It's not just Congress that's up for grabs in the midterm elections. Healthcare issues are sprinkled throughout a host of ballot votes in the states.

In Idaho, Utah, Nebraska and Montana, Medicaid expansion is on the chopping block. Maine is mulling over a proposal to hike taxes to pay for home care for the state's disabled and elderly. Massachusetts nurses are fighting to get safe staffing ratios approved while, on the other side of the country, California votes on refunding excess dialysis revenue and bonds to fund pediatric hospitals. Finally, medical equipment managers in Nevada are crossing their fingers to see if a sales tax exemption will be approved, hiking their bottom lines.

Here is a snapshot of key votes and what they could mean for the industry.

Medicaid expansion: Idaho, Utah, Nebraska and Montana

If voters in Idaho, Utah, and Nebraska — all red states — vote in favor of expansion it would mean health coverage for an additional 325,000 people, according to research from Avalere. Montana is voting on whether to keep its expanded program.

The four ballot initiatives come after a successful run in Maine where residents approved expansion in 2017. Despite the referendum, Maine's Republican governor has refused to implement the program.  

While 34 states including the District of Columbia have opened up the program to add more beneficiaries, 17 states — all dominated by Republicans — have held out, citing concerns including potential financial burden. However, the federal government picks up a majority of the costs for those added to the program, largely working adults without children with incomes up to 138% of the federal poverty level.

In Utah, the state legislature is opposed to full Medicaid expansion along with the local chapter of the anti-tax group Americans for Prosperity, the Salt Lake Tribune reports. Utah Gov. Gary Herbert, a Republican, signed a bill in March to expand Medicaid in a limited way and now the state is waiting for approval from the federal government, according to the Tribune. Herbert is not actively campaigning against the ballot initiative, according to his spokeswoman.

Nebraska Gov. Pete Ricketts, a Republican seeking reelection, does not support Medicaid expansion.

But there are some Republican backers.

Idaho's outgoing Republican Gov. Butch Otter endorsed Medicaid expansion and appeared in a TV ad urging a vote for the measure just days ahead of Tuesday's election. Otter had backed previous initiatives of expanding the program but all were rejected by the legislature, the Idaho Press reports.

Montana's initiative is facing significant pushback from tobacco companies, according to Montana Public Radio. Expanding Medicaid would be funded by a hike on taxes for tobacco. Cigarette maker Altria has spent the most against the initiative, which MPR reports is now the most expensive ballot initiative in Montana history.

On the supporting side, Utah expansion efforts are led by a group called Utah Decides Healthcare. One of its biggest backer is the Fairness Project, a nonprofit backing other expansion ballot measures, according to The Hill.

Nebraska's Democratic candidate for governor, Bob Krist, supports expansion — unlike his opponent, incumbent Governor Pete Ricketts. Insure the Good Life is the organization behind the ballot measure, and its largest source of funding comes from the Fairness Project, a nonprofit that is backing other expansion measures, according to the Norfork Daily News.  

Montana's Democratic Gov. Steve Bullock backs expansion. The state enacted Medicaid expansion in 2015 and its hospital association is a big supporter of the ballot measure.

Medicaid expansion is popular among voters both red and blue, according to John Cipriani, vice president of research for Global Strategy Group. He said very few of those polled wanted to see cuts to the program.  

A recent poll in Utah found that popularity for the ballot initiative is growing, and seen favorable among a majority of voters, according to the Salt Lake Tribune.

Nearly half of all births in the country are covered by Medicaid and nearly one in five Americans uses the program. It also covers a significant portion of seniors in nursing homes or long-term care facilities.

For rural hospitals, expansion can mean staving off the risk of closure and a better financial picture. Rural hospitals, and hospitals in general, benefit from Medicaid for patients who otherwise go uninsured.

Expansion also presents an opportunity for Medicaid managed care providers such as Centene and Molina who contract with states and pay them on a per member, per month basis to care for parts or all of their Medicaid population.

A medical equipment sales tax exemption: Nevada

Durable medical equipment manufacturers may see a small boon if a ballot measure in Nevada gains passage from voters.

Nevada Question 4 would direct the state legislature to exempt durable medical equipment, oxygen delivery equipment, and mobility enhancing equipment from sales and use taxes if prescribed by a healthcare professional.

