Feature Briefing

States get their say on health: post-election round up

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7810 (Published 16 November 2012) Cite this as: BMJ 2012;345:e7810
  1. Edward Davies, US news and features editor
  1. edavies{at}bmj.com

From assisted dying through to abortion, Edward Davies looks at some of the highlights from measures, propositions, and referendums put to the vote in the 50 states

The health news from last week’s election was dominated by the presidential result, securing the future of the Affordable Care Act. Mitt Romney’s pledge to repeal Obamacare has been seen off and so reform, in the largest sense, continues to plow its furrow. (http://www.bmj.com/content/345/bmj.e7587)

However, various states saw dozens of propositions and referendums relating to the health of the nation, including several states having their say on the president’s reforms and, in particular, the individual mandate.

Individual mandate

This was the part of the Affordable Care Act that was upheld by the Supreme Court in June and would require everyone to buy healthcare coverage. Voters in Alabama, Florida, Montana, and Wyoming all had a say on whether they wanted this and all but the Floridians were unhappy with it. In Florida they voted against a motion that would have banned the compulsory purchase of insurance (http://collinscenter.org/2012flamendments/amendment-1-health-care-services/), while in the other three states voters were agreed that nobody should force them to do anything.

Proposition E in Missouri went a step further and decreed by a margin of 62% to 38% that it should require legislative approval or a statewide vote to create a health insurance exchange, a likely consequence of compulsory insurance (http://www.kcur.org/post/missouri-voters-pass-proposition-e).

Many of the laws required to make the Affordable Care Act happen will take place at a federal level and states may not get that much say, but the votes show that the re-election of the president will not be enough by itself to see healthcare reform smoothly pushed through.

Physician assisted dying

A much closer and more emotive battle was fought by campaigners in Massachusetts over the issue of physician assisted dying. The Death with Dignity initiative or Question 2 proposed a measure that would allow for a terminally ill patient to be given lethal drugs. The patient would be defined as a patient with six months or fewer to live, and when requesting the drugs must be mentally capable to make medical decisions while consulting their respective doctors, the text of the measure says.

The campaign leading up to the vote had been fairly well covered and vociferous, with several polls suggesting it would pass comfortably. But on the day the measure was defeated by the narrowest of margins—1 516 584 (51%) against and 1 453 742 (49%) for. (http://www.bostonglobe.com/2012/11/07/dying/22ppArgemoWeHEF6GnsE5H/story.html)

Abortion and contraception

At the other end of the spectrum of healthcare, measures on abortion and contraception were debated in several states. In two of the standout measures on abortion Florida’s voters shouted down an amendment to the state constitution that would have prohibited the use of public funding for abortions (by 55% to 45%) (http://www.politico.com/2012-election/results/ballot-measures/florida/) and in Montana voters approved Legislative Referendum 120, requiring parental notification for a physician to perform an abortion on a minor, 16 years old or younger. The referendum did provide for some exemptions for abortions being performed without parental notification, such as a medical emergency or being waived in a youth court hearing. (http://www.greatfallstribune.com/viewart/20121106/NEWS01/311060026/Montanans-approving-ballot-measures-by-big-margins)

In California, voters in LA County passed Measure B by 56% to 44% (http://www.smartvoter.org/2012/11/06/ca/la/meas/B/). The measure, better known as the Safer Sex in the Adult Film Industry, requires all performers in pornography to wear condoms and also for porn producers to apply for a permit from the LA County Department of Public Health to shoot sex scenes. The fee will finance inspections of film sets, and violations will be subject to fines and misdemeanor charges.

The AIDS Healthcare Foundation, which drove the measure, has hailed it as a victory for public health and the safety of actors but others in the industry claim it is a violation of their freedom and will drive them to move their business elsewhere. Since the vote the Free Speech Coalition has announced its intention to challenge the measure in court. (http://news.avn.com/articles/Court-Challenge-Promised-in-Wake-of-Measure-B-Passage-493928.html)

Death penalty

Californians also rejected a proposition on their ballots, by 53% to 47%, that would have ended the death penalty in the state (http://www.bmj.com/content/345/bmj.e7613). Proposition 34 would have replaced the death penalty with life in prison, without parole. Prisoners already on death row would have had their sentences converted to life imprisonment.

California has 725 prisoners on death row, the most of any state. The Death Penalty Information Center says that there were 3170 prisoners on death row in the US as of April 2012. Since 1978 when California’s death penalty was reinstated, the state has executed 13 prisoners but it has not carried out any executions since 2006, when a court found flaws in the execution process. Prisoners on death row are more likely to die from natural causes than to be executed, because of the slow appeals process.


November 6 was also hailed as a good night for pot. The federal government is currently considering whether to block new laws in Colorado and Washington after the electorate voted to legalize marijuana. The Seattle Times has reported that Washington governor Chris Gregoire met deputy attorney General James Cole in Washington, DC and told Cole she would prefer to know “sooner rather than later, because Washington state is getting ready to decriminalize pot, which is still illegal under federal law.”

“I told them, ‘Make no mistake, that in the absence of an injunction of some sort, it’s our intent to implement decriminalization,’” Gregoire said to the Associated Press. “I don’t want to spend a lot of money implementing this if you are going to attempt to block it.” (http://seattletimes.com/html/localnews/2019676681_marijuana14.html?prmid=4939)

Oregon, on the other hand, rejected a similar law to legalize pot (http://abcnews.go.com/blogs/politics/2012/11/the-wacky-pot-law-that-failed-in-oregon/), but its proposers have promised to come back to the electorate in 2014.

Medical marijuana also received a resounding thumbs-up in Massachusetts and Montana for the treatment of illnesses including cancer, glaucoma, and Parkinson’s disease, while North Dakotans passed a ban on the smoking of tobacco in all public places.


Cite this as: BMJ 2012;345:e7810