Abortion, Medicaid highlight state health ballot tests

• Elsewhere, there are measures dealing with Medicaid expansion, the regulation of the dialysis industry, and even whether access to health care is a legally enforceable right.

The big picture: The biggest outcome for health care remains whether Republicans retake one or both houses of Congress.

• The GOP has its eye on potentially overhauling entitlement programs like Medicare, trying to repeal Democrats' drug pricing law, and investigating the federal pandemic response.
• But the statewide votes reinforce how many key decisions are devolving to governors, legislatures and state regulators.

Here's what we're watching:

Issue: Abortion rights.

Zoom in: Voters in California, Michigan and Vermont will consider whether to amend their state constitutions to protect the right to abortions.

• Kentucky and Montana voters will face questions on further restricting abortion rights and conferring legal rights on fetuses.

What to know: Such initiatives boost turnout, as we saw in the Kansas primaries when an amendment that would have struck abortion protections in the state's constitution was soundly rejected.

• In Michigan, the issue looms over the governor's race and appears to be bolstering Democrats.
• Polling from Emerson College shows 52% of voters in the Great Lakes state say they plan to vote for the measure, while 38% say they'll vote no and 10% are undecided.

What to watch: "The public is not as extreme as the politicians on both sides of the political spectrum. They're likely to not want a virtual ban on abortions, particularly when the health of the mother is at stake, when there is rape or incest, or a really unacceptably short time period," Lawrence Gostin, a law professor at Georgetown University, told Axios.

• "I think you might see, like in Kansas, people moving to moderation both on health care and abortion," Gostin said.

Go deeper: Fight for abortion rights moves to state ballots

Issue: Medicaid expansion

Zoom in: South Dakota, one of a dozen Republican-led holdout states that haven't expanded their Medicaid programs, will put the question to voters, per Lucille Sherman and Emma Hurt.

• Voters there in June rejected a GOP proposal that would have raised the threshold for passage.
• “It just makes sense. It’s time to get over it," Greg Jamison, a Republican South Dakota state representative told the New York Times about his own support for expansion.
• If Measure 28 succeeds, it would expand Medicaid eligibility to about 42,000 people at a total cost of $1.5 billion for the first five years, with the state’s share being about $166 million in that time.

Be smart: The idea is catching on in more red states. Ballot questions on the issue passed in Nebraska, Utah and Idaho in 2018 and Missouri and Oklahoma in 2020.

Issue: Health care as a right

Zoom in: Voters in Oregon will vote on whether or not to make the state the first to enshrine a right to health care with Measure 111, the Associated Press reports.

• If passed, the state would have an obligation to ensure residents have access to "cost-effective, clinically appropriate and affordable health care." This would not require universal or single-payer health coverage.
• Supporters say it would push the legislature to prioritize bringing down the cost of health care, and could lead the state to make moves like expanding Medicaid or state subsidies for health plans in order to close the coverage gap.
• Opponents say the measure will lead to far more people getting on Medicaid and lead individuals to sue the state over their health care, Oregon Public Broadcasting reported.

What they're saying: "You might find a lot of litigation in the state's courts such as 'I have the right to this very expensive medication,'" Gostin said. "The constitutional provision would be for 'cost-effective health care' so that gives the state some hedge in the courts. But I think they will have to defend themselves in litigation."

• Yes, but: The state may run into trouble with mental health or substance use treatments, areas that typically have long waits to access care and often don't have great insurance coverage, he said. "That opens the state up to litigation that could well succeed," Gostin said. "It could be pricey for the state."

Issue: Dialysis regulations

Zoom in: Voters in California will consider whether or not to approve tighter regulations for the dialysis industry, such as a requirement to have an on-site physician during all hours of operation.

• Clinics would also have to report dialysis-related infections and disclose the names of anyone who own at least 5% of the clinic.
• This measure is back after having been defeated twice in the last five years and takes aim at hugely profitable dialysis giants like DaVita and Fresenius Medical Care.

Between the lines: This is one of the most expensive ballot initiatives in history, coming up for the third election cycle in a row.

• The union backing the proposal has spent $8 million this time around, saying it's necessary to protect patients.
• Meanwhile, the industry has poured $86 million into rallying the opposition of patients, per the Los Angeles Times. In all, the dialysis industry spent more than $233 million, including in lobbying, to fight the state regulations by 2020.
• They've warned the proposition would force clinics to charge more or "shut down dialysis clinics throughout California."

Issue: Flavored tobacco product ban

Zoom in: Another health-related measure on the ballot in California would allow voters to reaffirm or overturn a ban on flavors in certain tobacco products such as menthol cigarettes or candy-flavored vaping juice.

• The ban was passed two years ago, but the tobacco industry lobbied enough support to put the issue to a vote, ABC News reports.

State of play: While doctors, children's health advocates and the state's Democratic party support keeping the ban, the state's Republican party has pushed against the law because it cuts into a major source of tax revenue, per ABC.

• Other opponents have pushed for higher taxes, rather than an outright ban on these products.

Issue: Medical debt rules

Zoom in: An Arizona measure, Proposition 209, would reduce the maximum amount of interest creditors can charge on medical debt to 3%, from a previous cap of 10%.

• It would also increase the assets exempt from debt collection and allow courts to reduce how much of a person's earnings can be garnished.

Between the lines: The measure could become a model in states unwilling to tackle medical debt through their legislatures.

Yes, but: Critics have warned efforts targeting medical debt can have unintended and costly consequences on all consumer debt and collection remedies.