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Medicaid Expansion Will Reduce Counties’ Costs for Indigent and Jail Health Care

The Legislature’s interim Study Committee on County Funding and Services held its second meeting yesterday. A presentation on the money counties spend on healthcare prompted Senator Jim Bolin (R-16/Canton), a staunch opponent of Medicaid expansion, to acknowledge one positive local budget effect of South Dakota’s newly voter-expanded health coverage for low-income people:

Another presentation Wednesday was on public healthcare subsidized by counties. Ray Koens of Minnehaha County said medical expenses had trended down from 2010 to 2019, but COVID-19 disrupted that decline.

Koens said the decision by South Dakota voters to expand Medicaid eligibility to 138% of the federal poverty level would further reduce demand for healthcare subsidies. Republican Sen. Jim Bolin said Medicaid expansion meant that state and federal governments now would be paying those costs rather than counties [Bob Mercer, “South Dakota Didn’t Seek Cyber-Protection Grant,” KELO-TV, 2023.07.12].

Shifting indigent health care costs from counties to state/federal Medicaid won’t solve counties’ budget stress. Over the ten years pre-covid, counties spent a total of $24.2 million on indigent health care. Those costs declined throughout the 2010s, thanks in part to the Affordable Care Act. But over the same period, county jail medical expenses grew and totaled $36.2 million. Medicaid’s inmate exclusion policy will prevent counties from shifting those jail medical costs to the Medicaid expansion rolls.

South Dakota county medical indigent expenses 2010–2019, presentation to Interim Study Committee on County Funding and Services, 2023.07.12.
South Dakota county medical indigent expenses 2010–2019, presentation to Interim Study Committee on County Funding and Services, 2023.07.12.
SD county mandated medical expenses 2010–2019, presentation, 2023.07.12.
South Dakota county mandated medical expenses 2010–2019, presentation to Interim Study Committee on County Funding and Services, 2023.07.12.

(For perspective, the Department of Legislative Audit reported to the committee yesterday that county general fund expenditures in 2019 totaled over $389 million.)

But Medicaid expansion may indirectly reduce those county jail medical costs by keeping people out of jail:

In states with Medicaid expansion (i.e., where eligibility is based solely on income), there have been correlated reductions in crime rates and arrests. Compared to counties in states that had not implemented expanded Medicaid coverage, counties in states with Medicaid expansion saw a 25% decrease in drug arrests, a 19% decrease in “violent offense” arrests, and a 24% decrease in “low-level” offense arrests. Looking at more specific types of crimes, researchers also found a 3.7% to 7.5% decrease in burglary, motor vehicle theft, robbery, and violent crime rates in counties with statewide Medicaid expansion.

Increased access to healthcare through Medicaid coverage also reduces recidivism. Prior to the Affordable Care Act (ACA), there were eligibility requirements that restricted Medicaid eligibility for formerly incarcerated people, but with expanded Medicaid coverage, most previously incarcerated people who meet the necessary income criteria are eligible for Medicaid. A study published in 2022 found that expanded Medicaid coverage resulted in significant reductions in the rate of rearrest, with a 16% reduction in arrests for violent crime for two years following release [Emily Widra, “Why States Should Change Medicaid Rules to Cover People Leaving Prison,” Prison Policy Initiative, 2022.11.28].

One of the causes of this interesting and salutary effect appears to be that more people with drug problems can afford to seek treatment and thus avoid getting arrested for their addictions.

So Senator Jim Bolin may be right in more ways than he thought. His interim committee may find that by expanding Medicaid, voters have already done a significant amount of the committee’s work for them by reducing both indigent and jail medical costs for counties.


  1. P. Aitch 2023-07-13

    My friends. How often does the inherent South Dakota “negativity bias” prove to be just “cryin’ before you’re hurt”?
    Why do you continue to immediately see something wrong with every new idea and every new thing?
    Time after time y’all … *insert unnecessary lecture here
    Try exploring why you carry this unhelpful trait like an anchor upon your lives.

  2. Loren 2023-07-13

    Why “see something wrong with every new idea and every new thing?” Because that “new idea” usually comes from the more progressive side of the aisle and they wouldn’t want any credit given for an idea that was not their own. It was particularly galling to see Kristi on the news bloviating about how thousands of folks are now taking advantage of the new program after years of standing in the way of medicaid implementation. Then again, it is not unusual for our Republican friends to brag about programs they always vote against. Here’s looking at you, Johnny, Marion, Duster, Kristi…

  3. Edwin Arndt 2023-07-13

    Because P., cryin’ after you’re hurt is to late. Theoretical thinking has its
    place. Not trying to foresee problems is irresponsible.

