RAPID CITY, S.D. — South Dakota is one of 14 states that has not expanded Medicaid under the Affordable Care Act, a move that would improve healthcare services for the state's large American Indian population, according to one expert.

Nurse Margaret Moss has spent 30 years researching and educating the public about the health of indigenous people. South Dakota has the fourth-largest percentage of Native Americans in the U.S., with rates of death from heart disease, diabetes, pneumonia and other causes that are significantly higher than non-Hispanic whites. And Moss said the numbers have been static for three decades.

"People think American Indians are the past, they're not around anymore,” Moss said. “And if you don't have a very good understanding or view of the history or politics, or culture of American Indians in a state, then you're not going to vote for things."

Gov. Dennis Daugaard appointed a coalition four years ago with the goal of improving healthcare for American Indians. But opposition from fellow GOP lawmakers led him to decide against applying for Medicaid expansion, and the coalition was disbanded last month.

In South Dakota, 36 percent of the 50,000 state residents who would qualify for expanded Medicaid are Native Americans. The state's Argus Leader newspaper recently reported the median life expectancy for Native Americans in South Dakota is 21 years shorter than the state average.

Moss said a huge obstacle for improving healthcare is patient misidentification, which is higher for American Indians than any other group.

"So, if the numbers are all wrong, we don't even really know what are the true death rates, what are the true cancer rates, or admission rates, access rates,” she said. “We don't know a whole lot because nobody asks, or they guess."

In the 1800s, the U.S. government promised to provide health services for tribes in exchange for their land. But Moss said the federal Indian Health Service is chronically underfunded. She noted there are now 573 federally recognized U.S. tribes. But when addressing policymakers, she's found few are familiar with their own state's demographics.

"'Do you know the tribes that are there, and what are they, and whatever?' And no one ever knows!” Moss said. “I said, if you don't know that, how can I even get to the intricacies of their specific problems."

The Indian Health Service is one of several agencies affected by the current government shutdown.


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Montana's 69th legislative session begins today and advocates for the state's Native population will be at the Capitol, tracking bills ranging from paid sick leave to Indian language and education.

Two key issues the Indigenous advocacy organization Western Native Voice will focus on this session are health care and voting access. A bill to ensure every reservation has a satellite voting office failed in 2021.

Keaton Sunchild, director of government and political relations for the organization, said the Native American Voting Rights Act will be brought again this year. He pointed out long distances and difficulty registering with tribal IDs are some of the biggest barriers Native Americans face in voting.

"For me, living in Great Falls, it's a five-minute drive at most to the elections office if something went wrong," observed. "For somebody living on the Fort Peck reservation, that could be a two-hour drive, one-way."

In 2024, Montana's Supreme Court ruled two voting bills were unconstitutional and disproportionately affected Native people. One would have ended Election Day registration and the second would have outlawed paid, third-party ballot assistance.

Sunchild noted health bills he will be tracking include requiring paid sick leave, the right to contraception and vitally, the status of Montana's Medicaid expansion, which is set to expire in June, unless lawmakers renew it.

"Making sure, at the end of the day, that Native communities and American Indians living off reservations are not harmed by any policies put in place," Sunchild emphasized.

The state's American Indian population has made up 20% of Medicaid expansion enrollment since 2016, according to the Montana Healthcare Foundation.

Funding for the Indian Health Service has increased over the past decade but the agency remains underfunded, which affects both the health and culture of South Dakota tribes.

In 2021, the life expectancy of a Native American or Alaska Native in the U.S. was just over 65 years. That's 11 years less than non-Hispanic white people, and the biggest gap since 1940.

Damon Leader Charge, director of tribal outreach for the Sanford School of Medicine at the University of South Dakota and former Tribal Health Administrator for the Rosebud Sioux Tribe said the Indian Health Service must provide health care for Native people but noted in a panel discussion care can be hard to get.

He noted people in his tribe who want to use the Indian Health Service to give birth have to travel 90 miles to Pine Ridge.

