South Dakota Constitutional Amendment I, Medicaid Expansion Conditioned on 90% Federal Funding Amendment (2026)

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South Dakota Constitutional Amendment I

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Election date

November 3, 2026

Topic
Public assistance programs and Public health insurance
Status

On the ballot

Type
Legislatively referred constitutional amendment 		Origin

State legislature


South Dakota Constitutional Amendment I, the Medicaid Expansion Conditioned on 90% Federal Funding Amendment, is on the ballot in South Dakota as a legislatively referred constitutional amendment on November 3, 2026.

A "yes" vote supports amending the South Dakota Constitution to make Medicaid expansion contingent on the federal government covering at least 90% of the program's cost. Under Amendment D (2022), Medicaid was expanded to persons with incomes below 138% of the poverty level, with 90% of the program’s cost covered by federal funding under the Affordable Care Act. If federal funding drops below 90%, the proposed amendment would remove the state’s constitutional obligation to provide the coverage.

A "no" vote opposes amending the South Dakota Constitution to make Medicaid expansion contingent on the federal government covering at least 90% of the program's cost.


Overview

What would this amendment do?

This amendment would condition state Medicaid expansion on federal funding remaining at or above 90%. Voters in South Dakota voted to expand Medicaid in 2022 when they approved Amendment D, which required the state to provide Medicaid benefits to adults between 18 and 65 with incomes below 133% of the federal poverty level.[1]

Under this amendment, if federal funding for Medicaid falls below 90%, the constitutional requirement for Medicaid expansion would no longer apply.[1]

What is the status of Medicaid in South Dakota?

The Medicaid program provides medical insurance to groups of low-income people and individuals with disabilities and is jointly funded by the federal government and the states. Medicaid eligibility, benefits, and administration are managed by the states within federal guidelines. Because South Dakota voters approved Amendment D in 2022, Medicaid was expanded in the state to include all individuals earning incomes up to 138% of the federal poverty level.[2]

In 2024, South Dakota voters also approved Amendment F, which allowed for the state legislature to establish work requirements for individuals eligible for Medicaid under the program expansion that voters approved in 2022. Under that amendment, work requirements apply to individuals who are not diagnosed as mentally or physically disabled.

Have other states expanded Medicaid?

The Affordable Care Act (ACA) was signed into law on March 23, 2010. The ACA provided for the expansion of Medicaid to cover all individuals earning incomes up to 138% of the federal poverty level, which amounted to $17,774 for an individual and $36,570 for a family of four in 2021. The law was designed to provide 100% of funding to cover the new recipients for the first three years and to cut off federal Medicaid funding to states that chose not to expand coverage. However, the United States Supreme Court ruled in National Federation of Independent Business v. Sebelius (2012) that the federal government could not withhold Medicaid funds from states that chose not to expand eligibility. According to the Kaiser Family Foundation, this ruling had the practical effect of making Medicaid expansion optional for states.[3]

As of 2025, 41 states and Washington, D.C., had expanded or voted to expand Medicaid, while 10 states did not.[4]

Text of measure

Constitutional changes

See also: Article XXI, South Dakota Constitution

The ballot measure would amend Section 10 of Article XXI of the South Dakota Constitution. The following underlined text would be added and struck-through text would be deleted:[1]

Note: Hover over the text and scroll to see the full text.

Beginning For the period beginning July 1, 2023, and ending on the day that the federal medical assistance percentage, described in 42 U.S.C. § 1396d(y) (January 1, 2025), is reduced below ninety percent, the State of South Dakota shall provide Medicaid benefits to any person over eighteen and under sixty-five whose income is at or below one hundred thirty-three percent of the federal poverty level plus five percent of the federal poverty level for the applicable family size, as authorized by federal law as of January 1, 2021. Such person shall receive coverage that meets or exceeds the benchmark or benchmark-equivalent coverage requirements, as such terms are defined by federal law as of January 1, 2021.