  4. P. Aitch 2023-07-13

    Edwin has negativity so deep in his soul that even when he’s trying to positively explain something it comes out negative.
    Edwin doesn’t understand that an assessment of a new thing should get equal investigation from both yes and no from the beginning.
    He starts with no and then tries to bolster that assessment ignoring any positive benefits in changing.
    Being confident in your problem-solving skills weighs most ideas to start with a yes.
    Then look for problems you’ll need to solve not problems that can sink the idea before it ever begins.
    Edwin’s mindset is common where he lives, though and that’s why Minnesota is prosperous, and South Dakota is stagnant.
    Negativity bias helps no one when a problem needs solving.
    EDwin. Watch the new movie Oppenheimer and see how your mindset would have had us all under Nazi rule today.

  5. Edwin Arndt 2023-07-13

    Yes P., I know several prosperous farmers whose mindset is much like mine.
    You decide which course is more likely to succeed and then proceed on that
    course. You also have to decide when a course is no longer profitable. There were
    hogs on our farm for probably a hundred years and in 2008 we decided the hog
    business was no longer worth while. As did many other family operations.
    We now raise cattle, corn and soybeans. I’m tired of explaining things to you
    from my point of view, but my point of view doesn’t square with yours. Very likely
    your life experience was different from mine.

  6. P. Aitch 2023-07-13

    – Let’s try an experiment in assessment and method, Edwin. Here’s a brand new idea. What do you think of it’s future?

    *Scientists have created a super-white paint that reflects the sun’s rays back into space and helps cool buildings.

    I’ll go first. I see the above explanation as a reason to go ahead with the project, invest money, and if problems arise, they can be addressed and solved. This is a very positive and probably profitable new idea.

  7. Edwin Arndt 2023-07-13

    In our part of the country the heating season is about as long as the air conditioning season.
    It might work in Kansas City. Go ahead and invest your money if you’ve a mind to. If this idea
    works it will be incorporated into new construction. In some parts of the country you will
    have to choose between the white paint and the solar panels.

    I believe this to be a realistic assessment.

  8. larry kurtz 2023-07-13

    How are 65 county seats and their bureaucracies either conservative or sustainable? They’re not; but, it’s the way Republican cronyism and patronage built barricades to democracy by providing benefits of the public dole to those who say they deplore big gubmint in a state that hates poor people.

  9. bearcreekbat 2023-07-13

    I don’t know about the accuracy of thre statement that “Shifting indigent health care costs from counties to state/federal Medicaid won’t solve counties’ budget stress,” but had the Medicaid expansion been in place “Over the ten years pre-covid,” the counties would not have “spent a total of $24.2 million on indigent health care.” Virtually every single indigent would have qualified for Medicaid and there would have been no basis for hoisipals and medical providers that ntreated these indigents to make claims against the counties pursuant to the County General Relief (i.e. “Poor Relief”) statutes. The failure of SD county commissiomers to support the expansion of Medicaid from the beginning was an incomprehensible middle finger to taxpayers.

  10. P. Aitch 2023-07-13

    Thanks, Edwin. I believe I understand your mindset and have for several years. Go Twins :O)

  11. P. Aitch 2023-07-13

    In Retro: The decision to not expand Medicaid was a failure of a decision.
    Most South Dakota legislators and officials are afraid to fail, and this example is partially why.
    It’s easy to pile on when a failure happens.
    Negative criticism and ridicule are entertainment in South Dakota.
    What’s important for your legislators is to be a success next time a federal program is offered.
    Buying as a nationwide group is almost always the cheapest way possible to help the most vulnerable people possible.
    Every day is a new beginning.

  12. All Mammal 2023-07-13

    My dad put a white steel roof on my house for me about a decade ago because it made sense. The Mediterranean community has known for thousands of years that white rooftops can keep the interior up to 40° cooler and the surface up to 80° cooler than dark energy-absorbing asphalt shingles. Light colored rooftops keep heat in during winter better too.

    Noticing how all newly constructed homes have black shingle roofing, which is in fashion has made me suspect the energy companies are in cahoots with the contractors to push the posh black roof look in order to keep heating and cooling costs up, at the expense of the homeowner and the planet.

    The old world went the practical route. We know better, yet choose to cause unnecessary harm to ourselves and the environment in the name of looking modern and fashionable.

    Metal roofing is reflective and lasts way longer than shingles. They do sell white paint for shingles too. AZ is developing white road pavement to replace blacktops that can cool entire cities by as much as the difference between life or death. A highschooler in Mexico competed in the world’s science fair for developing a white exterior paint that absorbs co2 when it rains…. we have to make the choice to forsake the energy corporations and replace them with new and old ideas that work.

  13. P. Aitch 2023-07-13

    Good post, AM. Lot of worthwhile information. Thanks for sharing. 👍🏻😊

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