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This election has the potential to affect public health and shake up hospitals, drug companies, and insurance industries in dramatic ways. Here are nine issues to watch as results roll in:

1. Cigarette tax hikes

Where: California, North Dakota, Colorado, Missouri

Four states are voting on whether to raise their tobacco tax. California’s proposing to increase the tax by $2 a pack; North Dakota $1.76; Colorado $1.75; Missouri 15 cents.


The $2 proposed hike would be a huge jump for California, which currently has one of the lowest cigarette taxes in the country, at just 87 cents per pack.

California’s bill has been backed by health groups including the American Cancer Society. Their goal: make it more difficult for people to pick up smoking and also make it more tempting for smokers to cut the habit. Tobacco companies including Philip Morris and R.J. Reynolds have drummed up more than $56 million to fight the measure.


The proposition is expected to raise $1.4 billion in tax revenue if passed, 13 percent of which would go to smoking cessation programs funded by the state. Research shows the taxes just might work — a 2014 surgeon general’s report found that smoking rates drop 4 percent with every 10 percent price increase on cigarettes.

 2. Marijuana legalization

Where: Arkansas, Florida, Montana, and North Dakota (medical)

Arizona, California, Maine, Massachusetts, and Nevada (recreational)

This year a record number of states are voting on marijuana use.

In many ways, the states that currently have legalized marijuana in some form — four and Washington, D.C., allow recreational use and another 20 permit medical marijuana — represent ongoing experiments in public health.

Proponents of legalization say that it creates millions in tax revenue, unburdens the criminal justice system, and provides health care options for sick patients. While many public health experts agree about the benefits, they also have concerns about widespread legalization because of the potential consequences of big companies latching on to the marijuana market, the changing public perception of marijuana’s safety, and the increasing potency of marijuana products in legalized states.

3. Drug price cap

Where: California

Proposition 61 would require most state agencies to pay no more for prescription drugs than does the US Department of Veterans Affairs, which receives a federally mandated 24 percent discount from manufacturers. It’s being closely watched nationwide for the precedent it could set for the industry.

In theory, the measure would lower drug costs for up to 7 million residents of California who get insurance coverage for their medicines through various state agencies, including low-income residents on the state version of Medicaid.

Supporters, including Senator Bernie Sanders, maintain the measure will make it harder for “greedy” drug makers to pursue “price gouging.” For its part, the pharmaceutical industry warns there will be “unintended consequences,” such as higher prices on some drugs or fewer choices for some state residents.

The ballot fight is believed to be the most expensive ever for a single ballot measure in California.

Recent polls show the race tightening. A poll released last Friday showed California voters evenly split, suggesting that drug companies have won over the vast majority of the many persuadable voters in recent weeks.

4. Porn actors’ condom usage

Where: California

Condom use in pornography is getting another look this election season, as California voters consider a ballot initiative known as Proposition 60. The state has required porn actors to wear condoms since 1992, with the reasoning that safer porn promotes safer sex.

But Proposition 60 aims to up the ante — it would allow state residents to file a complaint about violations of the law to the state’s Occupational Safety and Health Administration. If the agency doesn’t respond within three weeks, the individual who filed the complaint can sue those involved in the film’s production and, if they win, can collect a quarter of the penalties.

The proposal would also mandate that porn producers pay for STI testing for their actors. Some AIDS advocacy groups favor Proposition 60 as a way to better enforce existing laws. But the industry says the proposal will make adult film stars more vulnerable to harassment.

5. Neuroscience research

Where: Montana

Montanans are slated to vote on a divisive ballot measure that’s focused on neuroscience spending.

The basic idea is to set up the “Montana Biomedical Research Authority,” which would dole out $20 million a year for a decade to fund research on brain diseases and injuries and mental illness. Much like the California Institute for Regenerative Medicine, it’d be backed by state bond debt.

Advocates say these grants could help improve neurological care for Montanans — accelerating brain research and expanding the state’s participation in clinical trials. But the detractors argue that there just hasn’t been much success in brain research, citing the slow crawl over the past decade to find any meaningful treatments for Alzheimer’s disease. And they point out that $20 million isn’t much money when it comes to neuroscience research.

6. Gene-edited mosquitoes

Where: Key Haven and Monroe County, Florida

In the wake of the Zika virus, residents of the Florida Keys are voting in two nonbinding referendums on whether the government should begin field trials of a genetically modified mosquito made by Oxitec. The company’s Aedes aegypti produce offspring that die before they are able to reproduce, thus decreasing the total mosquito population and the spread of diseases. The mosquitoes have successfully been used in Brazil, the Cayman Islands, and Panama, but this would be their first use in the US.

In August the Food and Drug Administration gave the green light for the trials to go forward. The final decision rests with the Florida Keys Mosquito Control District.

7. Assisted suicide

Where: Colorado

A state ballot measure in Colorado would allow physicians to prescribe a lethal dose of medication to terminally ill adults who request aid in dying.

Supporters have raised more than $5 million and a September poll found 70 percent of voters back the measure, which would make Colorado the sixth state to allow assisted suicide. (The Washington, D.C., City Council is expected to approve a similar measure later this month.)

The Catholic Church and other religious groups are fighting back, arguing that it’s “illogical” to for the state to allow some patients to hasten their deaths, even as taxpayers are funding a public health battle against suicide in Colorado.

The measure has also drawn fire from disability rights advocates. Read more here.

8. Soda taxes

Where: San Francisco, Oakland, and Albany, Calif., and Boulder, Colo.

Ballot measures in the Bay Area would aim to tack an extra penny-per-ounce tax on to sugary drinks. The two sides combined have collected $46 million to make their cases, KQED reports.

Most of that money has come from familiar faces in the soda battle: The American Beverage Association has shelled out $28.7 million against the tax; former New York Mayor Michael Bloomberg and Texas billionaires John and Laura Arnold have spent more than $17 million supporting the taxes.

Proponents say the taxes will pull in millions in extra revenue for the cities and could help cut down on obesity and type 2 diabetes. Opponents counter that the tax will make living in the Bay Area even more expensive.

The Boulder, Colo., measure would add a tax of 2 cents per ounce on sugary drinks.

9. Universal health care

Where: Colorado

On Election Day, Colorado will decide whether to go where no American state has successfully gone before: single-payer health care.

The citizen initiative calls for the creation of ColoradoCare, a $30 billion annual program that would cover medical care for all the state’s citizens. It would divert money from existing federal programs, double the size of the state’s budget, and require a 10 percent payroll tax increase.

Based on one recent poll, the ballot initiative appears to face an uphill battle.

But what underlies the initiative is perhaps more meaningful than the outcome itself: People are not pleased with the state of American health care, and they don’t think a hopelessly gridlocked Washington can fix it.