South Dakota

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Who decides your health care, and what is on your ballot November 3.

1. Your numbers

These are the two numbers that differ most from state to state, and the decision behind them.

“Uninsured” means no coverage of any kind. Medicaid expansion is the federal offer, open since 2014, to cover adults earning up to 138% of the poverty line with Washington paying 90% of the cost. Your state took it.

2. Where South Dakota stands

South Dakota’s uninsured rate was 8.1% in 2024, against 8.2% nationally; 31 states have a lower rate and 19 a higher one. It fell from 8.3% in 2023, one of only eleven states where the rate went down. South Dakota expanded Medicaid to adults earning up to 138% of the poverty line because its voters ordered it by ballot measure in 2022, after the legislature declined; coverage began 7/1/2023. Amendment I on this year’s ballot asks voters to revisit that decision; see section 4.

3. Your ballot

Why these offices: between them they decide who gets covered, who may practice, what insurers must pay for, and how emerging health tools may be used in clinical care.

• Governor: Yes. The governor appoints the state medical board, the Medicaid director and, in most states, the insurance commissioner, and signs the budget that pays the state’s share of Medicaid.
• U.S. Senate: Yes. Congress sets the Medicaid formula and decides whether marketplace subsidies continue.
• U.S. House: Yes, every seat.
• State legislature: House and Senate. The legislature sets Medicaid eligibility within federal rules, decides who may practice what, and increasingly what AI may do in medicine.
• Attorney General: Yes. Reviews hospital mergers and polices debt collectors.
• Insurance Commissioner: Appointed in South Dakota, not elected. Approves rates and enforces what plans must cover.

4. Health measures: yours, and what other states are deciding

A ballot measure is a question you decide directly, instead of leaving it to an elected official.

Read the official wording before you vote; your state’s election site has the full text.

What other states are deciding. Nine states vote on a health question directly this year. Watch them: what passes in one state is proposed in another the next session.

• California: Props 3, 38, 40 and 44: permanent top income-tax rates for schools and health care; $8.4 billion for immunology research; a one-time tax on billionaires with 90% to health care; a 90% spending rule for community clinics
• Colorado: Props 132 and 135, Amendment 87: fentanyl possession a felony; a ban on sex-change surgeries for minors with Medicaid barred from paying; higher income tax above $500,000 with revenue to schools, health care and child care
• Idaho: Prop 1 and HJR 4: a right to reproductive freedom; the legislature alone may legalize marijuana or other controlled substances
• Massachusetts: Question 8: ends retail sales of recreational marijuana
• Missouri: Amendment 3: repeals the 2024 reproductive-rights amendment and prohibits most abortions and gender transition procedures for minors
• Nevada: Question 6: second and final vote on a constitutional right to abortion before viability
• North Dakota: Initiated Constitutional Measure No. 2: free breakfast and lunch in every public school
• Virginia: Question 1: a right to reproductive freedom in the state Bill of Rights

5. Where health decisions are not keeping up with future health

This page takes no side. There is no agreed definition of the minimum health every American should have, and that argument is what these elections are partly about. Below are three places where old rules, written for a system built around rescue, have fallen behind what is now possible. Each comes with one question to ask any candidate, of any party:

• The first opinion. About 75,000 people in South Dakota have no coverage. Consumer AI tools can offer information, but they are not a substitute for diagnosis or treatment. The Federation of State Medical Boards is studying AI used in the practice of medicine, including direct-to-consumer services and autonomous tools, and may issue model guidance for state boards. Ask: what safeguards should apply when AI gives health information or performs clinical functions, and who should be accountable when it is wrong?
• The debt. Many residents carry hospital debt that is difficult or impossible to pay. North Carolina reported erasing more than $6.5 billion for 2.5 million people after hospitals agreed to debt-relief policies in exchange for enhanced Medicaid reimbursement. Other states have used nonprofit partnerships and public funding to buy and retire qualifying debt. Ask: which approach, if any, would you support here, and how would you pay for and measure it?
• The numbers. Public reporting is uneven. The Census Bureau releases health-insurance estimates annually, but states generally do not publish a comparable yearly count of serious harm from diagnostic error. Ask: will you publish an annual uninsured rate and a serious-diagnostic-harm measure using a consistent, publicly documented definition, along with next year’s targets?

6. Your medical board

State medical boards license physicians and enforce professional standards. The Federation of State Medical Boards is developing recommendations about AI used in medical practice, including direct-to-consumer and autonomous services. The key questions are which activities count as the practice of medicine, what oversight is required, and who is accountable for harm.

7. Your next step

• Official South Dakota election site, with early-voting dates and your polling place: https://sdsos.gov/elections-voting/
• Register or check your registration: https://vote.gov/register/south-dakota
• Seven questions to ask anyone who wants your vote: robinblackstone.com/sevenquestions
• The map of who decides what: robinblackstone.com/whodecides
• Another state: robinblackstone.com/yourstate

Ask them yourself

These are the people who want your vote, or who already have the job. Each link is the official page where you can find yours and write or call. The seven questions to ask are at robinblackstone.com/sevenquestions, and so is the place to tell us what they said.

• Your governor’s office: https://governor.sd.gov/office/contact.aspx
• Your state legislators (find yours by address): https://sdlegislature.gov/legislators/find
• Your U.S. Representative (by ZIP): house.gov/representatives/find-your-representative
• Your two U.S. Senators: senate.gov/senators/senators-contact.htm
• Candidates for these offices: your state’s official election site above lists everyone on your ballot.

Save your South Dakota card (PDF)

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Where I stand. I am not a member of any party. This is not a paid announcement. I am not raising money, and nobody is paying me to write this. I am a surgeon with conflicts of interest like everyone in this field: I founded the companies and the charity that carry this work, and I write books about it. None of them profit from how you vote. — Robin Blackstone, MD