The State of South Dakota may not impose greater or additional burdens or restrictions on eligibility or enrollment standards, methodologies, or practices on any person eligible under this section than on any person otherwise eligible for Medicaid under South Dakota law, except that the State of South Dakota may, to the extent permitted by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, impose a work requirement on any person, eligible under this section, who has not been diagnosed as being physically or mentally disabled.

No later than March 1, 2023, the Department of Social Services shall submit all state plan amendments necessary to implement this section to the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services.

The State of South Dakota shall take all actions necessary to maximize the federal financial medical assistance percentage in funding medical assistance pursuant to this section.

This section shall be broadly construed to accomplish its purposes and intents. If any provision in this section or the application thereof to any person or circumstance is held invalid or unconstitutional, such invalidity or unconstitutionality shall not affect other provisions or applications of the section that can be given effect without the invalid or unconstitutional provision or application, and to this end the provisions of this section are severable.[5]

Support

Supporters

Officials

Arguments

  • State Sen. Casey Crabtree (R): "One of the key points by proponents of Medicaid expansion was that federal government pay 90% and South Dakota taxpayers pay the remaining 10%. Right now, that 10% is projected to cost South Dakota taxpayers about $20 million a year for the upcoming fiscal year … We want to emphasize that this proposed amendment honors the will of the voters. The voters passed Medicaid expansion with the clear understanding that the federal government would pay 90% of the costs. In 2024, the voters supported us by improving the constitutional language to allow for a work requirement for able-bodied adults. With this proposal, we are once again asking the voters to clarify their intent: If the federal match rate for Medicaid drops below 90%, do they want the legislature to be able to consider the budgetary implications?"

Opposition

Opponents

Officials

Arguments

  • State Sen. Liz Larson: “People shouldn’t die because they can’t afford to live. Medicaid expansion has been a lifeline for 28,000 South Dakotans, and it’s saved lives.”


Campaign finance

See also: Campaign finance requirements for South Dakota ballot measures

Ballotpedia did not identify ballot measure committees registered to support or oppose the ballot measure.[6]

Cash Contributions In-Kind Contributions Total Contributions Cash Expenditures Total Expenditures
Support $0.00 $0.00 $0.00 $0.00 $0.00
Oppose $0.00 $0.00 $0.00 $0.00 $0.00
Total $0.00 $0.00 $0.00 $0.00 $0.00

Background

Medicaid expansion under the ACA

See also: Medicaid

The Affordable Care Act (ACA) was signed into law on March 23, 2010.[7] The ACA provided for the expansion of Medicaid to cover all individuals earning incomes up to 138 percent of the federal poverty level, which amounted to $17,236 for individuals in 2019.[8][9][10] The law was designed to provide 100 percent of funding to cover the new recipients for the first three years and to cut off federal Medicaid funding to states that chose not to expand coverage. However, the United States Supreme Court ruled in National Federation of Independent Business v. Sebelius (2012) that the federal government could not withhold Medicaid funds from states that chose not to expand eligibility. According to the Kaiser Family Foundation, this ruling had the practical effect of making Medicaid expansion optional for states.[3]

From 2014 to 2016, the federal government covered 100 percent of the costs of state expansion of Medicaid. In 2017, the total cost of expanded coverage that the federal government financed decreased to 95 percent. The ACA was designed to decrease the amount the federal government covers to 94 percent in 2018, 93 percent in 2019, and 90 percent in 2020 and subsequent years.[11]

The Affordable Care Act had not provided tax credits to adults with household incomes less than the federal poverty line because the law had aimed to cover these people under Medicaid. In states that did not expand Medicaid, many of these adults fell into a coverage gap in which they neither qualified for Medicaid nor for federal tax credits to purchase health insurance. As of 2018, around 2.5 million people fell into this coverage gap across the states that did not expand Medicaid.[8]

Medicaid in South Dakota

The South Dakota Department of Social Services (DSS) is the agency responsible for administering Medicaid.[12] In 2024, the DSS reported that 140,074 individuals participated in the Medicaid program in 2024.[2]

