On January 3, 2021, the South Dakota Secretary of State’s office announced that an initiative to expand Medicaid qualified for the November 2022 ballot with 38,244 signatures deemed to be valid. South Dakotans Decide Healthcare reported submitting 47,000 signatures for the initiated constitutional amendment on November 8, 2021. To qualify for the ballot, 33,921 valid signatures were required.
The measure, Constitutional Amendment D, would amend the constitution to require the state to provide Medicaid benefits to adults between 18 and 65 with incomes below 133% of the federal poverty level. Because the Affordable Care Act includes a 5% income disregard, this measure would effectively expand Medicaid to those with incomes at or below 138% of the federal poverty level.
The measure is supported by the South Dakota State Medical Association, South Dakota Nurses Association, South Dakota Education Association, American Lung Association, American Heart Association, American Cancer Society Cancer Action Network, South Dakota AARP, and more.
The Affordable Care Act (ACA), also known as Obamacare, was signed into law on March 23, 2010. The ACA provided for the expansion of Medicaid to cover all individuals earning incomes up to 138 percent of the federal poverty level, which amounted to $17,774 for an individual and $36,570 for a family of four in 2021. The law was designed to provide 100 percent of funding to cover the new recipients for the first three years and to cut off federal Medicaid funding to states that chose not to expand coverage. However, the United States Supreme Court ruled in National Federation of Independent Business v. Sebelius (2012) that the federal government could not withhold Medicaid funds from states that chose not to expand eligibility. According to the Kaiser Family Foundation, this ruling had the practical effect of making Medicaid expansion optional for states.
From 2014 to 2016, the federal government covered 100 percent of the costs of state expansion of Medicaid. In 2017, the total cost of expanded coverage that the federal government financed decreased to 95 percent. The ACA was designed to decrease the amount the federal government covers to 94 percent in 2018, 93 percent in 2019, and 90 percent in 2020 and subsequent years.
The Affordable Care Act had not provided tax credits to adults with household incomes less than the federal poverty line because the law had aimed to cover these people under Medicaid. In states that did not expand Medicaid, many of these adults fell into a coverage gap in which they neither qualified for Medicaid nor for federal tax credits to purchase health insurance. As of 2018, around 2.5 million people fell into this coverage gap across the states that did not expand Medicaid.
To date, 38 states and Washington, D.C., have expanded Medicaid (six through ballot measures) while 12 states had not expanded Medicaid. Of the seven Medicaid expansion measures, six were approved (Maine, Utah, Nebraska, Idaho, Oklahoma, and Missouri) and one (Montana) was defeated. The Montana measure combined Medicaid expansion with a tobacco tax increase.
Constitutional Amendment C will appear on the South Dakota June 7 primary election ballot. The amendment, which was referred to the ballot by the state legislature, would require a three-fifths vote of approval for any ballot measures that increase taxes or fees or that would require the state to appropriate $10 million or more in the first five fiscal years. If Amendment C is approved by voters in June, the Medicaid expansion initiative on the November ballot would need to be approved by 60% of voters. As of 2021, ballot measures in South Dakota required a simple majority vote (50%+1) to be adopted.
A total of 67 measures appeared on statewide ballots from 2000 through 2020 in South Dakota. Of the total, 43% (29 of 67) were approved, and about 57% (38 of 67) were defeated. One measure was approved by voters but subsequently overturned by the courts, and a 2016 measure was approved but then repealed by the state legislature.