SIOUX FALLS, S.D. — Sanford Health's top doctor has some strong medicine for states that have opted not to expand Medicaid, including South Dakota, where the health care organization is based.

Her message: Your decision is killing rural hospitals and clinics.

"Now — not later — is the time for these holdout states to replant and replenish their healthcare resources so desperately needed in rural America," said Sanford Chief Medical Officer Dr. Allison Suttle in a  Sept. 21 column in the publication Modern Healthcare.

Suttle's rebuke is a remarkable one if only for where the company is based. Sanford Health is one of the largest employers in South Dakota, one of the 14 states that have chosen not to expand Medicaid and a place where even a whiff of the term "Medicaid expansion" can poison a policy's chances with some state lawmakers.

Suttle cited a 2018 study in  Health Affairs that linked an increasing number of rural hospital closures in states that haven't expanded Medicaid coverage, but also found such closures slowed quickly after states chose to expand the program.

"In the Upper Midwest, where Sanford Health is based, farmers have to plant their crops as early as possible in the spring because they know it’s a short season before the arrival of snow and bitter cold," she wrote. "Many of the physicians I work with grew up on farms and in small towns that lie within the borders of the states declining the Medicaid expansion. Planning ahead is in our bones, and that sense of urgency and focus should be a priority everywhere."

Suttle, a board-certified obstetrician and gynecologist, cited her own experiences in the column in describing the importance of health insurance coverage and hospitals to rural residents.

"The nonpartisan Medicaid and CHIP Payment and Access Commission has confirmed what should be obvious: Women without health insurance are far less likely to receive adequate prenatal care than women with coverage," she wrote.

States were granted the choice to expand coverage of Medicaid, essentially offering health insurance for a broader range of low-income people, under the Affordable Care Act enacted in 2010. The legislation was built on the concept that all states would expand Medicaid as a solution to cover low-wage earners who might otherwise fall into a coverage gap: making too much money to qualify for Medicaid coverage government assistance but too little money to quality for health insurance premium tax credits.

Most states expanded Medicaid, which is paid for by a mix of federal and state dollars, to cover that gap. And since there's no deadline for expansion, additional states have expanded Medicaid or continued the debate. But as of this writing, 14 states have chosen not to expand the program, for a variety of reasons including concerns about whether it's right to put more people on government support and fears of saddling taxpayers with expensive coverage in the future.

That decision effectively created a gap in coverage for some people, left to choose between having no insurance, altering their life and work to qualify for public assistance or spending a relatively exorbitant amount for health coverage.

About 2.5 million people fall within that coverage gap nationwide, according to  a Kaiser Health News analysis. The majority of those in the coverage gap live in the South, where the majority of holdout states are located. Of that number, 20,000 live in South Dakota, according to the KHN analysis, although other estimates place the number at more than twice that size.

South Dakota has never quite closed the door on the Medicaid expansion discussion, but lawmakers have firmly kept it from opening very wide. Former Gov. Dennis Daugaard proposed expanding Medicaid in 2016, but the state Legislature didn't support the idea. A group has proposed putting Medicaid expansion on the 2020 ballot, but is  not yet circulating petitions according to the Secretary of State's Office.

South Dakota last year requested a federal waiver to require some Medicaid recipients in the state's two most populous counties to work or get more schooling to keep their coverage. The waiver could potentially strip some Medicaid recipients of coverage, said  the Georgetown University Health Policy Institute's Center for Family and Children in June 2018. The waiver has yet to be approved by the Trump administration.

Asked for a response to Suttle's column, South Dakota Gov. Kristi Noem's spokeswoman Kristin Wileman released a statement that highlighted Noem's work to build a stronger state economy and her support for work requirements in existing programs, improved access for women through Medicaid and expanded telehealth options.

"Governor Noem has long said that she does not believe expanding Medicaid is the answer to solving our problems in accessing quality care," Wileman wrote. "Instead, she has worked to push forward consumer-driven alternatives that address the fundamental drivers of rising health care costs."