Health Policy and Direct Democracy: Predictors of Successful Measures, 2010-2024

Direct democracy is often used to shape state-level health policy. Although prior research has studied determinants of success for ballot measures generally, examination of health care-related measures (HRM) remains limited. This study addressed four questions: (1) Are HRM more likely to pass than non-HRMs (NHRM)? (2) Do HRM engage voters more than NHRM? (3) Do HRM draw more oppositional campaign spending than NHRM? (4) Among HRM, what characteristics predict success? The authors identified 96 HRM in 34 states during 2010-24 as well as 352 NHRM that appeared alongside them on the same ballot (n = 448). Using regression analyses to examine campaign outcomes, ballot completion, and spending, the authors controlled for initiative- and election-level covariates. Sensitivity analyses adjusted for "moral issues" (i.e., measures pertaining to abortion and euthanasia) and supermajority passage requirements. Their findings indicate that HRM drew greater voter engagement and were significantly more likely to pass than NHRM. Furthermore, increased oppositional spending was associated with lower odds of success for all measures. Results indicate that interest groups and voters view HRM pertaining to "morality" differently, and among HRM, oppositional spending is the strongest predictor of success. Additional research is needed on voter preparedness when it comes to health care policy on the ballot.