Campaigning ramps up as South Dakota voters consider Medicaid expansion

CUSTER, S.D. — A silver minivan decorated with a large sticker reading "Love Your Neighbor Tour" recently circumnavigated South Dakota.

Catholic nuns, Protestant pastors, a synagogue president and a Muslim nonprofit professional were among the interfaith leaders who packed into the rented six-seater or caravanned behind.

The road trip's mission: to register voters and urge them to support expansion of the state's Medicaid program to cover thousands more low-income adults.

"If we are living our faith, then we have a serious obligation to love our neighbor and to show that in very practical ways," Sister Teresa Ann Wolf, a Benedictine nun, said at one of the convoy's stops. "And one very simple, concrete thing we can do to help our neighbor — like 40,000 neighbors in South Dakota who need health care — is to vote yes for Amendment D."

Many South Dakotans are people of faith and might find this argument from religious leaders convincing, said Brenda Handel-Johnson, a Lutheran deacon.

South Dakota is one of 12 states that have not expanded eligibility for their Medicaid programs, and the only state where voters will decide in November whether to do so.

Medicaid, the nation's leading public health insurance program for low-income and disabled Americans, covers more than 82 million people and is jointly financed and operated by the federal and state governments.

More than a dozen interfaith leaders participated in the recent Love Your Neighbor Tour. Group members traveled more than 1,400 miles across South Dakota, an expansive but sparsely populated state with fewer than 900,000 residents. The group visited 25 towns in five days, meeting with people in restaurants, grocery and convenience stores, a library, and a church.

One stop was at a senior center in Custer, a small town in the Black Hills that teems with tourists during the summer but is home to only about 2,000 year-round residents.

Tour members and a small group of locals sat in a circle as they exchanged stories about loved ones and acquaintances who lack insurance. Some stressed how Medicaid expansion would help rural residents and health care services. One attendee, the chair of the local Republican Party, said it's inappropriate to insert a policy issue like Medicaid expansion into the state constitution.

South Dakotans will decide on Nov. 8, when they vote on the proposed constitutional amendment. The proposal would offer Medicaid coverage to an estimated 42,500 low-income South Dakotans ages 18 to 64.

About 16,000 of those people don't currently qualify for any government assistance with health coverage even though their income falls below the federal poverty level.

Some are parents who earn too little to qualify for federal subsidies to buy private insurance on the Affordable Care Act's marketplace but earn too much to qualify for South Dakota's Medicaid program. Others are adults without children or disabilities, who aren't allowed to enroll in Medicaid no matter how low their income.

Nationally, people of color are disproportionately represented within this "Medicaid coverage gap," according to a KFF analysis of census data. About half the people in the gap are working; others include students and caregivers.

Jennifer Green, a Rapid City mother of three, lives below the federal poverty level and has no health insurance. The 46-year-old said she has no public coverage options and can't afford the premiums to buy her husband's workplace insurance.

Green said she has two hernias, which prevent her from lifting more than 10 pounds, and a back injury from a car crash that makes it painful to sit long.

"With my situation, I'm not lazy. I know a lot of people think I might be, but I'm not. It's because of the amount of pain I'm in. … In fact, my leg is going numb now," Green said while standing outside her rental house. "I would work if I could."

Green would qualify for Medicaid under the expansion proposal. She said she would use the insurance for hernia and back surgery.

Americans for Prosperity, a conservative, libertarian organization that has campaigned against expansion proposals nationwide, was the lead fundraiser in an earlier effort to prevent the change in South Dakota.

The group supported an effort to create a 60% approval threshold for constitutional ballot questions that cost $10 million or more to implement, which would have included Medicaid expansion. In June, voters overwhelmingly defeated that proposal, so the expansion amendment will need only a simple majority to pass in November.

Keith Moore, director of Americans for Prosperity in South Dakota, said he opposes expanding Medicaid because the taxpayer-funded program has been victim to billions of dollars in fraud and error. Moore also pointed to states that ended up spending more than expected on expanded coverage.

The Medicaid expansion campaign is backed by the progressive Fairness Project, which has supported expansion ballot campaigns across the country. But the largest funders are South Dakota-based health care organizations, AARP, and the National Farmers Union. Other endorsers include Indigenous groups and the state's chamber of commerce, teachers union, and municipal league.

Supporters cite studies showing that Medicaid expansion increases the number of people covered by insurance, improves health outcomes, and saves money. Expansion could have a profound impact on Indigenous communities in the state. Native Americans in South Dakota are more than three times as likely to be uninsured as the overall state population.

Expansion supporters have been campaigning through the Love Your Neighbor Tour, TV ads, documentary screenings, and other methods. The opposition has been less visible but includes some Republican lawmakers, Americans for Prosperity, and the Farm Bureau, which offers health plans.

John Wiik, a Republican state senator, said opponents had expected voters to pass the June proposal to raise the approval threshold for constitutional amendments. After that ballot measure failed, he said, some opponents doubted it was worth spending money to try to defeat the Medicaid expansion proposal.

"I mean, let's face it. We are David versus three Goliaths wrapped in media armor," he said in a phone interview.

Wiik said everyone in the opposition assumed someone else would lead the campaign against expansion. He recently took charge by registering a committee to raise money for the cause. The committee formed after early voting began, and nearly two years after the pro-expansion campaign began raising money.

Opponents say it's unfair that, under expansion, some people who are happy with their federally subsidized private insurance would be forced onto Medicaid instead.

"You're going to cut into their quality of care really bad in a rural state like South Dakota, because we don't have enough providers that still accept Medicaid," Wiik said.

The pro-expansion campaign decided to propose a constitutional amendment, rather than a statute, and inserted deadlines into the text to ensure it is implemented. They wanted to make it harder for South Dakota legislators to block the ballot measure, as has happened on previous issues. Gov. Kristi Noem, a Republican running for reelection, opposes Medicaid expansion but said the state will implement the will of the voters.

Current health insurance options for low-income South Dakota adults

South Dakotans 18-64 years old with dependent children qualify for Medicaid if they earn up to 46% of the federal poverty level. That translates to $12,765 for a family of four.

Adults who don't have dependent children or certified disabilities generally don't qualify for Medicaid, no matter how poor they are.

Many moderate-income adults — with or without children — can qualify for Affordable Care Act subsidies to buy private insurance if their incomes are at or above the federal poverty level ($27,750 for a family of four or $13,590 for a single person).

How expansion would affect Medicaid eligibility

Adults, with or without children, who earn up to 138% of the federal poverty level could enroll in Medicaid. That's $38,295 for a family of four or $18,754 for a single adult.

Many immigrants, including those lacking permanent legal status, would still be barred from coverage.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.