THE PROGNOSIS

Supporters of marijuana legalization will get four chances across the country in November to add to the expanding map of states where the drug is legal for recreational and medical use.

Michigan and North Dakota have measures on the ballot to legalize recreational marijuana for adult use. In Missouri, there are three initiatives on the ballot to legalize marijuana for medical use, and voters in Utah will also vote on medical marijuana.

The ballot initiatives come as the push to legalize marijuana in a variety of states has picked up steam over the past year. At the beginning of 2018, Vermont became the ninth state to legalize marijuana possession and the first to do so through the state legislature. In June, voters in deep-red Oklahoma passed one of the most progressive medical marijuana bills in the country.  And last week, Canada became just the second country in the world to legalize recreational marijuana.

Here’s a breakdown of key things to know about what voters will decide on the issue in 15 days:

— Michigan: The initiative would allow people 21 and older to purchase, possess and use marijuana and edibles. It would permit adults to grow no more than 12 marijuana plants for personal consumption and establish a state licensing system allowing the state to regulate marijuana businesses. The initiative would establish a 10 percent tax on marijuana sales to be used for implementation costs, clinical trials, schools, roads and municipalities that have marijuana businesses. The bill would also change several legal marijuana violations from criminal to civil infractions.

— North Dakota: The ballot initiative would legalize possession, sale and use of marijuana for people 21 and older. It would penalize people under 21 for possessing or attempting to distribute marijuana. The bill would also expunge the records of people with previous marijuana convictions. My Post colleague Christopher Ingraham wrote that the effort “places no limits on possession … and doesn’t set up any sort of regulatory structure for the sales it would allow,” which supporters say is “by design.”

Tamar Todd, director of the Office of Legal Affairs at the Drug Policy Alliance, and Kris Krane, president of cannabis investment and management firm 4Front, said states close to Canada could be impacted by the country's recent legalization push.

"That news could be a little more prevalent in those cases than they would be in other parts of the country," Krane said. 

He explained that the most significant thing for legalization advocates if the ballot initiatives are successful is they would provide a win in a new part of the country.

“Michigan would be the first state in the Midwest to legalize marijuana for adults,” he said. “Most have been in the West Coast or Northeast; it would add a major populated Midwestern state.”

— Missouri: Voters will choose next month from three ballot initiatives legalizing medical marijuana. All three of the initiatives would mean medical marijuana sale, possession, purchase and use would be legal in the state. Proposition C would impose a 2 percent tax on sales. Amendment 2 would allow for up to six homegrown marijuana plants and would impose a 4 percent tax on sales. Amendment 3 would impose a 15 percent tax on sales.

If all three pass, a Missouri law indicates that “whichever measure receives ‘the largest affirmative vote shall prevail, even if that (measure) did not receive the greatest majority of affirmative votes,’ ” the Springfield News-Leader’s Will Schmitt explains.

— Utah: The initiative would allow people to obtain and use medical marijuana in certain edible forms for certain conditions -- and in some cases, would permit people to grow up to six marijuana plants for personal medical use. The proposal prohibits smoking of marijuana. It also establishes a state licensing system through which state officials can regulate medical marijuana businesses.

If voters pass the initiative , it could end up being mostly symbolic, Krane explained. That’s because Utah Gov. Gary R. Herbert (R) pledged earlier this month to call a special session after the election to consider a compromise deal hammered out between state leaders and advocates and opponents of the ballot initiative. “The good news here is that whether [Prop 2] passes or fails, we’re going to arrive at the same point,” Herbert said, reported the Salt Lake Tribune, which lays out what’s different about the state’s alternate plan.

But Krane said it could send a “powerful message” if deeply conservative Utah passes a medical marijuana law, especially so soon after Oklahoma adopted medical marijuana during a primary.

“Having the one-two punch of Oklahoma in a primary and then Utah would demonstrate it’s a nonpartisan, universally popular issue that will hopefully lead to more action at the congressional level,” Krane said.

Todd said having marijuana initiatives pass in conservative states “represents how mainstream marijuana law reform is, how bipartisan it is.”

“It's hit a tipping point where a majority of Republicans support even marijuana legalization outright, not just medical marijuana,” she said.

Krane said he hopes there can be some momentum for federal action as well, adding that politicians need to “catch up” with voters.

