People-powered policy: How ballot measures are shaping health policy

By Tamia Fowlkes, Wisconsin Health Journalism Fellow

At one of the final sessions of Health Journalism 2025, executive directors of three national ballot initiative organizations explored how citizen-led ballot initiatives are being used to expand access to health care across the United States.

As of June 2025, approximately 23 states allow residents to bypass their state legislatures and propose new laws or constitutional amendments through ballot initiatives. When enough signatures are collected to qualify a measure, voters can approve policies directly at the ballot box - a method that has been used to expand abortion access, raise the minimum wage and enact paid sick leave laws.

Despite their popularity among voters, such initiatives are limited to states in which citizen-led ballot measures were legalized through state law or constitutional amendment.

Panelists outlined the different types of ballot measures, including legislatively referred and citizen-initiated ballot measures, statutory policies and constitutional amendments, and statewide and municipal ballot measures.

Kelly Hall, executive director of the Fairness Project, said a successful initiative typically follows four critical stages before being adopted by a state or municipality: incubation, qualification, election and implementation. These stages vary significantly based on jurisdiction.

"It can take two years or more before election day to come up with what the policy will be," Hall said. "Organizers ask 'Can it win?' Then, there's doing the coalition building, getting a campaign together, collecting hundreds of thousands - if not over a million - signatures, in some cases, and then getting to election day."

Chris Melody Fields Figueredo, executive director of the Ballot Initiative Strategy Center, highlighted the strong voter support for reproductive health initiatives in 2024, especially in response to efforts to restrict abortion access.

"The point of these reproductive health ballot measures wasn't to elect politicians, it was to give people health care access," Fields Figueredo said. "The people want change."

Her organization supports ballot campaigns nationwide through strategic messaging, fundraising, and coalition-building. But, Fields Figueredo warned, the rise in popularity of reproductive rights initiatives has triggered political backlash, especially in conservative-leaning states.

Panelists cited recent efforts by Florida Gov. Ron DeSantis' aggressive push against a recent abortion ballot measure. The speakers noted that, in some conservative leaning states, ballot measures advocates faced threats of criminal prosecution for advertisements encouraging voters to support their movement.

Speakers warned reporters to watch for legislative efforts that could restrict ballot access - such as granting governors veto power over ballot initiatives, requiring signatures from every county or raising the threshold for passage.

These actions could result in increased challenges for ballot-measure advocates. With restrictive measures in place, "all the grassroots efforts are snuffed out," Hall said.

Hall, Fields Figueredo and Mayville emphasized that constraints on ballot initiatives undermine the passage of popular health resources that voters support such as Medicaid expansion, expanding school lunch programs and abortion access.

"The health of our democracy is an indicator for whether or not people will have healthy lives," Fields Figueredo said.

Tamia Fowlkes is a Public Investigator reporter for the Milwaukee Journal Sentinel.