by Cassandra Jaramillo, Jeremy Kohler and Sophie Chou, ProPublica, and Jessica Kegu, CBS News

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published. This story was reported in partnership with CBS News.

Year after year, while Roe v. Wade was the law of the land, Texas legislators passed measures limiting access to abortion — who could have one, how and where. And with the same cadence, they added millions of dollars to a program designed to discourage people from terminating pregnancies.

Their budget infusions for the Alternatives to Abortion program grew with almost every legislative session — first gradually, then dramatically — from $5 million starting in 2005 to $140 million after the U.S. Supreme Court overturned the right to an abortion.

Now that abortion is largely illegal in Texas, lawmakers say they have shifted the purpose of the program, and its millions of dollars, to supporting families affected by the state’s ban.

In the words of Rep. Jeff Leach, a Republican from Plano, the goal is to “provide the full support and resources of the state government … to come alongside of these thousands of women and their families who might find themselves with unexpected, unplanned pregnancies.”

But an investigation by ProPublica and CBS News found that the system that funnels a growing pot of state money to anti-abortion nonprofits has few safeguards and is riddled with waste.

Officials with the Health and Human Services Commission, which oversees the program, don’t know the specifics of how tens of millions of taxpayer dollars are being spent or whether that money is addressing families’ needs.

In some cases, taxpayers are paying these groups to distribute goods they obtained for free, allowing anti-abortion centers — which are often called “crisis pregnancy centers” and may be set up to look like clinics that perform abortions — to bill $14 to hand out a couple of donated diapers.

Distributing a single pamphlet can net the same $14 fee. The state has paid the charities millions to distribute such “educational materials” about topics including parenting and adoption; it can’t say exactly how many millions because it doesn’t collect data on the goods it’s paying for. State officials declined to provide examples of the materials by publication time, and reporters who visited pregnancy centers were turned away.

Funding for Texas’ Anti-Abortion Program Has Skyrocketed

As they restricted access to abortion, lawmakers also poured money into a program that was first called Alternatives to Abortion and recently rebranded as Thriving Texas Families. The program funds counseling, baby items and brochures, but not medical care.

Note: Data represents the amounts budgeted for Alternatives to Abortion, now called Thriving Texas Families, for each two-year budget period, including amendments made in that period. Sources: Alternatives to Abortion annual reports and the 2024-25 Texas budget bill (Lucas Waldron/ProPublica)

For years, Texas officials have failed to ensure spending is proper or productive.

They didn’t conduct an audit of the program in the wake of revelations in 2021 that a subcontractor had used taxpayer funds to operate a smoke shop and to buy land for hemp production.

They ramped up funding to the program in 2022 even after some contractors failed to meet their few targets for success.

After a legislative mandate passed in 2023, lawmakers ordered the commission to set up a system to measure the performance and impact of the program.

One year later, Health and Human Services says it’s “working to implement the provisions of the law.” Agency spokespeople answered some questions but declined interview requests. They said their main contractor, Texas Pregnancy Care Network, was responsible for most program oversight.

The nonprofit network receives the most funding of the program’s four contractors and oversees dozens of crisis pregnancy centers, faith-based groups and other charities that serve as subcontractors.

The network’s executive director, Nicole Neeley, said those subcontractors have broad freedom over how they spend revenue from the state. For example, they can save it or use it for building renovations.

Pregnancy Center of the Coastal Bend in Corpus Christi, for instance, built up a $1.6 million surplus from 2020 to 2022. Executive Director Jana Pinson said two years ago that she plans to use state funds to build a new facility. She did not respond to requests for comment. A ProPublica reporter visited the waterfront plot where that facility was planned and found an empty lot.

Because subcontractors are paid set fees for their services, Neeley said, “what they do with the dollars in their bank accounts is not connected” to the Thriving Texas Families program. “It is no longer taxpayer money.”

The state said those funds are, in fact, taxpayer money. “HHSC takes stewardship of taxpayer dollars, appropriated by the Legislature, very seriously by ensuring they are used for their intended purpose,” a spokesperson said.

