Ana B. Ibarra, Author at �鶹Ů�� Health News

Congressional Candidates Go Head-To-Head On Health Care — Again

Ana B. Ibarra — Mon, 24 Feb 2020 10:00:56 +0000

The California Democrats who fought to flip Republican congressional seats in 2018 used health care as their crowbar. The Republicans had just voted to repeal the Affordable Care Act in the U.S. House — and Democrats didn’t let voters forget it.

Two years later, Democrats are defending the seven seats they flipped from red to blue in California. And once again, they plan to go after their Republican opponents on health care in this year’s elections.

But this time around, it’s not just about the Affordable Care Act, now rests with the federal courts. Democrats are highlighting the high costs of prescription drugs, surprise medical bills and cuts to safety-net programs.

Health care “remains the single-biggest priority for most voters in 2020,” said U.S. Rep. Josh Harder, a Democrat who represents California’s 10th congressional district, in the northern San Joaquin Valley, which includes the cities of Modesto, Turlock, Tracy and Manteca.

Harder, who defeated Republican Jeff Denham in 2018, made the case then that eliminating the federal health law and its protections for people with

target=”_blank” rel=”noopener noreferrer”>preexisting conditions

would harm thousands of people in his district, including his younger brother, whose premature birth yielded $2 million in hospital bills.

Health care affordability — from drug costs to premiums — is still the No. 1 issue his constituents raise in conversations with him, he said.

“The problems haven’t been solved,” said Harder, who blamed the Republican-controlled U.S. Senate for stalling on addressing prescription and other health care costs. “A lot of folks out here feel like there’s still an unbelievably long period before they can see a doctor, and they think that the costs are way too high.”

Multiple calls and emails to Republican congressional candidates and the California Republican Party requesting comment were not returned. California voters will select their party’s congressional candidates in the Super Tuesday primary March 3.

Health care is indeed a top issue for voters, confirmed Mollyann Brodie, executive director of public opinion and survey research for the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

“What concerns people the most is health care costs and their own affordability of health care,” Brodie said. “And when we asked people what they thought Congress should be working on, prescription drug costs came right on top.”

A national Kaiser Family Foundation tracking poll from found that 81% of Democrats and 62% of Republicans surveyed said lowering prescription drug costs should be a top priority for Congress. Voters in both parties also want Congress to maintain protections for people with preexisting conditions and limit surprise medical bills.

Both Democratic and Republican candidates are taking note and are likely to feature health care prominently in their campaigns, but their messages will be different, said Nathan Gonzales, editor and publisher of , a campaign analysis site.

For example, progressive Democrats often advocate for “Medicare for All,” a national health care program that would cover everyone in the U.S.

Republicans oppose this idea fervently.

“Republicans will talk about a government takeover of health care, socialism, Democratic efforts to get rid of private health insurance and the cost of Democratic plans,” Gonzales said.

Ted Howze, one of three Republicans gunning in the primary to replace Harder, fits this description. He is running for Congress after “personally struggling with the failure of the health care system,” he said during

target=”_blank” rel=”noopener noreferrer”>a January debate

in Modesto. His first wife died in 2013 from an undiagnosed heart condition “that could have been treated,” according to his .

Among his top three priorities, he said, is making quality health care affordable for all Americans. But he proposes to do so through the private market, not more government-run programs.

“I will support any plan that covers preexisting conditions and that increases transparency and competition to drive costs down,” he said during the debate.

In at least one California district, health care has popped up in campaign advertising.

Twelve candidates are vying for the 25th Congressional District seat, which includes portions of Los Angeles and Ventura counties. The seat was vacated by former U.S. Rep. Katie Hill, a Democrat in October.

Voters in that district will face a double election on March 3: The first is a special election for the remainder of Hill’s term, which runs through the end of this year. The second is the primary for the full 2021-23 congressional term.

Among the candidates is former U.S. Rep. Steve Knight, the Republican who lost his seat to Hill in 2018. After voting to repeal Obamacare in Congress, he that he argued would have protected people with preexisting conditions. His campaign did not return multiple calls and emails for comment.

State Assembly member Christy Smith, a Democrat who is running for the seat, shared a personal story about prescription drug costs in .

Smith’s mom, a nurse, “died too young because she couldn’t afford the insulin to treat her diabetes and heart disease,” Smith says in the ad.

“My mom couldn’t afford the medicine and care she needed. I’m running for Congress to make sure you can.”

Another Democratic candidate, Cenk Uygur, co-founder of “The Young Turks,” a progressive YouTube news show,

target=”_blank” rel=”noopener noreferrer”>also made health care

the topic of his first TV ad. Tens of thousands of people die every year because they don’t have health insurance, he says in the ad. “What if your own child was one of them?”

Democrats may find more health care fodder for their campaigns as the year progresses, said Ivy Cargile, an assistant professor of political science at California State University-Bakersfield.

For instance, she said, on Feb. 10 the Trump administration released its $4.8 trillion 2020 , which includes deep cuts to Medicaid, the public health insurance program for low-income people.

Medi-Cal, California’s Medicaid program, has about 13 million enrollees. “Let’s assume this goes through,” she said. “That’s going to be fresh in the mind of voters going into the general election.”

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Newsom Touts California’s ‘Public Option.’ Wait — What Public Option?

Ana B. Ibarra — Tue, 11 Feb 2020 10:00:21 +0000

Several Democratic presidential hopefuls are pitching a federal “public option” as a way to expand health coverage and make it more affordable.

