Campaign Ramps Up as South Dakota Voters Decide on Medicaid Expansion

CUSTER, SD — A silver minivan emblazoned with a large sticker reading “Love Your Neighbor Tour” toured South Dakota recently.

Catholic nuns, Protestant priests, a synagogue president and a Muslim non-profit professional were among the interfaith leaders who packed into the rented six-seater or back caravan.

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

“If we live our faith, we have a grave obligation to love our neighbor and show it in a very real way,” Sister Teresa Ann Wolff, a Benedictine nun, said during a stop on the convoy. “And one very simple, concrete thing we can do to help our neighbors — like the 40,000 neighbors in South Dakota who need health care — is to vote yes on Amendment D.”

That argument may be convincing from many South Dakotan people of faith and religious leaders, 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 funded and administered by the federal and state governments. The 2010 Affordable Care Act allowed states to offer coverage to more people, with the federal government paying 90% of the cost.

More than a dozen interfaith leaders participated in recent Love Your Neighbor tours. Group members traveled more than 1,400 miles across South Dakota, a sprawling but sparsely populated state with fewer than 900,000 residents. The group visited 25 towns in five days, visiting people at 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 is crowded with tourists during the summer but has about 2,000 year-round residents.

A small group of tour members and locals sat in a circle as they exchanged stories about loved ones and acquaintances who did not have insurance. Some emphasized how expanding Medicaid would help rural residents and health care services One participant, the chairman of the local Republican Party, said it was 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 approximately 42,500 low-income South Dakotans ages 18 to 64.

About 16,000 of them currently do not qualify for any government assistance with health coverage even if their income falls below the federal poverty level.

There are some parents who earn too little to qualify for federal subsidies to buy private insurance in the Affordable Care Act marketplace but earn too much to qualify for South Dakota’s Medicaid program. Others are children or adults without disabilities, who are not allowed to enroll in Medicaid regardless of their income.

Nationally, people of color are disproportionately represented in this “Medicaid coverage gap,” according to a KFF analysis of census data. About half of the people are working in the gap; 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 cannot afford the premiums to buy her husband’s workplace insurance.

Green said he has two hernias, which prevent him from lifting more than 10 pounds, and a back injury in a car accident that makes sitting for long periods painful.

“With my condition, I am not lazy. I know a lot of people think I can be, but I’m not. This is the reason for the amount of pain I am in. … Actually, my legs are going numb right now,” Green said, standing outside her rental home. “I’ll work if I can.”

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

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

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

Keith Moore, director of Americans for Prosperity in South Dakota, said he opposes Medicaid expansion because the taxpayer-funded program has suffered billions of dollars in fraud and errors. Moore also pointed to states that have spent more than expected on expanded coverage.

The Medicaid expansion campaign is supported by the Progressive Fairness Project, which has supported expansion ballot campaigns across the country. But the biggest funders are South Dakota-based health care organizations, AARP and the National Farmers Union. Other supporters include tribal groups and state chambers of commerce, teachers’ unions and municipal leagues.

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

Expansion supporters are campaigning through Love Your Neighbor tours, TV commercials, documentary screenings and other methods. Opposition has been less visible but from some Republican lawmakers, Americans for Prosperity and the Farm Bureau, which offers health plans.

John Wick, a Republican state senator, said opponents had hoped voters would pass a June resolution to raise ratification limits for constitutional amendments. After the ballot measure failed, he said, some opponents doubted it was worth spending the money to defeat the Medicaid expansion proposal.

“I mean, let’s face it. We are David vs. three Goliaths covered in media armor,” he said in a phone interview.

Wick said everyone in the opposition assumed someone else would lead the campaign against expansion. He recently took it upon himself to register a committee to raise money for the cause. Committees formed after early voting began, and campaign funds for the expansion began nearly two years later.

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

“You’re going to have a really poor quality of care in a rural state like South Dakota, because we don’t have enough providers accepting Medicaid yet,” Wick said.

The pro-expansion campaign decided to propose a constitutional amendment instead of a statute and inserted deadlines into the text to ensure it was implemented. They wanted to make it more difficult for South Dakota legislators to block the ballot measure, as had happened on previous issues. Republican Gov. Christie Noem opposes Medicaid expansion but says the state will implement the will of voters.

KHN (Kaiser Health News) A national newsroom that produces in-depth journalism about health issues. Along with policy analysis and polling, KHN is one of three major operating programs KFF (Kaiser Family Foundation). KFF is a non-profit organization that provides health information to the nation.

Current health insurance options for low-income South Dakota adults

South Dakotans ages 18-64 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 do not have dependent children or certified disabilities generally do not 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 income is at or above the federal poverty level ($27,750 for a family of four or $13,590 for a single person).

How the expansion will affect Medicaid eligibility

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

Many immigrants, who do not have permanent legal status, will still be barred from coverage.

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