Voters in South Dakota to decide on Medicaid expansion to low-income residents in midterms

South Dakota voters on Tuesday are weighing whether to expand Medicaid health insurance to tens of thousands of low-income residents through a constitutional amendment.

If Constitutional Amendment D is approved by a majority vote, it would remove South Dakota from a list of 12 states that have not expanded eligibility for the government health insurance program to people earning up to 138% of the federal poverty level — currently about $18,800 for an individual or $38,300 for a family of four.

The Republican-controlled Legislature has declined to expand Medicaid eligibility under the 2010 federal Affordable Care Act, and Gov. Kristi Noem has opposed the idea. But proponents for expansion have found success through ballot measures across GOP-dominated states, and a wide coalition of health care groups and organizations backed a well-funded ballot campaign this year in South Dakota.

‘We’re a farm community, and people just can’t afford insurance so they need some more help,’ said Bob Pederson, a Sioux Falls retiree who voted to expand eligibility Tuesday.

Dave Melemseter, also voting in Sioux Falls, said he backed expansion even though he worried it would weigh heavily on the state budget. Melemseter — who like Pederson said he usually votes Republican — said it was important for people to have coverage.

‘I think it will pass and I think six years down the road, we’re going to be stuck with a really big bill,’ he said.

Once a proposition that was anathema to conservatives, its passage would be a sign of growing acceptance even in a deeply red state.

By amending the state Constitution, voters would also place Medicaid expansion outside the grasp of the Legislature. Roughly 40,000 people would become eligible for Medicaid.

A coalition of health care groups, including the state’s largest hospital systems, initiated the ballot campaign. It has also won support from organizations that range across the political spectrum, from the state Chamber of Commerce to the South Dakota Farmers Union, religious organizations and progressive groups.

Advocates for expansion say that Medicaid access would help low-income people who could be saddled with exorbitant hospital bills, while also allowing the state’s citizens to tap into over $1 billion in federal funds.

They have run ads that feature working-class people like farmers and hairstylists talking about their need for health care coverage.

The campaign has branded the amendment as a financial ‘deal’ for South Dakota. The federal government pays 90% of costs under a 2021 federal COVID-19 relief package, so the state would receive $1.3 billion in federal funding over five years for expansion. The state’s share over that time would be $166.2 million, but would also result in $162.5 million in savings, according to the Legislature’s research division.

But some Republican lawmakers have argued that the constitutional amendment would create a liability in South Dakota’s small state budget.

Groups like American for Prosperity, a free-market lobbying organization, also argue that Medicaid is a wasteful program and discourages people from seeking jobs where they can get private insurance.

In an effort to head off the Medicaid expansion vote, Republican lawmakers had proposed a separate constitutional amendment in this year’s primary election that would have required a 60% vote threshold on ballot measures that raise taxes or spend significant government funds. That proposal was overwhelmingly rejected by voters.

Noem, who is likely to win the governor’s post again, has said she is not in favor of expanding Medicaid but committed to implementing it if it passes.