Elizabeth DiLauro, Senior Policy Officer, Robert Wood Johnson Foundation
Giridhar Mallya, Senior Policy Officer, Robert Wood Johnson Foundation
Interviewer: Maya Schane, Grantmakers In Health
In this interview, Grantmakers In Health’s Maya Schane spoke with Elizabeth DiLauro and Giridhar Mallya of the Robert Wood Johnson Foundation about the importance of race-conscious policymaking and protecting access to ballot measures as key tools for advancing health and racial equity.
How do you define race-conscious policymaking, and what do you mean by ballot measure access?
Giridhar Mallya: With race-conscious policymaking, we think about a couple of things. First, this is a policy, program, or any sort of initiative that is designed to address the harms of racism. Second, by addressing the harms of racism, when done right, these policies or programs create solutions that everyone in a system can benefit from.
One great example is the ACCURE cancer care intervention, which was designed to reduce disparities in the timeliness and quality of cancer care. The intervention included culturally competent care navigation for patients; health equity training for providers; and tracking outcomes by race and other demographic characteristics.
Research demonstrates that this intervention not only reduced racial disparities in completion of treatment for lung cancer and breast cancer but also improved treatment completion for patients of all races. This example counters a very prevalent narrative right now that race-conscious initiatives are zero sum—that White people are losing out while people of color are gaining. But that’s not the case with this type of work, and that’s why we think it’s so powerful.
Elizabeth DiLauro: In terms of ballot measures, voters have access to a statewide ballot measure process—also called direct democracy or the citizen initiative process—in 24 states. This allows voters to propose policy changes at the state level and then vote on them directly at the ballot box. In the past decade or so, ballot measures have been critical ways to make progress on policies that advance health and racial equity, including issues like Medicaid expansion, minimum wage, paid leave, and reproductive rights—all things that are important to health and well-being.
In the wake of these policy wins, legislatures in several states are now trying to change the rules of the ballot measure process to make it harder, more complicated, and riskier for people to use this tool. Some of the changes are small and statutory, while others are big, constitutional changes to how the process works. The bottom line is that people in the states that are facing these attacks on the ballot measure process are losing access to this pathway to advance the issues they care about—and this is ultimately in service of preserving political power for the state legislatures.
Giridhar Mallya: So, why are we talking about these two things at the same time? They are both strategies to advance equity in our country right now and are both facing coordinated threats and attacks. Race-conscious initiatives are more about policy design and purpose, while ballot measures are more about the policy and decisionmaking process. Both are worth protecting, and the Robert Wood Johnson Foundation has been deeply engaged in doing so over the past two years.
In our current political climate, progress in health and racial equity can seem elusive, and there is an urgent need for defense. Tell us how you and the Foundation are viewing this challenge.
Elizabeth DiLauro: We are lucky in our roles to be supporting a network of partners that are advancing and defending policies that impact health and racial equity. Part of this work is the urgent defense that is so necessary right now to protect the tools that are under threat, like access to ballot measures and race-conscious policymaking.
But we know that we can’t only be focused on the intense defense that’s needed in the moment; we also need to be focused on where we want to go, five, 10, 20 years down the line. One of the things that we hear from partners time and time again, especially in this moment, is that funding them in a way that allows them to be nimble is critical. Doing so enables them to pivot and shift to meet their short-term needs while also working across partners, organizations, and movements to create the conditions for long-term change. Sometimes in philanthropy, there’s a tendency to fund with an ‘either/or’ approach. We fund either intensely for short-term defense or for longer-term change; or we support federal strategies or state-facing strategies. But the moment we’re in is really calling for all these approaches. We need both short-term defense and long-term planning, and we need a focus on what’s happening at the federal level while also building power and supporting change at the state level.
Giridhar Mallya: I’ll add that it can seem like progress on health and racial equity is really elusive, but when you look at these two issues, they have really strong support across a diverse set of groups in our nation. While DEIhas become somewhat of a “boogeyman” and is used to divide people, data shows pretty consistently that when you talk with people about the underlying values of diversity, equity, and inclusion, these are things that people value highly, regardless of their political ideology or where they live. Some of it comes down to how we talk about these issues, but it’s also important to give people a sense of what these policies and programs mean for their lives.
