Medicaid patients and dvocacy groups across the country are upset about problems patients have getting transportation for medical appointments.

This article was published on Wednesday, January 12, 2022 in Kaiser Health News.

By Rebecca Grapevine, Georgia Health News and Andy Miller  

Tranisha Rockmore and her daughter Karisma waited at an Atlanta children's hospital in July for their ride home.

Karisma had been at Children's Healthcare of Atlanta to have her gastrostomy tube fixed, Rockmore said. The 4-year-old, who has several severe medical conditions, has insurance coverage from Medicaid, which provides transportation to and from nonemergency medical appointments through private vendors.

After being told that a ride would not be available for hours, Rockmore said, she finally gave up and called her sister to drive them home to the South Georgia town of Ashburn, more than 160 miles away.

She said it wasn't the first time she had run into trouble with the Medicaid transportation service.

"Sometimes they don't ever come," said Rockmore, who doesn't own a car. Many rides have been canceled recently, she said; the company told her it couldn't find drivers. "Sometimes they make me feel like they don't care if my child gets to the doctor or not."

Rockmore's remarks would no doubt resonate with the Medicaid beneficiaries, relatives and advocacy groups across the country upset about problems patients have getting transportation for medical appointments. Not only are some shuttle drivers no-shows, but some patients have been injured during rides because their wheelchairs were not properly secured, according to lawsuits filed in Georgia and other states.

States are required to set up transportation to medical appointments for adults, children and people with disabilities in the Medicaid health insurance program. Transportation brokers — such as Modivcare, which Rockmore used — have subcontracts with local providers, often small "mom and pop" operations, to shuttle patients to and from needed appointments, including for dialysis, adult day care, and mental health and treatment for substance use disorders.

It's a lucrative business, with transportation management contracts that can be worth tens of millions of dollars for companies. The two companies that have contracts in Georgia have given extensively to political campaigns of elected officials in the state. The firms, Modivcare and Southeastrans, have also faced complaints, lawsuits and state government fines in Georgia and elsewhere. The two companies maintain, though, that the complaints relate to a tiny percentage of rides provided.

Medicaid nonemergency transportation "is absolutely a national challenge,'' said Matt Salo, executive director of the National Association of Medicaid Directors. "This is something practically all the states we talk to are dealing with. I don't think anyone has figured this out."

Beth Holloway, 47, of Wharton, New Jersey, said she has had multiple problems with rides. "Sometimes they arrive late, other times not at all," said Holloway, who has cerebral palsy and lives independently. "I've been stranded at doctors' offices for hours, sometimes out in the elements."

In Los Angeles, Rose Ratcliff and several other patients filed a lawsuit in 2017 against Modivcare, then known as LogistiCare; other local transportation brokers; and the insurers that run the state Medicaid program, known as Medi-Cal in California.

The pending suit alleges that Ratcliff and other patients like her missed crucial dialysis appointments and faced unsafe conditions during transport. It calls Modivcare the "broken link" in the Medicaid transportation chain and claims the company did not adequately respond to complaints from clients like Ratcliff.

Katherine Zerone, a spokesperson for Modivcare, said the company does not comment on pending litigation. In an initial legal response, it said the problems were linked to the independent transportation vendors and their employees, not Modivcare/LogistiCare.

After complaints were made about Southeastrans' service across Indiana, the state appointed a special legislative commission to review the company's performance. Indiana now publishes detailed complaint data for the Atlanta-based company each month.

In August, James Mills, a Bloomington man who uses a wheelchair, filed a lawsuit alleging that the company had violated the Americans with Disabilities Act and other civil rights laws by not providing a wheelchair-accessible vehicle to transport him to and from his appointments. The lawsuit alleges that because of the lack of wheelchair accommodation, Mills missed needed medical care and was even kicked off the patient lists of some of his local doctors.

"While we're unable to comment on pending litigation, we're aware of the matter and strongly disagree with the allegations,'' said Christopher Lee, an attorney for Southeastrans, which operates in seven states and Washington, D.C.

Two decades ago, Georgia was one of the first states to start using transportation brokers to manage its Medicaid transportation program. The two longtime providers in the state — Modivcare and Southeastrans — will receive a total of $127.6 million from the state this fiscal year. They are paid a per-member monthly rate that averages $5.60 in Georgia, regardless of how many rides, if any, a Medicaid user takes. The state was expected to announce new contracts for Medicaid transportation this month.

