-killed part. ;-) )
Merge VA and IHS—How about just one government health-care provider, with certain classes of people (veterans, tribal treaty beneficiaries, retirees…) designated as recipients of free care, but care available to everyone else for fee? Or how about going the other direction: eliminate direct government provision of health care services, but fund services for all citizens through an expanded Medicare?
Neither of those plans will come from the Governor’s health care task force. I just find it worth noting that when the Governor wants to find money to do some big project, he can do it. He is showing the will now to expand Medicaid (and I want to buy a sandwich for the guy or gal who showed him how to do it without spending any more South Dakota money); when will he show similar will to pay our teachers more?
CH, a Medicare for all would work very well. In European countries that have universal healthcare as well as private care, they also have separate care for the military and its veterans. The carve out must exist as military needs are much different in many cases than the needs of the rest of the public as there are multiple issues with each case. Regarding Native needs as well, there is a much different set of circumstances like the incredible high percentage of diabetes cases along with other diseases that run rampant among Native populations. My worry would be that both of these special cases of healthcare would be gutted by republicans at their first meeting.
I don’t disagree with your idea, Cory: that Denny Daugaard is being swayed by his top donors probably puts his conservative scorecard in the single digits.
Medicaid for all makes far better sense than any other alternative. Let South Dakota’s one-percenters spend cash at private clinics.
Many Native’s have private health coverage at present. Natives are also involved with the ACA, if they qualify. What the Medicaid Expansion is for is the working poor and those that earn less than $11,500.00 each year as a single person. When you do the math on that, it is $958.00 per month, which I am sure that the readers and responders to this blog would not be able to live on. Daugaard is just full of himself in the age old divide and conquer method of racist mentality by pitting the Native population in dispute with not only themselves, but with poor white folks. Here is a nugget for each of you to consider. Suppose you had a stroke that left you disabled. In addition to loosing your job, you would also have to suffer 24 months on no income before you become eligible for disability. Got any ideas on how you could make it without the government coming in to help you? Daugaard is a pompous arse that thinks his shell game will work. Nothing to see here, as Obama will never allow this trick to happen as is it is not appropriate.
i see it as perhaps a ruse daugaard is using to further delay any straightforward acceptance of medicaid expansion in SD. People are dying without coverage while daugaard is a political evil. and god help Indians’ healthcare, such as it is, as daugaard has now focused there to save face.
jerry, imagine what could happen if dem’s lose in 2016?
Maybe Daugaard can’t walk and chew gum at the same time and has decided to handle one issue at a time.
Or perhaps it is that Daugaard can see $$$ signs in Medicaid Expansion and sees $$$ being spent on teacher pay.
“Or perhaps it is that Daugaard can see $$$ signs in Medicaid Expansion and sees $$$ being spent on teacher pay.”
The $$$$ in was obvious even before the day Daugaard blindly pushed ahead with his ideological mythology and nonsense about $$$ not flowing in forever. Maybe he finally just woke up to SD economic reality. If so, it is years late.
Jerry, is it a trick pitting Indians against other constituencies? Couldn’t we read it as Daugaard getting the feds to improve IHS service and agreeing to do ACA in return? If both sides do what the plan appears to call for, don’t both Indians and the working poor come out ahead?
Yes, of course that would be the best way forward and the most honorable thing to do, which is to honor your word. Natives did not break their word on any of the ways of the treaties, they held honor above all else. Some may argue that, but I have never seen any form of the breaking of treaty words by any parties other than the US Government. To show that Daugaard speaks from both sides of his mouth, Natives would need to challenge him into showing the numbers and location of where he is pulling those from, his behind does not count as that is probably where they came from.
The congressional delegation from South Dakota is his party and it is in shambles in Washington at present. This congressional delegation is hell bent on shutting down the government while holding funding for Social Security, Medicare and this Medicaid as a hostage. Daugaard is a republican politician and is fully aware of that circumstance. His position then is to have the dog and pony show, that he knows full well will not bear fruit, and then sweep it under the rug. Rings a bell, doesn’t it with his blue ribbon joke against you and your fellows. He grins that crap eating grin, throws his hands up, and says damn, can’t be done because of the Natives.
The control of both chambers of congress guarantees that there will not be adequate funding for the increase of dollars to make the IHS more user friendly, they want that money to pay for wars both current and the ones only they can dream up. As honor goes, if the VA cannot be fully funded by republicans, why on earth would they even consider funding the IHS?
So, yes, finding a solution to the issues would be as simple as looking to North Dakota. This state also has reservations and a large Native populace. North Dakota is run by republicans and has a republican governor. He could add and also understands what math is so the state accepted Medicaid Expansion without trying to hold Natives hostage. Daugaard is a callous arse that is not clueless, he knows exactly what he is doing and he knows full well it will fail, but will play into the hands of the rest of the racists.
These are my opinions of this charade. I would ask Roger, Spike and all others to bring their opinions to your great question.
