The nation's eyes may have been more focused on Washington on Tuesday night, but issues on ballots across the country were shaping health policy in the states.
Voters rejected and approved measures dealing with the touchy issues of medical marijuana, physician-assisted suicide, and abortion in a number of states. Five states also voted on measures aimed squarely at the Affordable Care Act (ACA), with one -- Missouri -- passing an initiative that could hamstring efforts to establish its health insurance exchange under the ACA.
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Massachusetts citizens cast votes on two of those key health topics, and one -- a move to allow physician-assisted suicide -- was still too close to call as of Wednesday morning. With 93 percent of precincts reporting, there were still roughly 40,000 more votes against the measure than for it.
Specifically, the measure would allow state-licensed physicians to prescribe fatal medication to terminally ill patients requesting to end their lives, provided certain conditions are met. Oregon and Washington state already have legalized physician-assisted suicide through voter-approved ballot initiatives.
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Massachusetts, the home state of Republican presidential candidate Mitt Romney, did, however, become the 18th state to legalize medical marijuana, with the measure collecting a whopping 63 percent of the vote. The new Massachusetts law allows patients with a "debilitating medical condition" to possess up to a 60-day supply of marijuana for their personal medical use, provided they obtain written certification from their physician. Voters in Colorado and Washington state went even farther, passing measures allowing people to possess small amounts of marijuana for recreational use.
Arkansas voters rejected a medical marijuana measure similar to Massachusetts' on Tuesday, but by a very narrow margin: the initiative lost by roughly 29,000 votes.
Joseph Giaimo, DO, chair of the American Osteopathic Association's Bureau of State Government Affairs, said states tend to look to others in their region and analyze what they've done before taking action.
"To this end, it is possible that Massachusetts' decisions and process taken on medical marijuana and physician-assisted suicide could set a precedent for how states handle these issues," Giaimo, of West Palm Beach, Fla., told MedPage Today.
In Missouri, voters approved a measure with 63 percent of the vote that would prevent the governor or any state agency from establishing or operating a state-based health insurance exchange unless authorized by the legislature or voters. Under the ACA, exchanges would be a web-based marketplace for consumers to compare insurance plans.
However, "States that put up additional barriers will be inviting more federal involvement into implementation decisions and in some cases, possibly foregoing federal funding," Giaimo pointed out. "In Missouri, for example, if the state legislature or residents prevent a state-based exchange as required by law, the federal government will establish one. The intervention by the federal government would prevent policymakers and citizens from controlling the decisions being made."
Pay little attention to the anti-ACA measures that passed in Alabama, Montana, and Wyoming, experts say. Opponents say they carry little legal significance even if they pass since federal law trumps state law.
The initiatives are aimed at nullifying the ACA mandate to purchase coverage or face a penalty, but the efforts could make it difficult to enact single-payer health systems should the states choose to do so in the future.
In Florida, voters rejected a constitutional amendment to nullify the mandate by a 51-49 vote. It needed 60 percent of the vote to become an amendment.
Lawmakers in those states put the anti-ACA initiatives on the ballot before the June Supreme Court ruling upholding the constitutionality of the ACA.
"Even before the court decision, they were referring to changes that could not be made by states," Richard Cauchi, health program director at the National Conference of State Legislatures, told MedPage Today.
Prior to Tuesday night's election, 20 states already had enacted either laws or constitutional amendments opposing some specific aspect of the law, Cauchi said -- including Arizona, Ohio, and Oklahoma, which have enacted constitutional amendments.
In other healthcare-related state issues, Florida voters rejected a constitutional amendment that would have prohibited taxpayer funding of abortions, which the state doesn't do anyway. Amendment 6 collected only 44 percent of the vote, but would have needed 60% to pass as an amendment.
The measure, placed on the ballot by a Republican-majority legislature, would also have excluded abortion from privacy rights protected by the state constitution.
Initiatives on Medicaid had mixed results Tuesday night. Louisiana voters supported a constitutional amendment preventing money from the Medicaid Trust Fund for the Elderly from being used for other purposes when the state is eliminating a deficit. However, South Dakota voters rejected a measure to increase the state's sales tax from 4% to 5%, with the additional revenue split between K-12 public education and Medicaid.
Michigan voters rejected a proposal that would have provided financial services for elderly patients to help manage the cost of hiring in-home care workers. It also would have provided training for in-home care workers, and would have created a registry of workers who pass background checks.