South Dakota votes to expand Medicaid

Sunday, November 13, 2022

Voters in the US state of South Dakota passed an initiated state constitutional amendment expanding Medicaid Tuesday.

The citizen initiative, Amendment D, will alter the state constitution to make adults younger than 65 and “at or below 133% of the federal poverty level” eligible for the government healthcare program.

The 2010 Affordable Care Act required states to expand Medicaid coverage, but this provision was invalidated by the US Supreme Court two years later. Under that ruling, states are allowed to choose whether to implement the expansion; 39 states and Washington, D.C. already have.

Akeiisa Coleman, the Commonwealth Fund’s senior program officer for Medicaid policy, noted that rural hospitals in states that have pursued the expansion are more likely to remain solvent, because of “more supports to rural providers” from Medicaid. Coleman contrasted this outcome with that in non-expansion states, where uninsurance is more prevalent, leading people to refrain from seeking medical care and often experience worse results.

The Kaiser Family Foundation (KFF) reports that 8% of Americans lack health insurance; that number could increase if the federal COVID-19 public health emergency expires, possibly in early 2023.

In 2020, the South Dakota Department of Social Services found that over 115,000 residents of the state were enrolled in Medicaid, of a population of less than 900,000. According to KFF, 5% of South Dakotans did not have health insurance in 2021.

The South Dakota Senate rejected a bill to expand Medicaid 23-12 in February; Senator John Wiik (R-Big Stone City) contended, “We want the marketplace, not the federal government, to be in charge of your health care.”

The Republican-controlled South Dakota Legislature proposed requiring referendums to earn at least 60% of the vote to pass (instead of 51%), but was rebuffed by voters in June; the change would have taken effect prior to Tuesday’s vote.

Campaign director Zach Marcus of South Dakotans Decide Healthcare, which sponsored Amendment D, said, “Clinics or small rural hospital, you know, the more patients they see that can afford to pay, the better chances are they are they can remain solvent, right? I mean, it really is just that.” Proponents also argued that the amendment would bring South Dakota’s federal taxes back to the state.

“Amendment D will strengthen rural hospitals and clinics and make it easier for people in rural South Dakota to get health care,” Rapid City Mayor Steve Allender and retired entrepreneur Jim Woster said in the proponents’ section of the official ballot question pamphlet.

Meanwhile, the amendment’s opponents created No on Amendment D, chaired by Wiik.

Keith Moore, Americans for Prosperity State Director, argued, “[Y]ou’re either going to have to cut education, cut public safety, you’re going to cut services that you currently have, or you’re going to have to raise taxes.”

Writing the opponents’ section of the pamphlet, Moore said, “Expanding Medicaid shreds our Constitution and expands services to able-bodied adults under ObamaCare.” (Obamacare is a colloquial name for the Affordable Care Act).

Gov. Kristi Noem, a Republican running for reelection, ardently opposed the amendment. On September 30, in a broadcast gubernatorial debate, Noem said it would cover “younger individuals that are single, able-bodied, able to go get a job and a career here in South Dakota and have the potential to earn benefits that would pay their medical bills.”

Noem did say during the debate she would assent to Amendment D if it passed.

A South Dakota State University poll conducted from September 28 to October 11 of 565 registered voters determined that 54% supported Medicaid expansion, 18% opposed it, and 28% were unsure (the margin of error was about 4%). 67% of voters with household incomes less than $75,000 per year approved of the expansion, while only 47% of voters with household incomes over $75,000 per year did. 90% of Democrats, 55% of independents, and 30% of Republicans also backed the amendment.

Political scientist David Wiltse, who managed the poll, explained, “Health care costs are high, especially when you get into the rural areas where you have real issues of access. Anything that can alleviate the costs, anything that can make the process easier for citizens, you’re going to find support.”

Marcus of South Dakotans Decide Healthcare said at a watch party in Sioux Falls, “We’re going to stay cautiously optimistic, but we feel good.”

David Kapaska, the former CEO of Avera-McKinnon David Kapaska, declared, “South Dakotans deserve this.”

The Community HealthCare Association of the Dakotas’s Shelly Ten Napel announced, “For those 42,000 people in that coverage gap, this gives them the opportunity to get the health care they need while filling a missing part of the overall foundation of most rural hospital finances.”

As Amendment D was passing 55% to 45% Wednesday, Moore said, “Obviously, the people have spoken. We just hope the legislature and the government puts safeguards on the spending and keeps its promises.”

The South Dakota Legislative Research Council estimated the amendment would extend healthcare to 42,500 people and cost $1.5 billion over the first five years of implementation, most of which would be paid for by the federal government; South Dakota would spend $166 million and save $162 million.

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