The details of their proposals vary, but the general idea is to create a government-sponsored plan that could compete with private insurance.

“We have a public option, just so folks know,” California Gov. Gavin Newsom claimed last month as he unveiled his proposed 2020-21 state budget. “It’s called Covered California.”

Hmm, really?

California does not have a public option in the way most people understand the term. According to Newsom’s definition, offering a public option simply means ensuring that consumers have choices and affordable coverage, and that health plans are held accountable, things Covered California already does, his office said.

That’s a stretch, say some health care and political experts.

Covered California “is manifestly not a public option,” said Thad Kousser, chair of the political science department at the University of California-San Diego.

Kousser theorized that Newsom may be co-opting the term to make it seem like the state is making progress toward his goal of creating a single-payer system.

But if Newsom wants to flout the term, the state should “create a public option that doesn’t involve insurance companies, and Covered California is a market to buy insurance from insurance companies,” Kousser said.

Covered California is the state-run exchange, created under the Affordable Care Act, where some individuals, families and small businesses can purchase insurance.

A public option is considered less sweeping than single-payer, a system in which health care is paid for by a single public authority. , Newsom, a Democrat, campaigned for the creation of a single-payer program.

But that isn’t likely to happen anytime soon, for a variety of reasons. For one, the Trump administration has said any state plans to use federal dollars to implement single-payer.

At the national level, Democratic presidential candidates including former Vice President and former South Bend, Indiana, Mayor have pitched public-option plans that would allow, but not require, people to buy into government-run plans similar to Medicare.

The idea is to boost competition by allowing people to choose between private plans and a government-run plan — and reduce costs.

Only one state, Washington, is implementing its own version of a public option, but other states are considering it.

, a hybrid system in which the state will contract with an insurer to administer a public-option plan, will debut in 2021. The state will attempt to control costs by setting payment rates at 160% of what Medicare would pay for the same service. is proposing a similar idea.

This version is different from the presidential candidates’ proposals because an insurance company will be responsible for running the public-option plan — not the government. But, ultimately, Washington will give its residents a new health insurance option, and that’s not the case in California, said Billy Wynne, chairman of the Wynne Health Group, which recently launched the , a group analyzing the implementation of public-option programs.

But in California’s defense, he said, what constitutes a public option “is in the eye of the beholder.”

Peter Lee, executive director of Covered California, is also calling the exchange . He argues that public-option plans assume different forms, just like single-payer or Medicare for All proposals.

On the exchange, “plans don’t compete on their own terms; they compete on our terms,” Lee said. So, “is a public option only a government plan, or is it a public program that sets the rules of how private plans compete?”

Linda Blumberg, a health policy fellow at the Urban Institute, hazards an answer: While Covered California actively negotiates with health plans to keep premiums down, it “doesn’t quite have the spirit of a public option” because it doesn’t bear the financial risk that insurance companies do.

Newsom’s Healthy California for All Commission, which is debating how to get every Californian covered — with an emphasis on single-payer — gathered in Sacramento last month for its inaugural meeting. The commissioners briefly discussed the possibility of implementing a public option as a steppingstone to achieving universal coverage.

But the concept didn’t get much love, and some commissioners suggested that instead of creating a public option, the state should strengthen existing public programs. One commissioner said the idea of a public option had already fizzled.

“Whatever happened to Vanilla Ice, and whatever happened to Tiny Tim and Miss Vicki? Whatever happened to public option?” asked Dr. Robert Ross, president of the California Endowment, a foundation that focuses on expanding health care access among Californians. “It just kind of went away.”

The closest thing to a functioning public option in California, under the traditional definition, may be the L.A. Care Health Plan, a public, nonprofit insurer equally available to Los Angeles County residents with Medi-Cal, the state’s Medicaid program for low-income residents, and to those who earn too much to qualify for Medi-Cal.

John Baackes, the plan’s CEO, like the public-option plan described in the U.S. House version of the Affordable Care Act, before it was axed in the Senate. “Their definition of the public option was a public entity that did not have shareholders that would compete with commercial insurers in the individual market,” Baackes said.

L.A. Care, created to serve Medi-Cal patients, later opened to individuals and families who purchase their own insurance through Covered California or the open market.

For some time, Baackes said, the plan was the lowest-priced option in the Los Angeles area.

“Our enrollment skyrocketed because this is a very price-sensitive market, but in 2020, we were underbid by competition,” Baackes said. “To me, that’s exactly what the public option was supposed to do: put pressure in the marketplace. So I’m saying if you want to see how it works, look here.”

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For 2020, California Goes Big On Health Care

Ana B. Ibarra — Tue, 21 Jan 2020 10:00:56 +0000

California is known for progressive everything, including its health care policies, and, just a few weeks into 2020, state leaders aren’t disappointing.

The politicians’ health care bills and budget initiatives are heavy on ideas and dollars — and on opposition from powerful industries. They put California, once again, at the forefront.

The proposals would lower prescription drug costs, increase access to health coverage, and restrict and tax vaping. But most lawmakers agree that homelessness will dominate the agenda, including proposals to get people into housing while treating some accompanying physical and mental health problems.

“This budget doubles down on the war on unaffordability — from taking on health care costs and having the state produce our own generic drugs to expanding the use of state properties to build housing quickly,” Gov. Gavin Newsom said in a letter to the legislature, which accompanied the he unveiled last Friday. About a third of that money would be allocated to health and human services programs.