None of that has caused lawmakers to stop the cash from flowing. In fact, last year they blocked requirements to ensure certain services were evidence-based.

Leach, one of the program’s most ardent supporters, said in an interview with ProPublica and CBS News that he would seek accountability “if taxpayer dollars aren’t being spent appropriately.” But he remained confident about the program, saying the state would keep investing in it. In fact, he said, “We’re going to double down.”

What’s more, lawmakers around the country are considering programs modeled on Alternatives to Abortion.

Last year, Tennessee lawmakers directed $20 million to fund crisis pregnancy centers and similar nonprofits. And Florida enacted a 6-week abortion ban while including in the same bill a $25 million allocation to support crisis pregnancy centers. John McNamara, a longtime leader of Texas Pregnancy Care Network, has been working to start similar networks in Kansas, Oklahoma and Iowa. He’s also reserved the name Louisiana Pregnancy Care Network.

And U.S. House Republicans are advocating for allowing federal dollars from the Temporary Assistance for Needy Families program — intended to help low-income families — to flow to pregnancy centers. In January, the House passed the legislation, and it is pending in the Senate. Rep. Elise Stefanik, R-N.Y., castigated Democrats for voting against the bill.

“That’s taking away diapers, that’s taking away resources from families who are in need,” she said in an interview with CBS News after the vote.

But, as Texas shows, more funding doesn’t necessarily pay for more diapers, formula or other support for families.

Lawmakers rebranded Alternatives to Abortion as Thriving Texas Families in 2023. The program is supposed to promote pregnancies, encourage family formation and increase economic self-sufficiency.

The state pays four contractors to run the program. The largest, which gets about 80% of the state funding, is the anti-abortion group Texas Pregnancy Care Network.

Human Coalition, which gets about 16% of the state funding, said it uses the money to provide clients with material goods, counseling, referrals to government assistance and education. Austin LifeCare, which gets about 3% of the state funding, could not be reached for comment about this story. Longview Wellness Center in East Texas, which receives less than 1% of the funds, said the state routinely audits its expenses to ensure it’s operating within guidelines.

Texas Pregnancy Care Network manages dozens of subcontractors that provide counseling and parenting classes and that distribute material aid such as diapers and formula. Parents must take a class or undergo counseling before they can get those goods.

The state can be charged $14 each time one of these subcontractors distributes items from one of several categories, including food, clothing and educational materials. That means the distribution of a couple of educational pamphlets could net the same $14 fee as a much pricier pack of diapers.

A single visit by a client to a subcontractor can result in multiple charges stacking up. Centers are eligible to collect the fees regardless of how many items are distributed or how much they are worth. One April morning, a client at McAllen Pregnancy Center, near the Texas-Mexico border, received a bag with some diapers, a baby outfit, a baby blanket, a pack of wipes, a baby brush, a snack and two pamphlets. It was not clear how much the center invoiced for these items.

McAllen Pregnancy Center and other Texas Pregnancy Care Network subcontractors were paid more than $54 million from 2021 to 2023 for distributing these items, according to records.

How much of that was for handing out pamphlets? The state said it didn’t know; it doesn’t collect data on the quantities or types of items provided to clients or whether they are essential items like diapers or just pamphlets, making it impossible for the public to know how tax dollars were spent.

Neeley said in an email that educational materials like pamphlets only accounted for 12% of the money reimbursed in this category last year, or roughly $2.4 million out of $20 million. She did not respond to questions from ProPublica and CBS News about evidence that would corroborate that number.

The way subcontractors are paid, and what they’re allowed to do with that money, raised questions among charity experts consulted for this investigation.

In the nonprofit sector, using a fee-for-service payment model for material assistance is highly unusual, said Vincent Francisco, a professor at the University of Kansas who has worked as a nonprofit administrator, evaluator and consultant over the past three decades. It “can run fast and loose if you’re not careful,” he said.

Even if nonprofits distribute items they got for free or close to it, the state will still reimburse them. Take Viola’s House, a pregnancy center and maternity home in Dallas. Records show that it pays a nearby diaper bank an administrative fee of $1,590 for about 120,000 diapers annually — just over a penny apiece. Viola’s House can then bill the state $14 for distributing a pack of diapers that cost the center just over a quarter.

