A House committee advances a joint resolution that asks voters if they want to repeal Medicaid Expansion at the general election in November.
Many groups asked the Legislature for Medicaid expansion for years, but it fell on deaf ears as the Legislature never implemented it into state statute. In 2022 South Dakotans approved the expansion after a voter-led movement to put it on the ballot. It went into effect July 2023.
Now, Republican legislators are asking voters if they still think expansion is worth it, largely pointing to tough budget discussions the Legislature has had to make in recent years. Notably, this year the governor’s budget asks for flat increases in K-12 education, state employees and healthcare providers.
Rep. Aaron Aylward is the bill’s prime sponsor. He said it’s about asking the voters if this is where they want budgetary priorities moving forward, saying it really hit him during Gov. Larry Rhoden’s FY 27 budget address earlier this month.
"He was looking at, ‘Hey I don’t think we can do teacher pay increases, state workers don’t expect any increases, and then you look at the appropriations and the funding for just Medicaid overall is our biggest spender, so it’s just like ‘Holy smokes.’ So, my thinking around this is maybe the public still supports it, but maybe, as they look at the financial situation, maybe they don’t," Aylward said in an interview with SDPB. "So, I think it would be prudent to hold that back and just say keep it as is. I think it is the right thing to do to put it in front of the public, and maybe the public supports it even more this time. But I think it’s the right thing to do to ask them the question again.”
Some lobbyists pushed back in claims that Medicaid is driving the state's budget conversations. Tim Rave with the South Dakota Association of Healthcare Organizations told the committee Medicaid expansion accounts for around $39 million of the $1.8 billion medical services budget in South Dakota.
Other opponents said it would drive commercial insurance costs to make up for deficit costs hospitals would pick up the tab for on medical debt.
Aylward told the committee that even if the state stays at a 10% contribution rate and the federal government paid 90%, the state is projected to pay $35-40 million over the next five years. He said that jumps an additional $20 million for every additional 10% the federal government could cut. Aylward said both figures come from the Legislative Research Council.
Proponents also stressed policy decisions shouldn’t be in the state’s Constitution, but rather in codified law so changes, if needed, weren’t required by vote at the general election and could be made more quickly. Rep. Greg Jamison voted no on the joint resolution. He agreed with that statement but said it’s too little too late, saying at the time the public didn't trust them because of Medicaid discussions and issues with Initiated Measure 22 at the time.
“So, there was a lot of things happening where the public wasn’t trusting what we were doing or would do. I think the idea of having in the Constitution isn’t a good idea in all fairness," Jamison said in an interview. "But the realities are that’s how they brought it to us as voters and so there was no other way to change it really after that. It would be better to have in statute for all good reasons, but I think we lost our window of chance, if you will, to let that happen.”
Jamison acknowledged the challenges with the state's budget and this year's questions around the Big Three flat increases.
"We're getting squeezed in a lot of ways, and if that pressure keeps continuing, there will be other challenges we have to address," Jamison.
After an 8-4 vote, the bill heads to the House floor. It’s unclear if this would conflict with another resolution passed last year regarding Medicaid expansion or if this resolution could change the state’s spending formula of the program with the federal government.
The Legislature approved House Joint Resolution 5001 in the 2025 Legislative Session that voters will tackle in November. It keeps Medicaid expansion on the condition the federal match for the program covers at least 90%, the current rate. Some questioned during public opposition if Aylward's bill and 2025's HJR 5001 are both on the ballot, it could create issues around voter intent if both were to be approved.
Aylward said he had concerns about that initially but doesn't see it impacting the issue.
"It should get more of the public involved, and overall, it'll be a good thing," Aylward said.
He said through conversations with the Legislative Research Council that the amendment that gets the higher percentage "takes the cake."'
Jamison and others opposed to the proposal said it stacks onto an already large ballot this election cycle. Jamison said the two similar bills can be confusing to voters.
"There's an enormous amount of items that are going to be on the ballot already. So, if you've got two, one right after the other, you'll say, 'Wait a minute. what the...I just voted for that one, now am I voting the other out because I voted for that one?' or vice versa," Jamison said. "It's just a challenge we're facing right now with so many initiated measures and Constitutional amendments getting on the ballot."
