South Dakota ballot measure · November 3, 2026
South Dakota Constitutional Amendment I, explained
Repeal Medicaid expansion if federal funding drops below 90%. A ballot measure is a yes-or-no question put directly to voters — no candidate is involved, and the wording on the ballot is the wording that becomes law. This page shows that wording first, then what it actually changes.
The official wordingWhat appears on the ballot. Everything below explains it.
Title: An Amendment to the South Dakota Constitution that Repeals Expanded Medicaid Coverage if Federal Funding for the Program Drops below 90%. Attorney General Explanation: Medicaid is a program, funded by the State and the federal government, to provide medical coverage for low-income children, pregnant women, disabled individuals, and the elderly. In the 2022 General Election the voters approved Constitutional Amendment D, which expanded Medicaid eligibility in South Dakota. Amendment D requires the State to also provide Medicaid benefits to anyone over the age of 18 and under 65 whose income is at or below 133% of the federal property level, plus 5% of the federal poverty level for the applicable family size. Currently, federal law requires the federal government to fund 90% of South Dakota's Medicaid expansion. This proposed Constitutional Amendment ends the expanded Medicaid coverage if the federal funding for expansion drops below 90%. If federal funding drops below that 90% threshold, Medicaid coverage will once again only apply to low-income children, pregnant women, disabled individuals, and the elderly. Vote "Yes" to adopt the amendment. Vote "No" to leave the Constitution as it is.
What it actually means
In 2022 South Dakota voters wrote Medicaid expansion into the state constitution, requiring the state to cover adults aged 18 to 64 with incomes up to about 138% of the federal poverty level. Because it is in the constitution, only voters can undo it. This amendment attaches a condition: the constitutional requirement applies only while the federal government pays at least 90% of the expansion's cost. The amendment's own sponsors and the Attorney General who wrote the ballot language disagree publicly about what happens if the federal share falls — whether coverage ends by itself, or whether the requirement simply lifts and the Legislature then decides.
If you vote YES
- Article XXI, Section 10 of the constitution would apply only "for the period beginning July 1, 2023, and ending on the day that the federal medical assistance percentage … is reduced below ninety percent."
- While the federal share stays at 90%, nothing changes: the roughly 31,000 adults in the expansion group keep coverage and the state keeps paying its 10%.
- If the federal share falls below 90%, Attorney General Marty Jackley's ballot explanation says the expanded coverage ends and Medicaid "will once again only apply to low-income children, pregnant women, disabled individuals, and the elderly." The amendment's sponsors say instead that the constitutional mandate lifts and the Legislature is then free to keep, change or end the expansion.
- Either way, the state would no longer be constitutionally obliged to fund expansion out of its own budget if Washington reduced its share.
If you vote NO
- Article XXI, Section 10 keeps the wording South Dakota voters approved in 2022: the state "shall provide Medicaid benefits" to adults 18 to 64 with incomes at or below 133% of the federal poverty level plus a 5% disregard, with no funding condition attached.
- If the federal match fell below 90%, the state would still be constitutionally required to provide the coverage and would have to find the difference in its own budget, through taxes or cuts elsewhere, unless voters amended the constitution again.
- The roughly 31,000 South Dakotans in the expansion group would keep coverage regardless of what Congress does to the match rate.
- The 2024 amendment allowing the Legislature to impose work requirements on able-bodied expansion enrollees would remain in force.
The numbers that matter
- Adults in the Medicaid expansion group
- More than 31,000
- Total South Dakota Medicaid enrollment
- About 143,000
- Current federal share of expansion costs
- 90%
- South Dakota's regular federal Medicaid match
- 50.56%
South Dakota Department of Social Services, reported August 2026
South Dakota Department of Social Services, 2026
Affordable Care Act expansion match rate, 42 U.S.C. § 1396d(y)
Federal Medical Assistance Percentage for South Dakota outside the expansion, 2026
What each side says3 for, 3 against — quoted, not summarised
Why supporters say YES
"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 … 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?"
