South Dakota voters face a healthcare decision on the November 3 ballot as opponents of Amendment I warn that automatically repealing Medicaid expansion during federal funding shortfalls would restrict patient access, strain rural clinics, and shift more health care costs onto people with private insurance.
In Plain English: The Clinical Takeaway
- Uncompensated Care Burden: When uninsured patients lose coverage, hospitals treat medical emergencies anyway, forcing facilities to absorb financial deficits.
- Private Insurance Cost Shifting: Hospitals typically offset these unpaid emergency bills by raising prices for patients with commercial health insurance, ultimately driving up yearly family premiums.
- Preventive Care Disruption: Medicaid expansion currently provides critical early screenings and chronic disease management, keeping vulnerable populations out of high-cost emergency departments.
The Financial Mechanics of Uncompensated Care in South Dakota
Medicaid expansion currently provides about $400 million annually to hospitals, according to South Dakota Association of Healthcare Organizations President Tim Rave. Authorized by state voters via a 2022 citizen-initiated constitutional amendment, the program covers adults earning up to 138% of the poverty level under a 90% federal funding match established during the President Barack Obama administration. Because this expansion is embedded in the state constitution, only voters can alter it.
Amendment I, sponsored by former Republican Representative Will Mortenson of Fort Pierre, would automatically repeal Medicaid expansion if federal funding falls and no longer covers 90% of the program’s costs. Proponents argue the measure allows lawmakers to consider repealing, altering or maintaining it if federal funding falls below that level, giving lawmakers the flexibility to decide whether Medicaid expansion should continue, rather than protecting it ahead of other budget priorities, such as K-12 education. However, opponents counter that the measure threatens the operational stability of medical centers across the state.
Rural Hospital Vulnerability and Patient Access Risks
The ‘No on I’ coalition is led in part by Jean Hunhoff, a longtime nurse and former state lawmaker, alongside South Dakota Nurses Association President Deb Fischer-Clemens. They argue that undoing the expansion will disproportionately harm rural communities. Rural hospitals and clinics often operate on thin margins. Stripping away federal Medicaid reimbursement turns routine preventive visits and minor treatments into unreimbursed losses.
Fischer-Clemens emphasized that coverage protects real families by managing conditions before they escalate into emergencies. Without baseline insurance coverage, low-income patients may delay care, leading to conditions that require emergency room visits and surgeries. Hospitals cannot turn away patients because they are uninsured, meaning facilities must find other revenue sources, cut services, or charge other people more to make up their losses.
Contraindications & When to Consult a Doctor
Emergency departments remain obligated to stabilize patients regardless of their ability to pay.
Evaluating Fiscal Priorities Ahead of the November Vote
As the November 3 election approaches, voters must weigh competing governance philosophies regarding state budgets and public health safety nets. While supporters of Amendment I frame the measure as a vital fiscal guardrail, healthcare advocates warn that dismantling the program will not eliminate the underlying medical needs of vulnerable populations. As Fischer-Clemens noted, the public will pay for these people’s health care, whether you cut Medicaid or not—either through organized preventive Medicaid investments or through higher private insurance premiums.
References
- South Dakota Searchlight: Reporting on Amendment I and the No on I Coalition Press Conference (September 2026).
- South Dakota Association of Healthcare Organizations: Medicaid Expansion Reimbursement Impact Data.
