Voters in nine states will weigh in on a plethora of healthcare policy questions when they go to the polls Nov. 7.
Five states--Arizona, Arkansas, Nevada, Oklahoma and Oregon--will decide on proposals for spending the billions of dollars their states expect to receive from the national tobacco settlement, to be doled out during the next 25 years. In Arizona and Oregon, voters will choose between competing ballot initiatives on that topic.
Measures to expand treatment options for patients are on the ballot in three states. Colorado and Nevada will consider whether to approve the medical use of marijuana. In Maine, voters will decide whether to follow Oregon as the second state to allow physician-assisted suicide.
Healthcare providers in Colorado and Massachusetts are fighting ballot initiatives to cut taxes, which providers believe will threaten future healthcare funding, particularly for low-income residents.
Finally, ambitious healthcare reform hasn't dropped off the political radar screen. In Massachusetts, voters will weigh in on a proposal backed by a small coalition of physicians and consumer advocates that would require the state to implement universal healthcare coverage by July 2002. It would also limit HMO profits, guarantee patients the right to choose a physician and prohibit financial inducements to limit care.
Dueling initiatives would determine how the state will spend its $113 million per year from the tobacco settlement. Proposition 204 would use the funds to expand coverage of the state's Medicaid managed-care program, the Arizona Health Care Cost Containment System. Alternatively, Proposition 200 would target proceeds to fund hospice care, preventive care, prenatal care, the State Children's Health Insurance Program and a new mental health hospital. The Arizona Hospital and Healthcare Association supports Proposition 200, saying that its coverage is more wide-ranging and fiscally prudent.
Voters will decide whether to earmark $1.6 billion in tobacco settlement proceeds for preventive healthcare and research. The ballot initiative survived a court challenge by a caucus of black legislators, which asserted that it would usurp legislative authority. A coalition of provider groups is supporting the proposal.
The Colorado Health and Hospital Association is opposing three ballot measures that would affect hospitals and health plans in the state.
Amendment 20 would allow patients diagnosed with a serious or chronic illness to register with the state for permission to use marijuana for medical purposes. Patients would be required to get a written statement from a physician. Proponents say the measure would give seriously ill patients another treatment option. The hospital association says marijuana adds nothing to available medicines and that if it is legalized for medical use, it should be prescribed by physicians and dispensed by pharmacists.
Amendment 21 would provide annual $25-per-person cuts in taxes on property, income, utilities and vehicles in perpetuity or until those taxes are eliminated. The Colorado Secretary of State's office estimates that under the plan in 2003 the state government would lose $410 million and local governments would be out $892 million.
Supporters argue that Colorado's taxes are among the highest in the nation and that tax revenue would climb even if the measure is approved.
The hospital association says hospital districts and county-run hospitals stand to lose funding, and the tax reduction could force cuts in Medicaid and other health programs.
Amendment 24, meanwhile, would require counties, cities and towns of a certain population to develop voter-approved "growth-area maps" that would be used to control development. The maps would take into account the regional impact of development. Opponents, including the hospital association, say the amendment would hinder development, including the building of new healthcare facilities.
At least $1 million has been spent by each side in the battle over legalized physician-assisted suicide. The state medical society opposes the initiative.
"Assisted suicide is directly inconsistent with current and traditional medical ethics, and we're opposed to it," said Gordon Smith, executive vice president of the Maine Medical Association. The society advocates better access to end-of-life care.
As of mid-October, about 70% of Maine voters polled said they supported the initiative. Supporters agree that better end-of-life care is a start but still believe physician-assisted suicide should be available to patients who choose it.
"We should allow people to have their own scope of choices based on their own beliefs," said Kate Roberts, director of Portland-based Mainers for Death With Dignity, which put the initiative on the ballot.
Insurance companies and HMOs are fighting a ballot initiative that would implement universal health insurance coverage and temporarily prohibit conversions of not-for-profit healthcare companies to for-profit.
