Voters reject measure that could have triggered repeal of Medicaid expansion in South Dakota

South Dakota voters rejected a ballot question Tuesday that could have triggered a repeal of the state’s Medicaid expansion mandate.

When The Associated Press called the race at 1:22 a.m. Wednesday, 56% of the votes were against Amendment I and 44% were in favor. Over 80% of votes statewide had been counted.

Amendment I would have repealed the Medicaid expansion requirement in the state constitution if the expansion’s federal funding share fell below 90%. The Republican state lawmakers who sent Amendment I to the ballot said expanded Medicaid would be too expensive for the state in that scenario.

One of those lawmakers is Rep. Will Mortenson, R-Fort Pierre, who said Tuesday night that “fiscal policy is a tough sell on the ballot.” He said South Dakota’s schools and nursing homes, and the state’s balanced budget, could be imperiled if the state has to shoulder a bigger share of expanded Medicaid costs in the future.

“I hope the Legislature keeps an eye on this issue going forward,” said Mortenson, who did not seek reelection this year.

Some healthcare officials spoke out against Amendment I. Tim Rave is a Republican former legislator who’s now president and CEO of the South Dakota Association of Healthcare Organizations.

“I think South Dakotans want to make sure that their fellow South Dakotans are taken care of, and they don’t want to face those medical debt challenges,” Rave said Tuesday night.

Medicaid is a federal-state health insurance program for people with low incomes. During the administration of President Barack Obama, the federal government offered to cover 90% of states’ costs to expand eligibility. South Dakota’s Republican-dominated Legislature declined the offer.

In 2022, South Dakota voters approved a citizen-initiated state constitutional amendment. It required an expansion covering adults with incomes up to 138% of the poverty level, adding them to traditional low-income coverage groups such as children, elderly people and people with disabilities.

Among the roughly 143,000 South Dakotans covered by Medicaid, about 31,000 are enrolled through the expansion.

Deb Fischer-Clemens is a nurse, a Democratic former state lawmaker and former senior vice president of Avera’s Center for Public Policy. She’s currently president of the South Dakota Nurses Association. She said Tuesday night “by rejecting Amendment I, voters chose to protect healthcare access for more than 30,000 hard-working South Dakotans and their families.”

Since the expansion’s implementation through the end of the last state fiscal year in June, the state had spent a total of $76 million on it and received $870 million in federal expansion funding, according to the state Department of Social Services.

The broad tax and spending law that President Donald Trump signed in 2025 established work, school or community service requirements that are expected to take effect next year for Medicaid expansion enrollees.