On Tuesday, South Dakota voters approved Amendment F, amending the South Dakota Constitution to allow the state to set work requirements for Medicaid if approved by the federal government. The measure was passed 56% to 44% per the unofficial results.
The federal government does not establish work requirements for Medicaid. States that wish to add work requirements for Medicaid coverage must get approval of a section 1115 waiver from the Centers for Medicare and Medicaid Services (CMS). Georgia was the only state to have work requirements for its Medicaid program as of November 2024. Twelve other states were approved for a section 1115 waiver under the previous Trump administration. Under the Biden administration, CMS revoked all 13 waivers, and Georgia was the only state to regain their waiver after litigation.
State Representative Tony Venhuizen (R) argued in support of the measure. “Amendment F would allow South Dakota to consider a work requirement for working-age, able-bodied adults who want to enroll in Medicaid expansion. Currently, we can’t encourage these folks to seek work or training to get back on their feet, rather than stay on government programs for the long-term. By voting YES, we can fix the current language, which prohibits South Dakota from even considering a work requirement. Our welfare programs should care for those who can’t care for themselves – the elderly, the young, and the disabled. Amendment F allows the state to require able-bodied, working-aged people who enroll in Medicaid to work or go to school, to support themselves and their families.”
Sarah Graves, who is a nursing student and volunteer with the American Cancer Society Cancer Action Network, argued in opposition to the measure. “Voters approved Medicaid expansion to provide health coverage to thousands of South Dakotans and Amendment F will take away that health coverage for some of those residents. What Medicaid expansion means for people in the gap – those with low incomes who can’t get insurance through their jobs, and who can’t afford insurance on their own because the costs are sky-high – is that they are no longer forced to choose between medical care or rent, food, childcare, and other necessities. It also means that if they are too sick to work, they do not automatically lose access to care.”
The ballot measure does not immediately create any work requirements for Medicaid. It does make it possible for the state of South Dakota to consider adding a work requirement for the program. The citizen initiative that amended the state constitution in 2022 to expand Medicaid did not permit work requirements. Amendment F was referred to the ballot by the legislature to repeal the prohibition on work requirements.
Legislatures in two other states — Kansas and Mississippi — considered but did not pass bills to expand Medicaid in 2024. Both bills would have included work requirements.
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