Nine nursing homes in the state are considered "critical" to the long-term care for older South Dakotans.

The list includes Lemmon, Martin and Hot Springs and was developed by a task force to the South Dakota Health Care Commission. The health care commission was created in 2003 to establish long-term health care priorities in South Dakota and will report its findings and recommendations to improve access to long-term care to Gov. Mike Rounds by Nov. 1. Legislation in 2009 is possible.

The cities of Lemmon and Martin - both several miles from other nursing home services in South Dakota - are the most notable examples of the challenge largely brought on by geographic isolation.

The nursing homes on the critical list have found themselves there due to geography, primarily. They're small nursing homes, and as most know in South Dakota, small and rural are hardly an equation for outstanding success.

And that's the problem for South Dakota as well as the challenge.

There are 110 nursing facilities in South Dakota. What does putting nine on the list of critical mean exactly? For one, it means those facilities will get some extra attention from the state as the health care commission presents its report to the governor. It could also mean premium Medicaid payments to keep those rural facilities listed as critical operational.

The argument is small nursing homes serve rural populations; keeping nursing home residents in the areas they grew up in and around family. We certainly understand that and wouldn't want our own family members needing nursing home care to be 50 or 100 miles away. And small towns have an interest in keeping their nursing facilities open - it's not simply a business decision, but a community-minded one.

But with the increasing challenges before the state and nursing homes, is it time to rethink that? The state legislature has been coordinating the consolidation of South Dakota's smallest school districts. Should the same logic be applied to the state's smallest nursing homes?

Clearly there's a difference - schools are publicly funded and nursing homes are a private enterprise only supplemented by state Medicaid dollars and federal Medicare dollars. But if the state's smallest schools - the lifeblood of those small communities - are expected to fit into a more profitable mold, is there justification in increasing state funding/attention for other small ventures that face an uncertain future?

And it's a fairly uncertain future. As the baby boomers age, we'd expect to see an increase in need at the state's nursing homes. In fact, we'd be surprised if the state wasn't forced to remove the moratorium on nursing home beds in the next decade. But baby boomers also tend towards healthier lifestyles that may keep them from needing care and we'd expect a handful of private in-home option to be created for the aging population.

Future funding is uncertain, too. The state funding is critical for some nursing homes running primarily on Medicaid. What happens to nursing homes if Medicaid funding decreases? Considering the state's uncertain financial picture, we wouldn't take that too far off the table. And the Bush administration only recently backed off a plan to cut $5 billion over five years in Medicare funding to nursing homes. Federal and state budgets are facing the same issue.

The committee studying health care in South Dakota and making recommendations to the governor has its work cut out for it. Caring for people is expensive business and it comes from the heart. Translating that care into special consideration from the state, and the state budget, is another matter.