Political Smokeout

Medicaid expansion work group to meet next week

Gov. Dennis Daugaard’s task force to study Medicaid expansion under the Patient Protection and Affordable Care Act will meet next week in Pierre.

The 29-member task force will meet on Tuesday and Wednesday in a conference room at the Red Rossa restaurant in Pierre, near the Ramkota. The public meetings will run from 3 p.m. to 7 p.m. on Tuesday and 8:30 a.m. to 3 p.m. on Wednesday, with a public comment period from 5:30 p.m. to 7 p.m. on Tuesday.

This is the first of three or four meetings. Following next week’s Pierre meeting, there will be sessions in Sioux Falls and Rapid City, and perhaps another in Pierre.

The end goal is to “develop a report for Gov. Dennis Daugaard and the Legislature that identifies the ‘pros and cons’ of expanding Medicaid in South Dakota,” according to the report.

Next week’s agenda includes several overview sessions of Medicaid in South Dakota, the Affordable Care Act, expansion decisions in other states, the demographics of South Dakota’s Medicaid population and perspectives from the hospitals and the counties.

The membership of the task force includes legislators, state officials and members of the health care industry.

A quick glance over the membership suggests it might be open to Medicaid expansion — 14 of the 29 are from the health care industry, which has generally supported expansion, plus two Democratic legislators, who are also in favor. There’s six representatives of the state executive branch, five Republican legislators, and one representatives of the counties:

SD Medicaid expansion formally defeated for 2013

South Dakota won’t expand Medicaid to 48,000 low-income adults, a legislative committee voted Friday.

The unsurprising vote by the Joint Appropriations Committee to reject expansion came after Gov. Dennis Daugaard and many Republican legislators expressed opposition to expanding this year.

Many proponents of expansion were in the room Friday but didn’t testify.

“Clearly this Legislature didn’t seem inclined to take up the issue,” said David Hewett, president of the South Dakota Association of Health Care Organizations.

That didn’t stop Sen. Stan Adelstein, R-Rapid City, from making his case.

“This hidden tax is being paid by the citizens of South Dakota, in the order of magnitude of $50 to $60 million every year,” said Adelstein, referring to medical providers passing on the cost of charity care to paying customers.

Accepting federal money to expand Medicaid, Adelstein said, would provide those low-income people with health coverage, easing the burden on everyone.

Under the federal Patient Protection and Affordable Care Act, the federal government will pay 100 percent of the cost to expand Medicaid eligibility to 138 percent of the federal poverty line for the next several years. After that, the federal government promises to pay 90 percent of the costs.

Several lawmakers questioned the required funding for administering the Medicaid expansion, and said expansion should be in the form of a bill, not an amendment to the state budget.

The committee voted 13-5 to table Medicaid expansion, with Adelstein and four Democrats voting no.

But the issue of Medicaid expansion isn’t defeated. Daugaard aide Deb Bowman announced a committee to study Medicaid expansion over the summer. That workgroup will submit recommendations the governor and next year’s Legislature can consider in 2014.

Advocates urge Medicaid expansion, some lawmakers skeptical

PIERRE — South Dakota lawmakers heard an hour and a half of emotional testimony from advocates of expanding Medicaid to cover thousands of uninsured citizens, but many remained skeptical.

In a special joint hearing of the Legislature’s two Health and Human Services committees, medical professionals, hospital executives, religious leaders, county officials and people without insurance cast expanding Medicaid as morally and economically needed.

“Medicaid expansion is the best way to serve the low-income individuals,” said John Mengenhausen, CEO of Horizon Health Care of Howard. “Medicaid is also the least expensive way for the government to ensure that they’re providing health care for this population.”

Under the 2009 federal Patient Protection and Affordable Care Act, states are called on to expand Medicaid eligibility up to 138 percent of the federal poverty line starting on Jan. 1, 2014. Due to a Supreme Court ruling upholding most of the act as constitutional, however, states have a choice about whether to expand Medicaid. The federal government, under the law, will pay 100 percent of the added Medicaid cost for the next three years, then 90 percent after that.

