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South Dakota Constitutional Amendment D, Medicaid Expansion Initiative (2022)

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South Dakota Constitutional Amendment D
Flag of South Dakota.png
Election date
November 8, 2022
Topic
Healthcare
Status
Approveda Approved
Type
Constitutional amendment		Origin
Citizens

South Dakota Constitutional Amendment D, the Medicaid Expansion Initiative, was on the ballot in South Dakota as an initiated constitutional amendment on November 8, 2022. The measure was approved.

A "yes" vote supported amending the state constitution to require the state to expand Medicaid to adults between 18 and 65 with incomes below 138% of the federal poverty level beginning July 1, 2023.

A "no" vote opposed expanding Medicaid to adults between 18 and 65 with incomes below 138% of the federal poverty level.


Election results

South Dakota Constitutional Amendment D

Result Votes Percentage

Approved Yes

192,057 56.21%
No 149,616 43.79%
Results are officially certified.
Source

Overview

What did Constitutional Amendment D do?

See also: Ballot language and constitutional changes

Constitutional Amendment D amends the constitution to require the state to provide Medicaid benefits to adults between 18 and 65 with incomes below 133% of the federal poverty level beginning July 1, 2023. Because the Affordable Care Act includes a 5% income disregard, this measure effectively expands Medicaid to those with incomes at or below 138% of the federal poverty level.[1][2]

Have other states expanded Medicaid?

See also: Background

The Affordable Care Act (ACA), also known as Obamacare, was signed into law on March 23, 2010. The ACA provided for the expansion of Medicaid to cover all individuals earning incomes up to 138% of the federal poverty level, which amounted to $17,774 for an individual and $36,570 for a family of four in 2021. The law was designed to provide 100% of funding to cover the new recipients for the first three years and to cut off federal Medicaid funding to states that chose not to expand coverage. However, the United States Supreme Court ruled in National Federation of Independent Business v. Sebelius (2012) that the federal government could not withhold Medicaid funds from states that chose not to expand eligibility. According to the Kaiser Family Foundation, this ruling had the practical effect of making Medicaid expansion optional for states.[3]

As of November 2022, 38 states and Washington, D.C., expanded Medicaid (six through ballot measures) prior to the 2022 general election, while 12 states did not expand Medicaid. Of the seven Medicaid expansion measures that appeared on a state's statewide ballot prior to November 2022, six were approved (Maine, Utah, Nebraska, Idaho, Oklahoma, and Missouri) and one (Montana) was defeated. The Montana measure combined Medicaid expansion with a tobacco tax increase.

Was there another Medicaid expansion measure on the South Dakota ballot?

See also: South Dakota 2022 ballot measures

Initiated Measure 28 was another Medicaid expansion measure on the South Dakota 2022 ballot. Initiated Measure 28 would have expanded Medicaid to adults between 18 and 65 with incomes below 133% of the federal poverty level. The difference between Initiated Measure 28 and Constitutional Amendment D is that Constitutional Amendment D would amend the South Dakota Constitution, while Initiated Measure 28 would have amended the state law.

On July 11, 2022, Dakotans for Health, the campaign behind Initiated Measure 28, withdrew the initiative. Rick Weiland, co-founder of Dakotans for Health, said the campaign joined South Dakotans Decide Healthcare to support Constitutional Amendment D. "After conversations with South Dakotans Decide Healthcare members, we have agreed that the best path forward to accomplishing this goal is to join efforts behind one campaign," said Weiland.[4] Initiated Measure 28 was the first initiative to ever be withdrawn after qualifying for the ballot in South Dakota. In 2009, the legislature passed a bill establishing the withdrawal process.[5]

Text of measure

Ballot title

The ballot title is as follows:[2]

“ An initiated amendment to the South Dakota Constitution expanding Medicaid eligibility.[6] ”

Attorney General explanation

The attorney general's explanation for the measure is as follows:[2]

“

Medicaid is a program, funded by the State and the federal government, to provide medical coverage for low-income people who are in certain designated categories. This constitutional amendment expands Medicaid eligibility in South Dakota. It requires the State to provide Medicaid benefits to any person over age 18 and under 65 whose income is at or below 133% of the federal poverty level, plus 5% of the federal poverty level for the applicable family size, as provided in federal law. For people who qualify under this amendment, the State may not impose burdens or restrictions that are greater than those imposed on any other person eligible for Medicaid benefits under South Dakota law.

