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Four Democrats Join Sanford Push to Undo Any Willing Provider Initiative

I told them not to do it. The GOP spin blog told them not to do it. But twenty legislators have done it: they have chosen to cave to Sanford Health’s pressure and sponsor House Bill 1067, which would unravel the “Any Willing Provider” health insurance initiative passed by 62% of South Dakota voters in 2014.

The statute we created in 2014 (Chapter 58-17J) requires insurers to allow any willing, qualified physician in their coverage area to participate in their health insurance networks. Essentially, this means that if your employer provides health coverage from Sanford, you can still go to your own non-Sanford doctor, and your non-Sanford doctor can bill the Sanford insurance plan.

Sanford, of course, doesn’t like that. They want their insurance to drive business to their hospitals and clinics. So they offer the following amendments to undermine the people’s intent:

  1. HB 1067 defines “panel of providers” as “a list of all health care providers under contract with a health insurer for inclusion in one or more of the health insurer’s health benefit plans.”
  2. HB 1067 allows Sanford and other insurers to continue to offer plans with exclusive networks, as long as they offer at least one plan that obeys the “Any Willing Provider” provision: “All health insurers shall offer for sale at least one health benefit plan approved by the division that contains all of the health care providers which are in its panel of providers. However, nothing in this chapter limits a consumer’s ability to purchase, or a health insurer’s ability to offer for sale, health benefit plans that contain less than all of the health care providers which are in a health insurer’s panel of providers.”

The folks who sponsored Initiated Measure 17 say Sanford is trying to gut the Any Willing Provider law. Led by Dr. Stephen Eckrich of Rapid City, backers send out this press release decrying Sanford’s resistance to the popular will:

“This is an insult to the people of South Dakota,” says Dr. Stephen Eckrich, a Rapid City physician. “When the vast majority of the public say they are in favor of choosing their own doctor, they have spoken. However, Sanford thinks they are above the law and are putting their selfish interests ahead of the will of their patients.”

When IM 17 became law, every health care provider and insurance organization complied with patient choice except for Sanford Health Plan. They refused.

Dr. Eckrich adds, “This bill is an egregious example of an attempt by one special interest to subvert the legislative process and ignore the will of the people of this state. Who is the legislature going to listen to? It’s our hope they will not be bullied by Sanford Health or their dozens of lobbyists. The people deserve to have their voice heard” [Patient Choice for South Dakota, press release, 2016.01.20].

Who are the legislators so egregiously enabling Sanford’s effort to subvert the legislative process and ignore the will of South Dakota voters? HB 1067 lists the following twenty sponsors:

Representatives RoundsBealConzetCroninDrydenHawksHawleyJensen (Alex)Otten (Herman)PartridgePeterson (Kent), and Willadsen and Senators PetersBuhl O’DonnellHaverlyRuschShormaSolanoSutton, and Tidemann

Making my life more difficult—Senator Buhl O'Donnell, Senator Sutton, Rep. Hawks, and Rep. Hawley
Making my life more difficult—Senator Buhl O’Donnell, Senator Sutton, Rep. Hawks, and Rep. Hawley

Seventeen Republicans undermining the initiative process I can understand, but four Democrats?* Senator Angie Buhl O’Donnell, Senator Billie Sutton, Rep. Spencer Hawley, and (ulp!) Rep. Paula Hawks, our candidate for U.S. House? Democrats! We are the party of democracy! We are the party that listens to the people and respects the initiative process! As I hit the campaign trail this year to defeat Referred Law 19 (SB 69, the incumbent protection plan) and especially Referred Law 20 (SB 177, the youth minimum wage), I will be making a big deal about how we need to un-elect legislators who fail to respect the will of the voters as expressed in ballot measures. Respecting initiative and referendum is a key to Democratic success in this cycle. By sponsoring HB 1067, Senator Buhl O’Donnell, Senator Sutton, Rep. Hawley, and Rep. Hawks are undermining that message and undermining a key advantage Democrats can use to win in November.

Initiated Measure 17 appears not to have triggered the onerous government control or the higher costs that opponents claimed Any Willing Provider would bring. Absent evidence of such harms (and we’ll be listening closely for such evidence in House Commerce and Energy when it takes up HB 1067), there is no reason for Democrats or Republicans to undo the Any Willing Provider law passed by the people of South Dakota.

Correction 16:53 CST: My original story left Senator Billie Sutton (D-21/Burke) out of the count of Democrats sponsoring HB 1067. I apologize for that error.