A recent poll from the Pew Research Center found that 62 percent of Americans say that marijuana should be legal. Broken down by party, it found that 69 percent of Democrats say it should be legal, compared with 75 percent of independent voters who lean Democrat and 45 percent of Republicans. A Quinnipiac Poll from 2017 found 94 percent of Americans support legalizing marijuana for medical purposes.

Todd said the high level of support for marijuana legalization and medical marijuana is notable “at a time when we’re so divided on everything else.”

“I can’t think of another issue other than medical marijuana where 80 to 90 percent of Americans agree on it,” she said.

AHH, OOF and OUCH

AHH: The Trump administration is considering defining gender as unchangeable and fixed at birth, a move that would effectively eliminate federal recognition of transgender people, the New York Times’s Erica L. Green, Katie Benner and Robert Pear report.

The Department of Health and Human Services is looking to “define sex as either male or female, unchangeable, and determined by the genitals that a person is born with,” the Times reports, citing a draft of memo sent to key government agencies.

“Sex means a person’s status as male or female based on immutable biological traits identifiable by or before birth,” reads HHS’s memo, which the Times reports has been circulating since last spring. “The sex listed on a person’s birth certificate, as originally issued, shall constitute definitive proof of a person’s sex unless rebutted by reliable genetic evidence.”

“The move would be the most significant of a series of maneuvers, large and small, to exclude the population from civil rights protections and roll back the Obama administration’s more fluid recognition of gender identity,” Erica, Katie and Robert write. “The Trump administration has sought to bar transgender people from serving in the military and has legally challenged civil rights protections for the group embedded in the nation’s health care law.”

OOF: The confidential data of tens of thousands of consumers was hacked from one of the portals people use to enroll in Affordable Care Act health plans.

A federal law enforcement investigation into the breach is underway.

In apparently the first such breach since people began using HealthCare.gov to buy health plans under the ACA, the compromise exposed credit and other personal information for 75,000 consumers, my Post colleague Amy Goldstein reports, though she adds it’s a “relatively small share of the 8.7 million Americans who signed up for this year’s coverage.”

“But the breach comes as Trump’s health-care aides have been trying to foster a greater role for agents and brokers in the ACA sign-up process, instead of the HealthCare.gov computer system that consumers use directly,” Amy adds.

The hack also “throws into turmoil one aspect of the ACA’s insurance-signup process less than two weeks before the start of the annual enrollment period for coverage created by the 2010 health-care law."

OUCH: Scientists want to hit the pause button on a medical trial that’s partially based on a prominent heart researcher’s work the Harvard Medical School recently acknowledged was falsified or fabricated, my Post colleague Carolyn Y. Johnson reports.

Piero Anversa first reported on the regenerative effect of injecting cardiac stem cells into the hearts of people with heart failure. “Harvard disclosed a years-long investigation had identified ‘falsified and/or fabricated data’ in 31 papers from his laboratory, without specifying which publications were affected,” Carolyn reports.

“Anversa is not directly involved in the heart failure trial, which is being run by a national clinical trial network supported by $63 million in federal funds,” she adds. “But given the turmoil and uncertainty over the work that helped lay the foundation of the trial, outside researchers called for a pause and careful examination of whether it should proceed. The trial carries inherent risks, because it requires an invasive biopsy that can cause serious complications.”

TRUMP TEMPERATURE

— Trump on Wednesday will sign the opioids package passed by lawmakers this month and will announce the next part of the administration’s response to the ongoing crisis, Axios’s Sam Baker and Jonathan Swan report. Trump will be “joined in the East Room by roughly 20 other organizations announcing their own initiatives” during the announcement, where “health insurer Cigna will roll out a new initiative for veterans, and Adapt Pharma will announce it’s donating doses of Narcan, the overdose-revival drug, to every public library and YMCA in the country, [White House counselor Kellyanne Conway] said.”

For more on what the bill contains, see my colleague Colby Itkowitz's report on the legislation.

INDUSTRY RX

— Drug manufacturers are quietly making plans for their worst-case scenario. If Democrats recapture the House, they could work with Trump on their common goal of bringing down drug prices, taking action on legislation, the New York Times’s Robert Pear reports.

