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WASHINGTON — The presidential race is top of mind as election season draws to a close Tuesday. But there’s plenty more at stake, and many congressional races, ballot initiatives, and even local elections across the country carry significant implications for the future of health and science.

Congressional Democrats hope not only to expand their House majority but also to capture control of the Senate, which, if coupled with a Joe Biden victory, could pave the way for aggressive health insurance and drug pricing reforms.

Many voters will also decide on substantial reforms via statewide initiative or ballot proposal. Numerous states are weighing plans to decriminalize or legalize marijuana and other drugs. Other states are looking to tighten restrictions or raise taxes for e-cigarette and tobacco purchases.

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Further down the ballot, Democrats are also hoping to capture control of several state legislatures, which have served as local laboratories for health care policymaking on issues including drug pricing, Medicaid expansion, surprise billing, price transparency, and more.

Below, STAT outlines 10 congressional races or ballot initiatives across the country with major ramifications for the future of health and science.

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1. North Carolina’s Senate race

Sen. Thom Tillis, a Republican, is seen as one of the pharmaceutical industry’s staunchest allies in Congress. He’s among the leading recipients of drug industry PAC contributions, and he’s authored legislation that would strengthen intellectual property protections for U.S. corporations, likely making it easier for drug makers to preserve exclusivity on blockbuster drugs.

Tillis has paid for it politically. He’s the lone target of Patients for Affordable Drugs Action, the political advocacy group backed by the Texas billionaire activists John and Laura Arnold. Democratic campaign groups have relentlessly attacked him for his ties to the drug industry.

North Carolina is a critical swing state, and Tillis’ fate is very likely tied to Trump’s. But his loss would leave the drug industry without a key D.C. ally, and signal that drug prices remain as potent a campaign issue as they were in 2018.

2. Kansas’ Senate race

Democrats are typically long shots in Kansas, but Barbara Bollier, a trained physician and former Republican, has run a competitive race focused largely on health care issues like Covid-19, drug prices, Medicaid expansion, surprise billing, and access to abortion. She doesn’t currently practice medicine, but if she ekes out a win, she’d be the first female M.D. elected to the Senate.

Her opponent, Roger Marshall, is a doctor himself, and a longtime supporter of physician-owned hospitals. In keeping with the health care-themed race, he’s also campaigning on his medical background, including his recent volunteer work treating Covid-19 patients and continued advocacy for repealing the Affordable Care Act. Marshall, however, has faced several controversies, including insensitive comments about Medicaid beneficiaries in 2017, a maskless, indoor campaign appearance amid a local coronavirus outbreak, and questions about whether his family might benefit financially from his push to deregulate physician-owned hospitals.

3. Virginia’s 5th Congressional District

This district, like the Senate race in Kansas, is a reminder that for much of the country, the health care debate doesn’t revolve around “Medicare for All,” despite the consistent focus on single-payer health care throughout the Democratic primary.

The Democratic candidate, Cameron Webb, is a practicing physician and former Obama administration aide who’d be the first Black doctor elected to Congress (besides non-voting delegates from U.S. territories). Unlike many 30-something Democratic up-and-comers, he doesn’t support Medicare for All. If Webb can use his health care background to help flip a red-leaning seat, it would hammer home that Democrats can still win even on comparatively centrist health care platforms.

4. State legislatures

For all the fuss made the last several years over drug pricing and surprise billing legislation in Washington, it’s state legislatures, not Congress, that have had at least some success enacting health industry overhauls. It’s little surprise that industry groups, including drug manufacturers, have contributed millions of dollars to the campaigns of nearly 2,000 state lawmakers across the country.

Keep on eye on the battles for control of the Minnesota state Senate and both legislative chambers in Pennsylvania, Arizona, and North Carolina. If Democrats win control, it could set up fascinating health policy fights in 2021 and 2022.

5. Proposition 14: stem cell research in California

After approving a ballot measure funding stem cell research in 2004, Californians are facing the choice whether to re-up state support for the scientific field. Proponents argue that selling billions of additional bonds is not only a way to invest in research that could lead to new treatments, but that it will help fuel the state’s economy by propping up academic centers and biotech companies. Opponents contend the state has more pressing needs than the public funding of stem cell research and question how some of the initial funding was spent. Plus, this is not 2004. The initial measure was backed by voters at a time when the Bush administration was limiting federal support for certain stem cell research. Now, there is lots of taxpayer money, as well as philanthropic and venture capital, flooding into the field.

