Evaluating the Rise of State Ballot Initiatives in Healthcare

Over the last few years, state ballot initiatives have emerged as a powerful tool in shaping healthcare policy across the country, and they appear to be gaining traction as a productive means of enacting healthcare reforms.

For those of us keeping track, this feels like one of the new yet unsung trends in healthcare, so it seems worthy of a bit more scrutiny – and perhaps some sunshine as well.

Ballot initiatives are typically citizen-initiated measures, but can also be assigned via the legislative process or by a special state commission. The ballot initiative process allows citizens to propose statutes or constitutional amendments, depending on the state, and to collect signatures to place their proposals on the ballot for voters to decide.

Several factors have contributed to the growing use of state ballot initiatives for healthcare issues, but most prominent is the frustration over gridlock at the federal level. With partisan divides often paralyzing Congress, advocates see state ballot initiatives as a way to bypass such gridlock and instead enact reforms by putting them straight to voters.

State ballot initiatives have been used to address a wide range of healthcare issues, from tackling medical debt to prescription drug pricing reform. Notable examples of 2023 healthcare ballot initiatives include safeguarding abortion rights in Ohio, Medicaid expansion in South Dakota, establishment of a dental medical loss ratio in Massachusetts, and making healthcare a constitutional right in Oregon.

And already this year, there is a campaign in Florida to put Medicaid expansion on the ballot, while South Dakota is interested in amending its Medicaid expansion via a second ballot initiative in as many years.

The rise of such state ballot initiatives has seemingly profound implications for the future of healthcare policy. On one hand, they offer a promising avenue for enacting reforms in the face of federal polarization. By empowering voters to directly shape healthcare policy, ballot initiatives can lead to more responsive and representative policymaking.

However, the use of ballot initiatives also raises concerns about the role of money and special interests in shaping healthcare policy. Campaigns for ballot initiatives can be costly, and well-funded interest groups may have disparate influence in shaping the outcome of these initiatives.

Additionally, the complexity of healthcare policy can make it difficult for voters to fully grasp the implications of the initiatives they are voting on, resulting in unintended consequences or ineffective solutions.

As such, it’s important to note that because ballot initiatives continue to be an increasingly popular way to change or introduce laws, some states are attempting to make it tougher for such initiatives to be introduced and passed.

A great illustration occurred last year in Ohio. Although ultimately rejected by voters, Ohio’s Ballot Board approved ballot language to raise thresholds for ballot initiatives to pass. The proposal attempted to mandate that all measures receive 60 percent of the vote, with an increased number of signatures to be placed on the ballot.

Moving forward, it will be important to carefully consider the role of ballot initiatives in shaping healthcare policy and to ensure that they are used in a way that promotes transparency, accountability, and equity.

This is currently amplified by the upcoming elections later in the year, as we’re likely to see several more ballot initiatives pop up in the fall. But clearly, the growing trend of using ballot initiatives on healthcare issues reflects a mounting recognition that state-level action can be uniquely valuable in driving change in healthcare, and this warrants our attention.