But before they can get those diapers, parents must take a class. The center can also bill the state $30 for each hour of class a client attends.

Rep. Donna Howard, a Democrat from Austin, said the program could be more efficient if the state funded the diaper banks directly. Last year, she proposed diverting 2% of Thriving Texas Families’ funding directly to diaper banks, but the proposal failed.

Records show that in fiscal year 2023, Viola’s House received more than $1 million from the state in reimbursements for material support and educational items plus another $1.7 million for classes. Executive Director Thana Hickman-Simmons said Viola’s House relies on funding from an array of sources and that just a small fraction of the diapers it distributes come from the diaper bank. She said the state money “could never cover everything that we do.”

In some cases, reimbursements have created a hefty cushion in the budgets of subcontractors. The state doesn’t require them to spend the taxpayer funds they get on needy families, and Texas Pregnancy Care Network said subcontractors can spend the money as they see fit, as long as they follow Internal Revenue Service rules for nonprofits.

McAllen Pregnancy Center received $3.5 million in taxpayer money from Texas Pregnancy Care Network over three years, but it spent less than $1 million on program services, according to annual returns it filed with the IRS. Meanwhile, $2.1 million was added to the group’s assets, mostly in cash. Its executive director, Angie Arviso, asked a reporter who visited in person to submit questions in writing, but she never responded.

Texas Taxpayers Gave One Crisis Pregnancy Center $3.5 Million Over Three Years. It Spent Less Than $1 Million on Programs.

The nonprofit McAllen Pregnancy Center is a case study showing how anti-abortion centers can amass a surplus from the Alternatives to Abortion program, which is now called Thriving Texas Families

Note: Figures are rounded to the nearest thousand. Sources: McAllen Pregnancy Center Form 990 for 2020, 2021 and 2022, and Texas Health and Human Services Commission records obtained by ProPublica and CBS News. (Lucas Waldron/ProPublica)

“This is a policy choice Texas has made,” said Samuel Brunson, associate dean for faculty research and development at the Loyola University Chicago School of Law, who researches and writes about the federal income tax and nonprofit organizations. “It has chosen to redistribute money from taxpayers to the reserve funds of private nonprofit organizations.”

Tax experts say that’s problematic. “Why would you give money to a recipient that is not spending it?” said Ge Bai, a professor of accounting and health policy at Johns Hopkins University.

The tax experts disagree with Texas Pregnancy Care Network’s argument that the money is no longer taxpayer dollars after its subcontractors are paid.

“It’s still the government buying something,” said Jason Coupet, associate professor of public management and policy at Georgia State University, who has studied efficiency in the public and nonprofit sectors. “If I were in the auditor’s office, that’s where I would start having questions.”

State legislators and regulators haven’t installed oversight protections in the program.

Three years ago, The Texas Tribune spotlighted the state’s refusal to track outcomes or seek insight into how subcontractors have spent taxpayer money.

Months later, Texas Pregnancy Care Network cut off funding to one of its biggest subcontractors after a San Antonio news outlet alleged the nonprofit had misspent money from the state.

KSAT-TV reported that the nonprofit, A New Life for a New Generation, had used Alternatives to Abortion funds for vacations and a motorcycle, and to fund a smoke shop business owned by the center’s president and CEO, Marquica Reed. It also spent $25,000 on land that was later registered by a member of Reed’s family to produce industrial hemp.

In an interview with ProPublica, a former case manager recalled how Reed would get angry if employees forgot to bill the state for a service provided to a client.

The former case manager, Bridgett Warren Campbell, said employees would buy diapers from the local Sam’s Club store, then take apart the packages. “We’d take the diapers out and give parents two to three diapers at a time, then she would bill TPCN,” said Campbell.

Reed declined to comment to a ProPublica reporter or to answer follow-up questions via email or text. Neeley, the Texas Pregnancy Care Network’s executive director, said the pregnancy center was removed from the program because its nonprofit status was in jeopardy, not because it had used money on personal spending. She said the network wasn’t responsible for monitoring how A New Life for a New Generation spent its dollars: “The power to investigate these matters of how nonprofits manage their own funds is reserved statutorily to the Texas Attorney General and the IRS.”

