South Dakotans voted to expand Medicaid under the Affordable Care Act on Tuesday, providing tens of thousands of impoverished people with access to health care and dismissing state GOP attempts to sink the effort.
With 56% of the vote, the successful ballot initiative should practically ensure that more than 40,000 people gain access to the program when it takes effect in July. Many would not have had access to health care otherwise.
For residents like Sarah Houska, the decision is life-changing. In the summer of 2021, she had to leave a job that provided health insurance to care for her 5-year-old son, who needed intensive medical care.
Although she has since taken a part-time job at a dental office, Houska, 29, said she lives with the worry that if she develops any health problems, her family could lose stability.
"It felt so great, just so much relief, so much pride in our state for passing this amendment," Houska said Wednesday. "And it wasn't close. I wasn't biting my nails waiting for the vote to come in at all."
The ballot measure amended the state constitution to enshrine expansion for Medicaid health care coverage to all adults who earn up to 138% of the federal poverty level.
Previously, an adult with two kids would have had to make less than $10,590 a year to qualify for the public health care program, according to the Center on Budget and Policy Priorities, a progressive think tank. Now a family of three earning up to $31,780 would be eligible.
Eliot Fishman, the senior director of health policy for the health care advocacy group Families USA, said that in South Dakota parents with practically any work income were ineligible for Medicaid. Those who were not parents and lived without incomes, typically people with significant health, mental health or substance abuse challenges, also did not qualify.
"In a state like South Dakota, Medicaid coverage is going to be particularly important for people in manual labor and undercompensated roles in their substantial agricultural sector, and then the large uninsured population on Indian reservations," Fishman said.
To push through the measure, advocates organized a broad coalition that included the state Chamber of Commerce, farming and ranching groups, first responders and others. It took over two years, because advocates first pursued the process in South Dakota in October 2020.
Zach Marcus, the campaign manager for South Dakotans Decide Healthcare, said that there was some nervousness on Election Day but that supporters remained confident voters would push it through.
"Fairly early in the night, it seemed quite likely that we were going to win, but obviously, it takes time to count votes, and you never want to get ahead of yourself," he said.
It was not an easy journey for supporters. Opponents of expansion tried to undermine the effort by pushing through their own ballot measure, which would have increased the voter approval threshold to 60%. South Dakotans voted the idea down in June.
Republican governors and legislatures in numerous states have remained resistant to expanding Medicaid since the Supreme Court ruled in 2012 that a state’s participation in that part of the Affordable Care Act was optional. In response, progressive advocates in states like Missouri, Oklahoma, Idaho, Nebraska, Utah and Maine used the ballot initiative process to leapfrog partisan legislatures and speak directly to voters.
The Fairness Project is a national group that has helped local advocates push through progressive policies via ballot initiatives. Kelly Hall, its executive director, said that it started polling in South Dakota more than two years ago and that the results were not promising initially compared to the results of efforts in states like Missouri or Oklahoma.
"South Dakota has felt like the most challenging of the Medicaid expansion fights that we've taken on, and a lot of things could have gone wrong along the way," she said, lauding the coalition her group and others built to get the measure passed.
Hall said, however, that there is still work to be done to ensure state leaders implement the program.
Some Republican lawmakers have tried to put up roadblocks in other states despite measures' success. Last year, Missouri Republicans blocked funds after voters supported expansion. Utah Republicans shrank expansion in 2019 after an initiative passed, and GOP lawmakers in Idaho also tried to roll back an initiative vote.
South Dakota Gov. Kirsti Noem, a Republican overwhelmingly elected to another four-year term Tuesday, opposed expansion, but she said in a debate before the election that she would not go against voters' decision.
Noem's office did not respond to a request for comment.
"I do hope that she would enforce it if that's what the people chose," Houska said.
Despite the success of ballot measures to expand Medicaid nationwide, South Dakota is likely to be the final state where health care activists will be able to pursue such an effort. Only three of the 11 remaining states that have not expanded Medicaid have ballot initiative processes: Florida, Mississippi and Wyoming.
While there is hope for success in Florida and Wyoming, conditions in those states make it very difficult to push expansion through. The Mississippi Supreme Court, meanwhile, has ruled the state's initiative process to be unconstitutional, and the Legislature has yet to try to fix it.
Hall said her organization is likely to pursue other ballot measures to address health care issues, such as the one that just passed in Arizona, which capped interest rates on medical debt. Medicaid expansion, however, would not remain its focus.
There is hope in other states that legislatures might elect to pass expansion independently. President Joe Biden tried to make it more enticing by boosting federal matching funds through the American Rescue Plan Act.
Robin Rudowitz, the director of the Program on Medicaid and the Uninsured at the Kaiser Family Foundation, said there were some reasons for optimism.
"Wyoming came really close in their legislative session. And Kansas and Wisconsin governors, who have continued to support expansion, re-upped the issue. And similarly, North Carolina, there’s ongoing debate about expansion," she said. "So there were a few states that definitely restarted discussions."