— State Sen. Casey Crabtree (R-8)
"For every 10% of Medicaid expansion costs shifted from Washington to South Dakota, our state would have to find about $36 million more each year. That could mean higher taxes or cuts elsewhere. … Amendment I does not prevent South Dakota from continuing Medicaid expansion. It simply ends the constitutional requirement if federal funding falls below 90%. Legislators and voters could then decide whether expansion is still worth the new cost."
— Lt. Gov. Tony Venhuizen, Sen. Casey Crabtree and Rep. Will Mortenson, official "pro" statement in the Secretary of State's 2026 Ballot Question Pamphlet
The amendment "changes it from our hands being tied" if the federal government reduces its share, leaving lawmakers free to weigh the cost against the rest of the budget; lawmakers have estimated that a drop to a 70% federal share would leave the state about $72 million short.
— State Rep. Will Mortenson (R-Fort Pierre), the amendment's sponsor, to South Dakota Searchlight
Why opponents say NO
"A vote NO would allow approximately 30,000 South Dakotans who receive insurance through Medicaid expansion to keep their insurance and access the care needed to stay healthy, support their families, work, and contribute to their communities. A vote NO would ensure that changes in federal funding do not automatically take health coverage from South Dakotans."
— Deb Fischer-Clemens, RN, BSN, MHA, official "con" statement in the Secretary of State's 2026 Ballot Question Pamphlet
"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."
— State Sen. Liz Larson (D-10)
"Preventative care would go away for those folks, emergency room costs would go up for when they get sick. They just wouldn't have the same opportunities that people with insurance have. And it's unfair."
— Deb Fischer-Clemens, president, South Dakota Nurses Association, to South Dakota Searchlight
What's genuinely uncertain
- What the amendment actually does if the federal share falls is disputed by the people responsible for it. Attorney General Marty Jackley, who by law writes the ballot title and explanation, says it repeals the expansion automatically. Rep. Will Mortenson, who sponsored it, calls the title and explanation "100% inaccurate" and says the mandate merely becomes permissive; Lt. Gov. Tony Venhuizen, an original sponsor, said he was "a little concerned that it implies that this is automatic, and it is not." Tim Rave, president of the South Dakota Association of Healthcare Organizations, reads it as automatic: "I read the plain English of the bill. It says it will end if the federal match changes, period." No court has resolved it.
- Whether the federal match will in fact drop below 90% is unknown. The One Big Beautiful Bill Act of 2025 changed expansion eligibility rules and funding, but the 90% expansion match itself was still in place as of September 2026.
- If the mandate lifts rather than repealing coverage outright, what the Legislature would then do is unknown.
- No fiscal note was printed for this measure in the Secretary of State's pamphlet. The $36 million and $72 million figures cited above are the proponents' and legislators' own estimates, not an official estimate.
- The Attorney General's explanation as printed reads "133% of the federal property level"; the constitutional provision it describes says federal poverty level.
The bottom line
Whether the constitution should keep guaranteeing Medicaid expansion whatever Washington pays, or tie the guarantee to the 90% federal share voters were promised in 2022 — with the people who wrote and titled the measure publicly disagreeing about whether coverage would then end by itself or only become the Legislature's call.
One neutral sentence describing the tradeoff — not a recommendation.
Sources (3)The numbers in the text above link here
- 12026 Ballot Question Pamphlet — South Dakota Secretary of State — sdsos.gov
- 2Ballot measure could auto-repeal Medicaid expansion, attorney general says in contrast to lawmakers — South Dakota Searchlight — southdakotasearchlight.com
- 3South Dakota Constitutional Amendment I (2026) — Ballotpedia — ballotpedia.org
Checking it against the official text
The South Dakota Secretary of State publishes the certified measures and, in most states, an official voter guide with fiscal notes. That is the authoritative version. Everything here is an explanation of it, not a substitute for it.
Confirm this with the official source
Your ballot is determined by your election authority, not by us. Verify your registration, precinct, and sample ballot at South Dakota Secretary of State.
Other measures on the South Dakota ballot
Candidates on the same ballot
- U.S. Senate election in South Dakota
- South Dakota governor's race
- South Dakota's at-large congressional district