| We know that what you’re thinking about most is the election. So let’s turn to one of the few campaign issues that you probably haven’t seen a dozen different stories about every day: ballot initiatives. Why it matters: These sometimes-overlooked-but-consequential choices on the ballot give voters a direct say in policies, and allow them to bypass politically fraught legislative debates. Ballot measures in the past have forced a change in policy directions. They allowed citizens in several states to expand Medicaid or change social policies, including on abortion, when state elected officials were not eager to do so. This year, the health-related topics on the ballot include funding, abortion, transgender issues, Medicaid and more. By the numbers: This year, states are voting on more than 165 ballot initiatives overall, according to the National Conference of State Legislatures (NCSL). “The overall total number of ballot measures is pretty high,” said Helen Brewer, NCSL senior policy specialist. The number this year is higher than in 2020 and 2022 in particular. Zoom out: Overall, the most common topics for all ballot initiatives involve taxes, bonds and funding. Decisions on education, election and redistricting rules, environmental protection, and, yes, health care are also big issues. Some decisions are about ballot measures themselves. In three states, voters will decide whether to make it harder for a ballot measure to pass by raising the vote threshold for approving a constitutional amendment through ballot measures. The various initiatives range from issues that will directly affect most voters’ pocketbooks to more narrow decisions. Idaho voters will choose from a list of weapons to decide which should be designated the official state gun. Let’s dig into what some of these measures mean for health care. One of the big ballot issues this year is California’s proposed billionaire tax, which would not only fund health care but also serve as a test of whether one state, acting alone, has the stomach to impose taxes on the wealthy. The ballot initiative, proposed by a health care union, would set up a one-time tax of up to 5 percent on taxpayers and trusts with covered assets valued over $1 billion. Most of the funds would go to offset federal cuts in health care, while about 10 percent would go to food aid or education. The union said if federal funding falls and the state does not increase revenue to make up for it, about 3.4 million Californians could lose coverage and the health care workforce would shrink. California Gov. Gavin Newsom (D), a potential 2028 presidential hopeful, is among those opposing the proposal, known as Proposition 40. Newsom, pointing to the exits of a handful of billionaires from the state already, said that it does not make sense for the state to impose a tax that could push wealthy residents to relocate. On the other side are advocates including Sen. Bernie Sanders (I-Vermont), who could be in line to chair the Health, Education, Labor and Pensions Committee if Democrats retake the Senate. Two other ballot initiatives, Propositions 41 and 42, were filed to compete with Proposition 40, according to Ballotpedia. Read more about the spending on advocacy in this Washington Post story here. Let’s stick with California and some other initiatives on the ballot. → With the reliability of federal research dollars uncertain, Proposition 38 would steer state funding to a nonprofit immunology and immunotherapy research institute affiliated with the University of California system. An advisory council would oversee the program. The state could issue $8.4 billion in bonds under the proposal, and additional government funds could be provided for the work. → Another initiative, Proposition 44, would require nonprofit health centers to spend at least 90 percent of their revenue on program services, including patient care, rather than management and overhead. Financial penalties would be set to enforce it. The plan also authorizes criminal charges for falsified spending reports. This is a fight between health care union members and medical providers such as the California Medical Association and California Academy of Family Physicians. → Moving on, lead in drinking water is on the Louisiana ballot. An initiative would allow local governments to use public funds to identify, remove, or replace drinking water utility service lines affected by lead or other hazards. From 2000 to 2026, seven states have voted on — and approved — 14 ballot measures about drinking water systems, according to Ballotpedia. → Medicaid is a big issue for states next year, as more federal rules and funding cuts are set to take effect. South Dakota is voting on an issue that other states have considered in the past: whether to back out of an expansion of Medicaid eligibility if the federal government drops its contribution. Under the Affordable Care Act, federal officials cover 90 percent of the funding for people who became eligible under Medicaid expansion, while states kick in 10 percent of the costs. That’s a higher federal contribution than for other people on Medicaid. South Dakota voters will decide whether to scale back eligibility and cut back the number of people