South Dakota voters will decide in November whether the state should become the 39th to expand Medicaid underneath the Affordable Care Act, a move that will provide coverage to 42,000 low-income residents.
State officials on Monday officially placed the problem around 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 that program. South dakota Gov. Kristi Noem, a Republican, strongly opposes Medicaid expansion, although the authorities accumulates the majority 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 just about any new constitutional measures that increase taxes or cost the state $10 million or more. It might affect the Medicaid initiative in November.
South Dakota is among 12 states that have yet to grow Medicaid to any or all residents with annual incomes under 138% from the federal poverty level, or about $17,774. In South dakota, adults without dependent children do not qualify for Medicaid no matter income level.
Most states accepted the Medicaid expansion quickly after the ACA was implemented in 2022. 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 a lot more than 60% approval.
In the states without Medicaid expansion, collectively more than Two million Americans are in the so-called coverage gap with incomes excessive to qualify for Medicaid but too low to be eligible for a 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 who work in that gap, but the effort has stalled since Sen. Joe Manchin (D-W.Va.) announced last month he'd not offer the bill. In a Senate evenly split along party lines with universal GOP opposition to the bill, Democrats can't afford to get rid of just one 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 remain 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 when it passes, “if we want it, we're confident we are able to get to 60% support,” he said.
“Medicaid expansion will be a fiscal driver for South Dakota,” he said. “This is a health care issue, but it's additionally a common-sense dollars-and-cents issue.”
South Dakota may be the lone state to face a Medicaid ballot initiative this year. Advocates also have 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, based on the Fairness Project, which will help organize Medicaid ballot initiatives, including the one out of South dakota. The Fairness Project is funded through 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 2022 in both states. The Nebraska expansion was delayed for pretty much 2 yrs by state officials after voters approved a ballot measure in 2022.
Phil Galewitz:
pgalewitz@kff.org,
@philgalewitz
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