The South Dakota Department of Social Services must submit to the federal government all documentation required to implement this amendment, and must take all actions necessary to maximize federal funding for this expansion.[6]

”

Fiscal impact statement

The official fiscal impact statement was as follows:[7]

“ The proposed expansion of Medicaid could cover an additional 42,500 eligible individuals, with a total estimated cost over the first five years of $1,515,214,000. For the first five years under current federal law, the state's share of expenses could be $166,244,000 with the state recognizing additional general fund savings of $162,473,O00[6] ”

Constitutional changes

See also: South Dakota Constitution

The measure added a new section to Article XXI of the South Dakota Constitution. The following underlined text was added:[2] Note: Hover over the text and scroll to see the full text.

§ 10 Beginning July 1, 2023, the State of South Dakota shall provide Medicaid benefits to any person over eighteen and under sixty-five whose income is at or below one hundred thirty-three percent of the federal poverty level plus five percent of the federal poverty level for the applicable family size, as authorized by federal law as of January 1,2021. Such person shall receive coverage that meets or exceeds the benchmark or benchmark-equivalent coverage requirements, as such terms are defined by federal law as of January l, 2021.

The State of South Dakota may not impose greater or additional burdens or restrictions on eligibility or enrollment standards, methodologies, or practices on any person eligible under this section than on any person otherwise eligible for Medicaid under South Dakota law.

No later than March 1, 2023, the Department of Social Services shall submit all state plan amendments necessary to implement this section to the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services.

The State of South Dakota shall take all actions necessary to maximize the federal financial medical assistance percentage in funding medical assistance pursuant to this section.

This section shall be broadly construed to accomplish its purposes and intents. If any provision in this section or the application thereof to any person or circumstance is held invalid or unconstitutional, such invalidity or unconstitutionality shall not affect other provisions or applications of the section that can be given effect without the invalid or unconstitutional provision or application, and to this end the provisions of this section are severable. [6]

Readability score

See also: Ballot measure readability scores, 2022

Using the Flesch-Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE) formulas, Ballotpedia scored the readability of the ballot title and summary for this measure. Readability scores are designed to indicate the reading difficulty of text. The Flesch-Kincaid formulas account for the number of words, syllables, and sentences in a text; they do not account for the difficulty of the ideas in the text. The attorney general wrote the ballot language for this measure.

The FKGL for the ballot title is grade level 21, and the FRE is -35. The word count for the ballot title is 11.

The FKGL for the ballot summary is grade level 18, and the FRE is 18. The word count for the ballot summary is 143.


Support

South Dakotans Decide Healthcare led the campaign in support of the initiative.[8] The group provided a full list of endorsements, which are available here.

Supporters

Officials

American Indian Tribes

  • Cheyenne River Sioux Tribe
  • Crow Creek Sioux Tribe
  • Lower Brule Sioux Tribe
  • Oglala Sioux Tribe
  • Rosebud Sioux Tribe
  • Sisseton Wahpeton Oyate
  • Yankton Sioux Tribe

Unions

  • South Dakota Education Association

Organizations

  • AARP South Dakota
  • American Cancer Society Cancer Action Network
  • American Diabetes Association
  • American Heart Association
  • American Lung Association
  • Avera Health
  • Community HealthCare Association of the Dakotas
  • Democracy in Action
  • Greater Sioux Falls Chamber of Commerce
  • Leukemia & Lymphoma Society
  • Monument Health
  • Sanford Health
  • South Dakota Chamber of Commerce and Industry
  • South Dakota EMS Association
  • South Dakota Faith in Public Life
  • South Dakota Farmers Union
  • South Dakota Firefighters Association
  • South Dakota Hispanic Chamber of Commerce
  • South Dakota Municipal League
  • South Dakota Nurses Association
  • South Dakota State Medical Association


