周二，南达科他州选民将决定是否批准一项由共和党主导的州议会发起的投票提案，该提案将在国会降低联邦配套支付比例（目前为90%）时，自动废除医疗补助扩展计划。
On Tuesday, South Dakotans will decide whether to approve a Republican state legislature–led ballot measure that would automatically repeal Medicaid expansion in the event that Congress lowers federal matching payments, which currently sit at 90 percent.
这一共和党推动的举措发生在南达科他州选民批准另一项由公民发起的投票提案、通过医疗补助扩展计划的四年之后。
The Republican push comes four years after South Dakotans approved another citizen-led ballot measure to pass Medicaid expansion.
此举将使南达科他州成为最新一个实施医疗补助“触发法”的州，即如果联邦资金低于该门槛，将取消扩展计划。已有十个州通过了此类法律，几乎所有这些法律都会在医疗补助配套资金进一步下降时被触发——最近的是犹他州，该州于今年三月通过了医疗补助触发法。自唐纳德·特朗普总统于2025年重返白宫以来，其他保守州（包括俄克拉荷马州和西弗吉尼亚州）的共和党主导的立法机构也在推动医疗补助扩展触发法。
The move would make South Dakota the latest state to implement Medicaid-gutting “trigger laws” that would eliminate expansion programs if federal funding drops below that threshold. Ten states have already passed such laws, almost all of which would be triggered by any further drop in Medicaid matching funds—most recently Utah, which passed its Medicaid trigger law this past March. Republican-dominated legislatures in other conservative states, including Oklahoma and West Virginia, have also pushed for Medicaid expansion trigger laws since President Donald Trump resumed office in 2025.
“这要求州政府取消保障，”乔治城大学麦考特公共政策学院副教授亚当·西林告诉我，“州里不会对此进行辩论。这也不会取决于立法者。”凯斯西储大学法学与生物伦理学教授、该校法律-医学中心联合主任莎伦·霍夫曼解释说，联邦配套资金的设立旨在激励各州在2010年《平价医疗法案》通过时采纳医疗补助扩展，以尽量减少对州预算的影响。
“It requires the state to eliminate coverage,” Adam Searing, an associate professor of practice at Georgetown University’s McCourt School of Public Policy, told me. “There’s not going to be a debate in the state about it. It’s not going to be up to the legislators.”Federal matching funds were set up to incentivize states to adopt Medicaid expansion when the Affordable Care Act was passed in 2010, minimizing the impact on state budgets, explained Sharona Hoffman, professor of law and bioethics at Case Western University and co-director of the university’s Law-Medicine Center.
包括传统基金会和帕拉贡健康研究所在内的右翼政策智库一直主张削减联邦配套资金，这将触发相关法律生效。特朗普2025年预算法案——即所谓的“一个宏伟美丽的法案”——中近1万亿美元的医疗补助削减，涉及实施工作要求以及减少服务和资金，这促使全国各地的共和党州议员朝着这一方向行动。
Right-wing policy think tanks including the Heritage Foundation and the Paragon Health Institute have advocated for cuts to federal matching funds that would set trigger laws into motion. The nearly $1 trillion in cuts to Medicaid in Trump’s 2025 budget bill, the so-called “One Big Beautiful Bill Act,” which involves implementing work requirements and reducing services and funds, has encouraged GOP state legislators across the country to move in just that direction.
美国进步中心健康政策主任娜塔莎·墨菲表示：“我认为，很长一段时间以来，州政策制定者首次非常非常密切地关注联邦预算部分与州政府真正负责事项之间的关系。”
“I do think that state policymakers, for the first time in a long time, are paying very, very close attention to the relationship between federal portions of the budget and really what the state is responsible for,” said Natasha Murphy, director of health policy at the Center for American Progress.
但他们的联邦层面对应人物未能成功将医疗补助配套比例降至90%以下，尽管由参议员里克·斯科特（共和党-佛罗里达州）牵头曾试图修正《一个宏伟美丽的法案》以达到这一目的。
But their counterparts at the federal level haven’t succeeded in reducing Medicaid matching funds below 90 percent, despite an effort led by Sen. Rick Scott (R-Fla.) that would have amended OBBA to that end.
墨菲说，如果南达科他州通过该法律，且联邦配套比例最终被降低，对该州的后果将是灾难性的——正如在已经通过触发法律的各州一样。
If South Dakota passes the law and federal matching is ultimately lowered, Murphy said, the outcome for the state will be disastrous—as it would be in the states that have already passed trigger laws.
墨菲说：“这对医疗服务提供者、医院和医疗系统有一种逐级传导的影响。在像南达科他州这样拥有大量农村人口的州，这只会使情况雪上加霜。”但与联邦医疗补助削减周围的言论相比——共和党议员在很大程度上否认有削减服务或切断许多选民福利的意图，尽管影响显而易见——医疗补助扩展触发法律的欺骗性较小。
“There is a trickle-down impact that has on healthcare providers and hospitals and health systems,” Murphy said. “In a state like South Dakota, where you know you have a very [substantial] rural population, this is just going to compound.”But compared to the rhetoric around federal Medicaid cuts—where GOP legislators have largely denied the intent to reduce services or cut off many of their constituents, despite the clear impact. Searing grants that Medicaid expansion trigger laws are less deceptive.
“他们至少得承认：‘嘿，我们手握方向盘，如果联邦政府不给足够的钱，我们就要切断人们的医保，’”西林说。“OBBA削减更为隐蔽。但我认为这两者都不是好事。让更多人失去医保毫无道理。”
“They at least have to admit, ‘Hey, we are holding the steering wheel here, and we’re going to cut people off of their health insurance if we don’t get enough money from the federal government,” Searing said. “[OBBA] cuts are more insidious. [But] I don’t think either of them is a good thing. It doesn’t make any sense to have more people uninsured.”