Tuesday, there should be little doubt, was a toxic day for health — and health care — in America.

The implications of the election are widespread and multifaceted, ranging from the catastrophic impact a Trump presidency will have on climate change — and the attendant global health consequences — to the squeeze on reproductive health care access that will likely follow the rise of the Right.

At the state level, important health care–related ballot initiatives went down in defeat, including a universal health care referendum in Colorado and an initiative in California that was set to mildly loosen Big Pharma’s tentacle-like grip on the state’s finances (it would have merely allowed the state to purchase drugs at the discount already available to the federal government). Big Pharma and the insurance industry poured huge sums into lobbying campaigns against these initiatives — money that was evidently well spent.