According to the Las Vegas Review-Journal, the petition for the measure was filed by Bennett Medical Services, a home medical equipment company.

Voters approved the measure as Question 4 in the 2016 general election, but for an initiated state constitutional amendment to be passed in Nevada, the measure must pass twice in general elections, according to Ballotpedia.

It seems that approval of Question 4 is not a slam dunk, however. AdvaMed, the medical device trade lobby, has not taken a position on the measure, spokesperson Mark Brager told MedTech Dive.

And Ron Knecht, the Republican Nevada Controller, took to the Elko Daily Free Press to warn voters against approving the measure, noting that amending the constitution would prevent timely future reforms if they are deemed necessary.

“While this may be a good idea, it raises many questions in context of the various things the state does and does not tax. But even if one concludes as a matter of sound tax policy that these items should be tax-exempt, the legislature already has the power to exempt them now,” Knecht wrote.

Dialysis costs and revenue: California

One of the most expensive ballot initiative battles in history hails from California, where voters will decide if dialysis clinics should be required to refund patients or payers if their revenue exceeds 115% of the costs of direct patient care or healthcare improvements.

Proposition 8 has drawn a backlash and major spending from big industry players Fresenius Medical Care North America, DaVita and U.S. Renal Care. Opponents have collectively contributed more than $111 million to defeat it.

Industry argues the measure will limit patient care and force clinics to cut down on business hours or potentially even close.

“If the ballot initiative passes in California, you'll instantly have approximately 66,000 patients that are being treated in centers that mostly will be unsustainable,” DaVita Kidney Care CEO Javier Rodriguez said on the company’s Aug. 1 Q2 earnings call.

Andrea Harris, an analyst at Height Securities, predicts Prop 8 will fail, in large part due to the heavy industry spending, compared to only $18.8 million by proponents such as the Service Employees International Union. Harris pegged the likelihood of passage at 25%.

But an Oct. 16 SurveyUSA poll of 762 likely voters found that support for Prop 8 stood at 46%, with opposition lagging at 34%. The poller cautioned that opposition to ballot measures typically rises as the election draws nearer.

The California Democratic Party has endorsed the measure, while the California Republican Party opposes it. The Los Angeles Times and the San Francisco Chronicle editorial boards also both oppose the measure, arguing the measure is a proxy for a dispute between SEIU West, who has been trying to unionize dialysis workers, and Fresenius and DaVita.

Industry already fought off one challenge earlier this year when California Gov. Jerry Brown vetoed a bill designed to stop dialysis companies from allegedly steering patients into private insurance, a practice a group of insurers, unions and other stakeholders urged HHS to clamp down on in April.

A payroll and non-wage income tax for universal home care: Maine  

Medicare limits home care benefits to homebound seniors and disabled adults who only need skilled services occasionally, and state Medicaid programs rarely pick up the slack. With long term care insurance pricey and selective, that leaves a large gap in care for the elderly.

Maine's Question 1  would raise payroll and income taxes on the wealthy to finance in-home healthcare and social services those over 65 or with physical or mental disabilities at no cost.

Adults needing assistance with at least one daily activity such as walking, bathing, dressing, eating or personal hygiene would be eligible. Services include help from an aide, therapy, counseling, home repairs, medical devices and transportation.

Family caregivers would receive stipends as well, and the growing workforce of home health aides and caregivers would likely rejoice if the program was approved. Any companies that receive funds from the program would be required to spend at least 77% of the money on their workers.

The money would come from a payroll tax of 3.8% (half on employers, half on employees) and a 3.8% tax on non-wage income, such as investment interest.

Perhaps unsurprisingly, most business interests oppose the measure, along with all four candidates for governor. Jason Savage, executive director of the Maine Republican Party, called it a "horrible idea."

Raising taxes to pay for the initiative would make Maine a "more and more hostile environment for professionals and businesses," Savage told the Bangor Daily News.

But both taxes would apply on those with base income of $128,400, so the bump would only affect the wealthiest residents and businesses in the state, advocates argue.

"Too many Mainers are forced to quit their job to provide care or to let their loved ones suffer or send them to a facility where they don't want to be," Mike Tipping, a spokesperson for the Maine People's Alliance, told the Bangor Daily News.