The Texas attorney general’s office would not say whether it has investigated the organization. Records show that after KSAT’s story, state officials referred the case to an inspector general and that the Texas Pregnancy Care Network submitted a report detailing how it monitored the subcontractor.

The state requires contractors to submit independent financial audits if they receive at least $750,000 in state money; Texas Pregnancy Care Network meets this threshold. However, its dozens of subcontractors don’t have to submit these audits — something experts in nonprofit practices said should be required. In the fiscal year before the alleged misspending came to light, A New Life for a New Generation received more than $1 million in reimbursements from the state, records show.

When ProPublica and CBS News asked how the Health and Human Services Commission detects fraud or misuse of taxpayer funds, Jennifer Ruffcorn, a commission spokesperson, said the agency “performs oversight through various methods, which may include fiscal, programmatic, and administrative monitoring, enhanced monitoring, desk reviews, financial reconciliations, on-site visits, and training and technical assistance.”

Through a spokesperson, Rob Ries, the deputy executive commissioner who oversees the program at Health and Human Services, declined to be interviewed.

The agency has never thoroughly evaluated the effectiveness of the program’s services in its nearly 20 years of existence.

It is supposed to make sure its contractors are meeting a few benchmarks: how many clients each one serves and how many they have referred to Medicaid and the Nurse-Family Partnership, a program that sends nurses to the homes of low-income first-time mothers and has been proven to reduce maternal deaths. The Nurse-Family Partnership does not receive Alternatives to Abortion funding.

In 2022, the Texas Pregnancy Care Network failed to meet two of three key benchmarks in its contract with the state: It didn’t serve enough clients and it didn’t refer enough of them to the nursing program. The state didn’t withhold or reduce its funding. McNamara disputed the first claim, saying the state changed its methodology for counting clients, and said the other benchmark was difficult to hit because too few clients qualified for the nursing program.

In May 2023, when lawmakers passed the bill rebranding the program, the state also ordered the agency to “identify indicators to measure the performance outcomes,” “require periodic reporting” and hire an outside party to conduct impact evaluations.

The agency declined to share details about its progress on those requirements except to say that it is soliciting for impact evaluation services. Records show the agency has requested bids.

Lawmakers decided last year against enacting requirements that would ensure certain services were evidence-based — proven by research to meet their goals — instead siding with an argument that they would be too onerous for smaller nonprofits.

Texas’ six-week abortion ban took effect in 2021, and more than 16,000 additional babies were born in the state the following year. Academics expect that trend to continue.

But the safety net for parents and babies is paper thin.

Texas has the lowest rate of insured women of reproductive age in the country and ranks above the national average for maternal deaths. It’s last in giving cash assistance to families living beneath the poverty line.

Mothers told reporters they are struggling to scrape together enough diapers and wipes to keep their babies clean. A San Antonio diaper bank has hundreds of families on its waitlist. Outside an Austin food pantry, lines snake around the block.

Howard, the Austin state representative, said ProPublica and CBS News’ findings show that the program needs more oversight. “It is unconscionable that a [Thriving Texas Families] provider would be allowed to keep millions in reserve when there is a tremendous need for more investment in access to health care services,” she said.

Do you have any tips on state-funded anti-abortion programs? Cassandra Jaramillo can be reached by email at cassandra.jaramillo@propublica.org or by Signal at 469-606-9665.

Caroline Chen and Kavitha Surana contributed reporting.

This post was originally published on ProPublica.

by T. Christian Miller

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In 2020, Congress passed the No Surprises Act to protect patients from exorbitant medical bills that had burdened Americans with tens of thousands of dollars in debt. The law was designed to decrease the charges for patients treated by an out-of-network doctor during medical emergencies. Such ER visits often left people vulnerable to so-called surprise bills, in which their insurer would only pay a portion of the expensive treatment.