Arguments

  • Zach Marcus, campaign manager for South Dakotans Decide Healthcare: "Medicaid expansion is a good deal for South Dakota. It will boost the economy, create jobs, save rural hospitals, and every dollar that South Dakotans don’t have to spend paying down medical debt means more money to spend in their local communities. This is a healthcare issue, but it’s also a commonsense fiscal and economic issue. ... It will boost our economy, save rural hospitals, create jobs, help ensure hard working South Dakotans don’t drown in medical debt, and bring our hard earned tax dollars home. This is a healthcare issue, but it’s also a commonsense dollars and cents issue."
  • Steve Allender, mayor of Rapid City and the president of the Municipal League: "This would return hundreds of millions of our tax dollars to our state, keep rural hospitals open, and provide affordable care to hard-working South Dakotans all over the state."
  • Lower Brule Sioux Chairman Clyde Estes: “When you look at it, this is the year 2022. I think there should be no South Dakotans with no medical coverage. It’s health care, it should be a God-given right to everybody. A human life is precious and sacred, we’re all created for a purpose, and no medical care should be denied to any individual let alone any Native person or native South Dakotan for not being able to afford it.”
  • American Diabetes Association Director of State Government Affairs Carissa Kemp: "The American Diabetes Association is proud to join South Dakotans Decide Healthcare and add our voice in support of expanding Medicaid. People with diabetes need access to medications, supplies, and health care services to manage their diabetes, stay healthy, and prevent disabling or deadly complications. Yet, the health care costs of people with diabetes are more than double those of others. Relief is overdue for those struggling to stay healthy."
  • Sandy Frentz, former public health manager for the City of Sioux Falls: “Federal funding will pay for 90% of expansion costs, with the state of South Dakota responsible for the remaining 10%. Expanding Medicaid means South Dakota will save more than $63 million in general funds in the first two years alone as result of additional funding from [American Rescue Plan Act] programs. Medicaid expansion would also return more than $1.3 billion tax dollars to South Dakotans from Washington, D.C. over a five-year period.”


Official arguments

The following was the argument in support of Constitutional Amendment D found in the South Dakota 2022 Ballot Questions Guide:[9]

  • South Dakota 2022 Ballot Questions: No one should have to decide if they can afford life-saving health care, for themselves or their families. But right now, thousands of South Dakotans are stuck in the middle. They can't get insurance through their jobs, and they can't afford insurance on their own because costs are sky high. Voting YES on Amendment D means thousands of South Dakotans who work, but don’t make enough money to afford health insurance will be able to get it. South Dakotans who make less than $18,000 per year will be able to get health care, including:
    • Hard-working near retirees who don’t have jobs that provide health care
    • Small business owners who can't afford health care for themselves and their workers
    • Farmers and ranchers
    Currently, Washington politicians send $350 million of South Dakota’s tax dollars each year to California, New York, and 37 other states to pay for their health care instead. Voting YES on Amendment D ends that. It means we can keep those dollars right here in South Dakota, so hardworking South Dakotans can get health care coverage without raising taxes. Amendment D will strengthen health care in South Dakota, which will generate an estimated $3.5 billion in new economic output in South Dakota by 2025, including $800 million in 2023. Amendment D will ensure our workforce remains healthy, which leads to healthy businesses and a healthy economy. Amendment D will strengthen rural hospitals and clinics and make it easier for people in rural South Dakota to get health care. It’s common sense to keep our tax dollars for our citizens’ health care. Vote YES on Amendment D to keep South Dakota's tax dollars in South Dakota to help OUR communities. --- Steve Allender, Mayor of Rapid City; Jim Woster, retired businessman

Opposition

No on Amendment D led the campaign in opposition of the initiative.[10]

