South Dakotans Refuse to Weaken Ballot Initiatives, Keeping Hopes Alive for Medicaid Expansion

South Dakotans rejected a constitutional amendment on Tuesday that would have drastically weakened direct democracy in the state. The measure, known as Amendment C, was defeated 67 to 33 percent.

The result is a stinging defeat for the latest conservative effort to shut down popular initiatives, which in recent years have been a rare tool for progressive policies in red states. And it salvages a path for tens of thousands of people to newly qualify for public health insurance this fall.

Republicans rushed to place Amendment C on the June ballot to thwart a voter-initiated referendum on expanding Medicaid, scheduled for November. If Amendment C had passed on Tuesday, it would have changed the rules of that upcoming referendum—raising the threshold for passage to a tricky 60 percent.

Instead, the Medicaid expansion now only needs to clear 50 percent in November. Even in a ruby red state, that is an achievable goal. Since 2017, Medicaid expansion initiatives have met that threshold in all six states that have voted on it—Idaho, Maine, Missouri, Nebraska, Oklahoma, and Utah. 

Amendment C would have required a supermajority for any ballot initiative that is set to require $10 million of expenditures over five years. It was championed by conservative groups like the Koch brothers’ Americans for Prosperity. The organization framed the amendment as an anti-tax measure, arguing it would make tax hikes harder. But the Koch network has aggressively fought Medicaid expansion efforts in many places.

In red states, once Medicaid has hit the ballot, groups not typically associated with progressive politics have fueled its momentum. During Idaho’s referendum, the state’s sheriff association endorsed the initiative, casting it as a form of criminal justice reform. “Expanding coverage to low-income people with health issues or mental health issues,” a local sheriff said on behalf of the association, can “keep people out of jail” and make them “less likely to end up back in the system.” 

People released from incarceration often struggle to secure health insurance—an even greater hurdle  in states that restrict Medicaid eligibility. People in those states also have fewer options if they want to access treatment for issues that are widely criminalized like mental illness or substance use. These ramifications have helped fuel campaigns to expand Medicaid, most recently in Missouri, a state ravaged by the opioid crisis. While Americans for Prosperity does support some criminal justice reforms in red states, they also fight efforts to strengthen public services and health programs that could shrink incarceration (the group’s  South Dakota chapter did not respond to a request for comment).

South Dakota’s dominant Republican Party has blocked the Medicaid expansion ever since the U.S. Supreme Court made it optional for states in 2012. But the state’s GOP leadership has not been entirely united on the issue. Former Governor Denis Daugaard proposed broadening Medicaid during his tenure, only to be shrugged off by the legislature; meanwhile the proposal to put Amendment C on the June ballot barely passed the state Senate, with many Republican lawmakers voting against it.

The state’s current governor, Republican Kristi Noem, is a steadfast opponent of expanding Medicaid, raising questions about how, or even whether, state officials would actually implement it if voters instructed them to do so in November. In some though not all states that have voted on the issue, GOP politicians dragged their feet on expanding health care access if not outright ignored voters’ mandate.

Noem has already shown that she is ready to fight the will of her electorate. After voters legalized marijuana in 2020, she asked state courts to strike down the initiative on procedural grounds. The state supreme court, which is entirely made of GOP appointees, agreed last year. 

South Dakota Republicans have taken other steps to erode direct democracy, including a law last year that made it much more burdensome to gather signatures for an initiative, part  of a nationwide push by conservatives to limit voter-initiated proposals. Making ballot initiatives more onerous could have grave consequences for progressives, who have managed to successfully organize in red states to circumvent conservative legislatures on behalf of expanding Medicaid, increasing the minimum wage, hiking taxes on the wealthy, and strengthening voting rights.

GOP lawmakers in South Dakota were not able to increase the threshold of passage for initiatives on their own, without consulting voters, since the change would have affected the state constitution. And South Dakotans’ refusal to go along with this stands out as reaffirming the state’s historical legacy.

South Dakota was the first in the nation to adopt a process for citizens to initiate ballot measures. In 1898, voters approved a constitutional amendment to that effect that was pushed by local populist leaders—a legacy that voters reaffirmed on Tuesday. Among the 1898 measure’s chief champions was Robert Haire, a Catholic priest who clamored for democracy to be more direct. 

“These men make the laws to suit themselves—are a law to themselves,” Haines wrote about political leaders in the Dakota Reporter in 1891. “Of course, the entire plutocracy, given over to fleecing the values that labor produces, are afraid of the people.”

Quinn Yeargain contributed to the reporting for this article. Read their article that previewed Tuesday’s election.