  1. Greg 2016-01-21 08:08

    Looks like Paula Hawks is bought and paid for by her little special interest group. She will be a good fit in the US House representing the Sanford empire.

  2. Dana P 2016-01-21 09:36

    This is so disappointing (and angering!!) ….. in so many ways.

  3. Lynn 2016-01-21 10:15


    The way things are going it is highly doubtful Paul Hawks will win that US House seat anyways but it really is not surprising to see this. It looks like desperation.

  4. Monty 2016-01-21 10:26

    Hawley also supported rolling back Iniated Measure 14, the Daugaard Large Project Development Fund, going behind the back of Democrat leaders in Pierre and disparaging the work of the volunteers who collected signatures to put in on the ballot.

  5. Ann 2016-01-21 10:38

    Will this be voted on again by the people? What happens now?

  6. Loren 2016-01-21 10:56

    It’s just this sort of behavior that makes folks give up on voting all together! To use one famous quote, “What difference does it make?” ;-)

  7. Angie Buhl O'Donnell 2016-01-21 10:57

    Of course, I’m always reluctant to touch anything that was passed via ballot measure — if I thought this was undoing it I wouldn’t have touched it. I don’t think it’s doing that.

    The point of IM 17 was to require every health plan to offer an open plan, which I thought was important: if an employee worked for a company that only offered a closed plan (either Sanford or Avera) and they had been doctoring or wanted to get care from the other network, they were out of luck (unless they paid a bunch more out of pocket, which people often have trouble affording). The bill that’s been submitted keeps that in place: every insurer still has to provide an open plan, that can be used anywhere.

    But here’s the rub: not everyone wants an open plan, and some want a closed plan (which happens to be significantly cheaper). IM 17 as passed left them out in the dark, and I don’t think that’s fair.

    I truly don’t believe this undoes any intent of voters (though I believe reasonable people can disagree), and if I thought it was I wouldn’t be on board. Not for nothing, but this is also not the “David vs Goliath” that so many issues see or that this has been painted as. The for-profit specialty hospitals’ business model is built on cherry-picking healthy, low-risk, high-margin patients out of the patient population, which leaves sicker, riskier patients with fewer options and really only able to utilize traditional hospital settings.

  8. Ann 2016-01-21 11:36

    So Sanford is doing this out of the goodness of their heart so that the consumer does not have to pay more for health insurance?

    Sanford’s “open” plan will be so unattractive that no one will be able to afford it. It will be the same as choosing “out of network” providers in a closed plan.

    Let’s take it to the extreme and say United Health Care builds a clinic in town and then offers health ins. but you can only see their providers. Then Humana and Wellmark do the same thing. Will consumers be happy only seeing the limited providers who are employed by their health insurance company? Insurance should be independent of care.

    Maybe we should look at this in reverse. Sanford providers would only be allowed to bill Sanford Health insurance and are no longer in-network with any other insurances. Would they still move forward with this bill?

  9. caheidelberger Post author | 2016-01-21 11:50

    Senator Buhl O’Donnell! Glad to have you.

    I’m with Ann: I think the intent of this bill is to undo the intent of the voters. Ann’s scenario is plausible: we carve out this exception with HB 1067, and then Sanford makes its open plan so unappealing that businesses and individual purchasers have to choose the closed-network plans. IM 17 and the voters intended that doctors and patients wouldn’t get hung up on network exclusions. The intent was that, whatever health insurance we have, we can still go see our preferred (i.e., in town, closer, more convenient, more trusted) doctors.

    Ann, HB 1067 is for the Legislature to vote up or down. If the Legislature passes it, then we could refer it to a public vote, just as we had to refer last year’s youth minimum wage to a public vote. I’d hate to see that happen—voters could get frustrated if every initiative they pass has to be voted on twice to make it stick. More people will think like Loren that initiative and referendum aren’t worth the effort, and we don’t want that. Legislators, the voters made their intent clear. Unless there is some clear and present problem, leave IM 17 alone.

  10. John Nelson 2016-01-21 12:26

    As Deep Throat intoned: “Follow the money.” 17 was circulated and financed by the specialty hospital owners. The Blake Curds of this state want all of our money and they won’t stop until they have it.

  11. BOHICA 2016-01-21 12:41

    I think Senator Buhl is correct in her assessment of the situation. With expanded choice of almost anything there is a cost. I can pay the price for say premium gasoline or pay less for an ethanol blend. Competition keeps both options similarly priced.

