Affordable Care Act on the Ballot

The Patient Protection and Affordable Care Act on Statewide Ballots

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Updated Nov. 7, 2012, 4:15am MST

In spite of a June 28, 2012, opinion from the U.S. Supreme Court upholding most provisions of the federal Patient Protection and Affordable Care Act (PPACA, or sometimes just ACA for short), voters in five states weighed in this November on the question of whether the law's provisions will be enforced in their state. Voters in Alabama, Missouri, Montana and Wyoming approved ACA-related questions on November 6, while Florida voters rejected it.

Four states considered similar questions in 2010 and 2011. In all but one—Colorado—the proposals were approved. Colorado's proposal was unique in another way: Along with Ohio's in 2011, they were the only questions on the ACA that arrived on the ballot through the citizen initiative process. All other questions on this topic, this year and in previous years, were referred by state legislatures.

While clearly popular with voters, the long-term effects of these proposals is unclear. Under the provisions of the ACA, if a state does not set up its own health insurance exchange, the federal government will do so on the state's behalf. And a broader problem for states seeking to block implementation of the ACA is the preemption doctrine laid out by the Article VI of the U.S. Constitution, which states that the "Constitution and the laws of the United States ... shall be the supreme law of the land ... anything in the constitutions or laws of any state to the contrary notwithstanding." What ultimately happens after states pass these measures may end up in court.

The Affordable Care Act on 2012 Ballots

This year, voters in Alabama, Florida, Missouri, Montana and Wyoming had their say on the Affordable Care Act. While they differ in their details, most of the proposals are similar in their basic message: They generally amend the state constitution to prohibit compelling participation in a health care system or the purchase of health insurance. Some also guarantee the right to pay privately for health care services, and some prohibit the imposition of a fine or penalty for the failure to have health insurance. Voters in three out of four states considering these broad health care rights questions approved them on November 6; Florida voters rejected their version of this question.

Missouri's question was a bit different. Back in 2010, Missouri voters approved a law proposed by the legislature that prohibited the government from penalizing citizens for refusing to buy health insurance. This year, they approved a law prohibiting the state from setting up a health insurance exchange.

Statewide Votes on the Affordable Care Act



Measure # Summary Typea C/Sb Pass/Fail



Amendment 6

Prohibit any person, employer or health care provider from being compelled to participate in any health care system

L CA Pass
Arizona 2010 Proposition 106

Prohibit any law or rule from compelling any person, employer or health care provider to participate in any health care system; allow a person or employer to pay directly for and a provider to accept payment for lawful health care services without being penalized or fined; provide that the purchase or sale of health insurance in private health care systems shall not be prohibited by law or rule

L CA Pass
Colorado 2010 Amendment 63

Add health care choice as a constitutional right; prohibit the state from requiring or enforcing any requirement that a person participate in a public or private health coverage plan; restrict the state from limiting a person's ability to make or receive direct payments for lawful health care services

I CA Fail
Florida 2012 Amendment 1

Prohibit laws or rules from compelling any person or employer to purchase, obtain or otherwise provide for health care coverage; permit a person or an employer to purchase lawful health care services directly from a health care provider; permit a health care provider to accept direct payment from a person or an employer for lawful health care services; exempt persons, employers, and health care providers from penalties and taxes for paying directly or accepting direct payment for lawful health care services; and prohibit laws or rules from abolishing the private market for health care coverage of any lawful health care service

L CA Fail
Missouri 2012 Proposition E

Prohibit a state-based health exchange

L S Pass
Missouri 2010 Proposition C

Deny the government authority to penalize citizens for refusing to purchase private health insurance or infringe upon the right to offer or accept direct payment for lawful healthcare services

L S Pass
Montana 2012 LR-122

Prohibit the state and federal governments from requiring the purchase of health insurance or imposing any penalty, tax, fee or fine on those who do not purchase health insurance

L S Pass
Ohio 2011 Issue 3

Provide that no law or rule shall compel, directly or indirectly, any person, employer, or health care provider to participate in a health care system; no law or rule shall prohibit the purchase or sale of health care or health insurance; no law or rule shall impose a penalty or fine for the sale or purchase of health care or health insurance.

I CA Pass
Oklahoma 2010 Question 756

Prohibit forced participation in a health care system; permit direct payments for health services; permit private health insurance

L CA Pass
Wyoming 2012 Amendment A

Provide that the right to make health care decisions is reserved to the citizens of the state of Wyoming; permit any person to pay and any health care provider to receive direct payment for services

L CA Pass

a) Type:  L = legislative referendum
                I = citizen-initiated
                PR = popular referendum (a petition-driven effort to overturn a law passed by the legislature)
b) CA = constitutional amendment
     S = statutory

Key Ballot Measures

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