Voters Have Expanded Medicaid in 6 States. Is South Dakota Next?

“With people being put on Medicaid, you’re taking purpose from people, you’re taking dignity from people,” Mr. Moore said. “People need to work.”

But advocates say South Dakotans who need health care are already working; the state’s unemployment rate is 2.3 percent, the lowest figure in more than a decade. The prospect of new jobs is one reason the board of the South Dakota Chamber of Commerce and Industry voted to back Amendment D in September after a “healthy debate,” said David Owen, its president and chief lobbyist.

“The infusion of money into the health care system will help stabilize and create health care jobs,” he said. “When you look at this in reality, you just have to come to the conclusion that we keep South Dakota money here.”

Proponents of expansion are confident because there has already been a test vote. During the state’s primary election in June, voters rejected a ballot measure that would have required a majority of 60 percent to approve any constitutional amendment. That measure, known as Amendment C, was widely considered an effort by opponents of Medicaid expansion to thwart it.

“They put all their eggs in one basket,” Mr. Owen said. “It didn’t work.”

Once Amendment C failed, donations from Americans for Prosperity and other opponents dried up, said State Senator John Wiik, a Republican leading the fight against expansion. Referring to the state’s major health care organizations, he said, “I kind of feel like I’m up against three big old medical Goliaths, here all by myself.”

A recent survey by South Dakota State University that found 53 percent of likely voters supported Medicaid expansion, 20 percent were opposed and 27 percent were undecided. The coalition backing the amendment, which calls itself South Dakotans Decide Healthcare, has raised more than $3 million, most of it from health care organizations, according to campaign finance filings. Mr. Wiik said his side had raised “absolutely zero.”

Still, Mr. Wiik said he remained hopeful. He said Republicans in the state’s Legislature had taken steps to expand access to care by increasing reimbursement rates for health providers and helping the South Dakota Farm Bureau improve its health insurance offerings. (The Farm Bureau tilts Republican, while the farmers’ union leans Democratic.)