South Dakota passes Amendment D to expand Medicaid
For the 42,500 South Dakotans that fall into a health care coverage gap, the polling on Amendment D, the initiated amendment to expand Medicaid eligibility in the state, fell in their favor.
With 99% of precincts fully reported by 9 a.m. Wednesday morning, 56% of South Dakota voters opted to pass the amendment. The amendment requires the state to provide Medicaid benefits to any person between the ages of 19 and 64 whose annual income is less than $18,000, or "at or below 133% of the federal poverty level, plus 5% of the federal poverty level for the applicable family size," per the ballot pamphlet.
The amendment is now expected to go before Gov. Kristi Noem, who said she plans to honor the will of the voters and sign off on the legislation, according to comments she made during the gubernatorial debate on Sept. 30.
At a private watch party event Tuesday night in Sioux Falls for South Dakotans Decide Healthcare, one of the primary proponents of Amendment D, a small group of regional health care executives and practitioners mingled in the backroom of a brewery as a 98-inch large-screen television carried ever-pivoting coverage of the night's results.
"We're going to stay cautiously optimistic, but we feel good," campaign director Zach Marcus told the Argus Leader early into the ballot count.
The modesty undercut the results of the election, in which the "yes" vote on Amendment D kept a consistent margin of roughly 10% (56% to 44%) throughout the night to the delight of health care movers and shakers like former Avera-McKennan CEO David Kapaska, who told the Argus Leader "South Dakotans deserve this," and Shelly Ten Napel, Community HealthCare Association of the Dakotas.
"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," Ten Napel told the Argus Leader.
Keith Moore, state director of Americans for Prosperity, a libertarian lobbying group and a main opponent to Medicaid expansion, was disappointed but respectful of the result.
"Obviously, the people have spoken," Moore said. "We just hope the legislature and the government puts safeguards on the spending and keeps its promises."
Years of failed attempts preceded a successful Medicaid expansion in South Dakota
Medicaid expansion was first proposed before Americans in the form of the Affordable Care Act, or Obamacare, in 2010. Medicaid coverage was included as a provision in former President Barack Obama's landmark legislation, but the Supreme Court eventually struck down the requirement in 2012, putting the then-federal program under state's jurisdiction.
Randy Jacobson said Medicaid expansion was important to him.
"Too many people are getting hurt and don't get any help. That should never happen," he said. "If we can't help others in this world, what's the world turning into?"— Symmone Gauer (@symmoneagauer) November 8, 2022
Since then, South Dakota has remained as one of 12 hold-outs in Medicaid expansion. Including Washington, D.C., 39 states have expanded Medicaid. Based on previous Argus Leader reporting, Senate Republicans tried to push their own expansion by proposing Senate Bill 186 during the 2022 state legislative session, but the full Senate later rejected the bill.
South Dakota was poised to poll in favor of Medicaid expansion, multiple polls have shown. South Dakota State Univeristy's 2022 South Dakota Election Study showed 53% of South Dakotans approved of Amendment D, while only 20% opposed the ballot measure and 27% remained unsure. Though slightly less in favor, an Emerson College/The Hill poll found 51% of respondents planned to vote yes on Medicaid expansion, followed by 22% for no and 28% for undecided.
Moore, who has directed the opposition of the "no" vote on Amendment D, admitted the unfavorable perspective in a phone call prior to the election results.
"The polling has been more in their favor than ours, but we won't know until we see the results," Moore said at the time.
The cost of the initiated amendment would run the state about $166 million dollars, but it would eventually save South Dakota $162 million over a five-year span, according to a Legislative Research Council fiscal note. Opponents to expansion argue could cause the state to go over-budget in the coming years and leave holes in other sectors, such as education and public safety.
"Right, there's the federal rate that they're going to pay right now, [but] the question is: Do we trust the federal government to continue to pay that rate? As the rate rolls back, it's going to cost us more," Moore said. "What we believe is you'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."
Rural health care is set to benefit largely from Medicaid expansion, proponents argue. According to a 2018 study, Medicaid expansion has been associated with bolstered financial health and the lowered likelihood of closures of rural hospitals and clinics. Data from the Center for Healthcare Quality and Payment Reform shows at least 11 rural hospitals in South Dakota have at least some risk of closure.
"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," Marcus said.
Moore argued, however, Medicaid expansion would actually hurt rural hospitals, because some South Dakotans would be pushed off their free or low-cost health care plans and automatically enrolled into Medicaid, which he said charges less than private insurance.
National Academy for State Health Policy's Hospital Cost Tool shows a number of rural hospitals profit margins attribute their operating profit losses to Medicaid insurance. This includes Sanford Aberdeen Medical Center and Avera St. Lukes, which earn a majority of their income on commercial (private) insurance.
"I know the other side feels like it's gonna help rural hospitals, but when you talk about Medicaid rates and what they can charge, it is substantially lower than what people you know you can charge when people are on private insurance," Moore said.
This article originally appeared on Sioux Falls Argus Leader: South Dakota votes to expand Medicaid after results come in Wednesday
