In South Dakota, voters will get to decide whether to expand Medicaid to roughly 42,000 low-income individuals through a constitutional amendment on the November ballot. The measure would extend the social safety net program, providing health coverage for about 42 percent of the state’s uninsured nonelderly population, according to an estimate from the Kaiser Family Foundation. If the citizen-driven effort is successful, South Dakota would be the seventh Republican-controlled state to expand Medicaid via ballot initiative, bypassing the GOP governor and legislature. 

South Dakotans Decide Healthcare, the statewide coalition leading the effort, said that support for expanding Medicaid in the state is “very bipartisan,” ranging from “extremely conservative Republicans” to liberal Democrats. “It’s been 10 years now, the state legislature has never chosen to move forward with this and now it’s time for the people to have their say,” Zach Marcus, campaign manager for South Dakotans Decide Healthcare, told More Perfect Union in an interview.  

“For folks who tend to be more conservative, I think they look at, again, $1.3 billion in taxes that we’ve paid, coming back into our state and used to provide affordable coverage for people who are working hard, who are doing the right things, who are trying their best to live the American dream,” Marcus said. “And yet because of the way health care is structured in this country, they make too much money to qualify for some programs, but also don’t make enough money to actually afford coverage for themselves. So they’re stuck in this gap where a disease or a diagnosis of any kind all of a sudden is really setting them back and really making their entire life vulnerable.”

The measure, known as Amendment D, would amend the state constitution to provide Medicaid benefits to adults between 18 and 65 with incomes below 133 percent of the federal poverty level starting in July 2023. The coalition pushing for this measure is made up of a broad range of groups in the health care community, as well as faith leaders, educators, and farm workers. The South Dakota Association of Healthcare Organizations, AARP South Dakota, South Dakota Farmers Union, and Democracy in Action, are among the groups backing the effort. 

South Dakota’s Republican governor, Kristi Noem, is a staunch opponent of Medicaid expansion, saying that the proposal would cost the state more than projected. When a similar bill to expand Medicaid died in the State Senate earlier this year, Republican lawmakers falsely claimed that those who need Medicaid the most are already covered. “These are not disabled individuals that would be covered. They’re not single moms with kids…they’re already covered,” Noem said at a press conference earlier this year. “All these individuals are already covered. This would be able-bodied adults that do not have dependent children. We’re saying we’re going to pay their health care costs.”

Dustie Clemens of Spearfish, South Dakota, is among the tens of thousands who would be newly covered under the expansion. Clemens has ankylosing spondylitis, a painful condition that affects the back and joints, and is currently uninsured. She says the passage of Medicaid expansion in the state would be life changing. “My life would be completely different I think if I had health insurance, because I’d be able to be on medication to slow down my disease, I’d be able to plan further into the future,” she told More Perfect Union. “If Medicaid were expanded, I’m still going to work. There are lots of people who are still going to work. We just need a little bit of extra help.”

In recent years, advocates in red states have been particularly effective at advancing progressive policies by taking the issues directly to voters with ballot initiatives, from Medicaid expansion and minimum wage increases to marijuana legalization and reproductive rights. Since 2016, citizen-driven referendums have forced the expansion of the social safety net program in six Republican-controlled states, including Missouri, Utah, Oklahoma, and Nebraska. In Idaho, the Medicaid expansion initiative won with support from over 60 percent of voters.

The Fairness Project, an advocacy group created by a California health workers union, is one of the major players behind these successful ballot campaigns. Kelly Hall, executive director of the Fairness Project, told More Perfect Union that the Medicaid expansion push in South Dakota represents the “broadest coalition that we’ve had in any of these campaigns that we’ve worked on,” adding that it includes “a lot of people who are Republicans.” 

The success of these efforts has led to a right-wing backlash against the ballot initiative process. Conservative legislatures have, in some cases, tried to override the will of the voters by attempting to undermine aspects of the measures. Republican officials are also leading attacks on the ballot initiative process itself, proposing laws that would introduce supermajority requirements or make the process more cumbersome in hopes of complicating or severely limiting the public’s ability to bring issues directly to voters. 

South Dakota primary voters defeated one such attempted sabotage in June, overwhelmingly rejecting a GOP measure aimed at blocking the passage of Medicaid expansion in November. The Republican measure, known as constitutional “Amendment C,” would have raised the threshold for any ballot initiative that would “increase taxes or fees” or “require the state to appropriate $10 million or more in the first five fiscal years” from a simple majority to 60 percent. It was pushed by state lawmakers and bankrolled by the Koch brothers’ Americans for Prosperity. Despite drawing support from powerful corporate interests, the Republican scheme to derail Medicaid expansion was defeated by more than two-thirds of voters.

“They have been really transparent that they don’t think that they can win with voters on election day on this issue,” Hall said. “They decided to pull a sort of sneak attack with Amendment C, which was to say, rather than fighting against Medicaid expansion on the merits come November, we’re going to try to put something on the ballot in June that would change the rules of the game.”

Brian Bengs, the Democratic nominee for Senate in South Dakota, supports Medicaid expansion, and has made health care a key issue in his campaign against longtime Sen. John Thune. As the third-ranking Republican in the Senate, Thune was central to the GOP’s attempt to repeal the Affordable Care Act in 2017, which ultimately failed. Most recently, Thune, who has raked in tens of thousands of dollars from Big Pharma and other corporate interests, joined his party to vote against the PACT Act, a bill to expand health care benefits for veterans exposed to toxic burn pits, and to block a proposal that would have capped the price of insulin at $35 a month.