State ballot initiatives, races to watch

There are two major state healthcare ballot initiatives voters will decide this fall: a measure regulating California dialysis clinics and a proposal to give Oklahoma lawmakers more flexibility to fund the state’s Medicaid expansion.

Proposition 23 in California, which is supported by the influential Service Employees International Union-United Healthcare Workers West union, would require chronic-dialysis clinics to have an on-site physician while patients are treated, report data on infections and get permission from the state before closing clinics.

Dialysis industry giants DaVita and Fresenius have poured money into defeating the measure—$93 million to proponents’ $6 million, according to state disclosures— claiming it would create arbitrary bureaucratic requirements and cause some clinics to close.

Proponents say the measure would improve patients’ quality of care. SEIU-UHW spokesman Steve Trossman said the dialysis industry makes massive profits and could afford to comply with the regulations.

A 2018 SEIU-UHW-backed initiative that would have capped dialysis clinics’ profits failed, and newspaper editorial boards across California urged voters to reject this year’s proposal, calling it an intentional negotiating ploy.

Oklahoma voters will decide whether to take annual funds from a tobacco company settlement and let lawmakers use it to fund Medicaid programs, including the Medicaid expansion voters approved in

June. Republican Gov. Kevin Stitt supports the measure, while the Oklahoma Hospital Association has not taken a position.

States across the country will be facing a fiscal crunch as tax revenue plummets, and state government elections will determine how states face down their deficits.

Medicaid provider payments are likely targets, as states have limited options to cut other Medicaid expenditures as a condition of accepting federal aid.

“The question is how states react to fiscal constraints that they are facing. Will they cut

Medicaid? Will they cut elsewhere or create new sources of revenue?” said Heather Howard, a Princeton University lecturer and director of a program that gives states technical assistance on healthcare policy reform.

ACA backstop

States are on the forefront of policy innovation, and state legislatures and governors influence how aggressive policymaking could be. States could also step in if the Affordable Care Act is struck down by the Supreme Court this term, Howard said.

The most significant policy changes will come from states that are able to form so-called trifecta governments, with the governor and both chambers of the state legislature from the same party.

North Carolina is a battleground for the presidency and the Senate, but the GOP-run state Legislature—that has so far blocked Democratic Gov. Roy Cooper from expanding Medicaid—may also be up for grabs. If Cooper wins reelection and Democrats flip the Legislature, that could pave the way for the state to expand Medicaid.

Other potential trifectas include Democratic control in Minnesota and Pennsylvania, control by either party in New Hampshire, and GOP control in Alaska, state elections analyst Chaz Nuttycombe wrote for the University of Virginia Center for Politics.

The open Montana governor’s race will also be pivotal, as Democratic Gov. Steve Bullock reached his term limit and decided to run for the Senate. The state Legislature is currently controlled by Republicans.

In the past two years Congress has failed to pass reforms on even such issues as banning surprise billing and lowering prescription drug prices, which both parties generally agree should be addressed. The gridlock could continue no matter who wins the White House, which makes states important fronts of healthcare policy development.

“There are so many healthcare issues on which states are still innovating to fill that vac

● uum,” Howard said.

The question is how states react to fiscal constraints that they are facing. Will they cut Medicaid? Will they cut elsewhere or create new sources of revenue?” Heather Howard, a Princeton University lecturer