But even with a Democratic supermajority in the legislature, these proposals aren’t a slam-dunk. “There are other factors that come into play, like interest groups with strong presence in the Capitol,” including Big Pharma and hospitals, said Shannon McConville, a senior researcher at the nonpartisan Public Policy Institute of California.

Drug Pricing

Newsom’s plan to create a state generic drug label is perhaps his boldest health care proposal in this year’s budget, as it would make California the first state to enter the drug-manufacturing business. It may also be his least concrete.

Newsom wants the state to contract with one or more generics manufacturers to make drugs that would be available to Californians at lower prices. Newsom’s office provided little detail about how this would work or which drugs would be produced. The plan’s cost and potential savings are also unspecified. (Sen. Elizabeth Warren of Massachusetts, who is seeking the Democratic presidential nomination, at the federal level.)

Because the generics market is already competitive and generic drugs make up a small portion of overall drug spending, a state generic-drug offering would likely result in only modest savings, said Geoffrey Joyce, director of health policy at USC’s Leonard D. Schaeffer Center for Health Policy & Economics.

However, it could make a difference for specific drugs such as insulin, he said, which nearly doubled in price from 2012 to 2016. “It would reduce that type of price gouging,” he said.

Representatives of Big Pharma said they’re more concerned about a Newsom proposal to establish a single market for drug pricing in the state. Under this system, drug manufacturers would have to bid to sell their medications in California, and would have to offer prices at or below prices offered to any other state or country.

Californians could lose access to existing treatments and groundbreaking drugs, warned Priscilla VanderVeer, vice president for the Pharmaceutical Research and Manufacturers of America, the industry’s lobbying arm.

This proposal could “let the government decide what drugs patients are going to get,” she said. “When the governor sets an artificially low price for drugs, that means there will be less money to invest in innovation.”

Newsom’s drug pricing proposals build on his executive order from last year directing the state to negotiate drug prices for the roughly 13 million enrollees of Medi-Cal, the state’s Medicaid program for low-income residents. He also ordered a study of how state agencies could band together — and, eventually, with private purchasers such as health plans — to buy prescription drugs in bulk.

Homelessness

California has the largest homeless population in the nation, estimated at , according to the U.S. Department of Housing and Urban Development. About 72% of the state’s homeless or in cars rather than in shelters or temporary housing.

Newsom has asked for $1.4 billion in the 2020-21 state budget for homelessness, most of which would go to housing and health care. For instance, would boost health care and social services for homeless people via Medi-Cal. The money would fund programs such as recuperative care for homeless people who need a place to stay after they’ve been discharged from the hospital, and rental assistance if a person’s homelessness is tied to high medical costs.

A separate infusion of $24.6 million would go to the Department of State Hospitals for a pilot program to keep some people with mental health needs out of state hospitals and in community programs and housing.

Surprise Bills

California has some of the strongest protections against surprise medical bills in the nation, but to exorbitant charges because the laws don’t cover all insurance plans.

Surprise billing occurs when a patient receives care from a hospital or provider outside of their insurance network, and then the doctor or hospital bills the patient for the amount insurance didn’t cover.

Last year, state Assembly member David Chiu (D-San Francisco) that would have limited how much hospitals could charge privately insured patients for out-of-network emergency services. The bill would have required hospitals to work directly with health plans on billing, leaving the patients responsible only for their in-network copayments, coinsurance and deductibles.

But because of strong opposition from hospitals, which criticized it as a form of rate setting.

Chiu said he plans to resume the fight this year, likely with amendments that have not been finalized. But hospitals remain opposed to the provision that would cap charges, a provision that Chiu says is essential.

“We continue to fully support banning surprise medical bills, but we believe it can be done without resorting to rate setting,” said Jan Emerson-Shea, a spokesperson for the California Hospital Association.

Medi-Cal For Unauthorized Immigrants

California is the first state to offer full Medicaid benefits to income-eligible residents , regardless of their immigration status.

Now Democrats are proposing another first: California could become the first to open Medicaid to adults ages 65 and up who are in the country illegally.

Even though Medicaid is a joint state-federal program, California must fund full coverage of unauthorized immigrants on its own.

Newsom set aside $80.5 million in his 2020-21 proposed budget to cover about 27,000 older adults in the first year. His office estimated ongoing costs would be about $350 million a year.

Republicans vocally oppose such proposals. “Expanding such benefits would make it more difficult to provide health care services for current Medi-Cal enrollees,” state Sen. Patricia Bates (R-Laguna Niguel) said in a prepared statement.

Vaping

have restricted the sale of flavored tobacco products in an effort to curb youth vaping.

But last year, state legislators on a statewide ban on flavored tobacco sales after facing pressure from the tobacco industry.

Now, state Sen. Jerry Hill (D-San Mateo) is back with his proposed statewide flavor ban, which may have more momentum this year. Since last summer, a mysterious vaping illness has sickened people nationwide, leading to 60 deaths, according to the Centers for Disease Control and Prevention. , at least 199 people have fallen ill and four have died.

Hill’s bill would ban retail sales of flavored products related to electronic cigarettes, e-hookahs and e-pipes, including menthol flavor. It also would prohibit the sale of all flavored smokable and nonsmokable tobacco products, such as cigars, cigarillos, pipe tobacco, chewing tobacco, snuff and tobacco edibles.

