Post From Expert Insights
The November 2020 presidential election was filled with tension and emotions, causing a vitriolic atmosphere that consumed millions of Americans. While the spotlight was on the presidential and congressional races, many may not have realized that voters also decided on numerous ballot measures across the country. Build Healthy Places Network and Shift Health Accelerator visited the elections division webpage for every state, and gathered all of the statewide ballot measures, measure summaries, and election results that had impacts for racial and health equity.
In total, there were 120  statewide measures that American voters considered in the 2020 general election. Some of those measures would advance equity (e.g., paid family and medical leave), and others represent a step backwards (e.g., narrowing voter rights). A whopping 88 of those measures were passed. Many of these ballot measures have important implications for health equity, economic justice, racial equity, and climate change. Social determinants of health (SDOH) are the conditions where people are born, live, eat, work, play, and pray . The SDOH are responsible for the bulk of health inequities and continue to be propagated by past and current policies. These circumstances or conditions are often not decided or contributed to by an individual, rather they are shaped by the distribution of wealth, resources, and power from the local to the national level.
The 120 ballot measures we explored (the information and synthesis were gathered from the Secretary of State website for each state and/or the state ballot database from the National Conference of State Legislature) ranged from state constitutional amendments to citizen initiatives, some put on the ballot by legislatures and others by citizens. Communities then voted to pass or reject these policies. Yet, with centuries of exclusion and suppression, either by the government or influential players, low-income communities and communities of color have not been permitted to shape their environment, leading to inequitably distributed resources across these communities, impart due to historical and structural racism. This has led to limited access to affordable and safe housing, equitable education, health services, healthy food, and economic security.
Massive turnout in suburbs and cities, as well as an increase in voter registration in communities of color , point to an America that is diverse, desires an end to systemic oppression, promotes and funds healthy communities, and aims to make strides towards race and health equity. But, evident in the measures that advance equity and the measures that do not, America remains divided on what an “equitable future for all” looks like. The few ballot measures highlighted below are separated into three categories: 1) Ballot measures that passed that advance race and health equity, 2) Ballot measures that passed that are a detriment to race and health equity, and 3) Ballot measures that did not pass but would have advanced race and health equity.
Ballot measures that were passed that advance race and health equity:
In Arizona, Proposition 208 was passed which means residents who have a total income exceeding $250,000 would have their taxes increased. It is estimated that this measure will generate more than $827 million in revenue in year one, which will go towards funding education. This is critical because education has been identified as one of the most important modifiable SDOH, which can increase healthy behaviors and improve health outcomes .
In California voters passed Proposition 1 which restores voting rights after incarceration and allows those on parole to vote. This proposition will immediately restore the voting rights to 50,000 Californians and eliminate one form of voter suppression and institutional racism. Once categorized as a felon in the United States, voting rights in 9 states are stripped permanently and in 19 other states the right to vote is not restored until after prison, parole, probation. With Black Americans being imprisoned at nearly six times the rate of white Americans and Hispanic Americans being imprisoned at double the rate of white Americans , the restoration of voting rights is a social justice issue and would allow these communities to vote on ballot measures that directly impact their communities (e.g., access to medical care ).
Colorado approved the citizen initiative Proposition 118 which establishes a paid family and medical leave insurance program for 12 to 16 weeks. While only 6% of low-wage workers in the United States have access to paid family leave, the more workers who can take time off and balance family responsibilities, the healthier the workforce becomes . This is particularly important when nearly 50% of low-wage workers are women of color.
In Florida, voters passed Amendment 2 which raises the minimum wage to $10.00 per hour effective September 30th, 2021 with a goal of $15.00 per hour by September 30th, 2026. With the current federal minimum wage at $7.25 an hour, advocates have pushed for a $15.00 an hour minimum wage for nearly a decade. In 2018, the American Journal of Managed Care, stated that at least three mechanisms could link higher wages to a change in health status. Higher wages would make it easier for workers to access medical care; afford homes in safer neighborhoods; and increase job satisfaction. Just one emergency expense (~$500), can plunge an individual and/or family into an economic downfall. With more than 100 million Americans living at or below 200% of the federal poverty level (more than 50% of which are people of color) , ballot measures that address wage increases help Americans reach economic security which is a key player in SDOH.