One of the biggest health care reforms since Obamacare, the No Surprises Act appears to have worked in one important sense. Patients have reported fewer crippling bills. Although little hard data exists, an insurance industry survey found that consumers avoided some 10 million surprise bills in the first nine months of 2023. A think tank report also suggests that people are paying less for the care they receive in the ER and other medical situations covered by the law, such as air ambulance trips.

But a cumbersome government system to resolve payment disputes between doctors and insurers now threatens to undermine the law’s promise, according to interviews with industry players, recent data analyses and government documents.

One potential outcome: higher insurance premiums for everyone.

Another: fewer physicians available to treat rural populations.

Doctors said that insurance companies have been abusing the system to lower payments, stiff medical practices and kick physicians out of their networks.

“I’m trying to think of a polite word to describe the experience, but it has been just chaotic and inefficient,” said Dr. Andrea Brault, the head of the Emergency Department Practice Management Association, a physicians’ trade group. “It’s a costly, lengthy process.”

Insurers, however, charged that big physician groups — some of them owned by private equity investors — are trying to manipulate the process to squeeze out higher payments. “A small but significant number of bad actors” have flooded the system with cases “as a way to maximize revenue,” said Kelly Parsons, a spokesperson for the Blue Cross Blue Shield Association. “Should this trend continue, health care costs are likely to rise unnecessarily.”

An official at the Centers for Medicare & Medicaid Services said the rising number of disputes was a byproduct of the law’s success.

“The No Surprises Act is protecting millions of patients from surprise medical bills when they experience an emergency or get care from an out-of-network provider at an in-network facility,” said Jeff Wu, the deputy director of policy of CMS’ Center for Consumer Information and Insurance Oversight. “The incredibly large volume of disputes submitted since the law’s surprise billing protections became effective demonstrates the need for this law.”

For decades, private insurance customers had to worry about receiving giant bills from using out-of-network doctors, who typically charge more for services. This was especially true when they had to go to an emergency room, where people have little ability to choose which doctor or hospital to treat them. The No Surprises Act aimed to fix the problem by protecting ER patients so that they would get billed essentially the same as if they received care from in-network physicians and hospitals.

The law radically changed the dynamics of billing disputes. “Before the No Surprises Act, you had doctors and physicians fighting, with patients stuck in the middle. Now you just have doctors and insurers fighting,” said Zack Cooper, a professor of public health and economics at Yale whose research helped shape the law.

Under the law, out-of-network doctors or hospitals invoice insurers, which counter with their own offer. Some 80% of claims are resolved this way, according to the survey conducted by the insurance trade groups.

But when the two sides can’t agree, they go to battle in a system created by the CMS and other government agencies. There, an independent arbiter weighs various factors and determines the final payment amount. This arbitration is at the heart of many of the law’s unintended consequences.

Originally, the government estimated there would be about 17,000 cases a year. But in 2023, almost 680,000 were filed, according to data released in June. The result is an enormous backlog that has slowed payments to doctors, hospitals and medical groups. Decisions are supposed to take 30 days. Since 2022, however, more than half of the cases remain unresolved. Some have lasted more than nine months. Wu said that arbiters have “scaled up their operations” to reduce the delays.

In addition, the law has been challenged repeatedly in court — health care provider associations and air ambulance groups have filed nearly 20 lawsuits involving the No Surprises Act, according to legal experts at the O’Neill Institute for National and Global Health Law. Two cases have overturned the initial CMS guidelines governing the arbitration. The agency has been forced to make numerous adjustments to the process that have contributed to the long delays.

The most heated debate over the dispute system surrounds the payment and enforcement of arbiters’ decisions.

Federal health officials at first thought that the law would help lower the cost of medical care. Instead, arbiters have awarded higher amounts to doctors and other providers than expected — potentially driving up insurance premiums.

“The most likely outcome is that this law doesn’t save consumers on net and potentially pushes in the opposite direction,” said Loren Adler, a researcher at the Center on Health Policy at Brookings, which issued a recent study on the possibility.

While the amounts are higher than expected, they remain lower than what doctors’ groups have billed. Doctors charge that insurance companies are submitting artificially low payment amounts. As proof, they point to data from June that shows arbiters rule in favor of doctors the vast majority of the time.