Opponents

Officials

Organizations


Arguments

  • Gov. Kristi Noem: "What that does is make sure that Medicaid expansion would cover able-bodied single individuals that are able to work. And it also would include about an $80 million cost to the state ... It's something that I will continue to look at. That cost to the state is incredible. And the people that it covers are people that are single and able-bodied and able to work ... We have many open jobs, very few people in our state that are on unemployment right now."
  • State Rep. Tim Goodwin: "We keep taking all this “free” federal money, but what happens when and if the federal government goes bankrupt? It is almost unthinkable what would happen. I say it is time to draw a line in the sand and say, “enough is enough.” Another major reason not to do this is that we are covering the able-bodied workforce. Actually, we would be making winners and losers; those who make more than $17,774 and those who make less. It is the same for a family of four who make more than $36,570 and those who make less. This concept penalizes the able-bodied workforce who have worked hard to get a career that pays above this standard and those who have a job with health benefits. Is that what we want to do? Another point that needs to be made is that in South Dakota there are more jobs than workers available. Medicaid Expansion is only going to worsen our worker shortage."
  • Keith Moore, state director of South Dakota Americans For Prosperity: "We are being sold something like it is good for the economy... We are being sold this idea it is good for the economy, good for creating jobs, and so much more. Maybe it will create jobs for certain organizations, but it is not going to be good for our economy when the state is going to have to pay as much as it will for Medicaid expansion."


Official arguments

The following was the argument in oppositon to Constitutional Amendment D found in the South Dakota 2022 Ballot Questions Guide:[11]

  • South Dakota 2022 Ballot Questions: Amendment D – expanding Medicaid shreds our Constitution and expands services to able-bodied adults under ObamaCare. Expanding Medicaid is wrong for South Dakota for five reasons.
    • It will either lead to higher taxes or reduced spending on education. South Dakota already spends approximately 20 percent of our budget on Medicaid. Expansion always costs more than projected. South Dakota will either need to raise taxes or cut spending for schools, public safety, or infrastructure as a result.
    • It is unfair to the truly needy in South Dakota. Low-income kids, seniors, and individuals with disabilities will now have to compete with able-bodied working-age adults for the pool of money available to Medicaid. It will also hurt rural hospitals as fewer of their patients will have private insurance.
    • It forcibly removes families from their private health care plans and moves them to government-run Medicaid. Most South Dakotans who would be enrolled already have their own free or low-cost private plans. Expanding Medicaid means removing tens of thousands of low income South Dakotans from those plans without their consent and enrolling them into plans which fewer doctors accept. Also, if South Dakota expands under ObamaCare, waiting lists will get longer.
    • It is bad for South Dakota’s workers and businesses. The only qualification for Medicaid will be that South Dakotans must agree to stay poor - which leads to more welfare and less work.
    • The Constitution was never intended to contain language about specific government programs. This is a plainly bad idea. More government welfare is not the solution to our health care system— it is the problem.
    For our families and the future of our kids and grandkids, please vote “no” on Amendment D. --- Keith Moore, State Director, Americans for Prosperity

Campaign finance

See also: Campaign finance requirements for South Dakota ballot measures
The campaign finance information on this page reflects the most recent scheduled reports that Ballotpedia has processed, which covered through December 31, 2022.


South Dakotans Decide Healthcare led the campaign in support of the initiative. The committee reported $4.52 million in contributions.[12]

No on Amendment D registered to oppose the ballot measure. The committee reported $3,646 in contributions.[12]

Cash Contributions In-Kind Contributions Total Contributions Cash Expenditures Total Expenditures
Support $3,813,429.67 $715,551.68 $4,528,981.35 $3,813,434.67 $4,528,986.35
Oppose $0.00 $3,646.40 $3,646.40 $0.00 $3,646.40
Total $3,813,429.67 $719,198.08 $4,532,627.75 $3,813,434.67 $4,532,632.75

Support

The following table includes contribution and expenditure totals for the committee in support of Amendment C.[12]