Newsom has also called for a new tax on e-cigarette products — $2 for each 40 milligrams of nicotine, on top of already existing tobacco taxes on e-cigarettes. The tax would have to be approved by the legislature as part of the budget process and could face heavy industry opposition.

Tobacco-related bills are usually heard in the Assembly Governmental Organization Committee, “and that is where a lot of tobacco legislation, quite frankly, dies,” said Assembly member Jim Wood (D-Healdsburg), who supports vaping restrictions.

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From Clinic To Courtroom, Fighting For Immigrant Health Care

Ana B. Ibarra — Thu, 19 Dec 2019 10:00:39 +0000

OAKLAND, Calif. — Jane Garcia started as an intern at La Clínica de La Raza in the late 1970s, attracted by its mission to provide health care to all — especially immigrants, regardless of their legal status or ability to pay.

Forty years later, Garcia, 66, is the chief executive officer of the organization, which now operates more than 30 clinics in Alameda, Contra Costa and Solano counties and serves about 90,000 patients a year. About 65% of its patients are Latino, many of whom are immigrants.

Garcia, who has Mexican roots, grew up in the border town of El Paso, Texas. Her family frequently visited the Mexican city of Juárez for groceries, gas and haircuts, she recalled.

So advocating for immigrants came naturally to her as an adult, Garcia said, but she hasn’t limited her advocacy to the clinics.

In the 1990s, California experienced a paroxysm of anti-immigrant attitudes, similar to those that have manifested elsewhere in the United States today. Then-California Gov. Pete Wilson, a Republican, cracked down on illegal immigration and championed , which denied unauthorized immigrants access to public health care and education. The measure, adopted by voters in 1994, never took effect because it was by a federal court.

Garcia took Wilson’s administration to court in 1997 over its attempts to defund prenatal care for unauthorized immigrant women through Medi-Cal, the state’s version of the federal Medicaid program for low-income people. She filed the lawsuit on behalf of undocumented immigrant women — and won.

“It was a very brave thing to do back then, to put her clinic in the middle of this fight and be the spokesperson in this lawsuit,” said Carmela Castellano-Garcia, CEO of the California Primary Care Association, which represents health clinics. “I just remember being so impressed by her boldness.”

Today, La Clínica is the lead plaintiff in one of several lawsuits challenging the Trump administration’s attempt to expand the “, which would allow federal immigration officials to more easily deny permanent residency status to those who depend on certain public benefits, such as Medicaid.

Federal judges temporarily blocked the rule from taking effect in mid-October, so Garcia’s lawsuit is on hold.

La Clínica de La Raza, though, has a longer history. It was founded in 1971 by students at the University of California-Berkeley who were conscientious objectors to the Vietnam War, Garcia said. Instead of serving in the armed forces, they made a deal with the federal government to set up a free clinic in Oakland’s Fruitvale neighborhood, where residents had identified health care access as a main concern.

Garcia spoke with California Healthline’s Ana B. Ibarra in her office across the street from the original Fruitvale clinic. Garcia’s office is filled with plants, portraits of farmworker activist Cesar Chavez, images of Our Lady of Guadalupe and a framed “Health for All” poster.

The interview has been edited for length and clarity.

Q: Expanding health care access to immigrants has been your mission since Day One. What drew you to this cause?

I grew up in el barrio in El Paso, Texas. My family got many services from public health departments or through schools. Our shots, for example. So, I understood the importance of public health programs.

At the very beginning of my college career I was pre-med, but decided that chemistry and bio were not for me. When I was at Yale as an undergrad, I worked at a community health center as a translator and worked with mostly Puerto Rican families.

Then I got to La Clínica and really loved what they were doing. I just loved what the clinic movement was all about — social justice. And it really called to me.

Q: Why do you believe it’s important that everyone has access to comprehensive health care, regardless of immigration status?

Only by providing services to everybody can we have a true impact on the delivery system. When the flu season comes, it doesn’t ask your immigration status.

It behooves us all to keep all our communities healthy and to provide access at the most basic level so that we avoid emergency room utilization.

My daughter is an ER nurse and she tells me, “Mom, you don’t know how many people come in there using the ER inappropriately.” And that’s because they don’t have access to anything else. That’s their primary care.

Q: , low-income undocumented immigrant women could get prenatal care through Medi-Cal, but you’ve spent many years defending that coverage, including in court. Why was this so contentious?

Our focus has always been families, so we really focused on providing access to basic primary care, and prenatal care was a big issue for our communities back then because it was a political lightning rod — you had women who were undocumented seeking services.

We had to fight to make sure that the hospitals we went to to deliver our babies would admit our patients. And that our patients felt comfortable being there. We helped our patients access Medi-Cal or develop payment plans with the hospital. I remember our physicians hearing comments like, “You’re turning our hospital into a county facility.”

We filed a lawsuit on behalf of some undocumented women in 1997. They were the real soldiers in this. I was just the interface.

Q: Now La Clínica is challenging the Trump administration’s attempt to expand the public charge rule. How is this situation similar to your fight in the 1990s?

When this public charge issue came up, it was reminiscent from those days and everything about it reminded me about Prop. 187.

That was just one big period in time that was all about being anti-immigrant. And we are seeing the same things today: parents keeping their children at home and our number of appointments going down. This is round two of the same situation except that I think we have been able to change the narrative somewhat.