Georgia assessed a total of $4.4 million in penalties to the two companies over the period from January 2018 to December 2020 for failing to pick up patients on time and other problems. However, the state Medicaid agency essentially gave them discounts, charging the two companies only $1.2 million during that period, according to state Department of Community Health letters obtained through an open records request. In extending the brokers' contracts in the 2018 fiscal year, the state Medicaid agency agreed to cap damages at 25% of the assessed amount, Department of Community Health spokesperson Fiona Roberts said.

Modivcare said it's the largest transportation broker nationally, controlling about 40% of the market. The publicly traded company based in Colorado provides Medicaid transportation in more than 20 states.

Modivcare and other companies say only a tiny fraction of the rides they provide lead to complaints. "Our first priority is safe and reliable transportation," Zerone said. In Georgia, 99.8% of its trips are complaint-free, she said.

Andrew Tomys, Georgia state director for Southeastrans, said 99.9% of the trips his company services in the state are "free of valid complaints."

Both Modivcare and Southeastrans say they investigate each complaint to determine whether it's valid. In Georgia, Modivcare reported to the Department of Community Health more than 3,200 late rides or no-shows over a year out of around 2.3 million rides. Southeastrans reported just over 900 such problems out of around 1.4 million rides.

But patients and their advocates say that in many cases problems aren't reported, or complaints are ignored.

KHN tells the stories of Georgia in partnership with Georgia Health News. 

Georgia should peg any new contracts to timely rides, ease of use for beneficiaries and the overall ride experience, said Melissa Haberlen DeWolf, policy director of the advocacy group Voices for Georgia's Children.

In recent election cycles, Southeastrans and Modivcare — through its former corporate name LogistiCare — have been generous donors to Georgia Republicans, who have controlled state offices in the state for nearly two decades.

Southeastrans, as a company, has donated $126,000 to Georgia Republican campaigns and committees since 2017, according to documents on the Georgia Government Transparency and Campaign Finance Commission website.

Additionally, Southeastrans' co-founder and CEO, Steve Adams, has given at least $86,000 to Georgia Republican candidates for state office and to the state Republican Party since 2017, according to state filings. During that same period, Adams donated $3,800 to two state Democratic candidates.

"As a minority-owned business headquartered in Georgia for over 20 years, Southeastrans and its owner have contributed to a diverse mix of local causes and organizations," Lee said.

Modivcare, through LogistiCare, has given $48,350 to Georgia Republican candidates in state races since 2017, according to the Georgia Government Transparency and Campaign Finance Commission. It gave $750 to former Democratic state Rep. Pat Gardner, also according to the commission. Modivcare's Zerone did not answer questions about the company's political giving because she said it would be "competitive information."

Such contributions can help companies buy access to government officials, said Paul S. Ryan, a vice president at the government watchdog group Common Cause.

"Anytime a special interest doing business with the government can make big contributions to public officials handing out contracts or making other government decisions, it's a cause for concern," he said. "Average, everyday Americans can't buy the same influence."

Tranisha Rockmore said she's so fed up that she wants to get a car so she can avoid the transportation problems. "I'm to the point where I feel like they don't care about my daughter," she said. "You don't just do people's kids like that."

Andy Miller: amiller@kff.org, @gahealthnews

Scores of hospitals across the U.S. looking abroad to ease a shortage of nurses worsened by the pandemic.

This article was published on Friday, January 7, 2022 in Kaiser Health News.

By Nick Ehli  

BILLINGS, Mont. — Before Mary Venus was offered a nursing job at a hospital here, she'd never heard of Billings or visited the United States. A native of the Philippines, she researched her prospective move via the internet, set aside her angst about the cold Montana winters and took the job, sight unseen.

Venus has been in Billings since mid-November, working in a surgical recovery unit at Billings Clinic, Montana's largest hospital in its most populous city. She and her husband moved into an apartment, bought a car and are settling in. They recently celebrated their first wedding anniversary. Maybe, she mused, this could be a "forever home."

"I am hoping to stay here," Venus said. "So far, so good. It's not easy, though. For me, it's like living on another planet."

Administrators at Billings Clinic hope she stays, too. The hospital has contracts with two dozen nurses from the Philippines, Thailand, Kenya, Ghana and Nigeria, all set to arrive in Montana by summer. More nurses from far-off places are likely.

Billings Clinic is just one of the scores of hospitals across the U.S. looking abroad to ease a shortage of nurses worsened by the pandemic. The national demand is so great that it's created a backlog of healthcare professionals awaiting clearance to work in the U.S. More than 5,000 international nurses are awaiting final visa approval, the American Association of International Healthcare Recruitment reported in September.

