MOBRIDGE, S.D. -- Sitting in a wheelchair, his navy blue sweatpants covering the stump of his left leg, 76-year-old Burdell Blue Arm proudly shows off the third-place shuffleboard ribbon he won at his nursing home.
It is his first visit from his wife, Dollie, in three weeks -- the first time she has been able to make the 160-mile round-trip drive from their home on the Cheyenne River Indian Reservation.
Theirs is a familiar story for the many families in rural South Dakota whose loved ones are in nursing homes far away.
Like a number of other states, South Dakota banned construction of new nursing homes to cut back on Medicaid spending and encourage the growth of less costly alternatives such as assisted living facilities. As a result, parts of the state have no nursing homes.
The ban hits American Indians especially hard because of their extreme isolation and poverty. Nationally, there are only about 15 nursing homes on reservations, according to Traci McClellan, executive director of the National Indian Council on Aging.
This year, South Dakota's Legislature made the 1988 nursing-home ban permanent after the number of assisted living facilities grew twelvefold over the past 17 years.
While nursing homes offer round-the-clock medical care, assisted living facilities combine less frequent visits from healthcare professionals with other support services, such as food preparation or help with bathing.
The difference in cost is substantial. It can cost up to $50,000 a year for a person in a nursing home, and about half to two-thirds of that for a person in an assisted living home, according to Gail Ferris of the South Dakota Social Services Department.
The ban was aimed at controlling spending on Medicaid, the state-federal program that pays the medical bills of poor people. Ferris said the switch to less expensive options has saved individuals and the state more than $225 million.
The need to hold down Medicaid expenses is especially important in South Dakota because its population is graying. The number of young people dropped off during the 1990s, with many leaving the state for other opportunities, while the percentage of older people increased.
But families like Blue Arm's say they are paying a high cost for the savings.
There is no nursing home on the reservation, and his wife's car is not up to the trip, so she relies on relatives and friends to take her from Eagle Butte to Mobridge and back. As a result, her visits are sporadic.
''I want to stay close to her," Blue Arm said.
State Representative Jim Bradford's family members cared for his mother-in-law on the Pine Ridge Indian Reservation as long as they could. After it became obvious she needed professional care, the family found a place for her in a nursing home in Martin.
But the family finds it difficult to make the 100-mile round trip from Pine Ridge to Martin to visit her. The separation from her friends and family, especially her grandchildren, is taking a terrible toll, the lawmaker said.
''Mentally, she's not good because she feels that she has nothing to live for," he said.
In the Blue Arms' case, at least, there is hope.
In 2003, the state made an exception to the ban by giving permission for a new nursing home in Eagle Butte.
The project will be a pilot for the building of more nursing homes on reservations. Groundbreaking is expected within the next few months.
Blue Arm, who has diabetes and early dementia, said he has dibs on the first bed at the new home.
His family has good reason to want him close. Blue Arm's first stint in a nursing home was in Rapid City, where his wife said the care was so haphazard that another resident once wandered into his room and began urinating on them both.
''All the times I wasn't there, maybe that's what they're doing to him," she said.
Dollie Blue Arm said having her husband in Eagle Butte will allow her to monitor his care and spend her days with him.
''And if I get to that stage, I can move in with him," she said.