Committees in support of Constitutional Amendment D
Committee Cash Contributions In-Kind Contributions Total Contributions Cash Expenditures Total Expenditures
South Dakotans Decide Healthcare $3,813,429.67 $715,551.68 $4,528,981.35 $3,813,434.67 $4,528,986.35
Total $3,813,429.67 $715,551.68 $4,528,981.35 $3,813,434.67 $4,528,986.35

Donors

The following were the top donors to the support committee.[12]

Donor Cash Contributions In-Kind Contributions Total Contributions
Sdaho Enterprises $853,600.00 $0.00 $853,600.00
Avera Health $778,600.00 $0.00 $778,600.00
Sanford Health $753,600.00 $0.00 $753,600.00
Monument Health, Inc $600,000.00 $0.00 $600,000.00
American Cancer Society Action Network $115,000.00 $310,056.71 $425,056.71

Opposition

The following table includes contribution and expenditure totals for the committee in opposition to Amendment C.[12]

Committees in support of Constitutional Amendment D
Committee Cash Contributions In-Kind Contributions Total Contributions Cash Expenditures Total Expenditures
No on Amendment D $0.00 $3,646.40 $3,646.40 $0.00 $3,646.40
Total $0.00 $3,646.40 $3,646.40 $0.00 $3,646.40

Donors

The following were the top donors to the opposition committee.[12]

Donor Cash Contributions In-Kind Contributions Total Contributions
Americans for Prosperity - South Dakota $0.00 $3,646.40 $3,646.40

Methodology

To read Ballotpedia's methodology for covering ballot measure campaign finance information, click here.

Polls

See also: 2022 ballot measure polls
Are you aware of a poll on this ballot measure that should be included below? You can share ballot measure polls, along with source links, with us at editor@ballotpedia.org.
South Dakota Constitutional Amendment D, Medicaid Expansion Initiative (2022)
Poll
Dates
Sample size
Margin of error
Support
Oppose
Undecided
Emerson College Polling 10/19/22-10/21/22 1,500 LV ± 2.4% 50.9% 21.5% 27.5%
Question: "How do you plan to vote on Constitutional Amendment D, an amendment to the South Dakota Constitution which would expand Medicaid eligibility?"

Note: LV is likely voters, RV is registered voters, and EV is eligible voters.

Background

Medicaid in South Dakota

The South Dakota Department of Social Services (DSS) is the agency responsible for administering Medicaid. As of 2022, Medicaid in South Dakota was available to children, low-income pregnant women and parents, seniors in nursing homes, and individuals with disabilities.[13]

State medical programs in South Dakota include:[13]

  • Children's Health Insurance Program (CHIP);
  • Pregnant Women;
  • Disabled Children's Program;
  • South Dakota Medicaid for Workers with Disabilities (MAWD);
  • Home and Community Based Services for Developmentally Disabled;
  • South Dakota Medicaid for Individuals in Assisted Living Facilities, Nursing Facilities or Homes;
  • Quadriplegics who would Require Nursing Home Care if not for Special Services Performed in their Home;
  • Refugee South Dakota Medicaid;
  • Breast and Cervical Cancer Program;
  • Family Support Services;
  • South Dakota Medicaid for Certain Newborns;
  • South Dakota Medicaid for Individuals with Chronic Renal Disease;
  • South Dakota Medicaid for Individuals in Adult Foster Care Facilities;
  • Elderly Individuals who would Require Nursing Home Care if not for Special Services Performed in their Home;
  • South Dakota Medicaid for Youth Formerly in Foster Care; and
  • Low-Income Families.