An estimated 48,000 South Dakotans are currently uninsured with incomes under 138 percent of poverty. But around half of them would be eligible for subsidized insurance on the new health care exchanges.

Several people testified about how many uninsured are hard workers with families who have trouble making ends meet.

“These people are not lazy. They are not deadbeats. They’re not milking the system,” said Linda Sandvik, a Rapid City nurse.

Kathy Ruggles of Pierre told of refusing to seek needed medical care because of fears about the cost.

“Hospitalization is out of the question for many of us,” Ruggles said, speaking for “the poor people of South Dakota.” 

“It is bankruptcy waiting to happen. We risk have what little property we possess, such as our cars, seized for payment.”

Hospital leaders told lawmakers they were scheduled to absorb millions of dollars in cuts over the next decade as part of the Affordable Care Act. Expanding Medicaid would make up part of that shortfall, they said, by covering treatment currently paid for by the hospitals as charity care for the poor.

Two conservative activists testified against expanding Medicaid, with Florence Thompson of Caputa warning the Affordable Care Act would lead to shortages of doctors and drugs. 

“I urge our state to be a leader and say ‘No, we’re going to have the free market,’” said Stephanie Strong of Rapid City.

It’s unclear how many lawmakers’ minds were changed by the 90 minutes of testimony. Several said they remain opposed to expanding Medicaid.

“I will resist an expansion of Medicaid in the state. I think it would be insane,” said Sen. Phil Jensen, R-Rapid City.

Rep. Steve Hickey, R-Sioux Falls, said he’s torn on the issue.

“Your arguments are compelling,” Hickey said to proponents of expanding Medicaid, adding that he believes South Dakotans are “paying for this either way” by hospitals who shift the cost of care for the uninsured to other patients.

But Hickey said he worries expanding Medicaid is a way for health care companies to get richer, and that undeserving “bums” will get subsidized health care along with hard-working families.

Rep. Manny Steele, R-Sioux Falls, conceded that expanding Medicaid would help a lot of people with what he termed a “major problem.” But he said the cost to an indebted country of paying for the coverage would prove too much.

“I think we need to go back to the drawing board and come up with some new ideas on this,” said Steele. “On a temporary basis, this would help people who need to be helped. But on the long-term basis we’re looking at a disaster.”

Several lawmakers spoke out in favor of the expansion. Rep. Troy Heinert, D-Mission, told the committee his own family has been unable to find health insurance. Rep. Karen Soli, D-Sioux Falls, said she has concerns about expanding Medicaid but ultimately sees it as an obvious choice.

“There is no part of me that could not support this,” she said.

The joint committee took no action on expanding Medicaid Wednesday. There are several options for lawmakers if they choose to expand Medicaid, by amending existing bills. The Legislature could also do nothing this year and revisit the issue in 2014.

(UPDATE: This post has been updated to clarify a statement of Rep. Steve Hickey.)

Bill forbidding Medicaid expansion fails

Gov. Dennis Daugaard is opposed to expanding Medicaid, but he’s also against forbidding South Dakota from expanding Medicaid.

That’s the message that came out Monday, when Daugaard’s administration helped persuade the House State Affairs committee to reject a bill banning a state endorsement of Medicaid.

House Bill 1244, sponsored by Rep. Hal Wick, was a single sentence forbidding South Dakota from expanding Medicaid eligibility up to 133 percent of the federal poverty level, as called for under the Patient Protection and Affordable Care Act.

Wick and television producer Chuck Poppen said the state should pass that bill because expanding Medicaid would be costly to the state and policy.

But Kim Malsam-Rysdon, South Dakota’s secretary of the Department Social Services, said passing the law “only produces more red tape” given that Daugaard already would need legislative approval to expand Medicaid.

Daugaard has opposed expanding Medicaid this year, saying the state needs more information.

An array of organizations supporting Medicaid expansion also testified against the bill.

The committee voted 11-2 to kill HB 1244, with only Reps. Jon Hansen and Mike Verchio opposed.

“I think this is more of a go-on-record bill,” said Rep. Kristin Conzet, R-Rapid City. “Right now, this bill is not needed.”

