GOP Faces Another Red State Blow In Tuesday’s South Dakota Medicaid Expansion Vote

South Dakota voters Tuesday will decide whether to expand Medicaid via ballot initiative in what could be yet another blow to Republicans and their anti-Obamacare health policy.

A vote this week in South Dakota to expand Medicaid under the Affordable Care Act would be seen as the latest setback for Republicans, particularly in the Trump era, given the former President and his party made repealing the law a signature part of their health policy agenda for over a decade.

But Republican-leaning South Dakota is poised to be the sixth successful ballot campaign to expand Medicaid to hundreds of thousands of Americans since Trump took office in 2017.

“It is harder and harder for conservative politicians to stand behind the idea that the [Affordable Care Act] is just one lawsuit away from being repealed or overturned,” says Kelly Hall, the executive director of the Fairness Project, which is working with the ballot initiative’s supporters in South Dakota as part of the effort’s “Yes on D” campaign and has helped other states win Medicaid expansion.

Republicans that include South Dakota Gov. Kristi Noem are opposed to the ACA and the ballot measure, which would expand Medicaid to more than 40,000 in the state.

But the campaign in South Dakota, like other states, has included a bipartisan group of lawmakers, healthcare providers, businesses and unions. In rural states like South Dakota, where hospitals have been hit hard financially during the pandemic, support is broad to expand Medicaid.

In a New York Times story last week on the South Dakota Medicaid expansion vote, a conservative Republican legislator said the effort to broaden coverage “just makes sense.”

“It’s time to get over it,” South Dakota state Rep. Greg Jamison told the Times.

The campaign in South Dakota is the latest momentum to expand Medicaid coverage for the poor under the Affordable Care Act. In 2020, voters in Missouri and Oklahoma approved ballot initiatives to expand Medicaid, following the lead of successful ballot initiatives in 2018 in Nebraska, Idaho and Utah. Those states, like Maine in 2017, bypassed Republican governors and legislatures to expand Medicaid by public referendum.

South Dakota remains just one of only 12 states that has yet to expand Medicaid under the Affordable Care Act.

The expansion of Medicaid benefits under the ACA has come a long way since the U.S. Supreme Court in 2012 gave states a choice in the matter. There were initially only about 20 states that sided with President Barack Obama’s effort to expand the health insurance program for poor Americans.

The 12 holdout states including South Dakota that have yet to expand Medicaid have already missed out on generous federal funding of the Medicaid expansion under the ACA. The Fairness Project estimates passage of the ballot measure in South Dakota alone would “keep $328 million of (federal) tax dollars in-state each year.”

From 2014 through 2016, the ACA’s Medicaid expansion population was funded 100% with federal dollars. The federal government still picked up 90% or more of Medicaid expansion through 2020 and that was a better deal than before the ACA, when Medicaid programs were funded via a much less generous split between state and federal tax dollars.

“If passed, Amendment D would direct the state to expand Medicaid next year to any person aged 18 to 65 with an income up to 133% of the federal poverty level — about $19,000/year for an individual or $39,000/year for a family of four,” the Fairness Project said in a press release issued last week.