SIOUX FALLS, S.D. — At 19, Samson Mettler told his family's doctor in Sioux Falls he was transgender, opening up two paths: one a legal process, the other health care.

"Oh, that sucked," Mettler said, about coaxing a legal system — particularly in a red state — to acknowledge his gender identity.

Nevertheless, he started down the road.

Mettler drove 25 miles to the county seat in Canton, S.D., to face a judge. He took out an advertisement in the local newspaper — as per state law — to publicize his name change. He even had a county employee hang up on him when seeking an amended birth certificate.

But he never had doubts about his health care.

That's because Mettler's doctor worked for Sanford Health.

"I think as far as health care systems go," Mettler said, "Sanford is pretty progressive."

A growing dread — befitting the head-whipping partisanship of the modern U.S. — has laced recent public debate over Sioux Falls-based Sanford's plans to merge by the start of summer with Minneapolis-headquartered Fairview.

The marrying of leading health institutions — one super-charged by a philanthropist, another powered by the University of Minnesota's teaching hospital — has laid bare political differences between two states. While they share a prairie border, they are separated by an ideological chasm when it comes to health care access for women and transgender youth.

Some Minnesotans worry their health care could be under the thumb of the Dakotas, where lawmakers and a firebrand governor have pushed prohibitions on reproductive and gender-affirming care.

"As a citizen of the state of Minnesota, I do not have the ability to vote [in South Dakota]," said Jessica Rosenberg, a Fairview nurse at the St. Paul listening session, suggesting she had no power to sway politicians who've voted to ban abortion or gender-affirming care.

But the perception of Sanford is much different in its home state, where it's an often depended-upon source, amid political attacks, for gender-affirming and women's health care — including emergency abortions, albeit within the state's narrow parameters.

The health system is huge. With 24 hospitals and nearly 450 clinics across 220,000 square miles, much in the Republican-dominated Dakotas, Sanford is the nation's largest nonprofit rural provider.

South Dakota and Minnesota have long been cantankerous siblings, with South Dakota playing the more sparsely populated and occasionally cowboy-hatted cousin across Minnesota's southwestern border. But largely, the state's demographics resemble Minnesota's: lots of Scandinavian Lutherans in church basements, diehard fans of the Vikings and Twins, and increasingly diverse, according to U.S. Census data.

But last summer's ruling from the U.S. Supreme Court in Dobbs vs. Jackson Women's Health exposed the political differences between neighboring states. The high court ruling triggered a ban in South Dakota rendering abortion illegal except to save a mother's life. On Feb. 13, Gov. Kristi Noem signed a law banning puberty blockers and sex-affirmation surgeries, often used to treat gender dysphoria, in minors.

In Minnesota, Democratic Gov. Tim Walz signed an act codifying access to abortion in Minnesota with few, if any, legal barriers. Notably, the state's DFL-controlled Legislature is considering protecting transgender youth receiving health care in Minnesota from custody orders in other states.

Both types of care are rare in hospitals, officials say. According to the Minnesota Department of Health, only 156 of the more than 10,000 abortions in Minnesota in 2021 occurred in a hospital. In 2020, a doctor with Sanford, testifying before a South Dakota Senate committee, reported that only 19 minors sought gender-affirming care the year prior in South Dakota.

Still, the hyper-charged political environment has galvanized Fairview and Sanford leaders to assuage concerns about compromised care.

Sanford CEO Bill Gassen told a legislative hearing in St. Paul last month that doctor and patient decisions will remain locally controlled.

"The proposed merger will not result in fewer options for gender-affirming care and comprehensive women's health care including abortion care," he said.

Nevertheless, Rep. Zack Stephenson, DFL-Coon Rapids, who chaired the hearing, remained unconvinced that South Dakota's elected leaders wouldn't animate a new system, headquartered in Sioux Falls.

"This is really concerning to me, that a major health care provider in Minnesota would be so exposed to the South Dakota Legislature's whims," Stephenson told the Star Tribune. Pressed on what another state's Legislature could do, Stephenson pointed to a so-called Texas-style bounty abortion bill that deputizes citizens to sue care providers across state lines. "I don't think it's far-fetched."