Eligibility

As of 2022, low-income families (consisting of a parent or adult caretaker and a dependent child) were eligible for Medicaid based on the following income ranges and family size:[13]

SD Low-income family Medicaid eligibility
Household size Maximum gross monthly income
1 $617
2 $776
3 $888
4 $995
5 $1,106
6 $1,218
7 $1,327
8 $1,435


The state reported 141,620 individuals participating in the state's Medicaid program in fiscal year 2020.[14]

Medicaid expansion under the ACA

Policypedia Healthcare-01.png
See also: Medicaid and Obamacare

The Affordable Care Act (ACA), also known as Obamacare, was signed into law on March 23, 2010.[15] The ACA provided for the expansion of Medicaid to cover all individuals earning incomes up to 138 percent of the federal poverty level, which amounted to $17,236 for individuals in 2019.[16][17][18] The law was designed to provide 100 percent of funding to cover the new recipients for the first three years and to cut off federal Medicaid funding to states that chose not to expand coverage. However, the United States Supreme Court ruled in National Federation of Independent Business v. Sebelius (2012) that the federal government could not withhold Medicaid funds from states that chose not to expand eligibility. According to the Kaiser Family Foundation, this ruling had the practical effect of making Medicaid expansion optional for states.[3]

From 2014 to 2016, the federal government covered 100 percent of the costs of state expansion of Medicaid. In 2017, the total cost of expanded coverage that the federal government financed decreased to 95 percent. The ACA was designed to decrease the amount the federal government covers to 94 percent in 2018, 93 percent in 2019, and 90 percent in 2020 and subsequent years.[19]

The Affordable Care Act had not provided tax credits to adults with household incomes less than the federal poverty line because the law had aimed to cover these people under Medicaid. In states that did not expand Medicaid, many of these adults fell into a coverage gap in which they neither qualified for Medicaid nor for federal tax credits to purchase health insurance. As of 2018, around 2.5 million people fell into this coverage gap across the states that did not expand Medicaid.[16]

Medicaid expansion

As of January 2022, a total of 38 states and Washington, D.C., had expanded or voted to expand Medicaid, while 12 states had not. The map below provides information on Medicaid expansions by state; for states that expanded, hover over the state to view the political affiliation of the governor at the time of expansion.[20]

Medicaid expansion ballot measures

In 2017, Maine was the first state to approve a ballot measure to expand Medicaid. In 2018, there were four ballot measures proposing to expand Medicaid or renew expansion. Three were approved, and one was defeated. In 2020, Oklahoma voters approved a Medicaid expansion initiative. Missouri voters approved a Medicaid expansion initiative on August 4, 2020.

Year Measure Yes votes % No votes % Outcome
2017 Maine Question 2 58.95% 41.05% Approveda
2018 Utah Proposition 3 53.32% 46.68% Approveda
2018 Nebraska Initiative 427 53.55% 46.45% Approveda
2018 Montana I-185 47.30% 52.70% Defeatedd
2018 Idaho Proposition 2 60.58% 39.42% Approveda
2020 Oklahoma State Question 802 50.49% 49.51% Approveda
2020 Missouri Amendment 2 53.27% 46.73% Approveda

Path to the ballot

See also: Laws governing the initiative process in South Dakota

The state process

In South Dakota, the number of signatures required to qualify an initiated constitutional amendment for the ballot is equal to 10 percent of the votes cast for governor in the previous gubernatorial election. Signatures must be submitted by the first Tuesday of May during a general election year.

The requirements to get an initiated constitutional amendment certified for the 2022 ballot:

Once the signatures have been gathered and filed, the secretary of state verifies the signatures using a random sample method.

Details about this initiative

  • Laurie Jensen Wunder of South Dakotans Decide Healthcare sponsored the initiative.[1]
  • The measure was approved for circulation using volunteer (not paid) circulators on March 25, 2021.[1]
  • Proponents submitted another copy of the initiative on May 11, 2021, which was approved for circulation using volunteer and paid circulators on July 2, 2021.[1]
  • Sponsors reported submitting 47,000 signatures on November 8, 2021.[21]
  • On January 3, 2021, the South Dakota Secretary of State's office announced that the amendment qualified for the ballot with 38,244 signatures deemed to be valid.[22]

How to cast a vote

See also: Voting in South Dakota


Click "Show" to learn more about voter registration, identification requirements, and poll times in South Dakota.