After the vote, Wick said he had expected the bill’s defeat.

Another bill still alive, House Bill 1205, would expand Medicaid eligibility, though the Legislature can also expand Medicaid through the general appropriations bill.

Bill protecting insurance agents on health care exchanges passes committee

The South Dakota Legislature took a step Tuesday to include local insurance agents and keep out national insurance plans when it adopts a federally run health insurance exchange next year.

Health care exchanges, under the federal Patient Protection and Affordable Care Act, are online marketplaces where the uninsured can purchase health insurance plans with subsidies based on their annual income.

Senate Bill 139 would require plans on the exchanges to pay the same commissions to agents as they would pay for similar health insurance plans off the exchange.

It would also bar out-of-state “nationwide plans,” which would be regulated by their state of origin, not South Dakota, from selling on South Dakota’s exchange.

Insurance agents defended the bill as a way to stop agents from being shouldered out of the way by big insurance companies.

Jerry Diamond, a lobbyist for the Independent Insurance Agents of South Dakota, said nothing in SB 139 would prevent an individual from buying health insurance on the exchange without an agent.

The Senate Commerce and Energy Committee approved SB 139 unanimously Tuesday after amending it with a compromise designed to keep South Dakota in compliance with the federal law.

Daugaard: SD won’t run PPACA exchange

Gov. Dennis Daugaard has decided not to pursue a state-run health insurance exchange under the federal Patient Protection and Affordable Care Act.

Under that controversial health care law, states have the option of setting up exchanges — a set of authorized health insurance plans from which individuals can purchase insurance. States also can do nothing and let the federal government run an exchange for their state.

Daugaard’s administration has spent “hundreds of hours” studying health care exchanges, Daugaard’s senior adviser Deb Bowman said in an email sent to legislators. After this study, Bowman wrote, the governor concluded that “operating an exchange is too expensive” and it would be better to let the federal government do so.

The state’s study predicted an annual cost to operate a South Dakota exchange between $6.2 and $7.7 million.

Instead of a state-run exchange, Daugaard plans to use his authority under the health care law to regulate the federal government-run exchange, Bowman wrote.

Daugaard has yet to release a public announcement about the plan. His letter to legislators was posted online by state Sen. Dan Lederman, R-Dakota Dunes.

The return of Lora Hubbel?

Most people thought that her June 5 primary defeat to Sen. Den Peters meant that Lora Hubbel’s legislative career was done for at least the next two years.

That may have been premature.

Hubbel, who was redistricted out of her old District 11 into Peters’ District 9, told me she’s considering moving back into her old district to pursue the open senate seat vacated by Todd Schlekeway.

She’s not certain this is something she wants to do, admitting that aside from the expense it could be perceived as carpetbagging or “crashing someone else’s party” so soon after losing her primary. On the other hand, Hubbel said, moving back into the old district could be seen as a rebuke to the redistricting process that moved her away from her old constituents.

Of course, Hubbel would need to be chosen as the nominee, and there’s no guarantee of that. She’s obviously got some enemies among the establishment types, having made herself an outspoken critic of Gov. Dennis Daugaard’s administration over the Patient Protection and Affordable Care Act. And I’m told that some people in the activist wing of the South Dakota GOP aren’t sure Hubbel is the best messenger for their cause, either — as much as they share the same position on PPACA and intra-party enemies.

A few other current and former legislators are in the mix for the Schlekeway seat: outgoing Rep. Mark Willadsen, who also lost in the June primary, and ex-Rep. Keri Weems.

Read the story here.

Daugaard’s wait-and-see

My colleague Jon Walker reports that supporters of the Patient Protection and Affordable Care Act aren’t that upset Gov. Dennis Daugaard is waiting until January to implement PPACA in South Dakota.

“You’ve got to allow governors and politicians some wiggle room. How long did we wait for the Supreme Court? We can wait another four months,” said Bernie Hunhoff, Democratic leader of the state House of Representatives.

