In the past decade, ballot measures have been crucial in the adoption of policies that advance health and racial equity.
Race-conscious policies and the ballot measure process give us all a fair and just opportunity for health. Here’s why these tools are crucial for ensuring our country's policymaking is truly in service of racial and health equity.
One might not think to connect political conditions and ballot measures with health. But we need to because the people and processes that shape government decisions can dramatically affect the social conditions and well-being of individuals and communities.
As RWJF works to dismantle structural racism and counter the laws and policies created to deny health and opportunity to people based on their race, class, and gender, we want the people and communities facing the greatest barriers to be able to set policy agendas. We want them to create and implement solutions, whether related to housing security, financial stability, civil rights protections or other health interventions. To this end, RWJF is prioritizing two critical levers: ballot measures and race-conscious policies and programs.
Ballot Measures
In 24 states, ballot measures empower citizens to propose policy changes and vote on them at the ballot box. They are a vital form of direct democracy, giving voters a way to create meaningful change on issues that matter to them. In the past decade, ballot measures have been crucial in the adoption of policies that advance health and racial equity. Medicaid expansion, minimum wage increases, paid leave, and abortion access have all been strengthened in states through the ballot box—a testament to how historically marginalized communities can exercise their power in service of a healthy, multiracial democracy.
Ballot measures have become particularly important amid the polarization of state governments. Forty states now have “trifectas,” in which one political party holds the governorship and majorities in both chambers of the state legislature. This means a single political party can set and drive the legislative agenda. This polarization frequently stalls progress on policies that advance health and racial equity, even those supported by a majority of voters—including conservatives, centrists, and progressives. That makes ballot measures one of the few avenues for progress in many states.
In the wake of recent policy wins intended to advance equity, some state legislatures want to restrict ballot measures by increasing the number of signatures needed to put an issue on the ballot, raising the threshold (often to 60% from 50%) for passing a ballot measure, and/or requiring a ballot measure to pass multiple times before it is enacted. In 2023, more than 75 bills were introduced in state legislatures to make the ballot measure process harder, a trend that is continuing in 2024. By design, these efforts impede the progress that empowers people and make it more difficult to achieve a future where health in America is no longer a privilege reserved for only some.
Race-Conscious Policies and Programs
The United States needs policies and programs to address past and ongoing discrimination. We must be intentional in how we create opportunities for wellbeing. Race-conscious initiatives are an effective way to begin to right the wrongs of our past. They are designed, implemented, and enforced to explicitly consider race and mitigate the effects of racism.* These policies and programs are needed because for too long, our social practices, laws, and policies have placed more value on some lives than others because of race and other factors like gender and class.
Race-conscious initiatives can be deployed in any number of ways to build a future in which all people can thrive. In housing, special purpose credit programs provide home loans to Black and Hispanic people who have historically been denied credit. This is one pathway to reducing home ownership disparities. More fundamental reforms, such as reparations for descendants of people enslaved in the United States, can foster justice in wealth and health. In the healthcare realm, pathway programs have enabled more people of color to enter and succeed in medicine and health research. These efforts, and others, address disparities and impact opportunity.
Race-conscious initiatives are an effective way to begin to right the wrongs of our past.
Even before the U.S. Supreme Court’s decision in June 2023 to severely restrict race-based affirmative action in higher education, many of these policies were being challenged in courts and targeted through legislation. The ruling unleashed an avalanche of lawsuits, threatening initiatives in the corporate, healthcare, law, philanthropic, and voting domains as opponents intent on maintaining the unequal status quo saw their opening. Five states have passed—and 16 have proposed—legislation that prohibits state agencies from engaging in trainings and related efforts that address “divisive concepts.” Some laws go even further, seeking to snuff out diversity, equity, and inclusion programs entirely. This is part of a broader political effort to paint racial equity as un-American, unlawful, and discriminatory. In truth, reimaging the laws, policies, and practices that support health and wellbeing for all is the most American thing we can do.
The Road Ahead
We know our partners across the country have been working to dismantle racist structures for a very long time. RWJF is privileged to stand alongside them as we embark upon this journey. We need every tool we can secure along the way. Ballot measures and race-conscious policies and programs must remain in our toolbox. These are essential pieces of a comprehensive strategy to ensure everyone in this country—no matter who they are, where they live, or how much money they have—has a fair and just opportunity for health.
The Foundation is listening to, partnering with, and speaking out alongside organizations that are engaging in litigation, power-building, organizing, and advocacy to defend these equity-promoting tools of democracy. We are committed to this work and to creating the future that our children and grandchildren deserve.
*A growing body of literature distinguishes between race-conscious, race-based, and racism-based approaches. Here, we use “race-conscious” to be inclusive of all these concepts.
About the Authors
Avenel Joseph, vice president for Policy, brings a wealth of government, management, and political expertise to leading the Foundation’s Policy office and heading its Washington presence; serves as a key member of the Foundation’s senior leadership team; and guides, motivates, and inspires RWJF’s commitment to its policy and government engagement work.
Elizabeth DiLauro, senior policy officer, brings expertise in devising advocacy strategies that drive policy change nationally and in states, including mobilization, grantmaking, communications, coalition building, parent leadership, and technical assistance.