Particularly here in California, we don’t see the word “illegal” as much, and we see fewer visualizations of people crossing the border like cucarachas [cockroaches]. The messages that we were giving to patients at that time were not very different from the messages that we’re giving to patients right now. They are: Continue to get your services here, we’re a safe place, and we don’t share your information.

Q: Is this where you thought the country would be going into the 2020 election?

As a country, we’ve definitely taken some steps backward, there’s no question about that, but we’re not starting from point zero. As advocates, we’re way better armed with data and we can show you how much taxes immigrant families pay, we can tell you how significant they are to the workforce.

I think California, whether folks like it or not, is a leader. And with the state’s commitment to cover everybody, we will be able to demonstrate that, in the end, that strategy is the way to go in terms of having more healthy communities and a more productive society.

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Some Rejoice Over New California Health Insurance Subsidies. Others Get Shut Out.

Ana B. Ibarra — Thu, 12 Dec 2019 21:20:50 +0000

Syd Winlock bought one of the cheapest health insurance policies he could find for himself and his wife, Lisa, this year: a high-deductible plan with lousy coverage and a $1,500-per-month price tag.

For coverage next year, the Elk Grove, Calif., resident qualifies for new state-funded health insurance subsidies totaling about $870 per month. This aid allows him to buy a better plan with a lower deductible for about $1,200 per month.

That’s still high, he said, but any help is welcome.

“It made a huge difference,” said Winlock, 61, a small-business owner who provides accounting and point-of-sales systems to other businesses. “We were thinking that in 2020 we wouldn’t be able to keep our plan,” let alone afford an upgrade, he said.

Heather Altman, an independent environmental consultant in Long Beach, also hoped to qualify for the new state financial aid. But, after checking with a health insurance agent, she learned she won’t get anything. “At first I thought it might be a mistake,” she said. “It was disappointing.”

Starting Jan. 1, California to some consumers who buy health coverage through Covered California, the state’s Affordable Care Act insurance exchange.

Some of the subsidies will go to people who already qualify for the federal tax credits available to some Covered California consumers, primarily those with low incomes. But the assistance will also be extended to middle-income people such as Winlock who make too much money to qualify for the federal tax credits and have had to bear the entire cost of their premiums. California will be the first state to offer such help to middle-class consumers.

With open enrollment for Covered California going full steam — sign-ups for 2020 coverage end Jan. 31 — consumers are eagerly trying to determine whether they might qualify for the new aid and, if so, how much.

The results are mixed.

“It’s brought higher-income earners to call me, but most still earn too much” to qualify, said Kevin Knauss, a Sacramento-area insurance agent who also has clients in Los Angeles and the Bay Area. “Others are picking up $15 to $25.”

More than 486,000 people have already qualified for the new state subsidies, with more expected as open enrollment continues, Covered California announced Thursday. This includes about 23,000 middle-income enrollees who make too much to qualify for federal tax credits, said Covered California Executive Director Peter Lee.

Lee added that new enrollment is up by 16% compared with this time last year, largely due to the new state financial aid and insurance requirement.

This “is a small slice of who will sign up,” he said. “We’re optimistic there will be many, many more people covered by these state subsidies for the middle class.”

Earlier this year, Gov. Gavin Newsom signed a 2019-20 state budget that includes nearly $429 million for the subsidies. To help pay for them, the state is imposing a starting next year on people who don’t have health insurance — similar to the federal penalty the Republican-controlled Congress eliminated effective this year.

Covered California has estimated that nearly 1 million Californians could benefit from the new state money.

Some of the aid will go to low- and moderate-income people who earn between 200% and 400% of the federal poverty level, or roughly $25,000 to $50,000 for an individual and $51,500 to $103,000 for a family of four, based on 2019 figures. This group also qualifies for federal tax credits. The average household state subsidy in this category would be $21 a month, Covered California estimates.

The majority of the state assistance, however, will go to people whose incomes are between 400% and 600% of the poverty level — too high for federal aid but still low enough to make health care financially challenging. That’s between about $50,000 and $75,000 a year for an individual and $103,000 to $154,500 for a family of four. The average state assistance for this group will be about $460 a month, according to Covered California.

But falling into this income bracket doesn’t guarantee subsidies, as Altman learned.

She estimated she will make $60,000 next year, which puts her within the income range to qualify as an individual, but she won’t be getting any aid, and she doesn’t quite understand why.

Besides income, household size, location and age play a role in eligibility for the subsidies, Covered California’s Lee explained. For example, older people who live in areas with high health care costs have a higher chance of getting help, he said.

Altman, 47, who has severe asthma and is on multiple medications, said she can’t go without coverage, so she will pay $640 every month for a health plan next year, up $70 from this year.

“I was just glad that it was only an 11% increase,” she said. “In previous years, I’ve seen a 20-something percent increase.”

Winlock said he feels grateful he qualified for the state financial aid because it allowed him to buy a better plan. Now he can seek care that he has been avoiding.

“We’re pretty healthy, and I’m very active, but I do have an issue with arthritis that I haven’t been pursuing because just testing alone is very expensive,” he said.

Evette Tsang, an insurance agent in Sacramento, said that while news of financial aid is driving some customers to her office, the new insurance requirement — and the accompanying tax penalty — are ultimately motivating most people to sign up.

People who don’t have insurance in 2020 will have to pay the penalty when they file their state tax returns in 2021. The penalty will amount to $695 for an adult and half that much for dependent children. Some people with higher incomes instead will have to pay 2.5% of their income, which could make their penalty quite a bit heftier.