  12. mike from iowa 2016-01-21 13:00

    I thought competition was good to drive down costs,but not if competition is not allowed. No competition means monopoly which means higher captive costs,higher profits.

  13. mike from iowa 2016-01-21 13:04

    Senator,it seems to me you are addressing the wrong problem. The problem is greed and your fix doesn’t address greed. It makes it more likely that Sanford will collect more profits by doing the very thing Cory said-offering an onerous open plan no one will buy.

    Did the previous bill forbid companies from offering closed plans?

  14. jake 2016-01-21 14:50

    We recall the hue and cry of GOP “Death Squads” during the ACA discussion, don’t we> More of the same, and Senator Ann, you and the other Dems disappoint me. The first supporter listed was a Rounds–as if the insurance companies didn’t have enough influence to begin with! Saford is throwing up a ‘straw man’ to burn.

  15. Stephen Eckrich, MD 2016-01-21 14:58

    Senator Buhl O’Donnell has fallen for Sanford’s misrepresentation of the intent of IM 17, that is, that it requires all networks to have all providers on its panel. Read the law, “No health insurer…may obstruct patient choice by excluding a health care provider…if the provider…is willing and fully qualified to met the terms and conditions of participation as established by the health insurer.” The insurance company is in the drivers seat; they establish the terms and conditions. It is just that if I am willing to accept those conditions, they can’t exclude me. If Sanford wants to make a plan requiring that only their docs and facilities are participants, they can do that. The only way I could participate is if I got hired by them (That won’t happen!) In fact, that is the plan that Sanford employees are forced to have. The problem for Sanford is that a plan such as that would never be popular in the commercial marketplace. This bill is nothing more than a well financed, politically connected corporation trying to advance their own business agenda through the legislative process, ignoring the will of over 166,000 South Dakota voters from across the political spectrum.

  16. Lynn 2016-01-21 15:02

    It just keeps getting worse for the SD Democrats and now this. Another sellout.

  17. Caitlin 2016-01-21 15:28

    I am very, very disappointed in the three Democrats on this bill. I don’t have any expectations of the GOP, but saying this is okay because it just allows these companies to offer closed plans is the same logic that says the 18% payday loan bill is okay because it gives people the “choice” of agreeing to a higher interest rate!

  18. Jenny 2016-01-21 15:37

    So how much were they paid by the Sanford lobbyists again?

  19. Susan Wismer 2016-01-21 15:43


    You are leading your readers astray here. The story is exactly as Sen. Buhl explained, and her third paragraph re the specialty hospitals is especially on point.

    In the real world of health insurance, when your premium gets too expensive, you (or your employer, if you’re lucky), go looking for something cheaper. You/they find it with a different plan that may have some strings attached, such as choosing from an approved list of providers that the insurance company has bargained a cheaper rate with, in order to provide you with a cheaper insurance premium. Is it fair when your employer switches in mid-stream on you so that seeing your favorite doctor costs more? It doesn’t feel like it, but at least your employer or you were able to find a cheaper premium and remain insured! The specialty providers could even continue to provide service to you at the insurance company’s rate, but they don’t want to, so they took us all to the ballot box to in effect take away a bargaining chip that the insurance companies had.

    There is no free lunch, remember? How can the insurance companies provide you with the best value premium if we take away their ability to bargain with providers for the best value? If you want to stay with your doctor, do it, but don’t expect your employer to pay for it, and don’t buy the cheaper plan if you’re not willing to live by its rules.

    Really, the parallels between the 36% and 18% interest rate petitions and this one are instructive: Just like the 18% petition sponsors, the specialty hospitals, masquerading as advocates for Joe Average Citizen, conducted this elaborate and misleading publicity campaign using “patient choice” as their buzz words to distill a very complicated subject to a rallying cry, when what they were really doing was guaranteeing that they could keep charging whatever they felt like and the insurance companies would have to keep doing business with them. What the real effect of this initiative is without the fixes being considered now will be increased health care costs, which in the end limits ALL of our choices in more than just our health care. If health care isn’t going to overtake our entire economy, we have to figure out a way to put some brakes on its costs, and limiting the power of specialty providers to skim off the cream has got to be a piece of that.

    You’re on the wrong side here Cory. After all, any time you and DWC are on the same page, you know something fishy is going on.

