Assisted Dying and Marijuana Also Won at the Ballot Box

November 10, 2016

Colorado became the sixth state to allow physician-assisted suicide, and seven states legalized recreational or medical marijuana as voters decided on a slew of healthcare ballot issues on November 8.

Those results illustrate that although the election of Donald Trump as president promises to reshape healthcare policy on a national level, states have plenty of room to enact reforms of their own, sometimes with the support of their medical societies.

In Colorado, voters approved legislation already enacted by Oregon, Washington, Vermont, and California that allows a physician to prescribe a lethal drug to a terminally ill patient who requests it and self-administers it. There must be a determination beforehand, however, that the patient is competent and is making an independent decision and that he or she has received counseling on palliative and hospice care.

The Montana Supreme Court has ruled that physician-assisted suicide, also called assisted dying, is legal there because nothing in state law forbids it.

Like its counterpart in California, the Colorado Medical Society took a neutral stance on the question of physician-assisted suicide, in contrast to organized medicine's traditional opposition to the practice as un-Hippocratic.

Another healthcare trend spreading across the nation is legalization of marijuana for medical or recreational use. Voters in California, Maine, Massachusetts, and Nevada on November 8 approved recreational marijuana, joining Alaska, Colorado, the District of Columbia, Oregon, and Washington as Mary Janers. A recount of the narrowly divided vote in Maine remains a possibility, the Bangor Daily News reported last night. Recreational marijuana appears headed for defeat in Arizona.

State medical societies parted ways on the matter of party reefers. The Massachusetts Medical Society opposed recreational marijuana as a public health threat, whereas the California Medical Association preferred strict control and regulation to prohibition.

Medical marijuana won approval in Arkansas, Florida, and North Dakota — and expanded use in Montana — despite opposition from medical societies in those states, which pointed to the lack of scientific evidence and regulatory vetting. Twenty-eight states plus the District of Columbia have now legalized marijuana for treating cancer, chronic pain, glaucoma, HIV/AIDS, severe nausea, and other conditions.

Universal Coverage in Colorado Defeated

The affordability of prescription drugs became an issue in this year's presidential race, with both Trump and his Democratic opponent Hillary Clinton promising to reduce their cost. A November 8 ballot measure in California proposed to do the same thing, but 54% of voters said no.

Proposition 61 in the Golden State would have required the state's Medicaid program and other agencies to pay the same price for prescription medicines as the Department of Veterans Affairs pays. Pharmaceutical companies bankrolled a massive campaign against the measure. One of their allies was the California Medical Association, which warned that Proposition 61 could eliminate discounts that the state already enjoyed with drugmakers and remove many drugs from the Medicaid formulary, creating prior authorization hassles for physicians and patients.

An attempt to make healthcare more cost-effective met a similar fate in Colorado. Voters there rejected a ballot measure to create a universal coverage system that would replace private insurance and Medicaid for individuals under 65 years of age, which is an option under the Affordable Care Act (ACA). States that opt out of the ACA this way are entitled to all the federal funding they otherwise would receive.

Supporters said that "ColoradoCare" would expand coverage while lowering costs, but opponents said the plan would add too much to state taxes. The Colorado Medical Society said that the current healthcare system, however imperfect, would be better than the complex, untried system put forward.

Cigarettes and Soda Take a Hit

A number of public-health measures on state and local ballots produced mixed results.

California voters increased the tax on a pack of cigarettes from 87 cents to $2.87 to discourage smoking and raise money for smoking prevention and cessation programs. Proposition 56 also imposes an equivalent tax on e-cigarettes.

"This is a great day for public health in California," said Steven Larson, MD, MPH, the immediate past president of the state medical society, in a news release. "Proposition 56 will save lives, prevent kids from getting hooked on tobacco, improve access to health care, and fight cancer and other tobacco-related diseases."

However, cigarette tax hikes were voted down in Colorado, Missouri, and North Dakota.

Like cigarettes, too much sugar also is a public health threat, considering how it contributes to obesity and diabetes. Accordingly, voters in the California cities of Albany, Oakland, and San Francisco approved a penny-per-ounce tax on soda, sports drinks, ice tea, and other nonalcoholic beverages that are sweetened with sugar. Boulder, Colorado, passed a soda tax of twice that amount.

All those cities hope to duplicate what happened in Berkeley, California, where a penny-per-ounce soda tax enacted in 2014 — the nation's first — reduced consumption of sugary beverages by more than 20%, according to a study published last month in the American Journal of Public Health.

Follow Robert Lowes on Twitter @LowesRobert

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