"We're not having our babies within our tribal homelands," Leader Charge pointed out. "If our young parents don't have those type of teachings, in terms of maternal child health, that baby -- that Wakanyeja, that sacred being -- is going to really start off on the wrong foot."

Indian Health Service funding has increased 68% over the past decade, but experts said it is still too low. In 2017, spending per capita was less than half the spending for veterans and less than one-third for Medicare, according to the National Council of Urban Indian Health.

DenYelle Kenyon, associate dean of community health and engagement at the University of South Dakota, said the problems are multipronged, so the solutions must be, too.

"In our state, the tribal lands have a 'double whammy' of facing both the historical piece and being rural," Kenyon observed. "We really need to not only grow the hospitals and the providers, but approach this from that health equity lens."

She stressed it means looking at social determinants of health, which include other qualities of life that relate to health like access to healthy food, and educational and economic opportunities.


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By Amy Felegy for Arts Midwest.
Broadcast version by Judith Ruiz-Branch for Wisconsin News Connection reporting for the Arts Midwest-Public News Service Collaboration

Patty Loew attended five screenings of a new film this year. She wasn't joining box office masses at Wicked or Inside Out 2, but Bad River: A Story of Defiance.

The independent documentary, directed by Mary Mazzio and released in March, drew in masses of its own. AMC Theatres put it up on select big screens across the United States. Peacock started streaming it last month.

The documentary highlights longstanding issues facing the Bad River Band of Lake Superior Chippewa in northern Wisconsin. Loew 'Waswaagonokwe' (Torch Light on the Water Woman) is a citizen.

She and other Band members are interviewed in the film, which explores tragic boarding school histories and how members of the Band have faced violence and racism.

The documentary heavily focuses on the Line 5 dispute between the Band and Canadian energy company Enbridge. Loew, who recently retired as director of the Center for Native American and Indigenous Research at Northwestern University (among many other titles), addresses it in the film.

"My little tribe is standing up and saying, 'We're protecting the water, not just for us. We're protecting water for the planet.'"

Behind the Struggle

As it stands, 12 miles of a crude oil and natural gas pipeline run through Bad River land, constructed in 1953. In 2017, Bad River's tribal council voted against renewing the company's rights to use their land. It led to years of protests and activism when Enbridge refused to leave. Last summer, a federal judge gave Enbridge three years to shut down the pipeline on the reservation.

That reservation includes just under 40 miles of Lake Superior shoreline, thousands of wetland acres, and hundreds of miles of streams, rivers, and tributaries.

The documentary shows its beauty. Think grandiose drone shots and stunning water imagery.

"Bad River is where I go when I need my batteries recharged, when I need time to reflect, when I just need to get back in touch with things that make me happy," Loew says.

Last month, the Wisconsin Department of Natural Resources issued construction permits for Line 5 to reroute 41 miles south of the reservation and exit Bad River lands by 2026.

But Loew and other Band members who are interviewed in the film say that isn't enough to protect Mashiiziibii land and nearby areas from a potential pipeline burst. They want it shut down.

Enbridge lawyers and the U.S. government say they can't, citing a 1977 energy treaty with the Canadian government. But Bad River citizens say Ojibwe treaties, which established reservations and land rights, predate that by over 100 years.

"If such a rupture were to occur, nearly one million gallons of oil would spill into the river, flowing into Lake Superior and devastating the wild rice beds and fishing populations central to the Band's way of life," stated 30 Midwestern Native Nations in a letter to the White House in February.

There have been over 20 spills along the Line 5's 645-mile route since 1968, including over 14,000 gallons in Bad River land in 1972.

Despite the continued debate, Loew has hope.

"The right thing will eventually happen," she says.

"I think everyone-whether you live in a red or a blue state, or whether you are Native or non-Native-[wants] clean water and clean air, not just for themselves, but for their children and grandchildren."


Amy Felegy wrote this story for Arts Midwest.


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