Many low-income people in South Dakota would need to have a job in order to get Medicaid health care coverage, under a requirement that passed the Republican-led state Senate on Thursday.

The resolution next heads to the GOP-led House, after passing the Senate in a 28-4 vote.

South Dakota Republican lawmakers want to add the work requirement for people who are not physically or mentally disabled, and who are eligible for an expansion of the government-sponsored program that voters approved in 2022. The change, which took effect last summer, greatly increased the number of people who qualify for Medicaid.

The work requirement would still need to be approved by voters in November, and the federal government would then have to sign off on it.

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The 2022 constitutional amendment expanded Medicaid eligibility to people who earn up to 138% of the federal poverty level, which the state Department of Social Services says is up to $41,400 for a family of four.

The expansion was previously opposed by both Republican Gov. Kristi Noem and the GOP-controlled Legislature, which defeated a proposed Medicaid expansion earlier in 2022.

“Really, it’s a fundamental question,” Republican Senate Majority Leader Casey Crabtree, a prime sponsor of the work requirement, told reporters. “Do we want to incentivize those who can, or are able-bodied, those who can work, to do so? Or do we want to leave a gap where government dependency can become a way of life?”

He asserted that work requirements on other state programs have been successful.

Opponents lamented the work requirement as unnecessary, ineffective at encouraging work and going against the will of the voters — as well as creating more paperwork.

“This is about government bureaucracy,” Democratic Senate Minority Leader Reynold Nesiba said. “This is about denying health care to people who otherwise qualify for it.”

Republican Sen. John Wiik bemoaned the 2022 measure as “a petition mostly from out-of-state money to put a federal program into our constitution.”

“Our hands are effectively tied. We need to go back to the voters every time we want to make a change to this program,” he said. “And this is the point we need to learn: Direct democracy doesn’t work.”

Republican Rep. Tony Venhuizen, another prime sponsor, said the resolution is a “clarifying question” that wouldn’t reverse the 2022 vote.

“If this amendment was approved, and if the federal government allowed a work requirement, and if we decided we wanted to implement a work requirement, two or three steps down the line from now, we would have to talk about what exemptions are available,” Venhuizen told a Senate panel on Wednesday.

The expanded eligibility took effect July 1, 2023. Roughly 18,000 South Dakotans are enrolled in Medicaid expansion, according to state Secretary of Social Services Matt Althoff. Of those, 12,000 are already receiving food assistance, thus meeting a work requirement.

More people are expected to enroll in Medicaid expansion, something the Legislature’s budget writers are trying to estimate, Venhuizen said. The 2022 measure was estimated to expand eligibility to 42,500 people.