South Dakota’s Journey to Medicaid Expansion: An Update 

South Dakota is still on track to close its Medicaid coverage gap.

Voters in the state are set to decide whether to expand Medicaid through ballot initiative this November. Legislators opposed to expansion, recognizing the success of ballot initiatives to expand Medicaid in other states, made an attempt to prevent expansion – but this ended in failure. Another ballot initiative sponsored by the legislature appeared on the June primary election ballots. This measure, aimed directly at Medicaid expansion, proposed increasing the threshold needed for a ballot initiative to pass to 60% (from a simple majority of 50% plus 1) for any ballot initiatives that would increase taxes or require the states to appropriate $10 million or more in the first five fiscal years. You can read more about this in an earlier blog post.

An overwhelming 67% of voters rejected this measure, making it clear that South Dakotans don’t want their ballot initiative process to be changed, and preventing one potential block to Medicaid expansion. Complicating the pathway to Medicaid expansion are two ballot initiatives set to appear in November, One that would implement Medicaid expansion as a constitutional amendment, and the other as a state statute. Which of these measures will prevail is to be determined. What would happen if both are approved is also an open question.

Attempts to change the ballot process are not unique to South Dakota. In Mississippi, the state Supreme Court ruled the entire ballot initiative process invalid, after a citizen-led ballot initiative to approve medical marijuana was also ruled invalid. This halted efforts to get a Medicaid expansion initiative on the ballot in November, and although legislators promised to repair and reinstate the ballot initiative process, this year’s legislative session ended without any such fix.

Public support for Medicaid is high, even in non-expansion states, so it’s easy to see why opponents to expansion would be wary of ballot initiatives. The events in South Dakota make clear that voters recognize the importance of protecting their ballot initiatives, and the potential these can hold for helping move Medicaid expansion forward.

We will be watching the ballot initiative process play out in South Dakota through the vote in November.

Jade Little is a Project Coordinator at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.

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