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Health Affairs' Ellen Bayer and Kathleen Haddad break down the under-discussed state ballot initiatives that focused on health care in the 2022 mid-term elections.
Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join editors from Health Affairs, the leading journal of health policy research, and special guests as they discuss this week’s most pressing health policy news. All in 15 minutes or less.
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Alan Weil
The number of Americans experiencing symptoms of depression has tripled since the pandemic. How can health leaders help? The new season of the “After the Fact” podcast from The Pew Charitable Trusts explores the state of mental health in America. Listen to “After the Fact” to learn more about the challenges and possible new approaches to improve Americans’ well-being. Visit pewtrusts.org/healthaffairs to listen.
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Ellen Bayer
Hello and welcome to another episode of Health Affairs This Week, the podcast where Health Affairs editors go beyond the headlines to explore the health policy news of the week. I'm Ellen Bayer.
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Kathleen Haddad
And I'm Kathleen Haddad. So, Ellen, this is our first episode following the elections.
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Ellen Bayer
That's right. And as Health Affairs editors, we tend to see the news through a health policy lens. So besides following so many close House and Senate races, I found it really interesting to see how many state ballot initiatives there were related to health policy this year. And clearly the issue that's gotten by far the most attention during this election cycle is abortion rights.
00;01;17;17 - 00;01;46;11
Kathleen Haddad
Right. So today we wanted to talk about several issues that haven't gotten quite as much attention. The issue of Medicaid expansion in South Dakota, a ban on flavored tobacco in California and referenda in several states legalizing marijuana. So the expansion of Medicaid in South Dakota is notable for a number of reasons, Ellen, and not the least of which is it's a very red state with leaders who have historically been opposed to Medicaid expansion.
00;01;46;21 - 00;02;11;27
Ellen Bayer
I know, right? It's really interesting that this initiative was passed by voters, even though it was opposed by Governor Kristi Noem and a number of state legislators. The governor did say she'd support the initiative if voters approved it. And this latest action in South Dakota is part of a trend, really interesting trend in the last few years of states expanding Medicaid through ballot initiatives instead of through legislation.
00;02;12;18 - 00;02;20;20
Kathleen Haddad
So, Ellen, I know you'll tell us about the politics behind the ballot initiatives. First, tell us, what does the initiative actually do?
00;02;20;28 - 00;02;53;12
Ellen Bayer
So rather than expanding Medicaid by statute, it actually amends the state constitution to require South Dakota to provide Medicaid benefits to all adults between the ages of 18 and 65, with incomes at or below 133% of the federal poverty level. And because the Affordable Care Act set an income eligibility disregard equal to five percentage points of the federal poverty level, the ballot initiative effectively expands Medicaid to people with incomes at or below 138% of poverty.
00;02;53;18 - 00;03;22;26
Ellen Bayer
And according to the Kaiser Family Foundation, over 70% of the people who’d be covered under the Medicaid expansion in South Dakota are adults without children. And about 60% are in working households. And it’s interesting this ballot initiative was supported by a broad coalition that included the state's biggest hospital systems, the South Dakota Chamber of Commerce, the AARP and other consumer groups, provider organizations, a number of American Indian tribes, as well as religious organizations.
00;03;23;12 - 00;03;28;21
Kathleen Haddad
So, Ellen, what happens next? When will South Dakotans be able to access coverage?
00;03;29;00 - 00;03;39;11
Ellen Bayer
So the next step is for the state to submit to CMS a Medicaid State Plan Amendment by March 1st of 2023, and the expansion will take effect July 1st of next year.
00;03;40;05 - 00;04;08;27
Kathleen Haddad
And of course, evidence on the benefits of Medicaid expansion are well-documented in Health Affairs and elsewhere. They include improved access to care, better health, improvements in food, housing and financial security, and less racial and ethnic disparity in health insurance coverage. So, Ellen, now there are only 11 states left that have not expanded Medicaid. Given this trend toward expansion by ballot initiatives, can we expect to see the remaining do the same?
00;04;09;11 - 00;04;30;24
Ellen Bayer
You know, that's a really interesting question. When you look at the rules in the other states, it actually looks like probably that's not likely to happen. This week we published an article in Health Affairs Forefront by Billy Wynne and several coauthors, and we'll put a link to that in the show notes. The article talks about the outlook on several health policy issues at the state level, including Medicaid.
00;04;31;04 - 00;04;39;12
Ellen Bayer
And it points out that of the 11 states that still haven't expanded Medicaid, only two allow ballot initiatives. And those are Florida and Wyoming.
00;04;39;21 - 00;04;41;05
Kathleen Haddad
So what's happening there, Ellen?
00;04;41;15 - 00;05;03;03
Ellen Bayer
So Florida requires a 60% supermajority for a ballot initiative to pass, which is a really high bar. And Wyoming doesn't allow for ballot initiatives that would lead to expenditure of state funds. So expanding Medicaid there would have to be done in the more conventional way, by passing the legislature and being signed by the governor, which seems unlikely to happen.
00;05;03;24 - 00;05;29;13
Ellen Bayer
And most of the remaining non-expansion states are led by Republican governors and state legislatures that have traditionally been hostile toward the ACA. And the midterms really didn't change the political landscape in those states. So South Dakota is among the last group of states to expand Medicaid. Let's talk a bit about a state that's among the first to take action on another issue, banning of flavored tobacco.
