Demographics, Geography, Economy

South Dakota traverses over 75,000 square miles in the upper Midwest and is one of the United States’ most rural and frontier geographic areas. SD is home to diverse landscape that is divided into east and west by the Missouri River. There are 882,235 living in SD with an average population density of 10.7 people per square mile. Of SD’s 66 counties, 30 are rural and 34 are frontier (less than 6 people per sq. mile). The states’ two most populated counties are located on opposite sides of the state. There are nine federally recognized American Indian tribes within the SD borders.

The state's population by race and Hispanic origin is 84.4% White, 9% American Indian (AI), 2.4% Black, 1.7% Asian, 2.4% Two or More Races and 4.1% Hispanic or Latino. The population by sex is 49.5% female and 50.5% male. Just under 25% of the state’s population are persons under the age of 18, with 7% of persons under 5 years of age. Approximately 37% of the state’s female population is of childbearing age, 15 through 44.

South Dakota’s median household income is $56,499. Nearly 13% of SD households live below 100% of the Federal Poverty Level (FPL), with the 10 poorest counties either part of or adjacent to SD’s AI reservations. Reservations experience significantly higher poverty levels ranging from 22.3%-48.6%. Almost 12% of persons under 65 years of age lack health insurance. In addition, 91.7% of persons aged 25 years and older are high school graduates or higher and 28.5% have a bachelor’s degree or higher.  Key industries that shape SD’s economy include agriculture, mining, finance, manufacturing, and tourism.

The state of SD has administrative rules for services provided within the Children’s Special Health Services (CSHS) program, the state’s recognized name for the CYSHCN program. The rules outline eligibility requirements including income level and the chronic conditions that may or may not be covered. They also outline the types of treatment services that may be financially covered and the process by which the CSHS program reimburses families and healthcare providers for these services. South Dakota Codified Law 34-24-17 to 34-24-25 mandates newborn screening and while Administrative Rules of SD 44:19 specifies what diseases and conditions are required for screening. 

Strengths and Challenges

South Dakota possesses unique strengths and challenges that impact the health status of its MCH population. Specifically, SD is home to a growing healthcare industry that supports its MCH population. The states healthcare industry is projected to be among the largest growth industries from 2012-2022. This industry is projected to add 7,305 workers to SD's economy (from a level of 52,875 in 2012 to a level of 60,180 in 2022). The rate of growth is projected to be 13.8%, nearly double the 7.0% growth projected in total employment for all industries. 

This growth in the healthcare industry is significant because as baby boomers retire and leave the healthcare workforce, they are subsequently aging, requiring additional healthcare services. A focus has been placed on high school graduates who can replace the retirees in the workforce and continue to provide quality healthcare services across the state. The SD Departments of Education, Health, Labor and Regulation, and the SD Board of Regents have created a program to address this critical need for healthcare workers.  Health Occupations for Today and Tomorrow focuses on health career information and opportunities for SD students at all grade levels. The South Dakota Healthcare Workforce Center established within the Office of Rural Health (ORH) functions as a clearinghouse for healthcare workforce-related data and information. The Center is also designed to develop and implement programs and projects that assist individuals, agencies, and facilities in their efforts to address current and projected workforce needs. ORH also works to improve the delivery of health services to rural and medically underserved communities, emphasizing access.

Despite the growth in the healthcare industry and strategies to address the healthcare workforce, SD residents are challenged by the limited access to healthcare. Approximately two-thirds of the state is designated by the federal government as a Health Professional Shortage Area (HPSA). Health care provider shortages exist in primary care, dental health, and mental health. There are also 71 Medically Underserved Areas/Populations (MUA/P), including a shortage of primary care health services across the state. As of June 4, 2019, there were 4,442 physicians and 654 physician assistants licensed in SD. In addition, there were 1,140 actively licensed nurse practitioners and 34 actively licensed nurse midwives. 

Another challenge facing SD’s MCH population is a lack of transportation to access services and resources. This is compounded by factors such as poverty and geographic isolation. For some, this means traveling great distances (over 50 miles) to see a primary care provider and even further to see a specialist. Most healthcare specialists and the state’s lone children's hospital is located on the eastern side of the state. This adds additional travel and expense for families of children in the central and western regions of the state which can be as much as 400 miles away. Access to services and resources is further complicated on AI reservations by the lack of a reliable transportation system. 

The MCH program continues to identify strategies to address these challenges such as marketing program services to reach all eligible populations, recruiting and retaining adequately trained/prepared individuals to meet workforce needs (especially in remote counties and reservation communities), being responsive to populations with different cultures and beliefs,  impacting social media, and improving access to dental and mental health services.

