Initiated Measure 26 (2020) — South Dakota Medical Cannabis Program

Last verified: May 2026

The 2020 Vote

Initiated Measure 26 passed with 70%/30% support — one of the most lopsided cannabis-policy referendum results in U.S. history at the time it was cast. South Dakota became the first U.S. state to have voters approve adult-use AND medical cannabis on the same ballot (the adult-use measure, Constitutional Amendment A, was struck down 11 months later in Thom v. Barnett; medical cannabis survived).

The Statutory Framework — SDCL ch. 34-20G

IM 26 was codified at SDCL ch. 34-20G. Implementation rules are found in ARSD 44:90. The South Dakota Department of Health (SDDOH) administers the program from offices at 600 East Capitol Avenue, Pierre, SD 57501, with Whitney Brunner serving as Medical Cannabis Program Administrator as of 2026 (the founding administrator was Geno Adams).

Implementation Timeline & Noem-Era Delays

Although IM 26 passed in November 2020, Gov. Kristi Noem’s administration sought to delay implementation, asking the legislature to push the effective date from July 2021 into 2022. The state House moved a delay bill but House-Senate negotiations collapsed; the original July 1, 2021 effective date held.

Patient registrations began in late 2021. The first legal medical cannabis sale occurred on July 1, 2022, at the Native Nations Cannabis dispensary on the Flandreau Santee Sioux Reservation — a tribal facility that opened ahead of state-licensed competitors. The first state-licensed dispensary operations followed shortly thereafter, with Genesis Farms (Hartford, Sioux Falls, and a network of subsequent locations) widely identified as the lead state-licensed operator at the program’s launch.

Patient Population Growth

• May 10, 2022: 652 registered patients
• October 11, 2022: 3,768 patients
• October 10, 2023: 12,017 patients
• March 3, 2025: ~11,275 active cardholders
• February 2026: 18,036 patients, 535 caregivers, 208 providers
• March 1, 2026: 18,306 patients, 540 caregivers, 209 providers
• April 1, 2026: 18,759 patient cards, 219 approved practitioners

Patient counts dipped in late 2024 (from a March 2024 peak of ~13,500 to ~12,500 in September 2024) before resuming growth — a fluctuation the SDDOH FY2025 Annual Report partly attributes to "system safeguards and login requirements" affecting practitioner availability. By April 2026, the program was approving roughly 200–500 net new patient cards per month.

What IM 26 Established

• Patient registration system administered by SDDOH.
• Practitioner-certification framework (MD, DO, PA, APRN; in-person required).
• Establishment licensing for cultivators, manufacturers, dispensaries, and testing labs.
• Possession limit: 3 oz of cannabis flower (or product equivalent) per 14-day rolling period.
• Home cultivation: up to 3 plants for patients with permits.
• Allowed product slate: flower, edibles, vape carts, concentrates, tinctures, topicals (one of the broadest in the U.S.).
• Tax structure: 4.5% state sales tax (no separate cannabis-specific excise).
• Visiting-patient reciprocity for out-of-state cardholders.

What IM 26 Did Not Do

• Did not legalize recreational use. Recreational cannabis remained illegal under SDCL § 22-42-6.
• Did not protect employment. SDCL § 34-20G-24 expressly preserves employer drug-free workplace policies.
• Did not create DUI defense. Per se 5 ng/mL THC threshold under § 32-23-1 still applies to cardholders.
• Did not abolish "internal possession" doctrine. Schroeder/Whistler still permit prosecution of non-cardholders.

The 2023 Qualifying-Condition Freeze (SB 1)

The original IM 26 statute included a public petition process through which residents could ask SDDOH to add qualifying conditions. The 2023 SB 1 froze the qualifying-condition list at the statutory enumeration, revoking the public-petition process. Reform efforts to broaden the list (notably for chronic pain absent another listed condition, and for severe anxiety) remain a recurring legislative subject.

The 2024 License-Fee Increase (SB 43)

SB 43 (2024), signed by Gov. Noem March 14, 2024, raised the annual establishment certification fee from $5,310 to $9,000 — a roughly 70% increase. The original IM 26 statutory cap was $5,000. The Department of Health had originally requested authority to set the cap as high as $28,000.

Total Program Sales

SDDOH does not publish official cumulative sales totals. The Office of Medical Cannabis confirmed in a February 2026 public-records response that it "does not maintain, nor does it have submitted to it, an establishment-level sales/dispensing report." Cannabis Business Times has referenced a "$1.6 billion market" figure in coverage of the proposed 2026 medical-repeal petition, but the underlying methodology for that estimate is not disclosed publicly. Industry-side estimates from MJBizDaily (2022) projected first-year SD medical sales at $1.5–2 million and 2024 sales at $10–12 million.

The Repeal Threats & Defense

In 2025 and 2026, Sen. John Carley (R-Piedmont) introduced repeal-by-trigger and potency-cap bills that the Senate Health and Human Services Committee rejected (6–1 and 7–0). The Marijuana Policy Project noted: "Forty states have medical programs. None have repealed their state’s medical cannabis programs." A separate medical-cannabis repeal initiative tied to activist Travis Ismay has circulated since 2023 without yet qualifying for any ballot.

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