See also

External links

Footnotes

  1. ↑ 1.0 1.1 1.2 1.3 South Dakota Secretary of State, "Potential 2022 Ballot Questions," accessed July 16, 2021
  2. ↑ 2.0 2.1 2.2 2.3 South Dakota Secretary of State, "Medicaid expansion initiative (South Dakotans Decide Healthcare," accessed July 16, 2021
  3. ↑ 3.0 3.1 Kaiser Family Foundation, "A Guide to the Supreme Court’s Affordable Care Act Decision," July 2012
  4. ↑ Mitchell Republic, "Dual Medicaid ballot initiatives join behind one constitutional amendment," July 12, 2022
  5. ↑ KELO, "IM 28 withdrawal was a moment in history," July 13, 2022
  6. ↑ 6.0 6.1 6.2 6.3 Note: This text is quoted verbatim from the original source. Any inconsistencies are attributable to the original source. Cite error: Invalid <ref> tag; name "quotedisclaimer" defined multiple times with different content
  7. ↑ South Dakota Secretary of State, "2022 Ballot Questions" accessed Sep 20, 2022
  8. ↑ South Dakotans Decide Healthcare, "Home," accessed April 1, 2021
  9. ↑ South Dakota Secretary of State, "2022 Ballot Questions," accessed October 27, 2022
  10. ↑ South Dakota Secretary of State, "Statement of Organization," accessed Oct 7, 2022
  11. ↑ South Dakota Secretary of State, "2022 Ballot Questions," accessed October 27, 2022
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 South Dakota Secretary of State, "Campaign Finance Reporting System," accessed March 24, 2022
  13. ↑ 13.0 13.1 13.2 South Dakota Department of Social Services, "Medical Programs Available in South Dakota," accessed January 10, 2022
  14. ↑ South Dakota Department of Social Services, "2020 Medicaid Report," accessed January 10, 2022
  15. ↑ New York Times, "Obama Signs Health Care Overhaul Bill, With a Flourish," accessed March 23, 2010
  16. ↑ 16.0 16.1 Kaiser Family Foundation, "The Coverage Gap: Uninsured Poor Adults in States That Do Not Expand Medicaid Coverage," accessed October 23, 2019
  17. ↑ Kaiser Health News, "Consumer’s Guide to Health Reform," April 13, 2010
  18. ↑ Office of The Assistant Secretary for Planning and Evaluation, "Poverty Guidelines," January 25, 2016
  19. ↑ Kaiser Family Foundation, "Understanding How States Access the ACA Enhanced Medicaid Match Rates," September 29, 2014
  20. ↑ HealthInsurance.org, "Medicaid," accessed January 10, 2020
  21. ↑ DRG News, "South Dakotans Decide Healthcare organization gathers 33,921 valid signatures," accessed November 8, 2021
  22. ↑ South Dakota Secretary of State, "Ballot question validated for 2022 general election," accessed January 3, 2021
  23. ↑ South Dakota Secretary of State, “General Voting Information,” accessed July 23, 2024
  24. ↑ 24.0 24.1 24.2 South Dakota Secretary of State, “Register to Vote, Update Voter Registration or Cancel Voter Registration,” accessed July 23, 2024
  25. ↑ 25.0 25.1 NCSL, "State Profiles: Elections," accessed July 23, 2024
  26. ↑ 2025 South Dakota Legislature, "HB 1066," accessed April 2, 2025
  27. ↑ Under federal law, the national mail voter registration application (a version of which is in use in all states with voter registration systems) requires applicants to indicate that they are U.S. citizens in order to complete an application to vote in state or federal elections, but does not require voters to provide documentary proof of citizenship. According to the U.S. Department of Justice, the application "may require only the minimum amount of information necessary to prevent duplicate voter registrations and permit State officials both to determine the eligibility of the applicant to vote and to administer the voting process."
  28. ↑ 28.0 28.1 South Dakota Secretary of State, "General Voting Information," accessed July 23, 2024
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