South Dakota Votes on Tying Medicaid Expansion to a 90 Percent Federal Match. Its Sponsors and Its Ballot Language Disagree on the Effect.
Amendment I would end South Dakota's duty to cover 31,000-plus expansion adults if the federal match drops below 90 percent. Sponsors dispute the wording.
South Dakota voters decide on Nov. 3 whether the state's Medicaid expansion should stay in the constitution only as long as the federal government pays at least 90 percent of its cost. The measure, Amendment I, covers a group of more than 31,000 people.
Amendment I was placed on the ballot by the Legislature as House Joint Resolution 5001 in 2025. It would change the constitutional section added by Amendment D, the citizen initiative voters approved in 2022 that wrote Medicaid expansion into the state constitution. Polls in South Dakota close at 7 p.m. local time, Dakota News Now reported.
What does the official ballot language say?
It says the amendment ends expansion if federal funding drops. The title written by Attorney General Marty Jackley is "An Amendment to the South Dakota Constitution that Repeals Expanded Medicaid Coverage if Federal Funding for the Program Drops below 90%," according to the final statement filed May 18 with the Secretary of State.
The explanation says Amendment D requires coverage for adults over 18 and under 65 with incomes at or below 133 percent of the federal poverty level, plus 5 percent of the poverty level, and that federal law currently funds 90 percent of the expansion. If funding falls below that threshold, it says, "Medicaid coverage will once again only apply to low-income children, pregnant women, disabled individuals, and the elderly." A yes vote adopts the amendment. A no vote leaves the constitution as it is.
Why do the sponsors object to that wording?
They say the change would not be automatic. Rep. Will Mortenson, R-Fort Pierre, the measure's sponsor, called the title and explanation "100% inaccurate" and said the measure "would absolutely not immediately remove Medicaid coverage for the expansion population," according to KFGO's Sept. 19 report. Lt. Gov. Tony Venhuizen, an original sponsor, said the language "implies that this is automatic, and it is not." In their reading, the amendment removes a constitutional requirement and leaves the next decision to the Legislature.
Jackley told KFGO the language is accurate. Tim Rave, president and chief executive of the South Dakota Association of Healthcare Organizations, said the plain text means coverage "will end if the federal match changes." Sen. Casey Crabtree, the Senate sponsor, told Dakota News Now that the measure "only acts if Washington breaks its original promise of supporting this with a 90% federal match."
Neither reading changes anything on Nov. 4. Amendment I matters only if Congress changes the expansion match, and that is the trigger practices should watch.
What is at stake, by the numbers?
The state Department of Social Services reported more than 31,000 people in expanded Medicaid out of about 143,000 total Medicaid enrollees, KFGO reported. By the Script Pad's arithmetic, that is about 22 percent of the program, a little more than one enrollee in five.
The trigger is about the state's share. At a 90 percent match, the state pays 10 cents of every expansion dollar. At 80 percent it would pay 20 cents, double, and at 70 percent it would pay 30 cents, triple. Lawmakers estimate that at a 70 percent match the state would owe about $72 million to keep expansion going, KFGO reported. Rave put expansion payments to hospitals, clinics and other providers at about $400 million a year, which works out, by our rough division, to roughly $12,900 per expansion enrollee. Both figures come from the sides of the debate, not from an official fiscal note.
Separately, the department estimates that 1,213 South Dakotans could lose expanded coverage when federal work requirements take effect next year. Our coverage of the court fight over the work rule's medically frail test explains how those exemptions work.
What practices should watch
For South Dakota practices, the near-term coverage picture is the same whichever way the vote goes: expansion enrollees stay covered unless the federal match drops below 90 percent. The variables to track are federal, not state: any change Congress makes to the expansion match and the work requirement's start date. Practices with large expansion panels can identify those patients now, so that eligibility checks and patient notices are ready if either changes. Our overview of the eight health measures on today's ballot covers the other states.
Reported, fact-checked and edited by The Script Pad's editorial staff. See How we use AI.
This article is for professional education and does not replace clinical judgment. Treatment decisions should be based on the individual patient and current guidelines.