The legal rationale of how a neighboring state might control health care access in another state is dubious, according to experts.

Jill Hasday, professor at the University of Minnesota Law School specializing in constitutional law, acknowledged "controversy rages" about states where abortion has been banned seeking legal avenues to prosecute doctors in states with legalized access to reproductive care.

"In all likelihood, the issue will ultimately be fought out in the courts," Hasday said.

Recently in an interview with South Dakota News Watch, Attorney General Marty Jackley floated prosecuting Minnesota practitioners for providing medication abortion to South Dakota residents — even if delivered and picked up in Minnesota.

A spokesman for Jackley said the attorney general stands by his comments.

Still, political observers say, these jurisdictional fights over abortion would be happening with or without a merger. Moreover, in the statehouse in Pierre, S.D., where Republicans hold a 94 to 11 seat advantage, Sanford Health has sometimes been at odds with the Legislature, particularly as a caucus of social conservatives picks fights with Sanford in public.

A year ago, the South Dakota House approved a bill prohibiting employers — including Sanford — from requiring COVID-19 vaccinations for its workforce. The bill died in a Senate committee, but only after facing a slew of health care industry opponents.

In November, 56% of South Dakota voters approved expanding Medicaid — sealing a popular plank of the Affordable Care Act and bucking the state's GOP leadership — largely behind a public campaign funded, in part, by Sanford.

But Sanford's stances have come with political consequences.

This winter, when a scheduled gender summit at Sanford drew publicity in right-wing media, officials in the Noem administration cancelled a federal grant for the Transformation Project, a Sioux Falls-based transgender youth rights group that was co-sponsoring the event.

A state health official sent a letter to the Transformation Project declaring they'd failed to make quarterly reports. In a statement to the website the Daily Signal Noem's spokesman Ian Fury said, "South Dakota does not support this organization's efforts, and state government should not be participating in them."

Susan Williams, executive director of the Transformation Project, which is suing Noem over the canceled funding, defended the event, saying, "Sanford medical teams have provided transgender individuals in South Dakota with exceptional care for years."

On Jan. 13, the Midwest Gender Identity Summit at Sanford went forward, but picketers lined the roadway.

Days later in Pierre, Rep. Bethany Soye, R-Sioux Falls, introduced a bill to ban gender therapies, including surgery, for minors. She called out the health giant in her backyard.

"We have had attempts in the past to do similar legislation," Soye told the Washington Watch with Tony Perkins program. "But there wasn't as much in the media ... So the argument was, 'Oh, it's not happening in South Dakota.' But now, you really can't deny, because Sanford is being so up front with what they're doing."

Soye did not respond to requests for interviews.

The bill sailed through both legislative chambers and was signed Monday by Noem. Sanford did not speak against the bill during hearings but provided written opposition to the committees, noting that studies have that shown the lack of puberty-delaying treatments can "lead to increased mental health concerns, gender dysphoria, and suicides" for youth.

Michael Card, University of South Dakota political science professor, suggested the Medicaid campaign may have limited Sanford's lobbying power this session in Pierre.

"I suspect that Sanford's support for Medicaid expansion may not be the best situation for needing something from the Legislature," Card said.

Both Williams and a Sanford spokesperson said it's too early to discuss plans for a future summit.

Regardless, Sanford Health will continue to walk a tight-rope, trying to appease two ideologically different legislatures as it presses for this merger, and long after the deal is done.

Mettler said he was initially "dead-named" — a term describing being referred to by one's former name — at Sanford. But that ended when Sanford implemented a new system, putting "Samson" atop his medical chart.

"Honestly, the whole process was pretty good for me," he said.

But he paused when asked about the implications for fellow transgender people in a combined system.

"It would be good for South Dakota to be linked," he said, noting the combined system's economic and cultural vitality for Sioux Falls might give Sanford leverage over lawmakers hostile to transgender rights. "But maybe bad for Minnesota if those laws still pass."