Similarly, with ballot measure access, this is a form of direct democracy and people love the ability in our country to be able to weigh in directly on the issues that matter to them most. While the attacks on both the ballot measure process and race-conscious policymaking are egregious and harmful, there’s also an opportunity to help educate people about why these policy tools are so important and worth defending. That’s a real privilege that we have within philanthropy to help this work happen in our country.
As you just mentioned, it seems like there is actually more common ground on these policy issues in the public than we often realize. How can ballot measures and race conscious policymaking turn that shared support into action?
Giridhar Mallya: Nearly everybody feels like the health care system isn’t serving them well—whether it’s around costs, access, or being treated respectfully. But certain groups—like people of color and people with disabilities—bear the brunt of the failures of our health care system because of long-standing discrimination. Race-conscious policymaking enables people to identify what’s wrong with the system, determine the underlying and more proximate causes of this dysfunction, and develop solutions that improve the experience and quality of care for those disproportionately harmed while making the system itself better.
For example, we know that many women experience disrespect and discrimination during pregnancy-related care, and that has serious consequences for their health and the health of their babies. One strategy that has been used to address racial disparities is increasing access to doulas, who provide emotional, spiritual, and physical support to people during pregnancy and delivery and who serve as powerful advocates for patients. Research is increasingly showing that having access to a doula reduces disparities and improves pregnancy-related care for all patients. There are powerful examples like this in public health, community development, and so many other sectors.
Elizabeth DiLauro: As I mentioned earlier, ballot measures can be transformative for people’s health and well-being on issues like Medicaid expansion, paid leave, minimum wage, and more. A study in Health Affairs showed that from 2014-2023, more than 60 percent of ballot measures that passed were related to health. These are policies that are widely popular with voters across the political spectrum, but they don’t always have a viable pathway to advance through the legislature in some states.
We saw this play out in the elections last November. Voters in several states advanced paid sick leave and minimum wage increases through ballot measures. Additionally, voters in Arizona and North Dakota defeated efforts that would have changed the ballot measure process to make it harder for people to use. The results were clear – voters want to preserve the ballot measure process. And the issues that are moving on the ballot are being decided across party lines. In Nebraska, 59 percent of voters voted for President Trump in 2024, while 75 percent of voters passed paid sick leave—a supermajority of voters. There’s no question that these policies are popular, and they are policies that can materially change people’s lives and their opportunities for health and well-being.
Both race-conscious policymaking and the ballot measure process are facing pushbacks. Can you unpack what’s happening here and why?
Elizabeth DiLauro: It’s no surprise that the legislative attacks on the ballot measure process are happening in states that are also seeing progress toward equity being made through ballot measures. Our partners at the Ballot Initiative Strategy Center Foundation are tracking these attacks, and they found that there were more than 100 bills this legislative session that tried to change the rules and restrict access to ballots. This trend is likely to continue next year and will likely grow given the midterm elections.
The attacks can look different—some are big, constitutional changes to the process; others are a series of smaller statutory changes that add up to real impact. Across the states, tactics have included things like increasing the number of signatures needed to put something on a ballot, raising the threshold for a ballot to pass well beyond a simple majority—the standard in many states—or requiring a ballot measure to pass multiple times before it can be enacted.
Another trend we have seen this year is making the process to gather signatures significantly harder and riskier for canvassers. For example, both Arkansas and Florida passed laws this year which would allow criminal charges for canvassers if they made mistakes in the signature process. These tactics will continue to evolve and grow.
Giridhar Mallya: We’re seeing across both these issues that those behind the attacks are a powerful, well-resourced set of activists, think tanks, and legal groups. The opponents of these approaches often like to make it seem like the opposition is grassroots, but it really is powerful interests that are trying to keep people and policymakers from advancing strategies that make our country more equal.
Sometimes, it is directly about the policy at play—for example with ballot measures and paid leave, it is big businesses that are trying to prevent workers from getting access to paid sick leave, because they think it would affect their bottom line. With the attacks on DEI, it’s a mix of organizations: those who see race-conscious initiatives as reverse discrimination and those who are less interested in racism and its remedies themselves but have an intense interest in using racial issues as a way to dismantle institutions like government or higher education. We have seen this over the course of the civil rights movement, where efforts to advance racial equity have been used to sow division among people of different races and to distract from other efforts of conservative lawmakers.
