Medicaid expansion proposal was almost on Nov. ballot

The South Dakota Republican leadership, like many of their counterparts in Mississippi, opposes accepting federal funds to provide health insurance for primarily the working poor.

In South Dakota, the Republican leadership tried to prevent approval of an upcoming citizen-sponsored ballot initiative that would mandate the expansion of Medicaid if passed by voters in November. In a preemptive move, South Dakota legislators placed a constitutional amendment on the June party primary election ballot that would have required any citizen-sponsored initiative going forward (such as Medicaid expansion on the November ballot) to garner the approval of 60% of voters instead of the customary majority vote to pass.

South Dakotans rejected the constitutional amendment earlier this month, setting the table for their likely approval in November of the citizen-sponsored initiative to expand Medicaid to provide health insurance for primarily the working poor.

In Mississippi, if not for the action of elected officials, a proposal to expand Medicaid also most likely would have been on the upcoming November ballot. But unlike in South Dakota, the aim of the elected officials in Mississippi was not to stop Medicaid expansion, though that was one result of their actions.

In May 2021, the Mississippi Supreme Court ruled invalid a citizen-sponsored initiative to approve medical marijuana. In doing so, the 9-member elected Supreme Court also ruled invalid the entire initiative process. That decision halted the effort of Medicaid expansion supporters, including the Mississippi Hospital Association, to garner the required number of signatures needed to place the initiative on the November 2022 ballot.

Legislators said during the 2022 session they would fix the language that led to the Supreme Court ruling the initiative process invalid and reinstate it. But in the end, legislators could not agree on that fix and the session ended without legislators restoring the initiative process.

It would be easy to assume that legislators failed to restore the initiative process because they wanted to prevent another effort to place Medicaid expansion on the ballot. But the facts do not necessarily support that assumption.

One of the primary opponents of Medicaid expansion is House Speaker Philip Gunn. But Gunn was backing a proposal to restore the initiative process with essentially the same signature mandates as the original process.

Over in the Senate, Lt. Gov. Delbert Hosemann, the presiding officer, has indicated support for some form of Medicaid expansion. But it was Hosemann’s Senate leadership that was arguing for requiring a much greater number of signatures to place an issue on the ballot. The Senate’s proposal would have more than doubled the number of signatures needed to place an issue on the ballot, making it more difficult for Medicaid expansion supporters to succeed. In the end the two sides could not reach agreement on the mandated number of signatures.

In essence, the House, where Gunn opposes Medicaid expansion, was fighting not to make it more difficult to place issues on the ballot while the Senate, where Hosemann has indicated some support for Medicaid expansion, was advocating for making it much more difficult to place issues on the ballot.

Unless Gunn was using some super Jedi mind game where he was tricking the Senate with reverse psychology, his intent was not to block the initiative from being used for Medicaid expansion.

But it would make sense that those opposed to Medicaid expansion would be leery of the initiative process. After all, voters in six Republican states have subverted the wishes of their elected officials and expanded Medicaid.

As mentioned, South Dakota will likely be the seventh this November. And polls indicate Mississippians would have approved Medicaid expansion had it reached the ballot this fall.

The only state where the ballot initiative to expand Medicaid was not successful thus far, other than Mississippi, is Florida. And in that case, legislators were successful in changing the rules of signature gathering mid-stream and throwing up legal obstacles to the effort to expand Medicaid through the ballot initiative.

Thus far, 38 states have expanded Medicaid. The North Carolina Legislature is considering a Medicaid expansion proposal. Of those states that have not expanded Medicaid, only three – South Dakota, Wyoming and Florida – have mechanisms for citizens to bypass the Legislature and place initiatives on the ballot.

Perhaps there will be efforts again in the 2023 Legislature to restore the initiative process in Mississippi and give Medicaid supporters another opportunity to place the issue before voters.