January 2026 Hot Sheet: Florida & South Dakota Advocates Fighting For Medicaid Expansion — And Direct Democracy

01/21/2026

By: Hillary-Anne Crosby, Senior Manager of Public Policy Communications

Welcome back to The Hot Sheet!

Here, we give you a quick rundown of what you need to know about the ballot measure landscape — the trends, legislative analysis, highlights of what’s on the ballot, and why it all matters. 

For more in-depth analysis, our latest voter attitudes research, and information on the measures we’re tracking, head to our Ballot Measure Hub.

2026 Qualified Ballot Measures

As of January 7, BISC is tracking 60 measures qualified for 2026 ballots. 208 initiative campaigns are circulating petitions while 103 additional measures have been filed.

The Toplines

• Attempts to restrict the ballot initiative process and oppress voters are being branded as “protection” and “security” in order to sow distrust in direct democracy specifically and American democracy generally.
• Advocates with Florida Decides Healthcare are heading to federal court to defend their state’s initiative process against a slate of aggressive anti-direct democracy policies. Their lawsuit will have major impacts not only for their state, but for every state where the People’s Tool is under attack.
• A legislatively-referred measure on the November ballot in South Dakota threatens 2022’s voter-approved Medicaid Expansion initiative.
• BISC’s new case study explores how advocates are fighting back after legislators partially repealed successful economic justice initiatives in Missouri and Nebraska, and how implementation serves as a critical battleground for defending direct democracy amid rising authoritarianism.

Emerging Trend

When Voter Oppression Masks as Voter Protection:

• • “Protection” in Missouri
    During a September special session, some Missouri legislators felt called to “protect” voters from the tool that’s recently won them better wages, expanded healthcare access, restored abortion rights, and more. Passed in the state legislature largely along party lines and referred to the November 2026 ballot for voter approval, the so-called “Protect Missouri Voters” amendment seeks to dramatically weaken the People’s Tool.Under the amendment, citizen-led initiatives would have to pass in each of the state’s eight congressional districts in order to succeed. In other words, a single district failing to pass an initiative would mean total statewide loss. (Legislatively-referred measures, on the other hand, would still require only a simple majority.) There are no aspects of the amendment detailing how the majority of Missouri voters would be protected in the event that minority rule overrode an otherwise popular measure.The amendment’s sponsor, Rep. Ed Lewis emphasized that the concurrent majority requirement would require that a citizen-led initiative (and again: only citizen-led initiatives) have “broad geographic support” rather than the kind of broad support typically understood to be associated with election outcomes ( e.g. popular vote, majority will, etc).

• • “Concern” in UtahFrustrated by their repeated failed attempts to ignore the redistricting requirements put in place by a 2018 citizen-led ballot measure, some extremist Utah politicians are hoping to take their revenge on the initiative process itself. After a district court judge recently rejected a gerrymandered map drawn by the legislature, Gov. Cox said he had “deep, deep concerns” about direct democracy. Lawmakers have threatened to pursue a legislatively-referred amendment to limit the power of citizen-led initiatives.

• • “Securing” Elections in Maine, “Repairing” the Vote in Nevada
    Last fall, Maine voters soundly rejected an initiative that claimed to secure state elections through a series of voting restrictions that would have disproportionately affected older voters and voters with disabilities, rural residents, and shift workers. Proponents claimed the changes were “common sense” and “minor”, but included everything from requiring voters to show certain forms of photo ID to shortening the absentee voting period and to strictly limiting the number of ballot drop-off boxes. For the initiative’s architects, “securing” elections also meant barring family members from requesting absentee ballots for their elderly or disabled loved ones and banning prepaid postage from absentee ballot return envelopes.On the other side of the country, a Nevada group called Repair the Vote is attempting to pass their own voter ID initiative. A legislative compromise that would have required voter ID but also expanded the number of ballot drop boxes was ultimately vetoed by Gov. Lombardi, a voter ID proponent, who claimed continued concerns about the security of voting by mail. State law requires that constitutional amendments pass in two general elections; because the initiative received 73% of the vote in 2024, it needs just one more win this November to become law.  

    Despite these continued attempts to pass voter ID ballot measures the fact remains that such laws disproportionately affect marginalized and underrepresented groups. And to what end? Studies have repeatedly shown that voter fraud is ‘infinitesimally rare’ (for example, analysis of more than 25 million ballots across six states in 2020 found that less than 0.000019% showed any signs of being suspect).

So what are we to make of these ironic calls to protect voters by eroding their rights? Or supposed concerns about respecting the will of the people? Or these bad faith efforts to secure elections from the very voters who try to engage in them? These kinds of concerted efforts to sow distrust in the People’s Tool specifically and our elections generally, are part of a larger movement by some lawmakers to undermine our entire democracy. These attacks are branded as necessary defenses in order to deceive voters and to convince us that authoritarian rule is the solution to the chaos those same authoritarians have sown. 

But there is hope, too. BISC’s November 2025 polling on authoritarianism revealed voters are interpreting attempts to restrict ballot initiatives as tied to rising authoritarianism. That’s especially true for those already feeling increasingly concerned about the state of our democracy. As more Americans understand these oppressive efforts for exactly what they are, we must stand together against those who want to make ballot initiatives and our democratic systems harder to use, and protect our power to make real change for our communities. 

