Direct Democracy With Teeth: The Political Economy of Washington Initiative 678

Conor Norris

American Journal of Economics and Sociology, 2025, vol. 84, issue 5, 729-736

Abstract: Scope of practice laws restrict mid‐level professionals, like dental hygienists, from practicing independently. In 1997, Washington voters considered Initiative 678, which would have allowed dental hygienists to offer cleanings without dentist oversight, aiming to increase dental access. Due to a statewide advertising campaign by the dental professional association, the initiative failed. This paper examines county‐level support for Initiative 678. I find evidence that counties with lower dental care utilization, fewer residents with fluoridated water, and worse oral health predicted greater support for the initiative. These results are consistent with voters' interests shaping voting patterns, despite special interests influencing the outcome.

Date: 2025
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