Just a few days after Michigan Republicans walked back their controversial plan to exempt several majority-white counties from its proposed Medicaid work requirement after a widespread backlash and accusations of racism, South Dakota unveiled its own proposal that wades into a similar legal and political fight.
The draft waiver the state released this week proposes the implementation of a Medicaid work requirement for a five-year period only in the state’s two most populous counties, Minnehaha and Pennington, home to Sioux Falls and Rapid City respectively. While the both the state and its largest cities are overwhelmingly white, more than two-thirds of the state’s black residents and nearly half of the state’s Hispanic residents live in the two counties where the work requirements would take effect.
The state’s waiver justifies singling out the two counties by arguing that they were selected “based on population and access to employment and training resources,” and says other counties may be added “based on the initial outcomes of the pilot.”
If residents in those two counties who depend on Medicaid aren’t able to prove that they’re spending at least 80 hours per month working, studying, or searching for a job, they could lose their health care coverage.
South Dakota Gov. Dennis Daugaard announced he would be pursuing the waiver back in January, saying the new rules would “connect those who can work with jobs that give them that sense of self-worth and accomplishment.” Because South Dakota never expanded Medicaid under Obamacare, the work requirement would be imposed upon people in so-called “traditional Medicaid,” which in South Dakota means people earning up to 58 percent of the federal poverty level.
South Dakota’s waiver also steps squarely into the fight over whether Native Americans should be exempt from the new requirements. American Indian tribes and their supporters in Congress on both sides of the aisle have argued that it would be a violation of tribal sovereignty to force the work requirements on them, but the Trump administration has asserted that exempting Native Americans would be granting an illegal racial preference, and has empowered states to make the call.
South Dakota, which has the fourth-highest percentage of Native Americans in the country, writes that when they consulted with Native American groups while drafting the waiver: “Some of the tribes expressed concern or opposition to the demonstration and requested an exemption for American Indians.” Neither those concerns nor the threat of legal action, however, were not enough to persuade the state from plowing ahead.
“The counties included in the pilot do not include Indian reservations,” the waiver notes. “In addition, the State’s understanding is that CMS has determined that it cannot legally exempt American Indians.”
But Jerilyn Church, the CEO of the Great Plains Tribal Chairmen’s Health Board (GPTCHB) in South Dakota, told state officials in a conference call in April that by not granting American Indians an exemption, they were pursuing a policy that was both harmful and illegal.
“Medicaid is an extension of the treaty obligation,” Church said, according to the meeting minutes. “Most American Indians want to work; but, on the reservation there is limited opportunity. … Data is clear that it is harder for American Indians to obtain jobs off the reservation compared to other populations.”