  20. caheidelberger Post author | 2016-01-21 16:46

    Susan, I do feel nervous any time DWC and I (and Blake Curd, as John N reminds us!) end up on the same side. I also don’t like being caught in a fight between Sanford and rich doctors—that feels like a fight that a Bernie Sanders man never finds a winner in. I take your caution seriously.

    Are insurance rates up statewide? Are those rates up because of the Any Willing Provider measure and not inflation, ObamaCare, aging population, or other factors?

    Bargaining between insurers and providers: If insurers bargain with network doctors to get rates down to X, and then an out-of-network doctor says, “Hey, I want to participate,” don’t insurers still have the ability under AWP to say, “Sure, fine, but here’s what we pay for services”?

    Let’s be careful with the 36% vs 18% situation. In the rate-cap battle, we have good guys versus real bastards. In this AWP debate, I’m not convinced either side is as big a bastard as the payday lenders, but no one is clearly the virtuous actor, either. Both sides appear to have selfish interests.

    If the specialty doctors are bastards for cherry-picking clients for profit, how does repealing AWP incline them to quit that cherry-picking? Or how does keeping AWP exacerbate their cherry-picking?

    I’m going to need to hear some good committee testimony to persuade me that AWP has had negative effects on South Dakota’s health care market. Absent that, I feel perfectly comfortable saying HB 1067 upends the popular will, weakens faith in the initiative process, and should be voted down.

  21. H. Koiman 2016-01-21 16:48

    It’s no surprise that 20 legislators supported this bill. The big surprise is that there weren’t more. Those 20 people are looking after themselves and their families. Some day, they will no longer be in the legislature, and may be in need of jobs. Good paying jobs. With not a whole lot of work to do. We have seen Sanford provide these jobs time and again to people who have helped them out of a jam. Do not sell Sanford short. They have a nearly infinite amount of money to spend on this, they will buy advertising time on TV, and if you repeat a lie often enough, people will come to believe it.
    The worst thing is that Sanford’s basic premise is wrong. All of the recent research has shown that highly integrated healthcare systems actually have HIGHER cost and lower quality than competing independent healthcare facilities and providers. We see a microcosm of this in Sioux Falls, with the surgical hospital being in THE TOP 10 nationwide (never mentioned in the Argus) and meanwhile Sanford gets hit with a monetary penalty from Medicare for being in the lowest 25%.

  22. grudznick 2016-01-21 17:38

    This could simply be an example of Ms. Buhl and Ms. Wismer and Ms. Hawks and the other professional and experienced legislature people just understanding a bill better than Mr. H and some of his readers. I’m just sayin…

  23. grudznick 2016-01-21 17:39

    I should add that maybe Mr. PP doesn’t understand the bill any better than Mr. H. That’s why they are on the same side.

  24. caheidelberger Post author | 2016-01-21 21:03

    Or it could be an example of lobbyists under the Dome having more influence on a small number of legislators than they could exert on hundreds of thousands of voters statewide. Don’t be such an elitist, Grudz. ;-)

    I eagerly anticipate the informed committee testimony.

  25. Lars Aanning 2016-01-22 11:35

    Despite intense lobbying efforts by Sanford physician administrators who are also members of the South Dakota State Medical Association, the SDSMA has, in the interest of patient advocacy, always supported Measure 17…

  26. Rita 2016-01-22 16:45

    I agree with Dr. Eckrich. I have that exact scenario.

    My OBGYN has been my doctor for 14 years. But if I want to keep seeing her, she’s out of network and I have to pay out of pocket.

    If I don’t want to pay out of pocket, I can choose a participating provider. But that means I give up a doctor that has served me well for 14 years, knows my medical history extremely well and delivered my baby in exchange for someone who may or may not be an MD if our schedules don’t magically align.

    So I would be trading in my fantastic physician that I cultivated a patient/provider relationship with for 14 years for what will likely end up being a mid-level provider (CNP, PA-C or CNM). How can I expect the same level of care and expertise?

    And if I want to keep her, the only plans that will be available to me will be more than unappealing. They will be gouging me for my loyalty to my physician.

  27. leslie 2016-01-23 09:57

    Gee grudz u usually diss ms. Wismer at every turn. Chicken? Had Gov. Wismer been in office since the EB5 fraud it is likely Her Sharp Pencil Would Have Impaled Joop, sveen, Rounds tidemann And Daugaad, Regents & DOE would Be Quaking In Their Boots And Westerhuis Would Be Mopping Floors At The Pen. Jackley Might Be Working For The People Rather than RAGA. So Much For SDGOP’s 2014 cover-up And Election Fraud.