Tsang saw clients drop their coverage when the federal penalty was eliminated. “Now they’re coming back,” she said.

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Medi-Cal To Expand Eligibility To Young Undocumented Adults. But Will They Enroll?

Ana B. Ibarra — Thu, 21 Nov 2019 10:00:11 +0000

Starting in January, young adults can sign up for California’s Medicaid program regardless of immigration status.

But a fundamental question looms: Will they?

Some young people already say they won’t enroll in public coverage because they fear federal immigration policies could later penalize them for participating — though that fear might be unfounded.

Add to that their age. Young adults — both immigrants and non-immigrants — are notoriously hard to convince of the necessity of health insurance. The insurance industry even has coined a special term for them: “.”

“Young adults, undocumented or not, tend to consider themselves healthy,” said Cathy Senderling-McDonald, deputy executive director of the County Welfare Directors Association of California, which represents county human services directors. “They’re not thinking ‘This is something I need to worry about.’”

Medi-Cal is California’s version of the federal-state Medicaid program for low-income residents. In May 2016, the state began offering undocumented immigrant children up to age 19 full Medi-Cal coverage, funded by state money. Nearly 129,000 were enrolled in the program in March 2019, according to the most recent data available.

During budget negotiations this year, California lawmakers voted to use more state dollars to expand the program to all income-eligible adults ages 19 to 25, which will make California the first state to offer full Medicaid coverage to unauthorized immigrant adults. The state Department of Health Care Services expects to enroll about 90,000 young adults in the first year.

Of those, nearly 75% are currently enrolled in limited Medi-Cal coverage, which includes emergency and pregnancy-related care. The department plans to transition those individuals into comprehensive coverage, it said.

That leaves health officials and immigrant rights advocates grappling with how to persuade everyone else who is eligible to apply.

Undocumented immigrant adults of California’s uninsured population, about 58%, according to the Insure the Uninsured Project.

“The message we have to spread is to think about prevention and chronic conditions, which could start early in life,” said Jeffrey Reynoso, executive director of the Latino Coalition for a Healthy California.

Advocates must meet young adults where they are, Reynoso said, which means social media is key. His group is creating a social media toolkit that includes Instagram posts and sample tweets tailored to young adults, which will be available to partner organizations.

It also plans to use radio and ethnic media, in cooperation with other groups, to spread the message to families so parents and grandparents can encourage younger family members to sign up, he said.

“We can’t use traditional media to reach this population,” said Sarah Reyes, managing director of communications at the California Endowment, a foundation that promotes health insurance coverage for all Californians, regardless of immigration status. The endowment also is planning social media posts and radio spots on stations that cater to younger people, and is designing ads for display in convenience stores and markets, Reyes said.

Those who make up to 138% of the federal poverty level . This year, that means individuals with annual incomes of up to about $17,200 qualify.

Because Medi-Cal is free for most participants, most young people won’t have to worry about taking a financial hit, said Sarah Dar, senior manager of health and public benefits for the California Immigrant Policy Center. That makes them different from the so-called — who generally fall into the 18-to-34 age group — looking for private health coverage, where cost is a major consideration.

But age is not as great a barrier to enrollment as fear of federal immigration rhetoric and policies, Dar said.

For example, since 2017 the Trump administration has been fighting to end the Deferred Action for Childhood Arrivals (DACA) program, which allows some undocumented people, whose parents brought them into the country illegally as children, to live and work in the U.S. temporarily. The fate of the program rests with the U.S. Supreme Court, in the case Nov. 12.

The Trump administration is also trying to expand its , which would allow immigration officials to more easily deny permanent residency status to those who depend on certain public benefits, such as Medicaid. Federal judges from taking effect in mid-October.

But the fears may be misguided, Dar said. Participants of the DACA program already are eligible for Medi-Cal if they meet the income guidelines. And applying for Medi-Cal wouldn’t count against undocumented young adults should they become eligible to apply for permanent residency later because their coverage will be paid for with state, not federal, money, she said.

“We need to get out a clear message that public charge should not be a concern,” Dar said.

Esmeralda, 20, of Santa Maria, Calif., works in the fields picking strawberries and attends community college when the fruit isn’t in season. She agreed to speak to California Healthline on the condition that her last name not be used.

She needs glasses and has struggled with occasional but debilitating back pain since she was a child in Mexico. The pain sometimes forces her to stop working for the day.

The last time she went to a doctor was almost five years ago, when she started school in the U.S. and had to get vaccinated, she said.

Esmeralda said she would like to sign up for Medi-Cal but will wait to see how the process works for others. She wants to know whether they feel their personal information is being kept safe from federal immigration officials, she said.

“I would wait to make sure there are no problems,” she said in Spanish. “Obviously, with being undocumented, there is fear.”

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Dialysis Patients Panic As Financial ‘Life Raft’ Becomes Unmoored

Ana B. Ibarra — Thu, 14 Nov 2019 10:00:03 +0000

Russell Desmond a few weeks ago from the American Kidney Fund that he said felt like “a smack on the face.”

The organization informed Desmond, who has kidney failure and needs dialysis three times a week, that it will no longer help him pay for his private health insurance plan — to the tune of about $800 a month.

“I am depressed about the whole situation,” said the 58-year-old Sacramento resident. “I have no clue what I’m going to do.”

Desmond has Medicare, but it doesn’t cover the entire cost of his care. So, with assistance from the American Kidney Fund, he pays for a private plan to cover the difference.