Mississippi, Ballot Measure 2 passed which removes a Jim Crow era policy that required a gubernatorial or state office candidate to receive both the highest number of votes in a majority of state house districts and popular vote to win the election. If neither were met by any candidate, the State House of Representatives would choose a winner. The goal of this policy was to limit the voice of Black voters when it was initially passed.
In Mississippi, Measure 3 was passed which approved the State’s new magnolia flag design. This replaces the previous flag which had a confederate battle emblem.
In Nebraska, Initiative 428 passed which caps payday lenders’ rates at 36% annually. Across the United States the average interest rate on a two-week payday loan is 395% [10,11]. Payday loan locations are seen disproportionally in poor communities of color while more than 28% of all Black and Latinx adults do not have a credit score. Low-interest personal credit is essential to those seeking loans to secure education, opportunities to generate wealth, medical services, housing, and transportation.
Nebraska voters passed Amendment 1, a constitutional amendment to eliminate slavery or involuntary servitude as a punishment for crime. Utah’s Amendment C passed with a similar fix.
In Nevada, Question 6 passed which requires all utility providers to acquire 50% of their electricity from renewable sources by 2030. Currently, with about 85% of America’s energy coming from nonrenewable sources , and millions of Black Americans living near oil refineries, this is a major step forward to combat the climate crisis which disproportionately affects low-income communities and communities of color . According to the National Association for the Advancement of Colored People (NAACP), neither location nor income, but instead, race is the number one indicator for the placement of toxic facilities in the United States .
Similar versions of Oregon’s Measure 110 have been seen in a number of election cycles in the past decade. This measure makes the possession of small quantities of all drugs a minor violation. Also, it establishes an addiction treatment program funded by revenue from medical marijuana taxes and the cost savings from fewer imprisoned individuals due to a drug crime. The ongoing disparities in drug convictions for Black Americans continues to be evident . Convictions, instead of access to treatment, means difficulty in getting housing, employment, and for young Black Americans, getting student loans.
In Rhode Island, voters passed Question No.1 which amends the Rhode Island constitution to remove “Providence Plantations” from the official state name. Though a name change may not seem like a consequential policy, the acknowledgment that “Providence Plantations” is unacceptable and a reminder of one the most grotesque times in American history, matters. But superficial changes cannot be the solution. As America removes monuments, flags, and language that have been either tied to the enslavement of people, the glorification of the Civil War, or the intimidation of those involved in the civil rights movement, as a country, we must make strides that address the root of these issues.
Ballot measures that passed that are detrimental to the progress of race and health equity:
In California Proposition 22 passed, which allows for companies like Uber Technologies INC., DoorDash, and Lyft Inc. to continue classifying their drivers as independent contractors instead of employees. Because these workers will not be considered employees, rideshare programs are exempt from providing benefits and protections like paid time off, insurance, and vacation.
In Florida (and similar measures in Alabama and Colorado), Amendment 1 was passed which states that only citizens can vote in elections (which is already the law). The support for this amendment came after other states proposed initiatives to allow permanent residents and immigrants to vote in local elections. The constant vilification of immigrants and falsehoods around widespread voter fraud, has caused a knee-jerk reaction. Simple word changes may not seem impactful, but the push for new voter restrictions, and the lapse in reauthorization of the Voting Rights Act of 1965, continues to restrict and disenfranchise millions of voters. The Florida League of Women Voters said that this measure, “is cloaked in xenophobia and false patriotism. The amendment purports to limit voting to only U.S. citizens. […] there have been persistent efforts to suppress voter registration and voting.”
In Louisiana, voters supported Amendment 1 which adds to the Louisiana Declaration of Rights that the right to an abortion is not protected and that the government is not required to fund abortions. Stefani Bangel, New Orleans Abortion Fund Outreach Manager stated that, “People in Louisiana suffer when restrictions like these are passed. Women are suffering now…”. With amendments like this one, women are being denied access to medical care they might want or need.
Missouri passed Amendment 3 which will undo the Clean Missouri initiative. The Clean Missouri initiative was intended to limit partisan gerrymandering when the state redraws its district map in 2021. The initiative also limited campaign contributions and required that any contributions had to be made public. Gerrymandering is disenfranchising millions of voters and especially those in communities of color. Future redistricting must prioritize fair representation for communities of color who are drastically underrepresented in Congress.