I think right now, we are seeing that DEI is being used as a pretext for cutting essential government programs and services—whether it’s Medicaid, SNAP, or other programs that have broadly positive impacts on the health of people and communities. It’s important for funders to recognize that this isn’t new—whenever there is progress on civil rights or health equity, we are going to see pushback, and in some ways, that’s a signal to lean in even more and remain deeply committed to this work.
How are you and your partners protecting access to ballot measures and defending race-conscious initiatives in the current moment?
Giridhar Mallya: In terms of race-conscious initiatives, we’re working with 20 amazing partners across the country focused on four interrelated strategies, including legal advocacy and litigation, narrative and communications, supporting policymakers to keep race-conscious work going, and helping to organize and connect leaders across sectors who are facing these threats.
On the legal advocacy side, we have seen our partners be able to file lawsuits that challenge federal policies sometimes within 24 hours of this administration issuing executive orders that limit work around racial equity. One example is the thousands of NIH grants that were terminated based on their relation to work on DEI. Several of our partners filed lawsuits to reverse those terminations, and just a couple weeks ago, they obtained a positive ruling from a district court judge. Not only was NIH ordered to restart those grants, but there was a very powerful decision by a Reagan-appointed judge who said this is one of the most egregious examples of government-backed racial discrimination that he’s seen in his 40-year career. This doesn’t mean there is no more work to do there, and, in fact, we’ve now seen the Supreme Court block that ruling in part, but we are seeing some tangible and meaningful impacts of the work that our partners are doing.
Elizabeth DiLauro: We are giving grants to several state-based advocacy organizations who are working to protect the ballot process in states where there are urgent attacks on it. We’re working with partners in Arkansas, Idaho, Missouri, North Dakota, and Utah. In Mississippi, we are supporting partners working to restore the ballot process, since it has been voided for several years due to a state Supreme Court decision. At the national level, we partner with organizations like the Ballot Initiative Strategy Center Foundation and the Fairness Project Education Fund that are working to defend the ballot measure process and supporting partners in several states.
While progress is not linear, our partners are seeing success. One example is in Missouri—for more than five years, Missouri legislators have been attacking the ballot process using various tactics and strategies. There is a coalition of advocates called the Will of the People Coalition that has successfully organized and helped to defeat the attacks year after year. We expect those attacks to come back with more vigor next year, and the role of that coalition will be even more important in defeating them.
Can you share some lessons from your work that would guide other funders looking to get involved in race-conscious policymaking and protecting access to the ballot measure process?
Elizabeth DiLauro: Working more intensely in ballot-related work is new to the Robert Wood Johnson Foundation, and we are continuing to learn a lot of lessons as we navigate how to do so as a 501c3 private foundation. The number one thing I have heard from partners is that when they receive 501c3 funds early—and flexibly—it allows them to do early coalition building, organizing, public education, and build backend infrastructure. These are all things that are critical to have in place so they have the capacity and are ready for the attacks that come on the ballot process.
Additionally, ballot measure protection is a year-round, year-after-year effort. As I’ve mentioned, attacks on the ballot measure process take a variety of different forms—they can be through legislative means, through litigation, and even at the ballot itself. All are efforts to subvert the will of the people. Our partners are working year-round across a variety of different strategies to fend off these attacks, at the same time proactively planning for how to guard against future efforts to change the process. Being able to do so requires sustained investment over time.
Giridhar Mallya: While there are some legal rules within which foundations need to operate, we can do work to defend ballot measure access and to engage in race-conscious grantmaking. It just requires us to be smart and deliberate about how we develop and implement the strategy.
For race-conscious initiatives, one really important thing is to determine how the work is connected to your mission as a foundation, because that helps foundations make the case that this work is connected to your First Amendment rights as institutions. If racial equity is your mission, then strategies to advance and defend racial equity through litigation, advocacy, and narrative change are both necessary and defensible.
Lastly, in addition to our grantmaking dollars, this is a particularly important moment for foundations to use their institutional voice to talk about why the work matters, how it is connected to their mission, and why, despite the various threats that we’re seeing to work like this across our country, they are remaining committed. That’s a way that we as a sector can show up for our grantees and demonstrate that this work is worth continuing and worth defending.