"We are seeing an absolute boom in requests for international nurses," said Lesley Hamilton-Powers, a board member of AAIHR and a vice president for Avant Healthcare Professionals in Florida.

Avant recruits nurses from other countries and then works to place them in U.S. hospitals, including Billings Clinic. Before the pandemic, Avant would typically have orders from hospitals for 800 nurses. It currently has more than 4,000 such requests, Hamilton-Powers said.

"And that's just us, a single organization," added Hamilton-Powers. "Hospitals all over the country are stretched and looking for alternatives to fill nursing vacancies."

Foreign-born workers make up about a sixth of the U.S. nursing workforce, and the need is increasing, nursing associations and staffing agencies report, as nurses increasingly leave the profession. Nursing schools have seen an increase in enrollment since the pandemic, but that staffing pipeline has done little to offset today's demand.

In fact, the American Nurses Association in September urged the U.S. Department of Health and Human Services to declare the shortage of nurses a national crisis.

CGFNS International, which certifies the credentials of foreign-born healthcare workers to work in America, is the only such organization authorized by the federal government. Its president, Dr. Franklin Shaffer, said more hospitals are looking abroad to fill their staffing voids.

"We have a huge demand, a huge shortage," he said.

Billings Clinic would hire 120 more nurses today if it could, hospital officials said. The staffing shortage was significant before the pandemic. The added demands and stress of COVID have made it untenable.

Greg Titensor, a registered nurse and the vice president of operations at Billings Clinic, noted that three of the hospital's most experienced nurses, all in the intensive care unit with at least 20 years of experience, recently announced their retirements.

"They are getting tired, and they are leaving," Titensor said.

Last fall's surge of COVID cases resulted in Montana having the highest rate in the nation for a time, and Billings Clinics' ICU was bursting with patients. Republican Gov. Greg Gianforte sent the National Guard to Billings Clinic and other Montana hospitals; the federal government sent pharmacists and a naval medical team.

While the surge in Montana has subsided, active case numbers in Yellowstone County — home to the hospital — are among the state's highest. The Billings Clinic ICU still overflows, mostly with COVID patients, and signs still warn visitors that "aggressive behavior will not be tolerated," a reminder of the threat of violence and abuse healthcare workers endure as the pandemic grinds on.

Like most hospitals, Billings Clinic has sought to abate its staffing shortage with traveling nurses — contract workers who typically go where the pandemic demands. The clinic has paid up to $200 an hour for their services, and, at last fall's peak, had as many as 200 traveling nurses as part of its workforce.

The scarcity of nurses nationally has driven those steep payments, prompting members of Congress to ask the Biden administration to investigate reported gouging by unscrupulous staffing agencies.

Whatever the cause, satisfying the hospital's personnel shortage with traveling nurses is not sustainable, said Priscilla Needham, Billings Clinic's chief financial officer. Medicare, she noted, doesn't pay the hospital more if it needs to hire more expensive nurses, nor does it pay enough when a COVID patient needs to stay in the hospital longer than a typical COVID patient.

From July to October, the hospital's nursing costs increased by $6 million, Needham said. Money from the Federal Emergency Management Agency and the CARES Act has helped, but she anticipated November and December would further drive up costs.

Dozens of agencies place international nurses in U.S. hospitals. The firm that Billings Clinic chose, Avant, first puts the nurses through instruction in Florida in hopes of easing their transition to the U.S., said Brian Hudson, a company senior vice president.

Venus, with nine years of experience as a nurse, said her stateside training included clearing cultural hurdles like how to do her taxes and obtain car insurance.

"Nursing is the same all over the world," Venus said, "but the culture is very different."

Shaffer, of CGFNS International, said foreign-born nurses are interested in the U.S. for a variety of reasons, including the opportunity to advance their education and careers, earn more money or perhaps get married. For some, said Avant's Hudson, the idea of living "the American dream" predominates.

The hitch so far has been getting the nurses into the country fast enough. After jobs are offered and accepted, foreign-born nurses require a final interview to obtain a visa from the State Department, and there is a backlog for those interviews. Powers explained that, because of the pandemic, many of the U.S. embassies where those interviews take place remain closed or are operating for fewer hours than usual.

While the backlog has receded in recent weeks, Powers described the delays as challenging. The nurses waiting in their home countries, she stressed, have passed all their necessary exams to work in the U.S.

"It's been very frustrating to have nurses poised to arrive, and we just can't bring them in," Powers said.