  28. Poliglut 2016-01-30 13:26

    Those above–surprisingly even some who have Legislative experience and should know better–are buying into a lobbyist-load of BS. Sanford’s cynical move has nothing to do with patients saving money (note that under Patient Choice doctors must meet their terms) and everything to do with low-balling plans to employers on the backs of patients, who pay through increased travel, potentially higher co-pays, and by being thrown to doctors they don’t know and who don’t know their case histories, and, subsequently, increased risk of medical and prescription errors. This bill is about one thing only: Sanford using their wholly-owned insurance company to CARVE OUT MARKET SHARE. Don’t buy it, folks.

  29. Nerlin 2016-01-31 07:40

    Bottom line: it is a conflict of interest for hospital systems to be in the insurance business. Look for any other industry where this could happen: Geico or Progressive being in the body shop business? Casualty insurers owning tree services or construction companies that repair storm damage? How about AIG insuring their own complex debt instruments? How did that work out? Who is going to tell Sanford’s insurance company to not pay $8000 for a CT-Scan?

  30. mike from iowa 2016-01-31 10:58

    How about meat packers owning their own feedlots and livestock so they can buy from themselves and drive the price paid to other livestock producers down.

  31. Stephen Eckrich MD 2016-01-31 12:25

    Unfortunately, in South Dakota we are almost there. A recent study revealed that 86% of physicians in SD were employed by health care systems, the third highest in the U.S. The systems already have the doctors, and with them getting into the insurance business they can control the entire health care market and squeeze out the few, independent physicians that are left.

  32. Ann 2016-02-01 20:02

    Help me to understand why hospitals are allowed to own health insurance companies? Most insurance companies have prior authorization requirements for certain tests, hospital stays, medications, etc., so that a representative can verify medical necessity. This seems like it also protects the consumer from paying for services that may not be in their best interest.

  33. caheidelberger Post author | 2016-02-01 21:16

    Fair question, Ann! Single-payer would be a nice way to avoid that concentration of power. One payer, one risk pool for everyone, and all of us free to go see whatever doctor we want.

  34. Josh 2016-02-03 20:38

    Look at the basics of the issue. IM17 improved access for clients to see the provider of their choice. That’s a fact. it was a win for the voters in this state, and independent healthcare providers, like myself. Not specialty hospitals…..ALL independents, the tiny holdout percentage Dr. Ekrich refers to above that continue to practice with independent minds without corporate beurocracy dictating treatment patterns. Avera is no angel, either. Prior to IM 17, Avera refused my clinic from in network privileges for two decades. Since IM 17, I have been able to treat friends and family with Avera insurance for the first time. IM 17 works and any Sanford or Avera led attempt to change it will mean only one outcome………less choice and more “big healthcare” control of the marketplace.

  35. leslie 2016-02-03 21:08

    Josh, Stephen-thank you for alerting us to this

  36. Connie Bacon 2016-02-04 14:48

    Everyone is talking about physicians. What about other private healthcare providers? Private Physical Therapy Clinics.

  37. mike from iowa 2016-02-04 15:04

    And Congress voted for the 60th time to defund Obamacare.

  38. Josh 2016-02-04 16:00

    I am a private practice PT, OT, and Speech therapy clinic owner and we are just as affected if not more than the physicians are. I know of examples in Mitchell, Brookings, Aberdeen, Watertown, and others where private practice owners are not allowed in Avera and Sanford networks and illegal patient steering are commonplace. They buy out nearly all the physicians and place pressure on them to refer to their own therapy providers, regardless of insurance type. They know we don’t have the financial resources or teams of lobbyists to fight back and we are left praying that word of mouth and strong community ties can help you stay afloat despite all the cards stacked against us. This is not a Sioux Falls issue, a physician issue, or a specialty surgical center issue. It is a SD healthcare issue that affects all private healthcare providers trying to practice without the influence of “big healthcare” dictating our care patterns.

    Thanks for your testimony Connie, our profession, and private practitioners everywhere certainly appreciate it!!

  39. Les 2016-02-04 17:00

    This attempt just shows the serious problem of lobbyists in Pierre and a part time legislature without the ambition or energy to root out the facts, or easily bought and sold. Similar to our legislature giving the Feds our rights to control our future from our state DENR on the insitu issue in the Hills.

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