South Dakota Voters to Decide Medicaid Expansion

South Dakota voters will decide in November whether the state should become the 39th to expand Medicaid under the Affordable Care Act (ACA), a move that would provide coverage to 42,000 low-income residents.

State officials on Monday officially placed the issue on the ballot after validating thousands of petition signatures.

For nearly a decade, the Republican legislature has opted against expansion, citing concerns about the federal debt and worries that Congress would eventually cut federal funding for the program. South Dakota Gov Kristi Noem, a Republican, strongly opposes Medicaid expansion, even though the federal government picks up most of the cost.

To counter the Medicaid ballot initiative, GOP leaders are promoting a separate measure on the June primary ballot that, if passed, would require 60% voter approval for any new constitutional measures that increase taxes or cost the state $10 million or more. It would apply to the Medicaid initiative in November.

South Dakota is one of 12 states that have yet to expand Medicaid to all residents with annual incomes under 138% of the federal poverty level, or about $17,774. In South Dakota, adults without dependent children do not qualify for Medicaid regardless of income level.

Most states accepted the Medicaid expansion quickly after the ACA was implemented in 2014. After Republican lawmakers blocked widening eligibility, voters in Maine, Idaho, Utah, Nebraska, Oklahoma, and Missouri approved Medicaid expansion at the ballot box in recent years. Only the Idaho vote scored more than 60% approval.

In the states without Medicaid expansion, collectively more than 2 million Americans are in the so-called coverage gap with incomes too high to qualify for Medicaid but too low to qualify for federal subsidies to help them buy coverage through the ACA insurance marketplaces.

President Joe Biden’s Build Back Better legislation would expand federal subsidies to help those in that gap, but the effort has stalled since Sen Joe Manchin (D-WVa) announced last month he would not support the bill. In a Senate evenly split along party lines with universal GOP opposition to the bill, Democrats cannot afford to lose a single vote.

South Dakotans Decide Healthcare, a coalition of patients’ groups, health providers, faith leaders, educators, and farmers, is leading the initiative to expand Medicaid in the state. The group is following a playbook used elsewhere, emphasizing how Medicaid expansion will bring in millions in federal dollars and help rural hospitals stay in business.

Zach Marcus, the campaign manager for South Dakotans Decide Healthcare, said the group is pushing to defeat the 60% voter threshold ballot initiative. But even if it passes, “if we need it, we are confident we can get to 60% support,” he said.

“Medicaid expansion will be an economic driver for South Dakota,” he said. “This is a health care issue, but it’s also a common-sense dollars-and-cents issue.”

South Dakota could be the lone state to face a Medicaid ballot initiative this year. Advocates have also targeted Mississippi but must wait for state officials to reinstate the voter initiative process there. An effort to get an initiative before Florida voters is still being evaluated, according to the Fairness Project, which helps organize Medicaid ballot initiatives, including the one in South Dakota. The Fairness Project is funded by the Service Employees International Union-United Healthcare Workers West, a California union.

Voter-backed referendums have helped bypass GOP opposition to Medicaid expansion, but results have varied. For example, as of early last month, 210,000 people had enrolled in Oklahoma while Missouri had added fewer than 20,000, following expansions approved in 2020 in both states. The Nebraska expansion was delayed for nearly two years by state officials after voters approved a ballot measure in 2018.