Once they arrive, the international nurses in Billings will remain employees of Avant, although after three years the clinic can offer them permanent positions. Clinic administrators stressed that the nurses are paid the same as its local nurses with equivalent experience. On top of that, the hospital pays a fee to Avant.

More than 90% of Avant's international nurses choose to stay in their new communities, Hudson said, but Billings Clinic hopes to better that mark. Welcoming them to the city will be critical, said Sara Agostinelli, the clinic's director of diversity, equity, inclusion and belonging. She has even offered winter driving lessons.

The added diversity will benefit the city, Agostinelli said. Some nurses will bring their spouses; some will bring their children.

"We will help encourage what Billings looks like and who Billings is," she said.

Pae Junthanam, a nurse from Thailand, said he was initially worried about coming to Billings after learning that Montana's population is nearly 90% white and less than 1% Asian. The chance to advance his career, however, outweighed the concerns of moving. He also hopes his partner of 10 years will soon be able to join him.

Since his arrival in November, Junthanam said, his neighbors have greeted him warmly, and one shop owner, after learning he was a nurse newly arrived from Thailand, thanked him for his service.

"I am far from home, but I feel like this is like another home for me," he said.

Mary Laske became an activist, philanthropist and strategist focused on supporting medical research.

This article was published on Thursday, January 6, 2022 in Kaiser Health News.

By Gabrielle Emanuel, WBUR    

The roots of the National Cancer Act can be traced to a small home in Watertown, Wisconsin. In the early 1900s, a girl named Mary tagged along when her mother went to visit their laundress, Mrs. Belter, who had breast cancer.

When they arrived, the woman was in bed, her seven children around her. She was terribly sick. That day, Mary was only around 4 years old, but she remembered it for the rest of her life.

"When I stood in the room and saw this miserable sight, with her children crowding around her, I was absolutely infuriated, indignant that this woman should suffer so and that there should be no help for her," she recalled decades later, in 1962.

That girl grew up to be Mary Lasker, who transformed her outrage into action. Lasker became an activist, philanthropist and strategist focused on supporting medical research.

Belter, who'd had her breasts removed, survived.

"I'll never forget my anger at hearing about this disease that caused such suffering and mutilation and my thinking that something should be done about this," Lasker recounted.

In the first half of the 20th century, cancer was misunderstood. It was widely considered a death sentence, and some people believed it was contagious and something to be ashamed of.

"It was a disease diagnosis that was whispered about and kept secret," said Ned Sharpless, director of the National Cancer Institute. Sharpless said that to protect a person's dignity, doctors commonly fibbed about someone's condition or said that "the patient died of old age."

Decades of advocacy — and scientific breakthroughs — have dramatically changed that. The U.S. government has spent more money on the fight against cancer than any other disease, and many cancers are far less deadly than they once were.

A crucial moment in this evolution was the president's signing of the National Cancer Act into law 50 years ago, on Dec. 23, 1971.

Launching a Crusade

For years, Mrs. Belter's illness remained vivid in Mary Lasker's mind. About 40 years later, in 1943, her cook also fell ill with cancer. As Lasker — a person with wealth and status — helped her employee navigate the healthcare system, she was shocked to discover that cancer care had not advanced much.

So Lasker started a crusade. In the 1940s, broadcasters wouldn't say "cancer" on the radio. She worked to change that, with the help of her husband, Albert Lasker, an advertising executive. The couple persuaded Reader's Digest to do a series of articles about cancer. And Lasker persuaded her friend behind the Ann Landers advice column to write about it.

Lasker, who died in 1994 at age 93, didn't just focus on changing the popular perceptions of cancer. She wanted to cure cancer, and that demanded a real investment in medical research.

"The amount of money that's being spent for medical research is … well, it's just piddling," Lasker told Edward R. Murrow on CBS in 1959. "You won't believe this, but less is spent on cancer research than we spend on chewing gum."

After the United States put a man on the moon, Lasker started calling for "a moonshot for cancer."

"She understood that this was a big problem and the solutions needed to be big. But Mary was willing to think big," said Dr. Claire Pomeroy, president of the Albert and Mary Lasker Foundation.

Lasker built her movement: lobbying Congress and making the most of her time on the social circuit. She was a frequent visitor to the White House, as a friend of President Lyndon Johnson and his wife, Lady Bird.

At the same time, new treatments were being pioneered only a few miles away, at the National Cancer Institute in Bethesda, Maryland. Dr. Robert Mayer was working there, just beginning his career in medicine.

