In South Dakota, voters will decide on a constitutional amendment to condition state Medicaid expansion on federal funding remaining at or above 90%. Voters will decide on the amendment in the election on Nov. 3, 2026.

If federal funding falls below 90%, the constitutional requirement for Medicaid expansion would no longer apply. Voters adopted this constitutional requirement in 2022 with Amendment D, which was approved by 56%-44%. Amendment D expanded Medicaid to adults between 18 and 65 with incomes below 138% of the federal poverty level.

The amendment, House Joint Resolution 501 (HJR 5001), was introduced in the South Dakota House of Representatives. It passed the House by 59-7 on Jan. 21, 2025, and passed the Senate by 31-3 on March 3, 2025. Of the 91 legislative Republicans who voted, 90 supported the amendment, and one opposed it, while all Democrats opposed the amendment.

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. The Affordable Care Act (ACA), which was signed into law in 2010, provided for the expansion of Medicaid to cover all individuals earning incomes up to 138% of the federal poverty level. The law was designed to provide 100% of funding to cover the new recipients for the first three years and to end 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.

In 2024, South Dakota voters approved an amendment by 56%-44%, 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.

To date, 41 states, as well as Washington, D.C., have expanded Medicaid.

Sen. Casey Crabtree (R), who sponsored the amendment in the Senate, said, “One of the key points made by the proponents of Medicaid expansion was that the feds were going to pay 90 percent of the cost, and South Dakota taxpayers would only have to pay 10 percent. Right now, that 10 percent is projected to cost South Dakota taxpayers about $36 million a year.”

Sen. Liz Larson (D), who opposed the amendment, said, “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.”

Currently, this amendment is the only statewide measure on the ballot in South Dakota in 2026. There are four other constitutional amendments that have passed at least one chamber in South Dakota. If they pass both chambers, they will appear on the ballot in 2026.