Defending Direct Democracy

Florida Decides Healthcare et al v. Byrd et al

The Fight: On February 9, plaintiffs representing Florida Decides Healthcare will begin their federal trial against a slate of aggressive anti-direct democracy policies that have made it incredibly challenging for grassroots campaigns to collect initiative petition signatures. Their lawsuit focuses on several provisions of 2025’s House Bill 1205, including:

• • • Voter Information Disclosures: Invalidates a voter’s signed petition unless the voter discloses sensitive personally identifying information.
    • Criminal Fines and Penalties: Imposes criminal sanctions for racketeering related to “irregularities or fraud involving issue petition activities”, including filling in missing information on a signed petition.
    • Circulator Eligibility Bans: Bans individuals who are not Florida residents and U.S. citizens from circulating petitions, whether as volunteers or paid circulators. Also bans those who have been convicted of felonies and have not yet had their rights restored.
    • Verification Fee Increases: Authorizes the Supervisors of Elections to drastically increase the fees they charge campaigns to verify signatures.
    • 10-Day Return Requirement: Requires campaigns to submit signed petitions within just ten days — down from 30, dramatically increasing the cost of compliance and penalties for delays.

Working with a legal team that includes Elias Law Group and Southern Poverty Law Center, Florida Decides Healthcare successfully secured two major preliminary injunctions against some of HB 1205’s provisions last year.

Why It Matters: Florida is the only state in the Southeast where voters have access to the People’s Tool, and House Bill 1205 puts that power in grave danger. Without a workable initiative process, Floridians wouldn’t have been able to pass major policy wins like free universal Pre-K, a $15/hour minimum wage, voting rights restoration, land conservation, and so much more. The results of this lawsuit will hugely impact the fate of Florida’s future grassroots ballot initiative campaigns.

But when it comes to defending ballot measure access, the results of the Florida Decides Healthcare v. Byrd case will reverberate far beyond the Sunshine State’s borders. Anti-direct democracy policies in Florida have long served as a sort of blueprint for other states’ attacks on their own processes. Though led by Floridians, this lawsuit is a pivotal battle in the fight to defend direct democracy nationwide and to protect voters’ power to enact policies that make meaningful changes to their lives. 

Procedural traps like those crafted by HB 1205 are strategically used to drain time, momentum, and especially money from grassroots efforts. The direct democracy defenders with Florida Decides Healthcare aren’t giving in without a fight, and the campaign is actively fundraising to cover what are expected to be considerable litigation costs while they also continue their work to qualify for the November 2028 ballot. 

2026 Ballot Measure to Watch

Issue: Healthcare

South Dakota: Medicaid Expansion Conditioned on 90% Federal Funding (LR)

What It Does: Under this amendment, South Dakota will terminate its expanded Medicaid eligibility requirements if the federal funding match falls below 90%.

Why It Matters: Under the state’s Medicaid expansion, benefits are currently available to adults between ages 18 and 65 with incomes below 133% of the federal poverty level. When passed by voters in 2022, the expansion made an estimated 50,000 South Dakotans eligible to receive benefits — the legislature’s proposal would put them at risk of losing their Medicaid access. Doug Sombke, president of the South Dakota Farmers Union, has stressed that restrictions on the state’s Medicaid expansion would severely harm working-class people, pointing out that most farmers are struggling to make ends meet and can’t provide private healthcare benefits to their workers. The resolution’s sponsor in the senate pointed out that should federal funding match get cut to 70%, for example, the state would be on the hook for an additional $72 million to sustain expansion and South Dakotans would essentially be forced to choose between funding Medicaid access or public schools.

BISC ANALYSIS: When the Fight for Medicaid Expansion Becomes A Fight for Direct Democracy — And Democracy Itself:
South Dakota lawmakers have continually targeted Medicaid Expansion since voters approved Amendment D in 2022. But the years-long assault on this particular citizen-led ballot initiative is just one aspect of their broader efforts to limit direct democracy in the state. Similarly, while House Bill 1205 could make it especially difficult for Florida Decides Healthcare to qualify their Medicaid Expansion initiative, the policy’s provisions are intended to block virtually any grassroots effort.

As advocates in both states work to protect or win Medicaid Expansion for their communities, they’re simultaneously working to defend their constitutional right to the People’s Tool. Ballot initiatives are models for co-governance, giving voters an important role to play alongside their elected leaders in developing people-centered policies. But in a time of rising authoritarianism, too many lawmakers interpret voter collaboration and engagement as a threat to the consolidated state power. To defend our right to direct democracy is about defending our right to engage in democracy itself.

In Case You Missed It

BISC’s New Case Study: Defending the Will of the People: How Missouri & Nebraska Reveal the New Front Line for Economic Justice: The 2024 election saw a slate of impressive ballot measure wins, including two citizen-led initiatives in Missouri and Nebraska that secured the right to paid sick leave for hundreds of thousands of workers (plus a higher minimum wage and the promise of future inflation adjustments in Missouri). But during the 2025 legislative session, lawmakers worked to partially repeal those popular, voter-approved policies. A new case study from BISC explores what happened when lawmakers interfered, how state partners are fighting back, and why implementation is a critical battleground in the fight to defend direct democracy amid rising authoritarianism.

BISC’s Resource Library: Our Partner Portal Resource Library houses ballot measure information ranging from campaign tools, templates, and past campaign materials (Values, MOUS, RFPs, etc.) —  to campaign debriefs and memos highlighting best practices. This library is a unique resource that can help campaigns and organizations build strategies and operationalize racial equity. To request access to the library, please email [email protected]