Now, the fund, which helps about 3,700 Californians pay their premiums and out-of-pocket costs, is threatening to pull out of California because of a new state law that is expected to cut into the dialysis industry’s profits — leaving patients like Desmond scrambling.

The letter portrayed the fund as helpless. “We are heartbroken at this outcome,” it read. “Ending assistance in California is the last thing we want to do.”

But supporters of the new law are calling the threat a scare tactic. State Assemblyman Jim Wood (D-Healdsburg), the author of AB-290, said there is nothing in the measure that prohibits the fund from continuing to provide financial assistance to patients.

“AKF has simply made a conscious decision, without merit, to leave the state despite the many accommodations I made by amending the bill in the Senate to ensure that it can continue to operate in California,” Wood said in a written statement.

What’s behind this dispute is the tight relationship between the American Kidney Fund and the companies that provide dialysis, which filters the blood of people whose kidneys are no longer doing the job.

People on dialysis usually qualify for Medicare, the federal health insurance program for people 65 and older, and those with kidney failure and certain disabilities. If they’re low income, they may also qualify for Medicaid, which is called Medi-Cal in California.

But dialysis companies can get higher reimbursements from private insurers than from public coverage. And one way to keep dialysis patients on private insurance is by giving them financial assistance from the American Kidney Fund, which helps nearly 75,000 low-income dialysis patients across the country.

The fund gets from DaVita and Fresenius Medical Care, the two largest dialysis companies in the country. The fund does not disclose its donors, but an reveals that 82% of its funding in 2018 — nearly $250 million — came from two companies.

Insurance plans, consumer advocacy groups and unions have accused the American Kidney Fund of helping dialysis providers steer patients into private insurance plans in exchange for donations from the dialysis industry. Wood said his bill is intended to discourage that practice.

American Kidney Fund CEO LaVarne Burton denied the accusations and said her group plays no role in patients’ coverage choices.

Starting in 2022, will limit the private-insurance reimbursement rate that dialysis companies receive for patients who get assistance from groups such as the American Kidney Fund to the rate that Medicare pays. The rate change won’t apply to patients who are currently receiving assistance as long as they keep the same health plans. The bill will also address a similar dynamic in drug treatment programs.

To determine which patients receive financial aid, the law will require third-party groups to disclose patients’ names to health insurers starting July 1, 2020.

These disclosure requirements are spurring the American Kidney Fund’s decision to leave, Burton said. She argues that they conflict with federal rules and violate patient privacy.

“AKF has no choice but to leave or seek legal relief,” Burton said.

Brian Carroll says he had to move back in with his parents in 2016 after dialysis treatment because it left him too weak to work. Without premium assistance from the American Kidney Fund, he says, he’ll face even more financial strain. (Ana B. Ibarra/California Healthline)

In mid-October, the fund started sending letters to its financial aid recipients in California warning of its departure. And Nov. 1, it joined two dialysis patients , asking a U.S. District Court to rule the law unconstitutional.

Gov. Gavin Newsom cautioned against such actions , and urged “both opponents and supporters to put patients first.”

But as the threats and legal battle play out, patients are caught “squarely in the middle,” said Bonnie Burns, a consultant with California Health Advocates, a Medicare advocacy group.

Their options may be limited, she said. Those who don’t work won’t have access to employer-sponsored coverage to make up the difference. And in California, Medicare recipients under age 65 to purchase supplemental insurance known as Medigap.

The state Department of Managed Health Care offers a for affected patients, directing them to programs such as Covered California and Medi-Cal.

DaVita and Fresenius said insurance counselors and social workers at their clinics are working with patients to find other options.

“We will continue to treat all patients, regardless of insurance status,” said Paige Hosler, vice president of insurance management at DaVita. Hosler noted that some patients may qualify for DaVita’s charity care program.

Dialysis companies have been at the center of recent legislative and ballot-box battles, and have spent big to defend their bottom lines. Last year, they poured a record-breaking $111 million into a campaign to defeat Proposition 8, a ballot initiative that would have capped their profits. The measure failed.

The industry also in California on lobbying and campaign contributions in the first half of this year to oppose Wood’s measure.

Desmond said he understands why lawmakers targeted the dialysis industry but can’t fathom why they did so at the expense of patients.

Desmond was laid off from his job as a computer programmer in Massachusetts in 2009 and moved to California to join his brother. One year later, he was diagnosed with kidney failure.

He lives off his Social Security Disability Insurance benefits, which come to about $2,000 a month after his Medicare premiums are deducted. Medicare pays for 80% of his care.

He also qualifies for Medi-Cal coverage that comes with high out-of-pocket costs, so he relies instead on a private Aetna insurance plan to cover the remaining 20%. The American Kidney Fund has been paying the premiums for his private plan since 2015.

“What they did is take away our life raft and left us to drown,” he said of lawmakers.

Brian Carroll, 40, of Sacramento, has been on dialysis for five years. He moved back in with his parents in 2016 because, he said, dialysis left him too weak to work.

“I am now completely depending on other people,” Carroll said. The American Kidney Fund pays the $270 monthly premium for his private insurance plan that covers what Medicare doesn’t. “That’s an entire month of groceries and gas for me,” he said.

Carroll said he supported Proposition 8, even though dialysis companies argued it would force them to cut back services and shut down clinics.

In this situation, he’s not sure whom to blame — the lawmakers, who passed the law with no backup plan for patients, or the fund, which is essentially holding patients hostage.