Still, overall, providers have seen nearly a 40% decrease in reimbursements since the law took effect in 2022, according to a recent survey by the emergency physicians trade group. At least one doctors’ group, Envision Healthcare, mentioned the No Surprises Act as one of the reasons it filed for bankruptcy. (The company has since emerged from court oversight.)

If revenue decreases continue, some doctors’ groups may have to cut back on services. This would most likely be felt in rural hospitals, which often operate with thin profit margins and already have difficulty recruiting ER doctors. “This is threatening to the sustainability of many, many practices,” said Randy Pilgrim, the enterprise chief medical officer for SCP Health, which provides doctors to emergency rooms across the country. “There have been few practices in the over 30 states where we operate that haven’t been affected by this.”

Doctors have also said that insurance companies are making late or incomplete payments after decisions by the arbiter. Complaints to CMS have been ignored, doctors said. Wu, the CMS official, said the agency actively investigates complaints under its jurisdiction.

It is also not clear whether courts can force an insurance company to pay. Pilgrim said his company had submitted almost 75,000 letters to insurance companies pleading for reimbursements after winning an arbitration decision.

“There’s very little teeth” in the process, he said. “You just continue to plead your case and hope you get somewhere.”

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by Jessica Lussenhop

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Last month, former President Donald Trump announced he would not pursue a federal abortion ban, as many of his supporters hoped, and he criticized states with bans that make no exception for rape or incest.

Gov. Kristi Noem of South Dakota, who at the time was on a short list of candidates to become Trump’s pick for vice president, responded immediately. Even though her state’s ban has neither exception and is considered one of the strictest in the country, Noem highlighted the parts of Trump’s message that she agreed with and sidestepped the rest.

“.@realDonaldTrump is exactly right… this is about ‘precious babies.’ It should be easier for moms, dads, and families to have babies — not harder,” she wrote on X following Trump’s announcement. “South Dakota is proud to stand for LIFE and support babies, moms, and families.”

But some state lawmakers, health care advocates and political observers in South Dakota say that Noem does not always follow through on that rhetorical promise. Since she became the first female governor of South Dakota in 2019, she has rejected programs and millions of dollars in federal funds that would have benefited pregnant people, parents and children — policies that might be at odds with her vision of limited government.

That Noem doesn’t always follow through on her talk is an oft-repeated criticism, said Jon Schaff, a political science professor at Northern State University in Aberdeen, South Dakota, who put it another way: Noem, he said, is “all hat and no cattle.”

“You look like a cowboy, but you’re not one,” Schaff said of the well-worn phrase. “I think there’s been a sense that she’s maybe overly concerned about sort of the imagery of politics rather than the substance.”

Much of that criticism has been eclipsed by the fallout from Noem’s memoir, “No Going Back,” in which she provides an account of shooting and killing a pet hunting dog called Cricket two decades ago. Still, Noem has pitched herself as a governor, rancher and mom passionate about family values and a second Trump presidency. For his part, Trump has not yet publicly eliminated her as a potential running mate, so her record on taking “care of moms and their babies both before birth and after” bears examination.

Noem’s Record

Noem’s office declined to comment, saying responses from state agencies were sufficient. But her record does, in fact, include measures that support families. In 2020, she helped create the first paid family leave policy for state employees, and she expanded it last year from eight to 12 weeks. She extended the length of time that people in prison can spend with their newborns in a “mother-infant program” from 1 month to 30 months. And she expanded a program called Bright Start, which pairs nurses with first-time parents, to cover the entire state with a $2.5 million budget increase.

In a statement, a spokesperson for the South Dakota Department of Health wrote that Noem is “committed to freedom for life” and pointed to a recently launched mobile health clinic called Wellness on Wheels, which provides services to rural communities such as connections with federal Women, Infants and Children benefits and pregnancy risk assessments. Over half the state counties are defined as a maternal care desert.

“DOH programs like Bright Start, Wellness on Wheels, WIC, pregnancy care and many more support this initiative in ensuring our future generations are healthy and strong,” the statement said.