How about closing Ellsworth that has veterans to there,Can beleive to merge the V.A. then privatize it then nothing,
South Dakota hates poor people. If you choose to be poor, get the heck out and don’t come back until you pull yourself up by your bootstraps, you worthless bums. Why should we help you? It’s our money and it’s for our benefit.
Jerry,
Thanks for the request.
The first thing I see here is that what Daugaard is proposing is discriminatory and perhaps even racist. He could have Jackley in court, spending money, to promote his idea if tribes decide to challenge him.
The merging of the VA and IHS isn’t a new idea, it has been around for awhile and occasionally comes up. This is such a bad idea, we have two agencies that are bureaucracies fumbling to provide services. Do we want a huge monster that will attempt to provide services to veterans and Indians?
Daugaard needs to just drop the Indian thing and do the right thing, Medicaid Expansion for all.
My two question for Daugaard would be, is our state’s Indian population great enough to warrant your discriminatory Medicaid Expansion, and would you abandon Medicaid Expansion for all eligible South Dakotans if you can’t kick Indians off the program?
Jerry, maybe we can give Daugaard more credit than the Congressional delegation. Noem, Thune, and Rounds are trying to gut and shut the federal government. Daugaard’s proposal on face is a proposal to make the federal government work better.
Roger, flesh out for me how this plan is racist. (I hope I don’t sound like I’m being dense; I just want to nail this down.) I can see the nub of what you’re saying—this idea that Indians should be using their own health system instead of costing South Dakota’s health providers money. But what if (and this is not what Daugaard is proposing, but roll with me) what if we gave every tribal member an IHS charge card. No matter where they go—IHS facility, private hospital, whatever—they swipe that card, and the bill goes to IHS. Would that solve the problem of providing Indian health care under treaty?
Cory,
My concern about racism is that Native Americans that live off the reservation where there are no IHS services would not be served, on appearance it Indians would in that position would be ineligible for state Medicaid Expansion.
Even in Rapid City many Indians with and without private insurance, Medicare or Medicaid will choose to use the Community Health Center of the Black Hills because of the notoriously poor service provided by Sioux San.
If Indians are not provided with what they feel as quality healthcare, shouldn’t they have an alternative?
An IHS medical charge card would be the ideal thing to do for Indians in the positions I describe above. Would IHS in Washington, D.C. do it? Hardly!
The Bureau of Indian Affairs and Indian Health Service in D.C., Aberdeen, and the local facilities are so entrenched in their granite like bureaucracies they can’t be penetrated.
D.C. and Aberdeen are for the most part political payoff positions that have gone into 3 and 4th generations of employees, are they going to let a simple medical swipe jeopardize their positions?
Something else, Sioux San is a network provider that uses Pennington County as its boundaries. So if you are injured in Spearfish, you are out of network.
Here is the latest from Kaiser. Daugaard, the emperor of South Dakota has no clothes. ”
A new Kaiser Family Foundation report suggests that the Republican-controlled non-expansion states are seeing their share of Medicaid costs rise more sharply than expansion states. This trend undercuts a popular argument against the Medicaid expansion in states where Republican leaders continue to resist opting into the program, under which the federal government pays 100 percent of costs through 2016 and at least 90 percent share after.
The report found that total spending in expansion states grew by 17.7 percent, but the state spending only grew by 3.4 percent. Meanwhile, state spending on Medicaid in non-expansion states increased by 6.9 percent as total spending rose by 6.1 percent.”
There is no way in the world Daugaard is gonna get the Feds to blink on this. We are burning money at a record pace with next year, much worse. The ole crook better get some moolah from Joop to keep the ship floating as we are listing big time. We shall see what the meeting comes up with, my guess unicorns and leprechauns.
Good point, Roger. I don’t know how Daugaard’s plan connects non-reservation Indian residents with IHS care. It seems it would take a lot longer to turn that ship around than it would to simply expand Medicaid and let Indian users choose the most convenient provider for their needs. Maybe that’s Daugaard’s game: propose a policy change that would require such enormous investment and innovation from the feds that it wouldn’t reach full effectiveness for years… and holy cow, if we cut Indian residents off from Medicaid in the meantime, then yes, they end up with less access.
Republican politicians can always be counted on to do the right thing … after they’ve failed at everything else. ~ Winston Churchill (sorta)
pretty funi porter
I’d like to know who dreamed this up for Daugaard.
The government has “never” funded health care for indians anywhere near what it needs.
Talk about wierd, this one’s out there. Let’s have HHS block grant the funds to State…that seems to be going well in Pierre these days.
I agree with Mr Cornelius on the bureaucracy of IHS n BIA. too many granitites (thanks Roger for that one).
I know for a fact that high level health care Repubs are putting pressure on Daugaards administration to fix this. Shoot maybe the tribes should hire Joop to help the off rez natives. He seems to know how to extract large amount’s of cash from Pierre.
I know plenty of American Indians who are not members of any tribe. Little doubt Daugaard will funnel money to his donors rather than to people who need care.