6. Tobacco and e-cigarette taxes

A number of states are considering tax increases for tobacco and e-cigarette products, following years of controversy focused on the burgeoning vape industry and one of its major players, Juul, which has come under fire for aggressively marketing its products to underaged users.

Oregon is looking to curtail cigarette use and generate revenue for public health programs via a sharp hike in taxes on a pack of cigarettes — from $1.33 to $3.33. If the initiative, known as Measure 108, passes, it would also establish a tax on vape products.

In Oklahoma, Question 814 will determine whether voters consent to diverting some money from the state’s Tobacco Settlement Endowment Fund to help fund the Medicaid expansion that voters there approved in June.

7. Minnesota’s 8th Congressional District

Quinn Nystrom, a 34-year old insulin affordability advocate, is challenging Republican Rep. Pete Stauber in Minnesota’s 8th District. Nystrom is hoping a campaign laser-focused on drug pricing can propel her to Congress. Her election is a long shot — Stauber is wildly popular and has the backing of Trump, who carried by more than 15 points in 2016. If she wins, however, the victory would send a resounding message that drug pricing is a mobilizing issue for both Democratic and Republican voters.

8. Medical marijuana and other drug measures

More than two decades after California launched the country’s first medical marijuana program, the policy could continue its expansion even into deeply conservative states. South Dakota and Mississippi voters have the option of approving medical marijuana ballot measures, as the issue is no longer as divisive as it once was and warnings that allowing people to use marijuana for medical purposes could lead to health problems and lawlessness haven’t been borne out.

Beyond medical marijuana, voters in South Dakota, Montana, New Jersey, and Arizona will decide whether to legalize marijuana for recreational use among adults. And in Oregon, voters will weigh whether to decriminalize the possession of small amounts of drugs, including cocaine and heroin, while funding addiction treatment and harm reduction services. Separately, voters in Oregon and the District of Columbia will decide on first-of-their-kind initiatives on psychedelics. Oregon’s measure would legalize medicinal use of psilocybin, the active compound in psychedelic mushrooms, and D.C.’s would decriminalize the possession of psychedelic plants.

9. A New York scientist aims for Congress

In her bid to unseat the Republican Rep. Lee Zeldin in a Long Island district, Democrat Nancy Goroff has touted her scientific bona fides. The chemist at Stony Brook University has attacked Zeldin and linked him to the Trump administration’s handling of the coronavirus pandemic. If she pulls off the win, it could be a signal that voters are frustrated with the administration’s dismissal of scientific evidence and experts. Still, the race is listed as “lean Republican” in the Cook Political Report’s ratings of House races.

10. State-level abortion initiatives

Voters in two states — Colorado and Louisiana — will be voting on two proposals that could restrict abortions. Colorado’s Proposition 115 would prohibit abortion after 22 weeks of gestation, and Louisiana is deciding on whether the state’s constitution should be amended with language that would prevent the document from being used to protect abortion rights in the future.

Abortion is once again front and center after Justice Amy Coney Barrett’s confirmation to the Supreme Court last month. Barrett didn’t definitely say during her confirmation hearings that she would overturn Roe v. Wade, the landmark 1973 ruling that provided legal protection for abortion in the U.S. However, activists have pointed to some of her support for anti-abortion groups while she was a law professor at the University of Notre Dame as evidence that she would.

State-level abortion policies vary widely; fewer than half of U.S. states explicitly protect people’s right to the procedure. Even on its own, Colorado’s proposition could make a nationwide impact. The state is one of just six that does not restrict access to abortion after 20 gestational weeks; one of the few physicians in the country who is willing and able to provide abortions to people and families after that point operates in that state.

  • So we were told that legalization of weed and weed itself were not stepping stones to harder drugs. Yet now Oregon HAS decriminalized small amount of VERY dangerous and addictive drugs for personal use. Someone please explain to me how that makes any sense at all. You are going to tell me that people will now be more likely to get treatment? I will tell you that many more people will now get hooked, do dangerous things while using, raise the crime rate looking for ways to pay for now “legal” drugs, and put more non users at risk because of the users actions.

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