During Department of Social Services Secretary Matt Althoff's time, he’s overseen three changes to the state’s Medicaid program.
DSS has unveiled a new back-end program for Medicaid applications, rolled out voter-approved Medicaid expansion, and removed those from Medicaid coverage who no longer qualify following the end of a public health emergency.
That emergency prohibited states from scrubbing its Medicaid rolls. Last spring, the number of Medicaid enrollees was at 154,000.
Althoff, who has been at DSS for about a year, said the department scrubbed about 30,000 individuals once the emergency lapsed.
“Those are a lot of additional lives that are, in theory, insured in Medicaid. Our team began a process, methodically—we followed all Center for Medicaid and Medicare Services—to say how many of those cases can we do? And this was a big lift for our team," Althoff said.
Roughly 30 percent of enrollees were dropped from South Dakota’s Medicaid rolls. The 27 percent drop in children covered by Medicaid even caught the eyes of the federal government.
Althoff said a top reason people lost Medicaid coverage was of better pay.
“The reasons why individuals, through this unwinding, became disenrolled was well—they made more income. They got a job. I think that’s something that we celebrate," Althoff said. "The gainful employment was achieved and now they’re receiving adequate income—by federal poverty standards. We hope, too—don’t always know—with the benefit of health insurance.”
Medicaid is thirty percent of the state budget—the largest budget item for the state. This year, the state is spending just over $365 million to cover its share of Medicaid. The federal government picks up the remaining $1 billion.
Medicaid is about to get even more expensive for the state, when the federal incentive to expand Medicaid runs out. State lawmakers and the governor have already set aside $31 million to ease covering that cost.
State Republicans are already pushing a change to Medicaid – this one in the form of a ballot question. Some want voters to clarify whether they’ll allow lawmakers to pursue a Medicaid work requirement waiver.
“My biggest concern about the Medicaid expansion ballot amendment was that it put on the ballot something that had a huge, ongoing general fund cost with no plan to pay for it. I felt that that was pretty irresponsible," said Rep. Tony Venhuizen, R-Sioux Falls, who is a primary backer of the question, in February.
The ballot question is supported by the Department of Social Services. Venhuizen also sits on the committee that crafts the state budget.
“If you put something on the ballots that’s going to have a cost you should also have a plan to cover the cost," Venhuizen added.
South Dakota’s unemployment rate is around 2.1 percent. It’s unclear whether work requirements result in more individuals in the workplace.
According to the Kaiser Family Foundation, available data suggests Medicaid work and reporting requirements were confusing to enrollees and resulted in substantial coverage loss, including eligible individuals.
Some health care officials are worried that will happen here, too.
Initially, federal officials anticipated 52,000 new South Dakotans would enroll for Medicaid under expansion. Now, the state is anticipating 40,000. About 20,000 are enrolled through expansion, currently.
Officials say it could take up to 24 months before reaching full enrollment.
“We’re not even making an attempt out here to enroll people. Hence, our numbers are way down," said Representative Linda Duba, D-Sioux Falls, who would like to see the Department of Social Services perform outreach, to get more eligible individuals enrolled and to get their routine health care covered.
Duba also worries about who may be subject to the Medicaid work requirement.
“We have individuals who may need to go on Medicaid expansion, but they also may need childcare. If they need childcare, but they can’t afford childcare because they’re working, then what are they supposed to do?" Duba said. "How do they deal with that situation?”
Who will be subject to a work requirement will get determined by the state if the idea passes in November.
There’s another ballot question that has state lawmakers worried about state revenue and spending. That’s the question of whether to prohibit state sales tax on food, which could cost the state around $100 million in revenue. Sales tax collections are the state’s primary source of revenue.
Republican Sen. Lee Schoenbeck said voters are asking lawmakers to cut revenue and increase spending.
“You take all that money out of our budget and you’re going to train wreck—you’re not going to be talking about could you do a tuition freeze," Schoenbeck said, when referencing funding legislative priorities. "You’re going to say, ‘How many of these programs that are generating the welders, and the robotics, and the nurses and LPN’s, how many of those are you going to have to cut?' Because you don’t have any money.”