"Every Sunday night, the planes would fly in with patients," Mayer recalled.

Those patients were young children who had acute leukemia and were traveling to the National Institutes of Health to receive their monthly doses of chemotherapy. They came from all over the country because only a handful of hospitals were then capable of aggressively treating cancer patients.

"My colleagues thought we were a little crazy, that we would be giving people 'cell poisons,' which is what chemotherapy was thought to be," said Mayer, now an oncologist at the Dana-Farber Cancer Institute in Boston and a professor at Harvard Medical School.

Chemotherapy was still experimental, but the doctors at the National Cancer Institute were getting results. For one pediatric leukemia, the chance of survival improved dramatically.

"It wasn't just that they were people — they were children, and they were children at an adorable age of 3 or 4 or 5," Mayer said.

As the stories of these surviving children trickled out in the 1960s, a sense of optimism took hold.

Persuading Congress to Go Big

By the late 1960s, Lasker felt things were moving too slowly and decided to increase the pressure on lawmakers by taking out targeted newspaper ads in key congressional districts.

"This absolutely shocked the people in the House because they never had ads before and people were calling up from their districts and sending telegrams, and it caused quite a little commotion," Lasker said in an interview for the Oral History Research Office at Columbia University Libraries.

She also pestered President Richard Nixon, and publicly. She paid for full-page ads in The New York Times and The Washington Post. Big letters screamed out from the page: "Mr. Nixon: You can cure cancer."

The decades-long campaign in research labs, in the halls of Congress, and in the media finally paid off. On Dec. 23, 1971 — at about noon — Nixon spoke to a crowd of over 100 people, including Mary Lasker, members of Congress, and prominent scientists and doctors.

"Hope and comfort, the relief of suffering and the affirmation of life itself — these are qualities which have traditionally been associated with the Christmas season," Nixon said in a press statement. "There could be no more appropriate time than this to sign into law the National Cancer Act of 1971."

After signing the bill, Nixon posed for the cameras, with members of Congress arranged behind his chair. Sen. Edward Kennedy of Massachusetts, the Democratic whip and chief sponsor of the bill in the Senate, stood directly behind the president, his hand on the back of the chair.

That moment reveals how support for medical research had become politicized, according to Robin Wolfe Scheffler, a historian of science at the Massachusetts Institute of Technology. In Scheffler's analysis, Nixon signed the bill, in part, to ensure that his support for health research would not be in question during the 1972 presidential race. Kennedy was not seeking the nomination, officially, but was widely considered a possible front-runner.

"Nixon embraces the war on cancer as a way of taking an issue away from his potential future rivals, not necessarily because he has any particular desire to do something about cancer," said Scheffler, author of "A Contagious Cause: The American Hunt for Cancer Viruses and the Rise of Molecular Medicine."

Regardless of Nixon's motivation, the public investment was significant, $1.6 billion (almost $11 billion in today's dollars). The National Cancer Act funded biomedical research, set up oncology training programs and built a nationwide network of cancer treatment centers.

Many people thought the cancer moonshot would lead to a cure in five years, in time for the country's bicentennial in 1976. But curing cancer would prove to be much harder than going to the moon.

"I think you have to admit two things about the National Cancer Act. On the one hand, it was visionary and transformative. It was one of the most important things the United States has ever done in terms of biomedical research," Sharpless said. "At the same time, we also have to admit that it was very naive."

America's bicentennial came and went, but cancer death rates continued to climb. News anchors questioned whether taxpayers' money was being wasted.

"People declared the war on cancer 'a medical Vietnam,'" Scheffler said.

A debate ensued about whether the National Cancer Act's focus on basic research was misguided if it wasn't leading to advances in treatment. Environmental activists argued that the emphasis should have been on prevention.

It took time for the research investment to pay off, Sharpless said. "All this basic biology was bubbling beneath the surface. It doesn't look like much was happening in terms of cancer outcomes," he said. "But a lot was happening in the … cancer research space."

Now, 50 years after the funds started flowing, "we really are in a time of rapid progress," Sharpless said.

Although 600,000 Americans die from cancer each year, the overall death rate for cancer has dropped by about a third from its peak in 1991. But the progress has been uneven.

For some cancers, the prognosis is still bleak. For example, the vast majority of people diagnosed with pancreatic cancer die within a few years. But for other types of cancer, there have been major medical advances. Death rates for colorectal cancer, cervical cancer and prostate cancer have declined more than 50%. And there have been advances in the treatment of lung cancer, breast cancer and melanoma, among others.

