It’s still early, but so far at least eight of the estimated 90 state initiatives that voters will decide on this year are health-related, including four amendments, the most ever in one year, related to abortion access.

“Many states are still in the signature-gathering phase for initiatives, but by late August or early September we will have a much clearer idea of the total number of measures and whether that is in line with previous years or not,” said Amanda Zoch, project manager for elections and redistricting at the National Conference of State Legislatures.

By comparison, the overall number of initiatives related to health in both 2020 and 2018 was about two dozen. 

The process and timeline for voters to weigh in on initiatives or constitutional amendments varies by state, can be citizen-led or prompted by the state legislature, and can be a multiyear process. And even after signatures are collected they must be verified to qualify for the ballot, with some measures facing legal challenges or other hiccups, Zoch said.

Among the measures states are trying to put on the ballot are initiatives related to drug control policy as well as those inspired by the COVID-19 pandemic.

Twelve states have proposed potential measures that would decriminalize or legalize cannabis or hallucinogenic plants such as psilocybin mushrooms. Advocates argue that the drugs may have therapeutic uses. Oregon became the first state to legalize psilocybin for medical purposes in 2020.

Arkansas, Nebraska, Missouri, Ohio and Washington have proposed nine amendments that mainly target vaccine mandates. Some of the amendments also include language that would prohibit mask requirements and block forced medical interventions.

Abortion access

At least four states will vote on amendments related to abortion, with Vermont the only state considering a constitutional amendment to protect abortion access.

State lawmakers passed the proposed language in both chambers in two consecutive legislative sessions. Now voters will choose whether to add language to protect an “individual’s right to personal reproductive autonomy” to the state constitution.

Kansas, Kentucky and Montana voters, meanwhile, will weigh restrictions to abortion.

Kansans will vote during the state’s Aug. 2 primary on whether the state constitution should explicitly say abortion is not a protected right.

The Kansas Supreme Court ruled in 2019 that the state constitution protects this right, leading conservatives to try to change the language to protect future abortion restrictions from being litigated. 

“Our affiliate, Kansans For Life, said it’s going to be really difficult to pass laws if you know the opposition to the pro-life movement is taking these bills into state court instead of the federal court,” said Ingrid A. Duran, director of the department of state legislation at the National Right to Life Committee.

By contrast, Ashley All, spokesperson for Kansans for Constitutional Freedom, a coalition that opposes the constitutional change, said local groups are “encouraging people to vote no because this amendment would give politicians the power to make and pass any law they want regarding abortion, including a total ban.”

Kentuckians will face a similar vote on Nov. 8. The Kentucky measure would say that the constitution doesn’t provide a right to abortion and doesn’t require any funding for abortion.

In Montana, voters will decide if the state should require medical care for infants born alive after induced labor, a cesarean section or attempted abortion. It would declare any infant born under these circumstances to be a legal person, and failure to provide care could be subject to a $50,000 fine and/or up to 20 years in prison.

But other states also may include changes to abortion policy on the ballot, especially in light of the anticipated Supreme Court ruling expected to overrule almost 50 years of legal precedent establishing a right to an abortion under Roe v. Wade. A draft of that ruling was leaked to Politico earlier this month.  

On May 16, a grassroots group called Arizonans for Reproductive Freedom applied to collect signatures for a constitutional amendment that would protect abortion access until viability. The deadline for signatures is July 7.

That amendment seeks to overturn a 1901 law, enacted before Arizona became a state, that could take effect and block abortions in the state if Roe is overturned.

Health coverage 

South Dakota and Oregon voters will weigh in on amendments that would expand health coverage.

South Dakota is one of 12 states that have not expanded their Medicaid program. A citizen-led initiative would seek to expand coverage for 42,500 South Dakotans via two routes: one, already on the ballot, that would make it part of the constitution, and one, not currently on the ballot, that would make it law. Passage would make the state the seventh to expand Medicaid by ballot.

But the path is complicated. The South Dakota Legislature referred an amendment for the June 7 primary that, if passed, would require all voter initiatives to have a three-fifths supermajority to pass. The Medicaid amendment would be voted on during the Nov. 8 general election.

Dakotans for Health co-founder Rick Weiland said the group has also submitted signatures for a vote on the second route, making the expansion of Medicaid part of statute. He said voters may be more amenable to making the change as a law than adding it to the state constitution. 

“We’re encouraging people to vote for both,” he said of the expansion measures, adding if the amendment changing the threshold fails, there’s a much better chance of expansion. “I think there’s still a decent chance we’ll get it done in November,” he said.

Oregon voters will weigh in on a legislative referendum that would add language to the state constitution to ensure that residents have access to affordable health care.

The Oregon Nurses Association, part of a coalition of health and labor groups working to pass the amendment in November, said it plans a campaign website, increased outreach, fundraising and endorsements in the coming weeks.

“It also requires the state to balance funding health care with funding all other essential services, like public education. This measure establishes that Oregonians have a right to access health care, enshrines that right into the constitution,” said Scott Palmer, director of communications for ONA.

Opponents of the measure worry about the costs and how it will be paid for.

Substance use

California and Maryland are the only states with confirmed votes on drug regulations this fall.

A 2020 California law blocks the sale of flavored tobacco, with exceptions for hookahs and premium cigars. Violators are subject to a $250 fine. Proponents of the law say it will improve public health and crack down on youth tobacco use by limiting enticing flavors like bubble gum and cotton candy.

But opponents of the law, including several tobacco manufacturers, say the ban will harm small businesses and encourage tobacco users to purchase the products from other states without restrictions.

The California secretary of state certified in January that a referendum on the law would be put to voters.

Maryland voters could choose to legalize marijuana for adult use after the state legislature voted to include the measure as a constitutional amendment earlier this year.

NCSL data shows 18 states and the District of Columbia have enacted measures to regulate non-medical cannabis use among adults.

The Goucher College Poll, conducted by the Towson, Md., school, found 62 percent of Maryland residents support marijuana legalization and 34 percent oppose it. Majorities of Democrats, Republicans and independents were supporters.

The Drug Policy Alliance said it is also watching legalization efforts in Oklahoma, which is in the signature-collecting phase, and Missouri, which is waiting for signatures to be verified.