South Dakota’s Ongoing Battle for Medicaid

By Amelia Trello, Staff Writer

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South Dakota voters will decide whether to extend Medicaid eligibility under the Affordable Care Act (“ACA”) this November.[1] Residents of South Dakota have successfully elected to expand Medicaid six times—the upcoming vote in November could be number seven.[2]Currently, around five percent of the state remains uninsured.[3] Pregnant women, children, and the elderly are able to receive Medicaid benefits.[4] However, working parents must earn an income less than 63 percent below the federal poverty level to enroll—this equates to approximately $17,500 for a family of four.[5] Approximately 45,000 South Dakota residents are estimated to be covered by the expansion.[6]

In 2010, the ACA was signed into law by President Obama.[7]  The ACA required all citizens to have healthcare and provided assistance to those who could not afford healthcare.[8] The Act contained an individual mandate and an expansion of Medicaid.[9] The mandate required that “by 2014, non-exempt individuals who failed to purchase and maintain a minimum level of health insurance must pay a tax penalty.”[10]The expansion provision stated that states were required to accept the expansion of Medicaid in order to receive Federal funds for the state’s Medicaid.[11]

After Congress passed the ACA, many states brought actions seeking a declaration that the ACA was unconstitutional, arguing that the individual mandate exceeded the Commerce Clause, and that Medicaid expansion was “unconstitutionally coercive”.[12]These were the issues explored in the 2012 Supreme Court case, National Federation of Independent Business v. Sebelius.[13] Although the Supreme Court held the individual mandate constitutional, it also held that the Medicaid expansion was unconstitutional. Thus, the Medicaid expansion was left up to individual states.[14] It is because of this holding that South Dakota voters must continuously fight for Medicaid expansion.

Since the Supreme Court ruling, there has been a slow adaptation of expanded Medicaid. Expansion has occurred by executive orders as well as ballot initiatives.[15] Today, 12 states have still not expanded Medicaid, “leaving 4 million people without Medicaid coverage who would otherwise be eligible.”[16]

The differences between states that have expanded Medicaid and states which have not, are stark. States that have expanded Medicaid have seen “improved access to care, utilization of services, the affordability of care, and financial security among the low-income population.”[17] Moreover, Medicaid expansion has resulted in positive economic outcomes for hospitals, clinics, the labor market, and state governments.[18] Studies have shown that expansion has saved states money by “offsetting state costs in other areas.”[19] With clear benefits to the vast majority of stakeholders, it is clear why South Dakota voters desire to expand Medicaid a seventh time.

Although ballot initiatives, such as the one in South Dakota, have worked thus far, they come with their own set of issues. Many republican state legislatures are creating barriers for ballot initiatives.[20] For example, in Florida, Medicaid expansion requires a 60 percent voter threshold for Medicaid to pass.[21] Unfortunately, South Dakota may soon follow suit.[22] This barrier to Medicaid could pose a detrimental outcome for South Dakota citizens, healthcare providers, and their governments alike.


[2] Id.

[3] Id.

[4] Id.

[5] Id.



[8] Id.


[10] Id.

[11] Id.

[12] Id.



[15] ttps://



[18] Id.

[19] Id.


[21] Id.

[22] Id.

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