“Combine the rising blue wave — the Democrat fixation on pharmaceutical pricing — with President Trump’s populist focus on getting credit for cutting patients’ drug costs, and the industry could be confronting a perfect storm in 2019,” Republican health-care lobbyist John E. McManus told Robert.

“Democrats’ ideas include allowing Medicare to negotiate lower drug prices; putting a cap on Medicare beneficiaries’ out-of-pocket drug costs; requiring manufacturers to disclose and justify any significant price increases; and outlawing tactics used by brand-name drug makers to delay the development and marketing of lower-cost versions of their products,” Robert writes. “Drug companies say they are counting on the Senate — which political forecasters say is more likely to remain in Republican control — to stop legislation they oppose. But changes are coming there, too.”

STATE SCAN

— Iowa’s Republican Gov. Kim Reynolds is proposing allowing women to get birth-control medication at a pharmacy without a prescription.

“I think this is another opportunity for us to help with access, especially in rural Iowa, and to give more choices when it comes to family planning,” Reynolds told the Des Moines Register. “I think this is the direction we should go. I think by eliminating some of the barriers and making it available through a pharmacist, it will help reduce the rate of unintended pregnancies and abortions.”

Reynold’s Democratic rival Fred Hubbell is a “former Planned Parenthood board member who has made his support of legal abortion and women's reproductive health care central to his campaign,” the Des Moines Register’s Brianne Pfannenstiel reports.

Reynolds first proposed the policy during a gubernatorial debate with Hubbell last week. She said the plan is based on policies in places like Oregon and Utah. In Utah, women must fill out a form assessing the risk of taking such birth-control medication before they can get it over the counter, and they must check in with a physician every two years to continue getting contraception. In Oregon, trained pharmacists can prescribe birth-control bills and can also prescribe injectable contraceptives, Brianne reports.

— And here are a few more good reads from The Post and beyond: 

Voters in four states will decide Nov. 6 whether to expand Medicaid under the Affordable Care Act. The initiatives have spurred some $20 million in political spending.
Wall Street Journal
AGENCY ALERT
It's been more popular ever since Trump became president.
Axios
A grassroots ballot campaign embracing a key piece of Obamacare in Idaho, if successful, would defy Trump's efforts to shrink the program.
Politico
HEALTH ON THE HILL
Politics
The political irony: The issue that propelled the GOP to take over Congress in 2010 threatens the party now.
Colby Itkowitz
MEDICAL MISSIVES
Morning Mix
Had he been driving in Oregon, he might have been hit with a $500 fine.
Meagan Flynn
Health & Science
Researchers highlight importance of exercise in improving body composition, strength, physical function and quality of life.
Lynn Panton and Ashley Artese
Epidemiologists working on the world’s latest Ebola outbreak are racing to determine why so many children have been infected.
Stat
The violence threatened to again force the suspension of health workers’ efforts to contain the virus, which may have killed more than 150 people since August.
Associated Press
National
A week after the storm hit the Gulf Coast of Florida, most people have no access to cash, struggle to put their lives back together after widespread devastation.
Frances Stead Sellers, Kevin Begos and Katie Zezima
Signs of trauma aren’t surprising to experts who have studied people after major storms.
Associated Press
Grade Point
The university gynecologist has been accused of sexual misconduct by hundreds of current and former students.
Susan Svrluga
To Your Health
Women are having fewer babies and at older ages than in the past three decades.
Ariana Eunjung Cha
Women in strenuous jobs lost their pregnancies after employers denied their requests for light duty, even ignoring doctors’ notes, an investigation by The New York Times has found.
The New York Times
REPRODUCTIVE WARS
Two rules have forced closure of all but one Planned Parenthood center in the state. Abortion-rights supporters say it is an example of an "abortion desert" that could result if Roe is overturned.
NPR
SECOND OPINION
The Post's View
GOP candidates now say they will save a popular Obamacare provision. But how?
Editorial Board
DAYBOOK

Coming Up

  • The Medicaid and CHIP Payment and Access Commission holds a public meeting starting Thursday.
  • The Senate Health, Education, Labor and Pensions holds a hearing on Nov. 28.
SUGAR RUSH

Members of Congress called for Saudi Arabia to face repercussions in the aftermath of journalist Jamal Khashoggi's death: