The Medicaid expansion ballot initiative shows that state referendums can expand health care coverage, but they also have their limitations.
State ballot initiatives across the country to protect reproductive rights signal public rejection of U.S. Supreme Court’s decision to strike down constitutional protections for abortion Dobbs v. Jackson Women’s Health Organization. While some political pundits are right to view these ballot initiatives as victories for reproductive rights, they should also be understood as qualified victories. These state efforts, along with those in recent years aimed at increasing access to health care, also reveal the failures of the larger political process and the limitations of correcting those failures. To address these failures, ballot initiatives must be fought for and passed state by state. When access to reproductive and other health care is left to a referendum, uneven disparities are inevitably left behind.
The trajectory of national initiatives since then Dobbs This is not a new phenomenon in healthcare. Over the past six years, numerous Medicaid expansion ballot initiatives have corrected coverage gaps created after the Supreme Court’s 2012 ruling. NFIB v. Sebelius. The decision put the task of expanding health care to low-income people in the hands of elected state representatives, but many of them failed to take action. Voters in seven states – Idaho, Maine, Missouri, Nebraska, Oklahoma, Utah and South Dakota – rejected lawmakers’ inaction on the ballot by requesting state referendums.
The Equity Project, a nonprofit that works to use ballot measures to circumvent legal reform impasses, has spearheaded state ballot initiatives to expand Medicaid. The organization worked with local partners to help Maine become the first U.S. state to approve Medicaid expansion through a 2017 ballot initiative. The Equity Project subsequently conducted successful referendum campaigns in Idaho, Nebraska, Utah, Oklahoma, Missouri, and South Dakota.
American health systems historian Paul Starr commented, “Until the 2012 Supreme Court ruling on the Affordable Care Act, the history of health insurance protections was almost entirely a history of legislative and executive decisions.” But more recently, ballot initiatives Almost the only way to expand Medicaid.
Although Republican state governments resist expansion after reform Sebelius, expansion measures almost always get a first pass on the ballot. In South Dakota, for example, voters bypassed the state’s conservative Legislature to secure Medicaid coverage for an additional 45,000 South Dakotans.
Post-Medicaid Expansion Efforts Sebelius Paving the way for today’s state-level abortion initiatives.back Dobbs After repealing the federal constitutional right to abortion, voters in seven states—California, Michigan, Montana, Vermont, Kansas, Kentucky, and Ohio—passed ballot initiatives in a variety of ways at the state level. Abortion rights protected. Kentucky has rejected a constitutional amendment that would have prevented any state court from affirming the right to abortion. California amended its state constitution to prohibit interference with an individual’s reproductive freedom. Montana voters rejected a state bill that would have required providers to care for babies born at any stage.
In November, Ohio voters approved a ballot initiative to amend the state constitution to legalize abortion. Ohio’s success is particularly important given the state’s aggressive anti-abortion efforts.a few hours later Dobbs After the decision, Ohio reinstated its abortion ban six weeks later. Although subsequent lawsuits backed by Planned Parenthood and the American Civil Liberties Union blocked the ban, legal uncertainty and fear of retaliation frightened providers and reduced abortion access across the state. Republican lawmakers have also sought to curb voting before it begins, placing a measure on Ohio’s August special election ballot that would require a supermajority to amend the state constitution. But last summer, voters overwhelmingly rejected Republican attempts to block abortion protections.
Despite these successes, state ballot initiatives are ultimately limited in what they can accomplish. Ten states, including Texas, Florida and Wisconsin, have not expanded Medicaid coverage, a gap that has left millions of the lowest-income Americans in those states uninsured.
Achieving Medicaid expansion in these holdout states will be challenging. Florida is the only non-expansion state that allows for a ballot initiative process that would enable expansion. The Mississippi Supreme Court struck down the state’s ballot initiative process in 2021, halting the state’s expansion efforts. In the remaining states, if ballot initiatives were allowed, they would almost certainly pass. For example, polls show that 70 percent of Kansas voters support Medicaid expansion, but the Republican Legislature refuses to act. Even as the American Rescue Plan Act increased federal matching rates for expansion populations, politicians in non-expansion states remained hesitant.
Low-income residents in non-expansion states still lack health insurance coverage, with 1.9 million people in the coverage gap.Although Medicaid expansion is broader than some observers expected NFIB v. Sebelius, national success has not completely replaced nationwide coverage. The same may be true for reproductive health care. While state efforts will provide important access and protections, persistent disparities will come at great cost to health justice and equity.
The success of abortion voting in Ohio has inspired campaigns in Nevada, Florida, Pennsylvania, Arizona, Nebraska, Missouri and South Dakota, but those campaigns may still face legal, political and practical hurdles . For example, a Nevada judge recently blocked an abortion rights ballot measure proposed by Nevadans for Reproductive Freedom that would have written the fundamental right to reproductive freedom into the state’s constitution. While the group is awaiting a new decision on the appeal, it is also seeking an alternative, narrower ballot initiative that would guarantee the right to abortion only if the fetus is viable or necessary to protect the health of the pregnant patient. In Florida, a proposed ballot measure has the signatures needed to be on the 2024 ballot, but the state Supreme Court is currently reviewing the measure in response to calls from the state attorney general and other opponents seeking to block it.
In states that do not allow ballot initiatives, such as Texas and Kansas, the Legislature has imposed restrictions contrary to the preferences of the majority of those states’ residents. Not only does Texas ban abortion in almost all circumstances, but some counties have passed ordinances prohibiting abortions on local roads.
After the Supreme Court overturned Roe v. WadeNearly half of states outright ban or restrict abortion. Additionally, more than two-thirds of obstetricians and gynecologists nationwide reported that Dobbs This decision undermines their ability to handle pregnancy-related emergencies. Ballot initiative provides progress toward restoring abortion rights and broader health care. But without federal action, these rights will only benefit some.