South Dakota voters followed the pattern of six other states and voted this week to expand Medicaid, extending affordable health care to more than 40,000 adults largely working in jobs without health coverage like hospitality, food service, and construction. In taking this action, South Dakota now joins 39 other states and the District of Columbia. An impressive coalition worked to pass the measure and had amazingly broad support from groups as varied as the South Dakota Farmers Union, the South Dakota Municipal League and South Dakota Voices for Peace along with major national groups like the American Cancer Society.

With 56% of the vote, the Medicaid expansion amendment to the South Dakota State Constitution requires coverage to begin by July 1, 2023. The state’s Department of Social Services has already convened a “leadership team” to oversee implementation. DSS expects “that a “significant number of additional staff and technology resources” will be needed.”

While problems updating computer systems and capacity could pose some initial issues, signs are that the political leadership of the state intends to implement the clearly-expressed will of the voters.  As Governor Kristi Noem said in September, “Looking at this measure, it appears to be written constitutionally. So if the people pass it, it’ll be implemented.”

With passage in South Dakota, Florida and Mississippi remain the final two states where a ballot measure is perhaps possible (although Mississippi must pass new enabling legislation to revive their ballot process.) Otherwise, attention now turns to legislatures in the nine other states still refusing the coverage expansion. In the South, the state with the most movement has been North Carolina. North Carolina’s GOP-led House and Senate passed Medicaid expansion legislation this year, but could not agree on a final bill. However, pressure will build in the state for a deal to be enacted next year with the support of NC’s Democratic Governor Roy Cooper. Helping the chances of a deal:  While Republicans managed to gain seats in the North Carolina Legislature, they were not able to achieve a supermajority that would allow the GOP to overturn the Governor’s veto for the final two years of his term. Expect more bipartisan dealmaking on a variety of issues, including expansion.

Another wild card next year having the potential to affect this debate will be the loss of health coverage through Medicaid for many residents, especially in non-expansion states, as the COVID public health emergency and the associated continuous coverage rules end. [See CCF’s extensive research on this issue here.]

Overall, South Dakota voters have proven once again that the popular Medicaid program has broad bipartisan support and voters want it expanded to cover low-wage workers and other adults without affordable options. Next year will show how many other states were listening.