Ballot Initiatives: The New Political Tool Impacting Healthcare

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The impact of ballot initiatives on healthcare seems to be growing.

By Matthew Albright

As of this past weekend, with Election Day still approaching, an estimated 40 million Americans had already voted through absentee ballots or ballot drop boxes.

We won’t attempt a guess about how the races for the House and the Senate will go. However, I will suggest that for the healthcare industry and its current regulatory burdens, whether any particular congressional chamber is blue or red will not make much difference.

This is because a lot of the heavy regulatory lifts for healthcare today have strikingly bipartisan support in an otherwise polarized political environment.

Take, for example, the transparency requirements that both hospitals and plans publish detailed lists of their pricing for specific services, including negotiated rates with one another. It’s true that the transparency rules are based on a few sentences in the Patient Protection and Affordable Care Act, passed under President Obama, but the Trump Administration turned those few sentences into hundreds of pages of regulations.

The No Surprises Act was passed with strong bipartisan congressional support, also under the Trump Administration, including provider requirements on good-faith estimates and advanced explanations of benefits.

Although the genesis of the No Surprises Act and the transparency requirements occurred under a Republican administration, upon taking over, it is striking that the Biden Administration did not challenge those regulations – as the Administration did on many other regulations passed under Trump. Biden actually doubled down on them, writing extensive and ongoing regulations and promising enforcement of the requirements.

Interoperability too is bipartisan, from its birth under the younger President Bush as Meaningful Use to the most recent requirements under Biden.

So, whatever happens in the congressional elections, the outcome will likely not impact the current torrent of regulations that healthcare is now facing.

But let’s talk about another political tool on the ballot that has and will continue to impact healthcare, and that is the ballot initiative (also called ballot measures, popular initiatives, or voter initiatives). About half the states allow ballot initiatives, which are intended to create, amend, or repeal a state law or constitutional amendment.

Proponents of ballot initiatives say that they are direct democracy in action, pushing for policy that state legislatures have not or will not deal with appropriately. Opponents say that ballot initiatives are actually a frontal attack on democracy that gives too much power to small-interest groups with big marketing budgets.

Even though there are fewer ballot initiatives this year than we saw in most of the last 20 elections, their impact on healthcare seems to be growing. In recent elections, we’ve seen ballot questions in multiple states that have changed state policy on marijuana and Medicaid expansion. This week, across the country, citizens in various states will be voting on 28 ballot measures related to abortion.

Other ballot initiatives that affect healthcare this week:  

Massachusetts is asking voters to set an 83-percent medical loss ratio and add more regulations to dental plans.

Arizona’s Proposition 209 would reduce the maximum interest rates on consumer medical debt to 3 percent.

And a ballot initiative in Oregon would add an amendment to the state constitution stating that it is the obligation of the state to ensure that every citizen has affordable healthcare. 

While it may be that a vote for one party or the other won’t impact healthcare, one way or the other, these ballot initiatives will have an impact.

Hope you all voted!

Programming note: Listen for live legislative reports every Monday on Monitor Mondays and sponsored by Zelis.


Matthew Albright

Matthew Albright is the chief legislative affairs officer at Zelis Healthcare. Previously, Albright was senior manager at CAQH CORE, and earlier, he was the acting deputy director of the Office of E-Health and Services for the Centers for Medicare & Medicaid Services.

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