An economic assistance application for the South Dakota Department of Social Services

South Dakota Voters Reject Amendment I to Protect Medicaid Expansion

by

South Dakota voters have delivered a definitive message to the state legislature: the current Medicaid expansion program is not up for debate.

During Tuesday’s election, 56% of voters rejected Amendment I, a lawmaker-proposed measure that would have allowed the state to repeal the expansion if federal funding levels ever dipped.

The failure of the amendment marks the latest chapter in a long-standing tension between the state’s Republican-controlled government and the electorate. As the South Dakota Searchlight reported, the result suggests that despite recurring legislative efforts to reshape or scale back the program, the public remains committed to the expansion they originally cemented into the state constitution in 2022.

A Call for Legislative Stability

For those who spent months campaigning against Amendment I, the outcome shows that the time for tinkering has passed. Opponents of the measure argue that the program is already functioning as intended and that constant legislative interference creates unnecessary uncertainty for both patients and healthcare providers.

I think it shows that a majority of South Dakotans supported Medicaid expansion in the past and still do, and just don’t want to mess with it.

That sentiment comes from Tim Rave, a Republican former legislator who now serves as the president and CEO of the South Dakota Association of Healthcare Organizations. For Rave, the focus now pivots from ballot-box battles to the broader financial realities of the state’s healthcare infrastructure. He noted that his organization will closely monitor state revenues and how they might affect overall healthcare funding.

Deb Fischer-Clemens, president of the South Dakota Nurses Association and a former Democratic legislator, led the organized opposition to the amendment. She expressed a sense of relief that the voters have spoken so decisively, stating she is hopeful that the message is clear to lawmakers in Pierre.

“I just hope that they move on,” Fischer-Clemens said. “Other than that, we’ll be watching. We will be watching and paying attention and listening.”

Public comment from the health foundation nys proposed medicaid waiver amendment

The Budgetary Argument

While the voters have made their preference known, the fiscal concerns driving some lawmakers remain unresolved. Representative Will Mortenson, a Republican from Fort Pierre who sponsored the resolution that sent the issue to the ballot, warned that the state’s balanced budget could face pressure if the federal government shifts a larger share of the costs onto South Dakota.

Current estimates suggest that if federal support were to drop from its current 90% level to 70%, the state would need to cover approximately $72 million to maintain the program. State Senator Taffy Howard, a Republican from Rapid City who was reelected on Tuesday and serves on the budget committee, maintains that “something has to be done” regarding these potential constraints.

Whether the legislature will attempt a new approach in the coming session remains an open question, though Howard acknowledged she is unsure if lawmakers will revisit the program in the immediate future.

Shifting Sands of Direct Democracy

The rejection of Amendment I was accompanied by the failure of Amendment L, which would have raised the threshold for passing future constitutional amendments from a simple majority to 60%. This unsuccessful bid was viewed by many, including former Democratic legislator Reynold Nesiba, as an attempt by the Republican majority to “whittle away at direct democracy” following the success of the Medicaid expansion measure.

This is not the first time such an effort has failed. Voters previously rejected similar attempts to increase the bar for constitutional changes in 2018 with Amendment X and in 2022 with Amendment C. The recurring nature of these ballot questions highlights a deep-seated disagreement over how much power should rest with the legislature versus the voters at the polls.

The Human Stakes Ahead

These changes, which trace back to federal legislation often associated with the “One Big Beautiful Bill Act,” bring the national policy conversation directly into the lives of South Dakota families.

As the state moves forward, the intersection of these federal requirements and the state’s budgetary obligations will likely define the next session in Pierre. For now, the constitutional protection of Medicaid expansion remains intact, leaving lawmakers to weigh their fiscal concerns against the clear mandate of the voters.

Related reading

Read next