Roles, Responsibilities and Targeted Interests of State Health Agency

In December 2019, the DOH released its 2020-2025 Strategic Plan. The strategic plan provides a road map for the future and helps staff work together as a department to achieve meaningful outcomes. The plan is not designed to be a compilation of all DOH programs and services but instead helps identify new things to be accomplished as well as reflect key strategic initiatives the DOH is doing today and will continue in the future.

The DOH’s 2020-2025 Strategic Plan envisions “every South Dakotan healthy and strong”, with the mission of “working together to promote, protect, and improve health”.  The guiding principles of the DOH include serve with integrity, respect and compassion; focus on evidence-based prevention and outcomes; support data-driven innovation; achieve health equity in all communities; demonstrate proactive leadership and strengthen partnerships; and exhibit transparency and accountability.

The strategic plan addresses the following goals:

• Goal 1: Enhance the accessibility, quality, and effective use of health resources.
• Goal 2: Provide services to improve public health.
• Goal 3: Plan, prepare, and respond to public health threats.
• Goal 4: Maximize partnerships to address underlying factors that determine overall health.
• Goal 5: Strengthen and support a qualified workforce.

Each goal has objectives and key strategies to help guide DOH activities. There are also 13 key performance indicators that will be tracked to allow the DOH to monitor progress towards these goals. More information about the plan can be found at http://doh.sd.gov/strategicplan/.

The DOH also remains committed to providing comprehensive public health services and programs for and with underserved populations and communities throughout the state. Much of the state is designated as a HPSA and is therefore underserved.

The DOH’s centralized organizational structure delivers public health services across the state through 76 local community health offices. A wide array of public health services is provided including interpreter services, direct services, and outreach services provided by WIC, Title X Family Planning, and the Bright Start Home Visiting program. Community health staff provide infant safe sleep education, health and safety information, growth and development screening, prenatal education, immunizations, school nurse services, modified case management for high risk pregnant moms, postpartum care and support services for families with funding from and coordination with the MCH block grant. These offices are under the leadership of the Title V administrator and provide an avenue to gather input in program development as well as during program evaluation. A few examples of the communities that community health offices serve include the 54 Hutterite colonies throughout the state, the refugee resettlement of the Burmese Karen populations in the Huron and Aberdeen areas, and the expanding urbanization of Sioux Falls.

The DOH remains committed to fostering relationships with both Indian Health Service (IHS) staff and statewide tribal government/tribal health to identify opportunities to support MCH services on SD Indian reservations. The DOH has supported several tribal initiatives, such as the Project LAUNCH grant and Tribal MIECHV grants, by providing letters of support and community advisory board commitments. These partnerships are in place with the Sisseton Wahpeton Oyate MCH program, as well as Great Plains Tribal Chairmen’s Health Board on behalf of the Rosebud Sioux Tribe and Sisseton Wahpeton Oyate.

South Dakota Systems of Care

According to federally available data, the MCH Block Grant in SD aims to serve approximately 11,000 pregnant women, 12,000 infants, 253,000 children and adolescents age 1 through 21, and 45,000 children and youth with special health care needs. SD has 49 general community hospitals, of which 38 are critical access hospitals and 32 provide routine obstetrical services. There are five federally qualified health centers (FQHCs) and 60 rural health clinics. There are also five IHS hospitals in SD, of which only two provide routine obstetrical services. SD has one children’s hospital located on the East side of the state and 125 general pediatricians and approximately 75 subspecialists to serve the MCH population.

The Departments of Health and Social Services continue to prioritize and focus on social needs and behavioral health services integration. The OCFS is the outreach arm and community presence of the DOH and works closely with DSS programs that support health, social needs and behavioral health including Medicaid, Temporary Assistance for Needy Families (TANF) and the Supplemental Nutrition Assistance Program (SNAP).  These programs work directly with the 76 community health offices that administer WIC program and the Bright Start home visiting program. These programs are also forging new partnerships and services to address behavioral health needs as an emerging issue within the state.

An average of 116,000 South Dakotans relies on Medicaid for their healthcare each month. The vast majority, 68%, are children. Half of the children born in SD each year will be on Medicaid during their first year of life and 35% of all Medicaid recipients are American Indian (SD Medicaid). Medicaid eligibility for FY20 includes pregnant women at 138% FPL; children under 6 at 182% FPL, children age 6-19 at 116% FPL, parent/caregiver/relatives of low-income children at 52% FPL; CHIP (Children’s Health Insurance Program) at 209% FPL. Twelve percent of women of childbearing age are not insured by public or private insurance and 10 % of children under 200% FPL are uninsured (U.S. Census Bureau, ACS and Kaiser Family Foundation).