00;05;29;26 - 00;05;55;13
Kathleen Haddad
So, yes, moving on to a different issue. California voters passed a referendum that prohibits the sale of flavored tobacco products like vape cartridges and flavored cigars in stores and vending machines. The argument has been that flavored tobacco targets teens and addicts them to nicotine and leads them into smoking combustible cigarettes that are more harmful. An interesting note about this, Ellen,
00;05;55;21 - 00;06;16;00
Kathleen Haddad
this referendum was actually sponsored by the tobacco industry. It was an attempt to repeal a state law passed in 2020 banning the sale of flavored tobacco products. The tobacco industry spent 25 million on the campaign, but in swooped Michael Bloomberg and who spent 70 million, according to Politico.
00;06;16;29 - 00;06;25;01
Ellen Bayer
Wow. So how does this ban in California fit in with other federal and state tobacco restrictions? It seems like the landscape is such a hodgepodge.
00;06;25;19 - 00;06;57;15
Kathleen Haddad
Well, at the state level, California becomes the fifth state to restrict the sale of flavored tobacco products. Just drive up the I-95 corridor in the northeast and you'll find the other states New Jersey, New York, Rhode Island and Massachusetts and dozens of localities also are enacting flavored vape restrictions. San Francisco bans the sale of all e-cigarettes, period. At the federal level, Ellen, over the past decade, the FDA gained authority to regulate tobacco and vape products, but it has taken its time to act.
00;06;58;01 - 00;07;24;15
Kathleen Haddad
Two years ago, the FDA ordered flavored vape products off the market. The agency told flavored vape sellers like Juul they would have to submit credible scientific evidence of a public health benefit if they wanted back in the market. The FDA was slow to take enforcement action and received criticism for that. A stat investigation several months ago found vape shops all over the country were still selling flavored vape products.
00;07;25;08 - 00;07;27;23
Ellen Bayer
Well, maybe that's why the states and localities stepped in.
00;07;28;10 - 00;07;46;17
Kathleen Haddad
Yeah, I think maybe that's the reason. Ellen, just a few weeks ago, though, there was some news. The FDA and DOJ sought injunctions against six large vape retail companies across the country. The FDA's tobacco center has new leadership and the agency says it's committed to enforcement.
00;07;46;27 - 00;07;56;26
Ellen Bayer
So earlier this year, back in May, we had an episode of this podcast talking about the FDA's proposed ban on the sale of menthol flavored cigarettes. So what's going on with that now?
00;07;57;12 - 00;08;26;08
Kathleen Haddad
So that ban has not yet not taken effect yet because it's tied up in the courts. And as you know, Ellen, one concern was that it could target Black smokers who use menthol tobacco disproportionately more than White smokers. Like the menthol argument, the broader ban on all flavored tobacco products is controversial inside the public health community. While flavored vapes can addict teenagers, they can also help adult smokers quit combustible cigarettes.
00;08;26;22 - 00;08;33;19
Ellen Bayer
So I know Health Affairs recently published a Policy Insight article that proposed a compromise solution. Can you tell us a little bit more about that?
00;08;33;24 - 00;08;59;28
Kathleen Haddad
Yes, Ellen, the authors want to allow the sale of flavored e-cigarettes, but only in restricted adult environments like well walled-off rooms and vape and tobacco shops. They argue that the flavored e-cigarettes are much less dangerous than combustibles, and regulatory balance is needed between preventing teen addiction to nicotine and helping adults quit combustible cigarettes in addition to nicotine.
00;09;00;10 - 00;09;12;04
Kathleen Haddad
Combustibles have thousands of other chemicals that are actually are the cause of heart and lung disease. There are far fewer extra chemicals in e-cigarettes that we don't know really what all of them are.
00;09;12;22 - 00;09;21;19
Ellen Bayer
So leaving the nicotine wars for for the time being, there were also some states with ballot initiative last week that proposed to legalize recreational marijuana, right?
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Kathleen Haddad
Yes, Ellen, one being my home state of Maryland. The referendum passed by a wide margin. It legalized the possession and use of small amounts of marijuana by adults, loosened penalties for infractions and allowed people convicted under harsher penalties previously to apply for resentencing under the new guidelines. Missouri also legalized recreational marijuana. It was up for a vote in Arkansas, North Dakota and South Dakota, but those voters voted against.
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Kathleen Haddad
So Ellen, like the tobacco debates, there's some concern in the medical community that chronic marijuana use by teens harms the developing brain. Recreational use is not legal for adolescents, of course, but I'm not hearing much about the potential for unintended consequences from the broad trend toward legalization. So these questions, though, are perhaps for another time and perhaps for another podcast.
00;10;22;19 - 00;10;34;27
Ellen Bayer
So I think we'll need to leave it there for today. Thanks so much to our listeners for tuning in. Please leave us a review. And if you like this episode, subscribe to Health Affairs This Week wherever you get your podcasts. Thanks, Kathleen.
00;10;35;08 - 00;10;49;27
Kathleen Haddad
Thanks, Ellen.