covered by Medicaid if federal officials ever decide to drop their contributions for people in the expansion group to below 90 percent. → A number of states in previous cycles voted on abortion ballot initiatives. A handful of states are tackling the controversial issue this year, including some who are voting again even though citizens already approved ballot initiatives on abortion. Take the case of Missouri: Two years ago, citizens voted to protect abortion access in the state’s constitution. But now Republican legislators in the right-leaning state are asking Missouri voters to think again and say yes to an anti-abortion measure. The initiative approved two years ago and the one this year are both called Amendment 3. But the responses are the opposite from the previous vote: Voting no this year is a vote for abortion rights and in favor of sticking with the 2024 decision. Last time, a yes vote added those abortion rights to the state constitution. This year, voting yes would get rid of the new abortion rights and sub in pro-life language to ban abortion, except in cases of medical emergency, fetal anomaly, rape or incest. For cases of rape and incest, the abortion could only be performed before 12 weeks. It would require guardian consent for minors seeking abortions. It also would add transgender-related language. In three states, citizens will weigh measures to protect abortion rights. In Nevada, voters are asked on Question 6 to reaffirm their approval of abortion rights. In Virginia’s Question 1 and Idaho’s Proposition 1, voters will consider rights to abortion before fetal viability. → And several states are weighing in on questions about transgender people. Proposals include bans on surgery to alter a minor’s gender or biological sex traits and prohibitions on biologically male students from competing in girls’ sports. My colleague Annie Gowen covered this issue here. The numbers are in: The Pharmaceutical Research and Manufacturers of America (PhRMA) saw increased expenses, up from nearly $578.3 million in 2024 to $621.9 million last year, according to a recently filed Form 990 obtained exclusively by Health Brief. By the numbers: The drug industry trade group represents 34 companies. The approximately 7.6 percent spending increase by PhRMA came in a year when both Democrats and Republicans talked about the high cost of drug prices. President Donald Trump pressured drug industry executives to craft secret agreements, the so-called “most-favored-nation” (MFN) deals, designed to equalize some of their prices with those in other nations, either by lowering prices in America or raising them abroad. Drug companies struck deals with the White House that reportedly promised them protection from tariffs. → It was a good year for PhRMA President and CEO Stephen Ubl, who took home nearly $8.8 million in reportable compensation and $6.1 million in other compensation. Ubl, who joined PhRMA in 2016, announced in April he would retire, although he will stay on as a strategic adviser. The association’s incoming leader, Eric Cantor — a former Republican congressman who served for 14 years, including as House majority leader from 2011 to 2014 — starts on Nov. 9. Flashback: Last month, my colleague Megan Wilson tallied the top 100 health care lobbying spenders from January through September of this year. She found that organizations reported more than $408 million in advocacy spending. The top Republican and Democrat on the House Energy and Commerce Committee joined forces Monday to ask the key Capitol Hill budget experts to reevaluate the 10-year costs of a 2020 law designed to protect patients from surprise medical bills. The No Surprises Act “was the culmination of a multi-year bipartisan, bicameral effort to protect patients from the unfair practice of surprise medical billing and lower health care costs for American families,” wrote Brett Guthrie (R-Kentucky) and Frank Pallone Jr. (D-New Jersey) to the Congressional Budget Office. But the result was, well, a surprise. CBO expected the law to reduce health care costs and cut the federal deficit by about $17 billion over 10 years. This summer, CBO called for more research into the law, and acknowledged its original projections were off-base after court and regulatory decisions changed the details. Guthrie and Pallone’s letter requested that CBO analyze the total effects on private health insurance premiums and federal deficits, over the next decade, resulting from the dispute-resolution process created under the No Surprises Act. By the numbers: CBO initially estimated that 17,000 disputes would be filed annually. But 2.5 million disputes were filed in 2025 and 1.4 million were filed just in the first five months of 2026, the pair said. “The increase in volume of cases is resulting in higher administrative costs which is raising premiums for consumers and employees,” wrote Guthrie and Pallone. Nour Wood and Megan R. Wilson contributed to this newsletter.
This newsletter is published by WP Intelligence, The Washington Post’s subscription service for professionals that provides business, policy and thought leaders with actionable insights. WP Intelligence operates independently from The Washington Post newsroom. | 