But they do warn that waiting until January 2013 — or possibly July 1, 2013, depending on what laws are needed and whether Daugaard can get an emergency clause put on them — could be tricky. (Daugaard almost certainly can’t get a two-thirds majority with just Republicans — even if the GOP holds its supermajorities in both houses, there will be enough Republican dissidents in at least the House to require Democratic votes to pass that threshold.) The most far-reaching parts of the law take effect in 2014.

“We’re going to have to do a lot very quickly if we’re going to be up and running and in compliance by January of 2014,” (said Dave Hewitt, president of the South Dakota Association of Healthcare Organizations and an outspoken advocate of the reforms). 

Of course, it’s worth noting that Daugaard isn’t doing nothing. Members of his staff are researching and studying the possibilities surrounding a state exchange using a $5.9 million federal grant. That preparation, Daugaard’s staff say, will help the state be ready by January 2014.

Other parts of PPACA, of course, have already took effect, and South Dakota has already — controversially — implemented those. A series of provisions from PPACA, such as letting people stay on their parents’ health insurance well into their 20s, were included in Senate Bills 38 and 43, which passed last year and survived a recall drive. Those bills didn’t establish a health care exchange — “a virtual shopping mall for consumers to find coverage.”

Sen. John Thune, an opponent of PPACA, is sympathetic with Daugaard.

“If you’re Gov. Daugaard, and you make a lot of effort and incur expense creating an insurance exchange, and then the president and the new Congress repeal the law, it could be a lot of effort for naught. That’s a judgment call,” Thune said.

A spokesman for Sen. Tim Johnson, who supports the law, called on South Dakota to continue to implement it.

Daugaard is getting it from both sides here: he’s not doing enough to satisfy supporters of PPACA, but he’s doing too much to satisfy the law’s fiercest enemies. Will this Goldilocks approach steer South Dakota safely through this muddle, or get us eaten by a bear?

UPDATE: The Hill did an analysis of where the country’s governors stand on implementing the Medicaid expansion under the Patient Protection and Affordable Care Act. They found that seven states with Republican governors have given flat refusals to expanding Medicaid under PPACA even though the federal government will pick up most of the tab at first. Another seven Republican governors and one Democratic governor haven’t been firm but have suggested they won’t expand Medicaid. Eleven Democratic governors and one independent have said they will expand Medicaid coverage, while another Democrat is leaning yes.

That leaves seven Democrats and 16 Republicans, including Daugaard, as being uncommitted publicly either for or against the expansion of Mediciad.

Read their story here, including the full list of where states stand.

The Roberts switch

CBS News comes up with the great scoop that everyone had been trying to get since last week’s Supreme Court ruling on the Affordable Care Act came out: Chief Justice John Roberts originally voted to strike the bill down before switching to uphold it.

Jan Crawford’s piece is full of great details about how the court ended up with the decision it did — most of which seem to come from people sympathetic to the conservative justices who wanted to strike the whole law down.

Keep that apparent sourcing in mind when you read Crawford’s article. For example, Crawford notes that while Roberts’ opinion reflects some long-standing aspects of his judicial philosophy, including a belief in judicial restraint, but writes that “regardless of his thinking, it was clear to the conservatives that Roberts wanted the court out of the red-hot dispute.” 

That’s a sentence that’s sourced to someone on the conservative side, reporting what seemed “clear” to them, not to Roberts himself explaining his own thinking.

The story certainly gives a boost to efforts by conservatives to brand Roberts as a judicial Judas; not only did he have the more general “betrayal” of being a Republican appointee who voted to uphold a signature Democratic bill, but he apparently had a more specific betrayal of changing his view on the bill over a couple of weeks.

It also gives a little vindication to conservatives, who can point to the article’s allegations that Roberts was swayed by external pressure from President Obama and Democrats to delegitimize the Court’s ruling.

But what may be more striking is the article’s existence in the first place. The Supreme Court, unlike most parts of government, generally doesn’t leak. Both liberals and conservatives have remarked on the implications for the Court’s future harmony that one or more of the court’s conservative justices, or people close to them, attacked the Court’s chief justice through anonymous quotes in the press. 

I’m not complaining, here: as a reporter I’m all for as much transparency about the Court’s doings as possible. But something about the manner in which this information came to light seems a little untoward.