The measure, Question 5, would also require that no more than 10% of health plan premiums be spent on nonmedical costs. If the measure passes, a 17-member council would be charged with implementing a system to guarantee comprehensive health coverage for all Massachusetts residents by July 2002.
The conversion of not-for-profit hospitals, HMOs and health insurers to for-profit status would be prohibited until universal coverage is in place.
Question 5 would also enact patient protections, including granting patients the right to choose their providers.
The measure was spearheaded by a coalition of individuals that includes physicians and consumer advocates. The Massachusetts Nurses Association has endorsed the measure, but the Massachusetts Hospital Association has not taken an official stand.
A coalition against the measure, which is heavily funded by Blue Cross and Blue Shield of Massachusetts and Harvard Pilgrim Health Care, argues that passage will result in higher costs for consumers. Opponents said they will invest $4 million to fight it, outspending proponents by 100 to 1.
Some proponents of managed-care reform, including a not-for-profit group called Health Care for All and the Massachusetts Medical Society, said there is a risk that the measure could conflict with a state managed-care reform initiative signed into law in July.
Voters in the state will also consider two tax cuts, which the hospital association said it is "opposing in the strongest possible terms." The cuts would slash the state budget by an estimated 10%, or $2 billion.
Question 4 would reduce the state personal income tax over three years to 5% from 5.85%, with a projected $1.2 billion-per-year price tag.
Question 6 would allow tax credits for the state's road tolls and motor vehicle excise taxes and is estimated to cost $700 million annually.
The hospital association said tax cuts would mean reductions in state Medicaid and uncompensated-care reimbursement.
Gov. Paul Cellucci has backed the income tax rollback, but his administration has encouraged defeat of the so-called "Free the Pike" referendum, according to the Boston Globe.
Some state legislators have expressed concern that the state cannot swallow both measures. Proponents cite the strong economy and state budget surplus as reasons for returning the state personal income tax rate to 5%.
Voters will consider an initiative to require at least $12 million, or 40%, of the state's annual tobacco proceeds of $30 million be placed in a trust fund, with 90% of the income earned by the trust to be used for healthcare and the remainder to be reinvested.
The measure would also require that the money, which will total $750 million over 25 years, not be spent without a two-thirds majority vote by both houses of the state Legislature. The initiative is supported by a variety of healthcare organizations, including the state's largest hospital lobby, called MHA--an Association of Montana Health Care Providers.
Voters will consider a constitutional amendment to allow patients with AIDS, glaucoma, epilepsy and other diseases to use marijuana for treatment. The measure would also guarantee a steady supply of the drug.
The measure passed last year by a wide margin but needs approval a second time to be implemented under state law.
The Nevada Association of Hospitals and Health Systems has not taken a stand on the controversial measure. "We have other agenda items we need to push, and we don't want to use up our capital on this one," said association President Bill Welch.
Voters will decide whether to create a trust fund for tobacco settlement payments. The nearly $1.9 billion would be designated for cancer research, tobacco use prevention and cessation and other social services programs. It is supported by the Oklahoma Hospital Association and other provider groups.
Two competing ballot measures would dictate how the state spends its $2.2 billion share of the national tobacco settlement. Both seek to place the money in a permanent trust fund from which only interest proceeds would be spent.
One measure, sponsored by the Oregon Association of Hospitals and Health Systems and backed by the Oregon Medical Association, would devote all of the trust's earnings to rejuvenating the Oregon Health Plan, which covers the poor.
All money spent on OHP programs, such as the Children's Health Insurance Program, would be eligible for federal matching funds.
A competing measure crafted by the state Legislature and backed by various interests would allocate 40% of the fund's earnings to county health departments and the rest to a variety of human services. They include 20% for low-income housing, 20% for transportation for the elderly and disabled, 10% for anti-smoking efforts, 7% for Oregon Health Sciences University and 3% for creating a shelter for victims of domestic violence.
The American Cancer Society, the American Heart Association and the American Lung Association oppose both ballot measures, arguing that neither earmarks enough for smoking prevention.
--Compiled and edited
by Mary Chris Jaklevic