Rural health centers say Medicaid expansion key to delivering better care, growing economy

Among the coalition pushing for South Dakotans to support Amendment D is a group of community health centers, which are key sources of basic medical and dental services for low-income South Dakotans. However, opponents of the measure say the promises of the expansion don't align with reality.

Horizon Healthcare
The Yankton Community Health Center is one of 27 clinics that provide a low-cost option in rural and urban areas around South Dakota
Jason Harward / Forum News Service
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YANKTON, S.D. — Judale Carr knows what it’s like to live without health insurance. From 2019 until he qualified for Medicaid through disability two months ago, Carr was paying out of pocket for a variety of health problems, largely stemming from chronic back issues and a neck injury sustained while working.

He says the fear of medical costs is a constant topic of conversation among residents of the affordable housing complex where he lives in Yankton.

“Several friends of mine don't even go to the doctor because they just can't afford it. I say I know you can't afford it, but we're getting older and you have to get your blood pressure checked and make sure everything is alright,” Carr told Forum News Service on Sept. 20. “But it's like pulling teeth, because they don't want to have those types of bills hanging over them.”

Judale Carr
Judale Carr visits with Amanda Thoms, his provider at Yankton Community Health Center.
Courtesy Susan Smith, who works in marketing with Horizon Healthcare

During those years, Carr relied on the Yankton Community Health Center, one of several community health centers owned by Horizon Healthcare.

These community health centers, which can offer a sliding scale of lower rates to uninsured and underinsured populations due to partial federal funding, are a key provider of basic medical and dental services to lower income patients in rural and urban areas across South Dakota.


This year, they also make up part of the coalition in favor of expanding Medicaid in the state.

“For us, there's the piece of financial sustainability and the long-term viability of rural resources,” Shelly Ten Napel, the CEO of the Community Healthcare Association of the Dakotas, told Forum News Service. “But there's also the fact that these are our patients, our friends or neighbors. Whatever the impact is on our bottom line, it's hard to see people struggling every day with not being able to afford the healthcare that they need.”

Community health centers say Medicaid expansion would shore up rural access to health care

Michelle Kral, a community health worker and patient support navigator at the health center in Yankton, says she’s seen the difficult realities of South Dakota being one of 13 states in the country not to expand Medicaid since coverage was first offered to people ages 19-64 who sat below 138% of the federal poverty line in 2014.

She recounted a story of grandparents who had adopted their four grandchildren out of foster care. Although the children had qualified for Medicaid while living in Nebraska, that eligibility lapsed for three of the four children when they moved to South Dakota.

“They were just above qualifying for Medicaid. And they can't get affordable coverage on the marketplace because both of the grandparents have Medicare, so the kids don't qualify for tax credits,” Kral said.

Outside of the certainty expanding Medicaid could provide for families in similar situations, Horizon Healthcare CEO Wade Erickson says another part of his reasoning for supporting expansion is the economic effects of lower out-of-pocket costs for thousands of patients.

Of the estimated 42,500 people who fall in the Medicaid “coverage gap” — meaning they would become eligible for Medicaid if Amendment D passes — Erickson says some 7,000 reside within the Horizon system of health centers. He added that moving these patients from the current out-of-pocket sliding scale to Medicaid would lower uncompensated costs for Horizon and other community health centers in the state.

Horizon Healthcare CEO Wade Erickson
Courtesy Horizon Healthcare

“Having Medicaid expansion would reduce the uninsured bad debt, which then those people would be able to use that money in the community,” Erickson said. “They would have coverage that would allow them to spend that money locally, and really stimulate that local economy.”


According to Ten Napel, the Community Healthcare Association of the Dakotas (CHAD), which represents community health centers in North and South Dakota, has seen the benefits of Medicaid expansion in what is essentially a natural experiment, since Medicaid was expanded by voters in North Dakota in 2013.

Ten Napel pointed to the lower uninsured rate in North Dakota as one relevant metric for judging the effectiveness of expansion.

A Health and Human Services analysis from this year estimated the uninsured rate among those in the “coverage gap” at 20.4% in North Dakota as of 2020, compared to 35.4% in South Dakota that same year.

“When you have that stronger payer mix, there are just more resources to provide the type of care that you know your patients need,” Ten Napel said. “So whether that's transportation, whether that's support with medications or behavioral health, there's just more resources to do that.”

Opponents say Medicaid would fail to deliver on its promises

Among opponents of expanding Medicaid, there is a feeling that the program is being sold without enough focus on potential downsides.

“In the states where Medicaid expansion has happened, the numbers don't measure up,” Keith Moore, the state director for Americans for Prosperity in South Dakota, a right-of-center advocacy group, told Forum News Service. “Once it’s expanded, the states enroll more than twice as many individuals as projected. So then you got twice as much cost.”

Though Erickson admitted the difficulty of enrolling thousands of people into Medicaid, he said exceeding the estimate of 42,500 would not surprise him.

“It'll take time, but I think we could very easily exceed that,” Erickson said.


However, that does not necessarily mean costs will increase overall. While an analysis by the Center on Budget and Policy Priorities does show that about half of states have enrolled more than expected, it also concluded that “savings from the Medicaid expansion,” which include decreases in other state healthcare costs, “will continue to outstrip state expansion costs into the next decade.”

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An analysis from the Legislative Research Council in South Dakota estimates expansion would cost the state under $4 million over the first five years, although much of these savings come from federal incentives in the first two years, and each year after would cost around $22 million without changes to the program.

Still, Moore and other opponents of expansion, such as John Wiik, a Republican state senator from Big Stone City, have several other reasons for fearing the effects of expanding Medicaid.

Among the unintended consequences Moore had tracked in other states were a loss of private plans for lower-income workers and the ability for able-bodied people to access health care without working.

In addition, Wiik told the South Dakota Newspaper Association he was worried about increased demand amid a labor shortage, saying he “can’t guarantee that we have enough providers to keep up with the level and quality of service we are able to provide to those who desperately need it right now.”

Though Erickson admitted that economy-wide labor shortages have certainly been felt by Horizon Healthcare, he thought the industry could meet a potential spike in demand.

“The savings that will be brought to the state and economic stimulus it will create will drive the creation of new jobs in the healthcare industry,” Erickson said. “That will ultimately drive down costs and improve the overall health and quality of life of every South Dakotan.”

The open enrollment period, which allows signups for subsidize health insurance through, began on Nov. 1 and lasts until Jan. 15. On top of continued subsidies for individuals, a change to the "family glitch" could make thousands of families newly eligible for lower-cost coverage.

Jason Harward is a Report for America corps reporter who writes about state politics in South Dakota. Contact him at 605-301-0496 or

Related Topics: ELECTION 2022HEALTH NEWS
Jason Harward covers South Dakota news for Forum News Service. Email him at
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