Ballot measures that did NOT pass that would have advanced race and health equity:
California Proposition 21 failed which would have allowed the local government to decide on rent control measures and increased protections for renters to prevent discrimination. This proposition was seen as a step forward, allowing rent affordability while stopping and preventing evictions among communities of color, LGBTQ+ people, and people with disabilities. Like much of America, high rents and low wages are threatening the economic security for many communities.
After a summer full of racial justice protests, which reminded us how far we still must go for Black and brown Americans to be treated the same and have the same opportunities as white Americans, Californians rejected Proposition 209. This measure would have repealed the 1996 policy that banned public colleges and the government from considering race and gender in admissions and government hiring decisions. Prioritizing diversity in college and workplaces improves the opportunities and representation for communities that have been deliberately excluded.
Oklahoma’s Question 805 did not obtain enough support to pass. This would have prohibited the use of prior non-violent felonies to be used to extend prison sentences, which would have advanced criminal justice reform.
In Oregon, Measure 26-218 would have enacted a payroll tax on large employers. The revenue would have funded transit improvements, a rapid bus network, and programs benefiting students and low-income communities (e.g., free bus passes for youth and investing in affordable housing).
Though progress is slow, and some measures to advance equity did not pass, optimism should be high. The 2020 election saw the highest voter turnout in more than a century (during a pandemic nonetheless) with a booming message that justice will continue to be the focus in local, state, and federal elections. The election results showed that regardless of being a long-standing blue state (e.g., CA), a long-standing red state (e.g., OK), or a purple state (e.g., FL), voters are divided – voting to pass measures of social progress in some cases, and clinging to racist policies in others. Policymakers working together with cross-sector coalitions and community leaders must seize this moment to center and propose solutions that focus on race and health equity and advance the SDOH. We must be more progressive when the environment is less favorable and speak out on policies that will continue to hurt our low-income and communities of color. Stay tuned in early 2021, when Build Healthy Places and Shift Health Accelerator will publish the Healthy Neighborhood Investments Policy Scan and Strategy Menu which outlines policy actions, strategies, and mapping tool for multi-sector coalitions and leaders to make policy changes that value the wellbeing of everyone living in the US and support redressing the institutional and structural racism pervasive in our political, social, and economic systems.
Healthy Neighborhood Investments, a Build Healthy Places Network (BHPN) initiative funded by Blue Shield of California Foundation, conducted a federal, state, and local policy scan to identify opportunities for joint investment and partnerships across health systems and community development to advance racial equity, health equity, and the social determinants of health. The policy scan, due to be published in February, will put forth hundreds of policy strategies, that are intended to remove barriers and open progress toward racial and health equity. During the unique time of this project, the research team noticed a trend in the proposed ballot measures – a trend that illuminates where local communities across the U.S. are reckoning with the past and proposing policy solutions that focus on health and race equity. The goal of this article is to highlight key general election statewide ballot measures and their roles in racial and health equity and the SDOH.
 Catalyst, N. E. J. M. (2017). Social determinants of health (SDOH). NEJM Catalyst, 3(6).
 The 2020 Election by the Numbers
 Education and Education Policy as Social Determinants of Health
 “The gap between the number of blacks and whites in prison is shrinking” Pew Research Center, Washington, D.C. (2019)
 Kusner, J., Mitchell, A., Kenney, B., & Reiger, S. F. (2020). An Underused Treatment Strategy: Voter Enfranchisement. Journal of general internal medicine, 1-3.
 Ensures Health Equity for All Paid Family Leave
 What’s the Effect of Minimum Wage on Health? With Push to $15 an Hour, We May Find Out. (n.d.). Retrieved December 08, 2020, from https://www.ajmc.com/view/whats-the-effect-of-minimum-wage-on-health-with-push-to-15-an-hour-we-may-find-out
 100 Million and Counting: A Portrait of Economic Insecurity in the United States
 Ávila, A. C., Calleros, B. M., Felix, G., & Guillen, D. (2018). Impacts of Payday Lending in California among Communities of Color. Harvard Journal of Hispanic Policy, 30, 73-89.
 Why Credit Scores and Payday Lending Matter to Health
 U.S. energy facts explained
 Derman, B. B. (2018). Climate Change Is About US. Fence-Line Communities, the NAACP and the Grounding of Climate Justice. In T. Jafry (Ed.), Routledge Handbook of Climate Justice, 407-419.
 Environmental & Climate Justice. (2020, October 15). Retrieved December 08, 2020, from https://naacp.org/issues/environmental-justice/