The Medicaid expansion ballot initiative shows that state referendums can expand access to health care services, but there are limits.
State ballot initiatives to protect reproductive rights across the country demonstrate public rejection of the U.S. Supreme Court's decision overturning constitutional protections for abortion. Dobbs v. Jackson Women's Health Organization. Some political experts have celebrated these voting actions as victories for reproductive rights, and rightly so, but they should also be understood as conditional victories. These national efforts, and those that preceded them in recent years, aim to increase access to health care, while also highlighting the failures of larger political processes and the limits of redressing them. To address these failures, we need to fight and pass ballot initiatives state by state. When access to reproductive and other health care is put to a referendum, gaps that feel uneven will inevitably remain.
The trajectory of state-level efforts since then dobbs It is not a new phenomenon in medicine. Over the past six years, numerous Medicaid expansion ballot initiatives have corrected coverage gaps that emerged in the wake of the 2012 Supreme Court ruling. NFIB vs. Sebelius. The decision left the expansion of health care to low-income people in the hands of elected state legislators, many of whom took no action. Voters in seven states – Idaho, Maine, Missouri, Nebraska, Oklahoma, Utah, and South Dakota – rejected inaction in state legislatures and petitioned for state referendums.
The Fairness Project, a nonprofit organization dedicated to using ballot measures to avoid legislative gridlock, has been at the forefront of the movement to expand Medicaid through state ballot initiatives. The organization worked with local partners to help Maine become the first state in the nation to approve Medicaid expansion through her 2017 ballot initiative. The Fairness Project has since led successful referendum campaigns in Idaho, Nebraska, Utah, Oklahoma, Missouri, and South Dakota.
Paul Starr, a historian of the American health care system, says, “Until the Supreme Court's decision on the Affordable Care Act in 2012, the history of health insurance protections was almost entirely a history of legislative and executive decisions.'' ” commented. But these days, ballot initiatives have become almost the only path to Medicaid expansion.
Despite Republican state governments resisting expansion; sebelius, Expansion measures almost always pass at least once. In South Dakota, for example, voters bypassed the state's conservative legislature and secured Medicaid coverage for an additional 45,000 South Dakotans.
Postwar Medicaid expansion efforts sebelius It paved the way for today's state-level abortion efforts.rear dobbs While the federal constitutional right to abortion was abolished, voters in seven states – California, Michigan, Montana, Vermont, Kansas, Kentucky, and Ohio – protected abortion rights at the state level through ballot initiatives in a variety of ways. did. Kentucky has rejected a proposed constitutional amendment that would prevent state courts from recognizing the right to abortion. California has amended its state constitution to prohibit interference with an individual's reproductive freedom. And voters in Montana rejected a state bill that would have required health care providers to care for infants born at any stage.
Last November, Ohio voters approved a ballot initiative to amend the state constitution to make abortion legal. Ohio's success is particularly significant given the existence of an active anti-abortion effort in the state.After several hours dobbs was decided, and Ohio reinstated its ban on abortion six weeks later. A lawsuit backed by Planned Parenthood and the American Civil Liberties Union later blocked enforcement of the ban, but legal uncertainty and fear of retribution chilled providers, reducing abortion access across the state. did. Republican lawmakers also sought to curtail voting activity even before a vote was cast by including a measure on Ohio's August special election ballot that would require a supermajority to approve an amendment to the state constitution. But voters last summer overwhelmingly rejected Republican attempts to block abortion protections.
Despite these successes, there are limits to what state ballot initiatives can ultimately accomplish. Ten states, including Texas, Florida, and Wisconsin, have yet to expand Medicaid coverage, leaving millions of Americans with the lowest incomes in those states uninsured. There is.
And achieving Medicaid expansion in these holdout states will prove difficult. Florida is the only non-expansion state that allows for a ballot initiative process that could allow for expansion. The Mississippi Supreme Court struck down the state ballot initiative process in 2021, halting expansion efforts in the state. And if the remaining states allow ballot initiatives, they are almost certain to pass. For example, polls show that 70 percent of Kansas voters support expanding Medicaid, yet the Republican Legislature refuses to act. Even when the American Rescue Plan Act increased the federal matching rate for the expansion population, politicians in non-expansion states remained hesitant.
Low-income residents in non-expansion states continue to lack health insurance, leaving 1.9 million people in the coverage gap. Medicaid expansion has been more widespread than some observers expected; NFIB vs. Sebelius, state success doesn't completely replace national coverage. The same may apply to reproductive medicine. National efforts provide important access and protection, but continued disparities come at a high cost to health justice and equity.
The success of Ohio's abortion vote has galvanized movements in Nevada, Florida, Pennsylvania, Arizona, Nebraska, Missouri, and South Dakota, but these movements still face legal, political, and practical challenges. may face major obstacles. For example, a judge in Nevada recently rejected an abortion rights ballot measure by Nevadans for Reproductive Freedom that enshrined the fundamental right to reproductive freedom in the state constitution. The group is awaiting a new appeals court decision, but it is less expansive and would guarantee the right to abortion only until the fetus is viable or if necessary to protect the health of the pregnant patient. Alternative ballot initiatives are also being pursued. In Florida, a proposed ballot measure has gathered the signatures needed to be on the 2024 ballot, but the state Supreme Court is currently considering it in response to calls from the state attorney general and other opponents to block the measure. ing.
In states that do not allow voting, such as Texas and Kansas, Congress has imposed restrictions against the wishes of the majority of those states' residents. Not only does Texas ban abortion in almost all situations, some counties have also passed ordinances that prohibit people from traveling on local roads in search of an abortion.
After the Supreme Court overturned Roe vs. Wade, nearly half of states have enacted outright abortion bans or pregnancy restrictions. Additionally, more than two-thirds of obstetricians and gynecologists nationwide report that: dobbs This decision worsened the ability to deal with pregnancy-related emergencies. Ballot initiatives provide progress toward restoring abortion rights and health care access more generally. But without federal action, those rights will only reach some people.
