Abortion One of Several Key Healthcare Ballot Issues

Across the country, voters have the opportunity on Tuesday to cast their ballot on a range of weighty healthcare issues, from abortion access to Medicaid expansion to the sale of flavored tobacco. MedPage Today provides an overview of some the measures and touches on the implications for clinicians and the patients they treat.

Abortion Access

When the Supreme Court struck down Roe v. Wade in June — the historic 1973 decision that established a constitutional protection for abortion — the high court gave the power to determine women’s reproductive futures back to the states. On Tuesday, at least five states will give voters a chance to have their say on questions of women’s reproductive rights.

Michigan’s Proposal 22-3 would determine whether a nearly 100-year-old ban would once again make abortion illegal. The ballot measure would revise the state’s constitution to declare that every individual has a “fundamental right to reproductive freedom, which entails the right to make and effectuate decisions about all matters relating to pregnancy, including but not limited to prenatal care, childbirth, postpartum care, contraception, sterilization, abortion care, miscarriage management, and infertility care.”

After fetal viability, the state “may regulate the provision of abortion care,” however, “in no circumstance shall the state prohibit an abortion that, in the professional judgment of an attending health care professional, is medically indicated to protect the life or physical or mental health of the pregnant individual.”

The Michigan Supreme Court allowed the question to be included in the ballot after anti-abortion Republicans tried to remove it, citing “spacing and formatting errors” in the text that abortion rights advocates used while canvassing, according to Politico.

In California, Proposition 1 would amend the state’s constitution to include language “prohibit[ing] the state from denying or interfering with an individual’s reproductive freedom in their most intimate decisions, which includes their fundamental right to choose to have an abortion and their fundamental right to choose or refuse contraceptives,” according to the California Secretary of State’s office.

And a statewide ballot question in Vermont asks whether voters are willing to amend the state constitution to add that “an individual’s right to personal reproductive autonomy is central to the liberty and dignity to determine one’s own life course and shall not be denied or infringed unless justified by a compelling State interest achieved by the least restrictive means.”

Meanwhile, in Kentucky, a proposed constitutional amendment takes the opposite approach, adding a new section to the state’s constitution saying that “to protect human life, nothing in this Constitution shall be construed to secure or protect a right to abortion or require the funding of abortion.”

And in Montana, a ballot measure asks voters to approve the Born-Alive Infant Protection Act, which affirms that “infants born alive, including infants born alive after an abortion, are legal persons” and requires healthcare providers to “take necessary actions to preserve the life of a born-alive infant.”

Healthcare providers found guilty of “failing to take medically appropriate and reasonable actions to preserve a born-alive infant’s life” would face a fine of up to $50,000 and/or up to 20 years’ imprisonment.

Medicaid Expansion

On the Medicaid front, voters in South Dakota will vote on whether to expand Medicaid, providing an estimated 42,500 eligible adults 18-65 with access to the program in its first year.

While he doesn’t oppose the measure, Joseph Antos, PhD, a senior fellow at the American Enterprise Institute, a right-leaning think tank, is skeptical. “The lure of easy money up front versus potentially having to raise taxes down the road is always an issue,” he said, explaining that after the “bonus Medicaid payments” for the expansion population disappear, the increased costs will remain.

The Affordable Care Act gave states the option to expand Medicaid for most low-income adults up to 138% of the federal poverty level. As of February 2021, 12 states have yet to take that option, according to the Kaiser Family Foundation. For expansion states, the federal government pays a 90% federal matching rate for the expansion population (FMAP), plus an additional 5-percentage-point increase for 2 years after expansion is implemented, courtesy of the American Rescue Plan Act, signed into law in 2021.

In a state with a “primarily agricultural base,” workers often do not have employer-sponsored insurance and Medicaid could help fill the gap. But in many cases, the ability to access healthcare is as much a problem of distance as insurance coverage or ability to pay. “Expanding Medicaid seems to me to be a pretty good idea, but it’s not going to solve the rural healthcare problem,” Antos said.

Healthcare as a Human Right

In Oregon, a different coverage-related ballot measure would make it the first state in the country to declare healthcare a human right. If the measure passes, Oregon’s constitution would state that “every resident of Oregon has access to cost-effective, clinically appropriate and affordable healthcare as a fundamental right.”

Antos characterized the ballot measure as “virtue signaling,” adding that the measure is not tied to any funding and also could lead to a morass of legal problems. “Mostly what I see is trouble here, if they pass this,” Antos said, adding that because Oregon is a very rural state, the fact that someone might have to travel for hours to reach a hospital capable of addressing a serious health problem could be seen as a violation of a human right.

The Medicaid program could also potentially be sued if the doctors closest to an individual low-income person do not accept Medicaid. And providers themselves might be sued “because they’re not opening their doors wide,” he added.

Joan Alker, executive director and co-founder of the Center for Children and Families at Georgetown University, was less concerned about the ballot measure than the effect that the governor’s race could have on Oregon’s Medicaid program.

In September, Oregon became the first state in the country to provide continuous coverage for Medicaid to children 0 to 5 years old, and for 2 years to all children age 6 and up, as Alker and a colleague detailed in a recent blog post. “That’s a big deal in the Medicaid world,” she told MedPage Today.

It’s especially important given that millions of children across the country could potentially lose health insurance when the continuous coverage protections of the COVID-19 public health emergency end, noted the post. Despite the federal government approving the Oregon waiver, if an independent or Republican candidate becomes governor of the state, it’s unclear whether that person will commit to implementing it, she said.

Flavored Tobacco

In addition to abortion, Californians will be voting on another significant healthcare measure: Proposition 31. If passed, the measure would ban the the sale of flavored tobacco in most stores and vending machines.

In 2020, the California legislature and Gov. Gavin Newsom (D) approved a law banning the sale of candy and fruit-flavored tobacco products. But the tobacco industry spent millions and set the wheel spinning on a referendum against the law, which at least temporarily prevented it from being enforced, according to KCRA3.

Proponents of the ban argue that flavored products appeal to young people and could lead to another generation harmed by the tobacco industry, given that they mask the taste of nicotine and make addiction more likely, as Susanne Tanski, MD, MPH, a pediatrician and tobacco control expert who represented the American Academy of Pediatrics, said during a congressional hearing on the issue in 2019. Critics of the measure, however, say that a blanket ban could give rise to an underground market for the products.

More than 80% of young people and young adults who use tobacco report using flavored tobacco products, and three-fourth of those say they would stop using the products if they were not flavored, according to a 2017 study in Tobacco Regulatory Science.