One year after Congress passed the largest health care cut in this nation’s history, the damage is exactly what experts warned it would be — and it is landing hardest on Black and brown communities. Medicaid and Children’s Health Insurance Program (CHIP) enrollment is down 5 million people nationwide. More than 1,000 hospitals, clinics and maternity wards have closed or cut services. And even more severe provisions will be introduced in 2027 and 2028. This is a stark reminder that political power is a social determinant of health, and that breakdowns in representation and accountability in our democracy have brutal consequences for our most vulnerable communities.
Today, we are seeing accelerating attempts to strip communities of representation at the state-level. In Louisiana, far-right Republicans led an effort to eliminate their “jungle primary” system and institute a closed party primary to control the choices of voters in their state. In Tennessee, after Democratic lawmakers protested a new “congressional gerrymander that eliminated the state’s lone majority-Black district,” Republican lawmakers stripped all Democratic lawmakers from their committee assignments.
At a time when politicians are increasingly trying to choose their voters and shrink the field of people who can hold them accountable, Massachusetts has a chance this November to do the opposite and demonstrate the national leadership we’ve been historically known for. Question 3 would replace our party primaries with an all-party primary: one ballot, every candidate, every voter — Democrat, Republican, independent, unenrolled — and the top two finishers advance to the general election.
It’s how Boston and many Massachusetts cities and towns already elect their mayors and city councils. This fall, voters can extend that same system to the State Legislature, as well as statewide and congressional offices.
This will strengthen accountability and representation and advance racial justice and public health in the commonwealth. Let’s start with the plain math of representation. Massachusetts has ranked dead last in the nation in electoral competitiveness for years running, and over 60% of our 2024 legislative races drew no opposition at all. In the rare cases where there is competition, most of those elections are decided in low-turnout primaries by 15-20% of the electorate, a group that is older, whiter and wealthier than the average voter. When the fuller, more diverse general electorate (70-80% of voters) shows up in November, it often finds nothing left to decide.
People of color make up 29% of Massachusetts’s population but hold only 17% of seats in the Legislature. In states with a similar all-party primary system, legislators are much more representative of their population in race, gender and age. And politicians are more likely to listen when they face meaningful competition.
Representation means accountability and that is evident when it comes to the public’s health. Research consistently finds that communities with higher civic participation see better health outcomes and that legislatures with more representative membership produce policy that better serves the people affected by it. We saw the harms of inadequate representation during COVID-19 here in Massachusetts, when communities that had long been shut out of decision-making bore the worst of the pandemic’s toll.
We understand the instinct to respond: “People should just show up and vote in the primary.” Craig has spent three decades in public health, first as a nurse and later helping to run the state’s family health and racial equity programs. Health care experts used to blame patients who missed their doctor appointments, saying if they cared enough or were educated enough, they would show up. Only later did experts recognize the barriers were structural — transportation, scheduling, trust — and redesigned care to meet people where they were.
Voting works the same way.
The fix isn’t to blame voters; it’s to build a system that meets voters where they are, in the general election, and empowers them to choose their representative and hold them accountable.
Massachusetts has a long history of national leadership on civil rights, racial justice and public health. This November, we have the chance to lead again — by giving every voter a real say in who represents them. Representation means accountability. Accountability means better outcomes for our communities. Vote yes on Question 3.
Craig Andrade is a registered nurse, athletic trainer, massage therapist, strength and condition specialist, health and public health educator, health care administrator, public health administrator and racial justice and health equity advocate and facilitator with masters and doctoral degrees in public health from Boston University School of Public Health. Jerren Chang is President and CEO of Partners In Democracy.