There are multiple Medicaid programs in South Dakota, each with their own eligibility and rules. As of 2025, state medical programs in South Dakota included:[12]

  • Medicaid Expansion - Adult Group (approved by voters in 2022);
  • Children’s Health Insurance Program (CHIP);
  • Low-Income Families;
  • Pregnant Women;
  • Newborns;
  • Medicare Savings Program;
  • Individuals in Assisted Living Facilities, Nursing Facilities or Homes;
  • Breast and Cervical Cancer Program;
  • HOPE Waiver for Individuals in Assisted Living or Community Home Facilities;
  • HOPE Waiver for Individuals Living in their Homes;
  • CHOICES Waiver for Children and Adults with Disabilities;
  • Family Support 360 Waiver for Children and Adults with Disabilities;
  • Disabled Children's Program;
  • Assisted Daily Living Services Waiver for Individuals with Quadriplegia;
  • South Dakota Medicaid for Workers with Disabilities (MAWD);
  • Individuals with Chronic Renal Disease;
  • South Dakota Medicaid for Youth Formerly in Foster Care;
  • South Dakota Medicaid for Individuals in Adult Foster Care Facilities;
  • Adults Currently and Formerly Receiving Supplemental Security Income; and
  • Refugee Medical Assistance.


Medicaid eligibility

As of 2025, adults under the Medicaid expansion were eligible for Medicaid based on the following income ranges:

South Dakota Medicaid Expansion Adult Group
Household size Maximum gross monthly income
1 $1,800
2 $2,433
3 $3,065
4 $3,698
5 $4,331
6 $4,963
7 $5,595
8 $6,228

Constitutional Amendment D (2022)

See also: South Dakota Constitutional Amendment D, Medicaid Expansion Initiative (2022)

On November 8, 2022, South Dakota voters approved Constitutional Amendment D by 56.21% voting to approve the amendment and 43.79% voting to reject the amendment. The amendment required the state to provide Medicaid benefits to adults between 18 and 65 with incomes below 133% of the federal poverty level beginning July 1, 2023. Because the Affordable Care Act includes a 5% income disregard, this measure effectively expanded Medicaid to those with incomes at or below 138% of the federal poverty level.[13][14]

The amendment was placed on the ballot through a citizen initiative campaign. South Dakotans Decide Healthcare led the campaign in support of the initiative, and reported $4.52 million in contributions. No on Amendment D opposed the measure, and reported $3,646 in contributions.

Constitutional Amendment F (2024)

See also: South Dakota Constitutional Amendment F, Medicaid Work Requirement Amendment (2024)

On November 5, 2024, South Dakota voters approved Constitutional Amendment F by 56.12% voting to approve the amendment and 43.88% voting to reject the amendment. The amendment allowed the state legislature to establish work requirements for individuals eligible for Medicaid under the program expansion that voters approved in 2022. The expansion mandated the state to extend Medicaid to adults between 18 and 65 with incomes below 138% of the federal poverty level. Under this amendment, work requirements apply to individuals who are not diagnosed as mentally or physically disabled.[15]

Medicaid expansion

As of March 2025, 41 states and Washington, D.C., had expanded or voted to expand Medicaid, while 10 states had not. The map below provides information on Medicaid expansions by state.

Path to the ballot

Amending the South Dakota Constitution

See also: Amending the South Dakota Constitution

A simple majority vote is required during one legislative session for the South Dakota State Legislature to place a constitutional amendment on the ballot. That amounts to a minimum of 36 votes in the South Dakota House of Representatives and 18 votes in the South Dakota State Senate, assuming no vacancies. Amendments do not require the governor's signature to be referred to the ballot.

House Joint Resolution 501 (HJR 5001)

The following is the timeline of the constitutional amendment in the state legislature:

  • January 14, 2025: House Joint Resolution 501 (HJR 5001) was introduced to the South Dakota State House.[16]
  • January 21, 2025: the House voted 59-7 to pass the amendment.[16]
  • March 3, 2025: the Senate voted 31-3 to pass the amendment.[16]


Partisan Direction Index = 98.9 (Republican)
Democratic Support
0
Republican Support
98.9
How does this vote compare to other legislative ballot measures in 2026?
Learn more about the ballot measures PDI →
South Dakota House of Representatives
Voted on January 21, 2025
Votes Required to Pass: 36
YesNoNV
Total5973
Total %86104.3
Democratic (D)060
Republican (R)5913
South Dakota State Senate
Voted on March 3, 2025
Votes Required to Pass: 18
YesNoNV
Total3131
Total %8992.8
Democratic (D)030
Republican (R)3101

How to cast a vote

See also: Voting in South Dakota

See below to learn more about current voter registration rules, identification requirements, and poll times in South Dakota.

How to vote in South Dakota


See also

  • Ballot measure lawsuits
  • Ballot measure readability
  • Ballot measure polls

External links

Footnotes

  1. ↑ 1.0 1.1 1.2 South Dakota State Legislature, "House Joint Resolution 5001," accessed March 5, 2025
  2. ↑ 2.0 2.1 South Dakota Department of Social Services, "South Dakota Medicaid Report SFY24," accessed March 14, 2025
  3. ↑ 3.0 3.1 Kaiser Family Foundation, "A Guide to the Supreme Court’s Affordable Care Act Decision," July 2012
  4. ↑ Kaiser Family Foundation, "Status of State Medicaid Expansion Decisions," accessed March 15, 2025
  5. ↑ Note: This text is quoted verbatim from the original source.
  6. ↑ South Dakota Campaign Finance Reporting, "Search Committees," accessed March 15, 2025
  7. ↑ New York Times, "Obama Signs Health Care Overhaul Bill, With a Flourish," accessed March 23, 2010
  8. ↑ 8.0 8.1 Kaiser Family Foundation, "The Coverage Gap: Uninsured Poor Adults in States That Do Not Expand Medicaid Coverage," accessed October 23, 2019
  9. ↑ Kaiser Health News, "Consumer’s Guide to Health Reform," April 13, 2010
  10. ↑ Office of The Assistant Secretary for Planning and Evaluation, "Poverty Guidelines," January 25, 2016
  11. ↑ Kaiser Family Foundation, "Understanding How States Access the ACA Enhanced Medicaid Match Rates," September 29, 2014
  12. ↑ 12.0 12.1 South Dakota Department of Social Services, "Medical Programs Available in South Dakota," accessed March 14, 2025
  13. ↑ South Dakota Secretary of State, "Potential 2022 Ballot Questions," accessed July 16, 2021
  14. ↑ South Dakota Secretary of State, "Medicaid expansion initiative (South Dakotans Decide Healthcare," accessed July 16, 2021
  15. ↑ South Dakota Legislature, "Senate Joint Resolution 501," accessed February 27, 2024
  16. ↑ 16.0 16.1 16.2 South Dakota Legislature, "House Joint Resolution 5001," accessed January 24, 2025
  17. ↑ South Dakota Secretary of State, “General Voting Information,” accessed July 23, 2024
  18. ↑ 18.0 18.1 18.2 South Dakota Secretary of State, “Register to Vote, Update Voter Registration or Cancel Voter Registration,” accessed July 23, 2024
  19. ↑ 19.0 19.1 NCSL, "State Profiles: Elections," accessed July 23, 2024
  20. ↑ 2025 South Dakota Legislature, "HB 1066," accessed April 2, 2025
  21. ↑ Under federal law, the national mail voter registration application (a version of which is in use in all states with voter registration systems) requires applicants to indicate that they are U.S. citizens in order to complete an application to vote in state or federal elections, but does not require voters to provide documentary proof of citizenship. According to the U.S. Department of Justice, the application "may require only the minimum amount of information necessary to prevent duplicate voter registrations and permit State officials both to determine the eligibility of the applicant to vote and to administer the voting process."
  22. ↑ 22.0 22.1 South Dakota Secretary of State, "General Voting Information," accessed July 23, 2024
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