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South Dakota is Next

South Dakota is Next
By Aditya Singh • Issue #22 • View online
Among a number of crucial elections and ballot measures across the country’s 2022 midterms, South Dakotans passed a referendum to expand Medicaid in accordance with the Affordable Care Act and American Rescue Plan.
However, it’s unlikely that the uninsured in South Dakota will immediately be able to use Medicaid even if now they’re eligible. Why is that?

Source: New York Times 2022 Midterms Coverage
Source: New York Times 2022 Midterms Coverage
Medicaid and its Expansions
Medicaid is a program that offers health insurance to low-income Americans. It is administered at the state level but paid for by a combination of the state and federal government. Because the program is administered at the state level, there are variations from state-to-state with regards to what specific services are covered, and most relevant to today’s discussion, eligibility.
Before 2010, there were large discrepancies in the eligibility requirements for Medicaid across the states. In fact, federal funding at this point only covered a subset of low-income individuals such as children, pregnant women, parents of dependents, those with disabilities, and the elderly. Without federal funding to help offset the cost of higher enrollment into Medicaid, many states left low-income “childless adults” out of eligibility.
The 2010 Affordable Care Act (ACA) rehauled Medicaid to establish eligibility for anyone under 65 and at or below 138% of the federal poverty line. When it was passed, this expansion of Medicaid eligibility was supposed to be the go-to method of insurance coverage for those without insurance and those who would be unable to afford subsidized private plans.
To limit fiscal strain on the states, the ACA outlined that the federal government would pay most of the cost of the expansion for the states.
Although the Medicaid expansions were supposed to be nationwide, the Supreme Court ruled in National Federation of Independent Business v. Sebelius that Congress did not have constitutional authority to require the expansion, thus making the program optional for states to adopt.
Going into 2021, 12 states had still not adopted expansion. The American Rescue Plan (ARP) authorized additional federal funding incentives to encourage holdouts to expand Medicaid.
South Dakota's Amendment
The pro-expansion campaign led by South Dakotans Decide Healthcare got the measure on the ballot after getting 24,000 petition signatures.
Voters in Maine, Idaho, Utah, Nebraska, Oklahoma, and Missouri adopted Medicaid expansions through ballot measures when state legislators pushed back on adopting them. Despite voters passing these initiatives, lawmakers in Missouri, for example dragged their feet on implementing Medicaid expansions.
Missouri passed its expansion in 2020, set to take effect summer 2021. As of February 2022, there were more people who had pending applications to the state Medicaid program, MO HealthNet, than the number of people enrolled via the expansion at that point. 64.2k were approved in comparison to 73k still pending applications.
Federal law requires that applications take no more than 45 days to process while a report found that typical applications took 70 days. In many other states, Medicaid applications take no more than a week to process.
The legislature initially refused to fund the expansion, but in August, a judge ordered the state to accept applications for those eligible according to the ballot initiative. No applications were processed until October of 2021 because of necessary computer updates.
However, South Dakota’s ballot measure which passed last week with a 56% “Yes” vote took the form of an amendment to the state constitution, and the text outlines specific deadlines in 2023 to ensure the expansions happen in a timely manner.
Some concerns about implementing the Medicaid expansion are already being voiced. For one, South Dakota’s tools for handling Medicaid applications and enrollments are very manual, and it’s one of three states without an online account that can be used to monitor applications and upload documents to renew coverage.
The Department of Social Services must work to build out not only the internal infrastructure to handle an influx of enrollees to the program, but a cellphone-friendly system to manage Medicaid accounts must be created in time for summer 2023.
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Aditya Singh

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