"We have made remarkable progress," said Dr. Ahmedin Jemal, an epidemiologist at the American Cancer Society. "But there is a certain segment of the population that is not really benefiting from the advances that we have made in the past five decades."

Significant gaps in cancer death rates remain along racial, economic and geographic lines. And insurance makes a big difference — people with consistent health insurance are more likely to survive cancer than people who are uninsured or experience disruptions in health insurance coverage.

Jemal pointed to policies that can help reduce cancer death rates, including smoke-free workplace laws, tobacco excise taxes and the expansion of Medicaid, the federal-state program that provides health insurance to low-income people. Jemal said some states in the South and Midwest that did not expand Medicaid were found to have slightly higher cancer death rates.

Advocates like Jemal say a goal for the future is to make sure all Americans — no matter where they live, what race they are or how much they earn — have access to 50 years of cancer progress.

This story is part of a partnership that includes WBUR, NPR and KHN.

This story relied on archived interviews with Mary Lasker conducted by the Oral History Research Office at Columbia University.

State officials this week officially placed the issue on the ballot after validating thousands of petition signatures.

This article was published on Thursday, January 6, 2022 in Kaiser Health News.

By Phil Galewitz  

South Dakota voters will decide in November whether the state should become the 39th to expand Medicaid under the Affordable Care Act, a move that would provide coverage to 42,000 low-income residents.

State officials on Monday officially placed the issue on the ballot after validating thousands of petition signatures.

For nearly a decade, the Republican legislature has opted against expansion, citing concerns about the federal debt and worries that Congress would eventually cut federal funding for the program. South Dakota Gov. Kristi Noem, a Republican, strongly opposes Medicaid expansion, even though the federal government picks up most of the cost.

To counter the Medicaid ballot initiative, GOP leaders are promoting a separate measure on the June primary ballot that, if passed, would require 60% voter approval for any new constitutional measures that increase taxes or cost the state $10 million or more. It would apply to the Medicaid initiative in November.

South Dakota is one of 12 states that have yet to expand Medicaid to all residents with annual incomes under 138% of the federal poverty level, or about $17,774. In South Dakota, adults without dependent children do not qualify for Medicaid regardless of income level.

Most states accepted the Medicaid expansion quickly after the ACA was implemented in 2014. After Republican lawmakers blocked widening eligibility, voters in Maine, Idaho, Utah, Nebraska, Oklahoma and Missouri approved Medicaid expansion at the ballot box in recent years. Only the Idaho vote scored more than 60% approval.

In the states without Medicaid expansion, collectively more than 2 million Americans are in the so-called coverage gap with incomes too high to qualify for Medicaid but too low to qualify for federal subsidies to help them buy coverage through the ACA insurance marketplaces.

President Joe Biden's Build Back Better legislation would expand federal subsidies to help those in that gap, but the effort has stalled since Sen. Joe Manchin (D-W.Va.) announced last month he would not support the bill. In a Senate evenly split along party lines with universal GOP opposition to the bill, Democrats cannot afford to lose a single vote.

South Dakotans Decide Healthcare, a coalition of patients' groups, health providers, faith leaders, educators and farmers, is leading the initiative to expand Medicaid in the state. The group is following a playbook used elsewhere, emphasizing how Medicaid expansion will bring in millions in federal dollars and help rural hospitals stay in business.

Zach Marcus, the campaign manager for South Dakotans Decide Healthcare, said the group is pushing to defeat the 60% voter threshold ballot initiative. But even if it passes, "if we need it, we are confident we can get to 60% support," he said.

"Medicaid expansion will be an economic driver for South Dakota," he said. "This is a healthcare issue, but it's also a common-sense dollars-and-cents issue."

South Dakota could be the lone state to face a Medicaid ballot initiative this year. Advocates have also targeted Mississippi but must wait for state officials to reinstate the voter initiative process there. An effort to get an initiative before Florida voters is still being evaluated, according to the Fairness Project, which helps organize Medicaid ballot initiatives, including the one in South Dakota. The Fairness Project is funded by the Service Employees International Union-United Healthcare Workers West, a California union.

Voter-backed referendums have helped bypass GOP opposition to Medicaid expansion, but results have varied. For example, as of early last month, 210,000 people had enrolled in Oklahoma while Missouri had added fewer than 20,000, following expansions approved in 2020 in both states. The Nebraska expansion was delayed for nearly two years by state officials after voters approved a ballot measure in 2018.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz