Voters in five states Tuesday appeared poised to follow Kansas’ lead to support fewer restrictions on abortion.

California, Michigan and Vermont voters all approved measures amending their state constitutions to enshrine the right to reproductive freedom, including abortion. Kentucky voters, meanwhile, rejected a measure that would have amended the state constitution to say there is no explicit right to an abortion or public abortion funding.

In Montana, voters appeared poised to reject a controversial measure that would modify medical care requirements for infants born following an abortion and penalize providers who do not comply with the requirement. Violators could be subject to a $50,000 fine and/or up to 20 years in prison. 

The wins for abortion rights activists follow Kansas voters’ decision during the state primary in August to overwhelmingly reject an amendment that would have changed the state constitution to explicitly not protect the right to an abortion.

Polling from the Kaiser Family Foundation and Associated Press VoteCast showed that about 4 in 10 voters in states with abortion on the ballot said the Supreme Court’s decision in June overturning Roe v. Wade had a major impact on motivating them to vote. 

Democrats had hoped to capitalize on that momentum during the midterm elections, though other health priorities put up to voters had mixed results.

In Kentucky, where voters rejected an anti-abortion measure, 61 percent of Democratic women in an AP VoteCast survey said the decision to overturn Roe had a major impact in whether they voted. The poll was conducted from Oct. 31 through Nov. 8.

Both California and Vermont’s ballot measures were initiated by the state legislatures and passed overwhelmingly. Advocates spent more than $9 million in support of California’s measure.

The citizen-led Michigan measure passed with more than 56 percent of the vote, as of Wednesday. The referendum guarantees residents the right to contraception and abortion, with the state allowed to regulate abortion access after the point of fetal viability. 

2022 marks the highest number of state ballot measures focused on abortion.

“I think the fact that we have these many reproductive rights ballot measures is an indicator that we’re going to see this issue go before the people in more states,” Ballot Initiative Strategy Center Executive Director Chris Melody Fields Figueredo said during a call with reporters Oct. 20.

In all, 17 of the 136 state ballot measures had implications for health care, including measures on Medicaid, marijuana, medical debt and access to affordable care.

Coverage expansion

South Dakota on Tuesday became the seventh state to expand Medicaid by ballot, with 56 percent voting in favor of the initiative.

With South Dakota’s vote, only 11 states will not be accepting federal incentives to expand their programs to cover more low-income adults who are not eligible for subsidies on the exchanges.

Expansion is expected to cover an additional 42,500 South Dakotans who earn below 133 percent of the federal poverty level. 

“Citizens took matters into their own hands to pass Medicaid expansion via ballot measure, showing us once again that if politicians won’t do their job, their constituents will step up and do it for them,” said Kelly Hall, executive director of the Fairness Project, an advocacy group that helped lead the ballot initiative.

An initiative enshrining the right to “affordable health care” in the Oregon constitution was still too close to call as of Wednesday morning. Preliminary tallies indicated the referendum could fail.

Drug policy

Voters were split on initiatives related to marijuana, nicotine and psychedelic drugs.

Voters in two of the five states considering recreational marijuana legalization for adults passed their initiatives.

Maryland voters legalized recreational marijuana use and directed their state legislature to pass laws to regulate distribution and taxation. In Missouri, voters legalized marijuana sales, which will be taxed, and will allow some individuals charged with marijuana-related offenses to petition for release from incarceration or parole.

“With each state that successfully legalizes cannabis, we are one step closer to dismantling the federal prohibition of cannabis,” said Toi Hutchinson, president and CEO of the Marijuana Policy Project, which was involved with the efforts in Maryland, South Dakota and North Dakota.

But South Dakota rejected an initiative to legalize possession, distribution and use of marijuana, with 53 percent of voters opposed. 

Fifty-five percent of North Dakota voters opposed allowing adults to grow up to three cannabis plants and establishing an adult-use cannabis program by next October.

Arkansas voters also voted against legalizing the commercial sale of marijuana.

California voters upheld a 2020 state law banning most flavored nicotine products, excluding cigars and hookah products.

The initiative is the latest in a salvo of state laws cracking down on e-cigarettes and menthol cigarettes as the Food and Drug Administration continues deliberations at the federal level. Opponents spent nearly $23 million against the initiative; advocates spent more than $6 million.

Colorado, one of the first states to legalize recreational marijuana for adults, may further relax its drug policies.

The state appeared poised to approve a measure that would define some psychedelic plants and fungi as “natural medicine,” which would decriminalize growing and transporting the drugs for personal use by adults 21 or older. Denver voters previously decriminalized psilocybin mushrooms in 2019.

But the statewide ballot initiative would also create a Regulated Natural Medicine Access Program for administering these so-called natural medicines. While clinical researchers have said initial findings on psychedelics are promising, the FDA recently approved esketamine, a ketamine derivative, for depression.

Natural Medicine Colorado PAC spent over $3.9 million in favor of the initiative this year, according to Colorado Secretary of State expenditure data.

A similar initiative to decriminalize hallucinogenic drugs in California did not pass the threshold for the November ballot.

Oregon is the only state to have legalized psilocybin in supervised settings. In 2020, voters approved a ballot measure decriminalizing possession of controlled substances, with a maximum fine of $100.

Other issues

Other results in three states touched on dialysis requirements, medical debt and dental insurance.

Californians overwhelmingly rejected an initiative to implement new requirements for dialysis clinics, according to the California Secretary of State’s office. Similar initiatives were overwhelmingly rejected in 2020 and 2018 amid concerns that the additional costs would force clinics to close.

The initiative would have required clinics to have at least one physician on site during all operating hours and require permission from the state to close operations. It also would have prohibited discrimination based on insurance type.

Supporters and opponents of the initiative poured millions into the battle, with more than ​​$86 million spent in opposition alone.

Arizona voters overwhelmingly approved a ballot measure aimed at reducing the burden of medical debt, a growing problem in the state and across the country. Under the measure, which passed with 72 percent of voters in favor, the interest creditors can charge on medical debt would decrease from 10 percent to 3 percent. 

It would also increase the value of a debtor’s home protected from creditors from $250,000 to $400,000 and limit wage garnishment for medical debt to a maximum of 10 percent of earnings.

Arizona is the first state to change medical debt collection practices through ballot measures, but several states have dealt with the issue through legislation in recent years. One in 5 Americans are affected by medical debt, with about $88 billion in outstanding bills currently in collections, according to the Consumer Financial Protection Bureau.

Massachusetts approved a measure that would require dental insurance plans to spend 83 percent of money collected from premiums on patient care. While Massachusetts has a similar requirement for health plans, one does not exist for dental plans. The measure will take effect Jan. 1, 2024.