Nurse-to-patient staffing ratios: Massachusetts

Nurses across the country have been rallying for "safe staffing" legislation, laws that would regulate nurse-to-patient staffing ratios in hospitals. California passed such legislation in 2004, and voters in Massachusetts will have an opportunity to do the same with Question 1.

If Question 1 is greenlit, hospitals would be forced to comply with limits on the numbers of patients assigned to hospital nurses. Those limits adjust for acuity and hospital setting. Emergency room nurses would be assigned anywhere between one and five patients while medical and surgical nurses would be assigned a maximum of four patients. Psychiatric nurses would be limited to five patients.

Hospitals that don't comply with the mandate would face fines of up to $25,000 per violation per day.

Proponents of Question 1 cite the risks that short-staffed and overworked nurses pose to patient safety, health outcomes and workforce retention in hospitals. Recent research has shown that patient-heavy staffing ratios are costing patients their lives, especially in intensive care units. Massachusetts already has mandated staffing ratios in ICUs, a mandate passed in 2014 in a compromise made between the Massachusetts Health & Hospital Association and the Massachusetts Nurses Association.

Opponents of the ratio mandates, such as the American Hospital Association and the American Organization of Nursing Executives, have argued that they create unmanageable hiring costs and make scheduling and staffing rigid. A frequent line used by the hospital industry is that high costs will cause hospitals to close, and opponents of Question 1 have said community-based services will have to be eliminated to adjust for the cost of hiring and training more nurses. 

Those are just a few of many warnings issued by The Massachusetts Health & Hospital Association, the lobby pouring money into ads to defeat the ballot question. The industry has been rallying behind a recent study from the Massachusetts Health Policy Commission arguing the ballot question would cost Massachusetts hospitals $676 million to $949 million a year and force them to hire as many as 2,286 to 3,101 additional full-time nurses in order to be in compliance.

Nurses unions estimate the costs are closer to $47 million a year. 

Unfortunately for nurses, voters seem to be leaning toward "no" on Question 1, according to a Suffolk University/Boston Globe poll taken earlier this month. That poll found that 59% of 500 likely voters oppose Question 1, while only 32% support it.

Bonds for children's hospital construction: California

One might think more cash for the state's sickest children would be an easy win, but Proposition 4 has proved surprisingly controversial in one of the nation's most liberal states.

The initiative would allocate $1.5 billion for the Children's Hospital Bond Act Fund, creating a pool of taxpayer dollars awarding grants to children’s hospitals for construction and renovation projects.

Some 72% of the fund, or $1.08 billion, would go to eight nonprofit hospitals treating low income children or those with special health needs. About 18% would go to five University of California hospitals and the remaining 10% would fund grants to public and private hospitals providing pediatric care to children with chronic or infectious diseases.

However, skeptics say the price of the bond is actually $2.9 billion given interest. Some say it's merely rewarding hospitals for fiscal mismanagement, leaving them with no incentive to control costs. It's also the third bond measure to prop up the state's children's hospitals, critics note — and all three of the initiatives were created by the California Children's Hospital Association, which represents the eight private hospitals that will receive 72% of the money if Prop 4 passes.

"This measure is intended to primarily benefit the same hospitals that are funding the 'yes' campaign," wrote Elizabeth Wall Ralston, former president of the League of Women Voters of Los Angeles, in The Sacramento Bee.

California Children's Hospital Association also created a ballot measure committee, Yes 4 Children's Hospitals, which raised almost $11 million to support Prop 4 as of Sept. 22. There is no opposing PAC.

The hospital ask has increased with each ballot: from $750 million in 2004 (which passed with 58% of the votes) to $980 million in 2008 (passed with 55%). California already has $74.2 billion in bond debt.

Media editorials ring with support, however, with encomiums for the proposition abounding in the Los Angeles Times, San Francisco Chronicle, Santa Cruz Sentinel, Mercury News, Sacramento Bee and San Diego Union-Tribune.

Los Angeles' Democratic Mayor Eric Garcetti also supports the measure, which will require a simple majority to pass. It's likely everything is coming up roses for California's pediatric hospitals again in 2018.