WASHINGTON — While Vice President Harris and former President Trump are dominating the headlines in the last two weeks before the election, there is a lengthy list of health care proposals and down-ballot races that could heavily shape health policy.
More than a dozen states are voting on health care issues ranging from abortion access to psychedelics use, paying for long-term care, and medically assisted suicide.
A handful of those states with ballot initiatives also have key Senate races that could dictate which party controls the chamber and sets the agenda next year.
Here’s STAT’s rundown of key ballot measures and races that could transform state and federal health care and ignite new debates.
Reproductive rights
Ten states have abortion initiatives on the ballot, the most since the Supreme Court overturned Roe v. Wade in 2022.
Overwhelmingly those are measures to affirm abortion rights, with the exception of two competing measures in Nebraska. One would enshrine the state’s current 12-week ban into the state constitution, with exceptions for rape, incest and the parent’s health. The other would protect abortion access up until fetal viability, or at least 22 to 23 weeks, and allow later procedures to protect the parent’s life.
Most of the other state ballot initiatives would establish a constitutional right to abortion up until a fetus’ viability. In South Dakota, which currently has an abortion ban, the amendment would bar restrictions during the first trimester of pregnancy but allow state regulation in the second trimester “only in ways that are reasonably related to the physical health of the pregnant woman.”
Other proposals are broader. Maryland’s would establish a right to reproductive freedom in its constitution. Colorado’s initiative would allow for the use of state funds to provide abortions. While federal funding of abortion is outlawed, nearly half of U.S. states allow Medicaid to cover the procedure.
Abortion rights advocates are largely optimistic: In six states’ ballot initiatives since Roe fell, voters have sided with abortion rights.
Senate control
There are at least nine competitive Senate races this year, many of them with the chance to tip the chamber’s control to Republicans. Several of those are happening in states where abortion access — and health care issues in general — have been hotly contested debate topics. But while Democrats have made these central issues in campaigns, the odds that they will protect their majority — or flip GOP seats in Florida and Texas — appear slim.
In Montana, for instance, Democratic Sen. Jon Tester has run on protecting abortion access and shoring up federal health care programs such as Medicare and Medicaid, but has distanced himself from Harris’ presidential campaign. He is currently lagging in the polls behind newcomer Tim Sheehy.
Similarly, in Ohio, Democratic Sen. Sherrod Brown is fighting to maintain his seat in one of the most expensive Senate races on record. Both Ohio and Montana voted for Trump in the 2020 election, but have reelected their Democratic senators in the past. Brown, who explored a presidential run in 2019, has backed a public option for health insurance and supported Medicare negotiation on drug prices. But he has also pushed to focus his race on the red-leaning state and not the top of the ticket.
Florida and Texas are the only states where pollsters indicate Democrats could possibly flip a GOP-controlled seat, and those possibilities are narrow. Harris will campaign in Texas with Democratic candidate Colin Allred on Friday night, focusing on abortion rights.
Legalizing cannabis and psychedelics
Three states — Florida, North Dakota and South Dakota — are voting on whether to join half the country in allowing recreational use of marijuana. Most states allow medical use of cannabis or its components, and federal agencies are exploring reclassifying the drug, which could, slowly, ease research of its benefits and risk.
Cannabis businesses have poured money into passing these initiatives, particularly in Florida. That state’s governor, Ron DeSantis, opposes the measure, and has argued it is too broad to allow the government to properly regulate the booming cannabis industry.
In Massachusetts, which already allows for both medical and recreational cannabis use, voters will decide on a measure that would legalize psychedelic substances for people aged 21 and up. It would also establish a commission and state advisory board on regulating natural psychedelics such as psilocybin mushrooms.
If the measure passes, Massachusetts would join Oregon and Colorado in legalizing and attempting to regulate broader psychedelics use.
Work requirements for Medicaid
South Dakota is reviving a debate sharpened during Trump’s presidency over imposing work requirements on certain Medicaid enrollees. The Trump administration encouraged states to implement work requirements and approved several waivers.
President Biden vowed in his first week as president to reverse those moves, and Medicaid later rescinded the Trump-era guidance that laid out how states could apply for the waivers.
South Dakota’s ballot initiative asks voters to amend the constitution so the state could “impose a work requirement on eligible individuals” in order to receive Medicaid under the expansion that took effect last year. The requirements would not be applied to people with mental or physical disabilities, the measure states.
If it passes, a future Harris administration could still sit on a waiver request and stymie efforts to impose Medicaid eligibility conditions. Other state efforts, even under the first Trump administration, were met with lawsuits. However if Trump is reelected, South Dakota could be a bellwether for states looking to revisit the fight.
340B program
Californians are set to vote on a proposal that would overhaul the 340B drug discount program and potentially provide a roadmap to pharmaceutical companies looking to curb the costly program.
The measure would require that facilities spend at least 98% of their net drug sale revenue from 340B on “direct patient care.” Providers that violate the requirement risk losing their license and tax-exempt status.
The California initiative appears targeted at a particular organization and has been driven by an unusual cohort of apartment builders. Still, it comes amid longtime debates in Washington and across states about reforming the program and reining in hospitals that claim they are disproportionately serving uninsured and underinsured patients.
Medically assisted suicide
West Virginia voters will decide whether to prohibit “the practice of medically assisted suicide, euthanasia, or mercy killing of a person.” Eight states allow medically assisted suicide, and at least three other state legislatures are debating it.
While the practice is currently illegal in West Virginia — and many other states — the broad language of the ballot measure would make it virtually impossible for the state legislature to ever allow physician-assisted deaths, sometimes also referred to as medical aid in dying.
Long-term care and state regulations
A Republican-backed ballot initiative in Washington would let state workers and self-employed residents opt out of paying taxes towards the state’s long-term care benefit, WA Cares.
Proponents of the measure say the payroll tax, enacted last year, is deeply unpopular and will not benefit many Washingtonians. Opponents, among them AARP and disease advocacy organizations, say an opt-out will effectively kill the program and leave many residents without support when a family member is sick. AARP estimates that there are roughly 800,000 unpaid family caregivers in the states.
Washington’s ballot fight reflects a growing federal debate about how to support long-term care and who pays for it. Harris launched a “Medicare at home” plan this month that would provide coverage for home care support on a sliding scale, based on seniors’ income and needs. An at-home support plan is conservatively estimated to cost at least $40 billion, according to Brookings Institute.
Separately, in Arizona, there is a ballot initiative that could hamstring state agencies’ rulemaking in health care and other issues. Proposition 315 would require those agencies to submit proposed rules that cost more than $100,000 to the state’s economic office. If the office determines the rules could cost $500,000 or more over five years, the measure requires legislative review.
Republican legislators argue the ballot measure will control the state budget and improve transparency. Opponents, many of them former agency heads, argue it will unnecessarily lengthen the regulatory process.