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October 1, 2003

State Ballot Initiatives for Health Care Reform

JAMA. 2003;290(13):1775. doi:10.1001/jama.290.13.1775

Throughout the last decade, physicians in several states have used ballot initiatives as a way to become politically active in campaigns intended to return to them some degree of control over their practices and the patient-physician relationship.1,2 Ballot initiative campaigns also provide medical students unique opportunities to work with physicians to affect health policy and hone their political advocacy skills. The initiative process, available in 24 states, allows citizens to circumvent the slower legislative process to adopt laws and amend state constitutions.1 In recent years, the initiative process has been used to advance controversial policies that at times have been blocked or ignored by legislature.1,3 In most states, an initiative must be affirmed by a simple majority of voters to carry the force of law. Of the more than 70 citizen-driven initiatives on election ballots in 2000, 11 addressed health care issues, including allocation of tobacco settlement funds, legalizing physician-assisted suicide and medical marijuana, and universal health coverage.2,4

One such campaign was the Massachusetts Health Care Reform Ballot Initiative of 2000. This ballot initiative grew out of the discontent of Massachusetts physicians with the use of financial incentives to limit patient care and control costs, the pressure to increase patient volumes as a means to increase profits, and policies that restrict a patient's freedom to choose or change his or her physicians.3 A group of 2300 physicians and health professionals drafted a ballot initiative calling for universal health care access, managed care reform, and a moratorium on the conversion of nonprofit hospitals and health plans to for-profit status.

In addition to participating in political strategizing and canvassing, medical student interns worked alongside physicians and other volunteers to collect more than 100 000 signatures from voters in Massachusetts to secure placement of the initiative on the November 2000 ballot.5 The measure, despite minimal fundraising and organization, narrowly failed at the polls, with 48% of the vote.5 In a poll taken about a month before voting, 72% of respondents reported that they supported the initiative.6 The opponents, including health maintenance organizations, several Massachusetts lawmakers, business associations, and other insurers, spent $5 million on an advertising campaign that portrayed the reforms as flawed, bureaucratic, and costly.7 The proponents, on the other hand, invested only $100 000 in their campaign.

Although the initiative did not become law, it helped renew legislative interest in health care reform. Its popularity, combined with other polling data, indicated that health care reform was important to the citizens of Massachusetts and thus prompted the Massachusetts legislature to enact a managed care reform bill that had been stymied in the legislature for more than 3 years.8,9 The bill passed by the legislature affirmed the autonomy of physicians to make clinical treatment determinations for their patients which had been restricted by managed care organizations. In addition, it strengthened protection from gag clauses that prevented physicians from discussing with patients the provisions of their health plan. The managed care bill addressed many of the issues cited as contributing to physicians' perceived erosion of autonomy and dissatisfaction.3

Although the Massachusetts Health Care Reform Initiative failed at the polls, it was indirectly successful. A well-crafted and organized initiative campaign may serve as the impetus for lawmakers to more expediently enact important health care legislation.1,8 Medical students have also participated in similar ballot initiative campaigns in California in 1994 and Washington in 2000.10 In the face of corporate interests that usually dominate the initiative process, physicians and medical students have the unique advantage of direct health care experiences. These can be integrated with the political expertise of professional campaign staff to build coalitions, fundraise, advertise, and reach out to voters. Initiatives can be an efficient method for physicians and medical students to influence health care legislation, advance health care reform initiatives, and draw attention to policy issues that affect medical practice and patient-physician relationships.

Broder D. Democracy Derailed: Initiative Campaigns and the Power of MoneyNew York, NY: Harcourt; 2000.
Goldberg C. State referendums seeking to overhaul health care system.  New York Times.June 11, 2002, sect 1:1.
The Ad Hoc Committee to Defend Health Care.  For our patients, not for profits: a call to action.  JAMA.1997;278:1733-1737.
 National Conference of State Legislatures Ballot Measures Database. Available at: http://www.ncsl.org/programs/legman/elect/dbintro.htm. Accessed October 25, 2002.
 Massachusetts Election Statistics: Public Document #43. Boston: Commonwealth of Massachusetts; 2000.
 September 2000 Quarterly Poll, conducted September 19-22, 2000. Boston: McCormack Institute at University of Massachusetts.
LeBlanc S. On some questions, money talks.  South Coast Today.November 9, 2000. http://www.s-t.com/daily/11-00/11-09-00/a05sr023.htm. Accessed September 10, 2003.
 Massachusetts Chapter 141 of the Acts of 2000: An Act Relative to Managed Care Practices in the Insurance Industry. Available at: http://www.state.ma.us/legis/laws/seslaw00/sl000014.htm . Accessed October 10, 2002.
 The Winding Road to Managed Care Reform. Available at: http://www.massmed.org. Accessed October 18, 2002.
 Washington Secretary of State Initiatives History and Statistics. Available at: http://www.secstate.wa.gov/initiatives/statistics.aspx. Accessed October 28, 2002.