– Leslie Wolfname, a registered nurse who works one day a week at the Urban Indian Health clinic here, regularly sees the problems of uninsured American Indians. She watches her bosses trying to eke by on the $800,000 from Indian Health Service that their clinic shares with a similar one in Pierre.

And she sees Indian patients who cannot get the care they need, because their problems are too serious for the small center and they lack the insurance to go elsewhere. These were struggles that some hoped President Obama's health care law would address.

But Wolfname remains uninsured. Even after government subsidies, the $300 it would have cost her family of four to secure insurance through the federal exchange felt like too much, given that she and many other Indians are accustomed to free health care on reservations. "I know I've got to have health insurance," said Wolfname. "I know it, but … it's hard because I've never had to pay for it."

Nine months after Obama's health care law expanded medical coverage for millions of people, the promised benefits are slow to reach some Indians, who already face disproportionately high rates of obesity, diabetes and mental health problems.

The reasons are both political and historical — and the stakes are particularly high in South Dakota, where Indians lead the nation in poverty.

Long-standing federal treaties guarantee free health care through Indian Health Services, but that is generally contained to government-run hospitals on the reservation, where services are limited and where less than a quarter of Indians in the U.S. still live. Many, such as Wolfname, lack the money or are culturally resistant to paying the additional cost of insurance through the federal exchange.

South Dakota is also one of 23 states that rejected an expansion of Medicaid, after a Supreme Court ruling in 2012 put the decision into the hands of individual states.

Republican Gov. Dennis Daugaard, like most governors who opposed enlarging the program, cited concerns that the federal government might not live up to promises to cover the cost of the expansion and said he didn't want the state to be stuck with the bill.

An expansion would have provided free Medicaid coverage to an additional 14,000 low-income Indians in South Dakota, and given a financial boost to struggling Indian health facilities.

Before the federal insurance exchange began enrolling people last fall, half of South Dakota Indians between ages 18 and 64 lacked insurance. The state doesn't track who has signed up for Obamacare. But according to two of the three companies offering health insurance here through the exchange, just 3 percent to 3.5 percent of enrollees were Indian, in a state where 9 percent of the population is Indian.

As of March, just .3 percent of people nationwide who enrolled in the federal insurance exchange were Indian — about one-fifth their overall population.

Skepticism runs deep

"Going through Obamacare?" asked Mike Salcedo, a member of the Yankton Sioux. He doesn't have health insurance and works part-time doing landscaping and handling livestock at rodeos. "I heard … that it wasn't really all that great, that it's not worth the paper it's printed on."

He was among dozens of needy people in Sioux Falls, many of them Indian, streaming into The Banquet ministry on a recent evening for a free meal of roast beef, pineapple, potatoes and carrots. Many grew up on Pine Ridge Reservation, the second poorest place in America.

Often barely employed, usually without insurance, they told of shunning the Indian health clinic in the city because of a minimum $25 co-pay. Instead, some said, they drive 45 minutes north to pick up medications at a tribal-run facility in Flandreau, though that hospital won't see patients for more serious matters unless they are a Flandreau Santee Sioux tribal member.

Many Indians also travel 110 miles southwest along rural roads to the Indian Health Service Hospital on the Yankton Sioux reservation in Wagner. There, in front of a squat brick building, the parking lot is full. People stream in and out, clutching bags of medications. One-fifth of the patients are from Sioux Falls.

Facilities like this, after years of the federal government underfunding Indian Health Services, are advocating for more Indians to secure insurance. Indians receive special privileges to sign up: They never have to make co-pays, just monthly premiums, and unlike other groups they are not subject to a financial penalty for lacking insurance.

The waiting room is a testament to that push. By enrolling in the federal exchange, "you have better access to services that the Indian Health Service, tribal programs, or urban Indian programs may not provide," one poster says, while a TV screen offers more details.

Inside, one of the few takers was Wagner resident Jessica Sanchez, who hobbled through the door of the hospital with an injured foot. She signed up for a high-deductible health plan with Sanford through the exchange after learning through her employer that she could gain it for free through a federal subsidy.

Now Sanchez can access muscle spasm medication that the Indian hospital didn't have, and she doesn't have to worry anymore that the agency will deny her claims for more serious conditions.

She realizes many of the patients who come in, even if they work, don't have coverage of their own. "There's hardly anybody around that offers insurance," Sanchez said.

Geographic disparities

Only 3 percent of the people who have signed up in the Dakotas are Indian, according to Sanford Health, one of three providers of insurance to South Dakotans who sign up through the federal exchange. The company is also the sole insurer for the program in North Dakota.

"We saw very, very little education in South and North Dakota," said Ruth Krystopolski, executive vice president for care innovation at Sanford Health. "There's a lot of geography to cover, and not a strong way to disseminate information out to each of the tribal areas.

Differing state decisions on Medicaid have furthered the confusion.

If some South Dakota Indians moved just over the border to Minnesota or North Dakota, they could likely qualify for those states' newly expanded Medicaid programs for people making up to 138 percent of the poverty line at no extra cost to them — illustrating new geographic inequalities in the ways Indians access health care.

That problem was reinforced in research last year by the Kaiser Family Foundation, a nonprofit that studies health issues and noted that different state decisions about Medicaid would foster disparities in the medical coverage available to tribal members.

For instance, Jessica Siers likely could have qualified for Medicaid if she moved a half-hour east from Sioux Falls into Minnesota. Instead, the uninsured member of the Oglala Lakota tribe walked into the emergency room at Sanford Medical Center this spring and racked up more than $10,000 in still unpaid bills for a heart condition. She still isn't sure how she'll get an angiogram recommended by a Sanford doctor.

Nicole Culbert, a federal health care navigator who met with Siers, voiced frustration that South Dakota's decision not to expand Medicaid was leaving some Indians behind.

"They're not getting any help," said Culbert, a benefits coordinator at Urban Indian Health in Sioux Falls. "And there's nothing we can do except watch people suffer with diseases that can be treated if we could just expand health care."