Abortion

At times, Noem has tried to put distance between herself and the state’s abortion ban, which was put in place by a trigger law that was passed before she took office. The ban only allows the procedure to “preserve the life of the pregnant female.” But she has not embraced opportunities to add exceptions to the ban’s language, even after calls to do so from within her own party.

Three female Republican lawmakers attempted to enact legislation to add “risk of death or of a substantial and irreversible physical impairment of … major bodily functions” to the permissible circumstances for an abortion. Rep. Taylor Rehfeldt, Sen. Sydney Davis and Sen. Erin Tobin — all registered nurses who identify as pro-life — met several times with Noem staffers as they tried to build support for the measure, and they believed they had Noem’s support. But as opposition emerged from anti-abortion advocates, principally South Dakota Right to Life, Noem did not help. Rehfeldt withdrew the bill.

“I never got an official statement from her office,” Rehfeldt said. “But I will tell you that there was consensus, and then all of a sudden there wasn’t.”

In the next legislative session, Rehfeldt brought a new bill that mandated that the Department of Health and the state attorney general create an educational video intended to clarify — but not change — the ban’s language; Noem signed that one in March. Susan B. Anthony Pro-Life America released a statement thanking Noem “for making South Dakota the first state to protect women’s lives with a Med Ed law.”

Medicaid Expansion

Maternal and infant health outcomes are particularly alarming in the state’s Native American population. About 44% of all pregnancy-associated deaths from 2012 to 2021 were Native Americans and Alaska Natives. In 2023, more than 3% of all Native American babies born in South Dakota had syphilis, part of an unprecedented modern outbreak.

One component of the problem is the chronically underfunded Indian Health Service hospitals and clinics, which are overseen by the federal government. If South Dakota expanded eligibility for its Medicaid program, as 39 other states and the District of Columbia have done, it would infuse IHS facilities with badly needed additional money from newly covered patients.

“That may be like a job position for a new doctor or salary for a dentist,” said Janelle Cantrell, head of the Medicaid and health care exchange enrollment program at Great Plains Tribal Leaders’ Health Board in Rapid City, South Dakota.

But Noem has opposed and delayed expansion. In 2022, South Dakota voters took the decision out of her hands by approving a ballot initiative for Medicaid expansion. According to state Rep. Linda Duba, a Democrat, Noem has dragged her feet on the expansion, which has resulted in far fewer residents enrolling than expected. At the same time, Noem supports adding a work requirement to Medicaid eligibility, which is popular among GOP governors.

“There’s nothing proactive going on,” Duba said. “That comes from the administration. They didn’t want Medicaid expansion. They’re doing everything they can to slow-walk it and keep the enrollments down.”

Department of Social Services Cabinet Secretary Matt Althoff said in a statement that Medicaid expansion enrollment is going “efficiently and smoothly,” and that he expects a monthly average of 40,000 enrollees a month in the next fiscal year. He pointed to the state’s low unemployment rate and rising per capita personal income as an explanation for below-expected enrollment.

Early Childhood

South Dakota has no state-funded preschool program. Noem’s administration declined to apply for $7.5 million in federal money to pay for a free summer meal program for low-income children, something several GOP governors have also done. She also helped defeat proposals to pay for school lunches for eligible students and once called subsidized child care a “line in the sand” she wouldn’t cross.

“I just don’t think it’s the government’s job to pay or to raise people’s children for them,” she said in a radio interview in December 2023.

Some of Noem’s own initiatives have fallen flat. A pledge to eliminate the state’s 4.5% grocery tax, a full sales tax on all food items that only South Dakota and Mississippi charge, was a cornerstone of her 2022 reelection campaign. Repealing the tax, she said, would help “single moms who may rent an apartment and have a tough time feeding their kids with the rising food costs that we have.”

But the bill to repeal the tax failed to pass one of its first committee hearings, despite the Legislature’s Republican supermajority.

“It is amazing to me how much of a national profile that Kristi Noem has, in some ways not being all that successful in terms of achieving legislative agendas,” said state Sen. Reynold F. Nesiba, a Democrat and the chamber’s minority leader.

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