In addition to who represents them in Congress and in state legislatures, voters on Tuesday will weigh in directly on issues including abortion, marijuana and vaping.
Here are the measures we’re watching on Tuesday:
Abortion
Five states will have abortion on the ballot Tuesday, the most abortion-related ballot initiatives ever to take place in a single year. The referendums come more than four months after the Supreme Court overturned Roe v. Wade, eliminating the constitutional right to an abortion that had been in place for nearly 50 years and kicking the issue to the states.
Voters in Vermont, California and Michigan will decide whether to enshrine abortion rights in the state constitution, while proponents of Kentucky’s ballot measure are seeking to make it clear that abortion can be banned in the state.
Montana, meanwhile, would mandate health providers to give medical care for children “born alive” after an abortion, or face criminal charges.
Polls show most Americans support some form of abortion access, and while there’s some disagreement about whether national Democratic races are focusing too much on abortion, advocates are eager to take the issue directly to the voters.
“I think regardless of where you think the right conventional wisdom is around how candidates should be balancing issues in their own platforms, there is an undeniable energy around voting directly on abortion issues in the states where voters are given that opportunity,” said Kelly Hall, executive director of the Fairness Project, a progressive group that helps organize ballot measures.
In Michigan, a key battleground, residents will vote on a ballot measure that would amend the state constitution to protect the right to make choices on reproductive issues, including abortion but also contraception, prenatal care, postpartum care, miscarriage management, sterilization and infertility.
In Kentucky, voters face the opposite question. The amendment would explicitly put into the state constitution that there is no right to an abortion. Kentucky effectively outlawed abortion with a “trigger” law after the Supreme Court’s ruling in June. Proponents of the ban say the measure would ensure that state courts don’t block the law in the future.
The only abortion-related ballot measure to have already come before voters since Roe v. Wade was overturned was in Kansas, where voters this summer decisively rejected a proposal almost identical to the one on which Kentucky will vote Tuesday.
Medicaid expansion
South Dakotans will vote on whether to expand Medicaid coverage to more than 42,000 individuals, against the wishes of state Republicans like Gov. Kristi Noem.
If it passes, South Dakota would be the seventh GOP-led state that opposed expansion to extend coverage through a ballot measure.
Noem has said she would accept the results and work to implement expansion if the measure passes. She is rumored to be considering a presidential run or posturing for a possible opening on a GOP ticket with former President Trump if he ultimately mounts a bid to run again in 2024.
Under the Affordable Care Act, the federal government will cover 90 percent of the costs for states to expand Medicaid coverage. To date, just 12 states have refused to do so. The American Rescue Plan, which passed in 2021, allows the federal government to cover 95 percent of the costs for two years after expansion takes effect.
For South Dakota, the government would send $110 million, offsetting $50 million in state costs, according to an analysis from the Kaiser Family Foundation.
Progressives have been working to broaden access to ObamaCare in red states for years, and the Fairness Project’s Hall said South Dakota would be a “capstone” to that work. Trump won more than 60 percent of the vote in South Dakota both times he ran.
But South Dakota may be the last state where advocates can directly put Medicaid expansion in front of voters. The only states that remain after South Dakota that allow citizen-led ballot measure processes are Wyoming and Florida.
In Florida, initiatives must pass with at least 60 percent of the votes to be added to the constitution, which is a major obstacle. In Wyoming, advocates are looking to pass expansion legislatively.
Marijuana
Five states are voting on marijuana legalization: North Dakota, where voters defeated legalization in 2018; Missouri; Maryland; Arkansas and South Dakota, which previously passed legalization only to have it overturned by the state Supreme Court.
Nineteen states and the District of Columbia have already legalized small amounts of cannabis for adult recreational use.
Arkansas voters approved medical marijuana in 2016, the first state in the South to do so. The ballot measure would modify the state’s existing medical program. Polling shows a majority support the measure, but the front-runner for the state’s next governor, Sarah Huckabee Sanders (R), opposes it.
In North Dakota, voters approved the legalization of medical marijuana in 2016 but rejected a recreational legalization measure in 2018. If enacted, the new measure will permit adults 21 and older to possess up to one ounce of cannabis and small quantities of cannabis products, such as concentrates and infused products.
In 2020, a majority of South Dakotans approved the legalization of recreational marijuana. But after a challenge funded by Noem, the state Supreme Court ultimately determined the language on the constitutional amendment wasn’t clear enough.
This time though, polling shows the measure is lagging and it’s unclear if there is enough support to pass it.
In Missouri, the measure would legalize cannabis and automatically expunge criminal records for thousands of Missourians convicted of nonviolent cannabis offenses in the past. Missouri passed legislation decriminalizing cannabis for personal use in 2014, and voters approved medical marijuana in 2018.
Medical debt
Voters in Arizona will be asked to vote on a measure aimed at cracking down on medical debt collection, and advocates hope it could be a model for other states if it passes.
According to the Kaiser Family Foundation, roughly 23 million people — or nearly 1 in 10 adults — owe medical debt, and 3 million people owe more than $10,000. It disproportionately impacts people with low incomes or disabilities, as well as the Black population.
The measure would cap the interest rate on medical debt at 3 percent, down from the current 10 percent. It would also limit debt collectors’ ability to seize a person’s house, belongings or car, or garnish wages.
“We’ve had a lot of conversations as a country about health care and why it’s important for people to get coverage. … We have not really had a national conversation that takes issues of debt and debt collection out of the weeds and into common parlance,” said Hall.
“No one should be going into debt collection or into a cycle of poverty because they’ve had a health care experience,” she said.
Critics of the measure, who largely represent creditors, say it is too broad and will impact other areas of debt beyond health. They also argue it won’t do anything to lower the overall cost of care.
Vaping
California voters will decide whether to ban flavored tobacco, including vaping products and menthol cigarettes. California would become the second state in the nation to enact such a ban after Massachusetts if it passes.
State lawmakers first passed the ban in 2020 but it never went into effect amid furious lobbying from the tobacco industry and vaping advocates. Now the measure is up for public referendum.
The measure is getting serious amounts of money from both sides. Philanthropist Michael Bloomberg has personally spent tens of millions of dollars in support of the referendum, responsible for nearly all the measure’s funding.