Healthcare

South Dakota Republicans Put a Measure on Tuesday's Ballot That Would End Medicaid Expansion for 30,000 People If Washington Cuts Its Share

South Dakota voters expanded Medicaid themselves in 2022. Now the Republican legislature has put Amendment I on the ballot, which ends the expansion if federal funding drops below 90%. Ten states already have 'trigger laws' like it, and Republicans in Congress have already tried to make that cut.

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South Dakota Republicans Put a Measure on Tuesday's Ballot That Would End Medicaid Expansion for 30,000 People If Washington Cuts Its Share
Photo: Brian Cahn/Zuma, via Mother Jones

In 2022, South Dakota voters expanded Medicaid themselves, through a ballot measure. On Tuesday, the Republican-controlled legislature is asking them to put an off switch on it.

Amendment I would change the state constitution so that South Dakota no longer has to provide expanded Medicaid if the federal government's share of the cost drops below 90%. The state attorney general's official ballot explanation says the measure "ends the expanded Medicaid coverage" if that happens. The legislature put it on the ballot, Ballotpedia reports.

The money it's tied to supports health coverage for about 30,000 South Dakotans, Dakota News Now reports.

A switch waiting for Washington to flip it

Mother Jones reported on October 31 that if Amendment I passes, South Dakota would become the 11th state with a Medicaid "trigger law." Ten states already have one. Almost all of them would be set off by any further drop in federal matching money. Utah passed the most recent one in March. Republican legislatures in Oklahoma and West Virginia have pushed for them too.

"It requires the state to eliminate coverage," Adam Searing of Georgetown University's McCourt School of Public Policy told Mother Jones. "There's not going to be a debate in the state about it. It's not going to be up to the legislators."

Supporters say it isn't that simple. The amendment's Senate sponsor, Republican Casey Crabtree, told Dakota News Now that "it only acts if Washington breaks its original promise of supporting this with a 90% federal match." Opponents read it the other way. "If this amendment is supported, then we are done with Medicaid expansion," said Jean Hunhoff, a nurse and former lawmaker.

Republicans in Washington have already tried to break that promise

The 90% match is the deal that came with the Affordable Care Act: the federal government pays most of the cost so states can afford to cover more low-income adults. A trigger law only matters if Congress cuts that share. And Republicans have already tried to.

In 2025, Sen. Rick Scott of Florida pushed an amendment to Trump's budget bill that would have lowered the federal match. It didn't pass. But two right-wing think tanks, the Heritage Foundation and the Paragon Health Institute, have both called for cuts to the match, Mother Jones reports.

The budget bill that did pass cut Medicaid by nearly $1 trillion, and Mother Jones reports it has encouraged Republican state lawmakers to move in this direction. We've reported how Republicans scheduled most of that pain for after the midterms. In Arkansas, the Trump administration refused to renew the state's Medicaid expansion, which covers more than 211,000 people, citing rules in that same law.

That's how a trigger law works: the state sets it now, and a cut in Washington sets it off later.

Who would feel it

"In a state like South Dakota, where you know you have a very [substantial] rural population, this is just going to compound," Natasha Murphy of the Center for American Progress told Mother Jones. She said it would hit health care providers, hospitals and health systems.

"There are hospitals in South Dakota that are very much balancing on the edge," Deb Fischer-Clemens, an opponent of the amendment, told Dakota News Now.

Searing said trigger laws are at least more honest than the federal cuts. "They at least have to admit, 'Hey, we are holding the steering wheel here, and we're going to cut people off of their health insurance if we don't get enough money from the federal government,'" he said. "I don't think either of them is a good thing. It doesn't make any sense to have more people uninsured."

The short version

South Dakota voters expanded Medicaid in 2022. Their Republican legislature has put Amendment I on Tuesday's ballot, which would end that expansion, now supporting coverage for about 30,000 people, if the federal share falls below 90%. Ten states already have trigger laws like it, and Republicans in Congress, backed by Heritage and Paragon, have already tried to cut that federal share.

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