“What I do know is that you can’t just leave dialysis patients like this,” Carroll said. “It’s cruel.”

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Flavor Bans Multiply, But Menthol Continues to Divide

Ana B. Ibarra — Fri, 08 Nov 2019 10:00:41 +0000

As states and communities rush to ban the sale of flavored tobacco products linked to vaping, Carol McGruder races from town to town, urging officials to include what she calls “the mother lode of all flavors”: menthol.

McGruder, co-chair of the African American Tobacco Control Leadership Council, has tried for years to warn lawmakers that menthol attracts new smokers, especially African Americans. Now that more officials are willing to listen, she wants them to prohibit menthol cigarettes and cigarillos, not just e-cigarette flavors, to reduce smoking among blacks.

McGruder and other tobacco control researchers are using the youth vaping epidemic — and the vaping-related illnesses sweeping the country — as an opportunity to take on menthol cigarettes, even though they are not related to the illnesses.

“We started to see that vaping is something that we could leverage in order to deal with this whole menthol issue,” said Valerie Yerger, an associate professor of health policy at the University of California-San Francisco.

Menthol is a substance found in mint plants that creates a cooling sensation and masks tobacco flavor in both e-cigarettes and cigarettes. Those properties make menthol more appealing to first-time smokers and vapers, even as they pose the same health threats as non-menthol products and .

African American smokers prefer mentholated cigarettes, according to the Centers for Disease Control and Prevention.

But even as tobacco control activists see opportunity, some African Americans, including smokers, fear discrimination. They predict that banning menthol will lead to a surge in illicit sales of cigarettes and result in additional policing in communities that already face tension with law enforcement.

Joseph Paul, director of political and civic affairs at City of Refuge Los Angeles, a church with about 17,000 members in Gardena, Calif., spoke at a board of supervisors meeting in September against a proposed flavor ban in Los Angeles County that was adopted a week later.

If officials truly wanted to end youth vaping, he later told California Healthline, the ordinance should have targeted only vape flavors and exempted adult smokers and their menthol cigarettes.

“Menthol cigarettes are very popular in the black community, my people smoke menthol cigarettes,” he said.

The prohibits sales but not possession of flavored e-cigarette products, menthol cigarettes and chewing tobacco in the unincorporated area of the county, inhabited by about 1 million people. Shops have until April to clear their shelves of flavored tobacco products.

Paul warned that people will start selling menthol cigarettes illegally: “It’s supply and demand.” That will make the community more vulnerable to police harassment, he said.

In New York City, when officials proposed a ban on menthol cigarettes earlier this year, which has yet to be acted upon, the Rev. Al Sharpton made a against the measure: Banning menthol would lead to greater tensions with police in black communities.

“I think there is an Eric Garner concern here,” the civil right rights activist in July, referring to the well-known case of a 43-year old black man who died in a chokehold in 2014 while being arrested by New York City police on suspicion of selling single cigarettes.

The flavor bans that are have more to do with e-cigarettes than menthol cigarettes.

That’s because a mysterious vaping-related illness more than 2,050 people nationwide and led to at least 39 deaths. In California, residents have fallen ill and at least three have died, according to the California Department of Public Health.

Most of those illnesses have been associated with vaping cannabis products, and yet politicians’ urge to adopt flavored tobacco bans continues.

In July 2016, Chicago became the first major U.S. city to ban menthol cigarette sales, but it limited the prohibition to within 500 feet of schools.

Of the more than in the country that restrict or ban the sale of flavored tobacco, fewer than 60 include restrictions on menthol cigarettes, according to the Campaign for Tobacco-Free Kids.

Aspen, Colo., will ban all flavored nicotine products, including menthol cigarettes, effective Jan. 1. A few communities in Minnesota already have such bans in place. In California, close to 50 communities restrict or ban flavored tobacco products; of those, more than 30 include restrictions on menthol cigarettes. Notably, San Francisco banned menthol cigarettes along with all flavored tobacco products in 2018, before banning all vapes and e-cigarettes earlier this year.

At the national level, the Food and Drug Administration banned the sale of flavors in combustible cigarettes in 2009, but exempted menthol. Last November, the agency on menthol-flavored combustible cigarettes, calling their use among youths “especially troubling,” but it has not yet taken action.

Then the Trump administration said in September it would soon ban all flavored e-cigarette products, but it from banning mint and menthol.

Menthol, which was in the 1920s, is as old-school as it gets when it comes to flavored tobacco, yet it hasn’t prompted action in the way that vape flavors such as cotton candy and strawberry-melon have. That’s because vaping was embraced by a specific population: affluent white teens, Yerger said.

Big Tobacco aggressively pushed menthol cigarettes on black youths in the 1950s and 60s, and now some people consider Kools and Newports part of black culture, McGruder said.

McGruder and others point out that the tobacco industry has supported and funded civil rights groups and causes, forming relationships with prominent black leaders such as Sharpton. Big Tobacco Sharpton’s organization, the National Action Network, and similar groups.

McGruder said it’s difficult for the African American community to contradict respected male civil rights and religious leaders, so when they argue that menthol bans will lead to criminalization, the community listens.

But Bobby Sheffield, a pastor and vice president of the Riverside County Black Chamber of Commerce, said the criminalization argument is a scare tactic.

“We’re not trying to have anyone incarcerated because they have this product in their possession,” Sheffield said. His organization, which represents local businesses, started campaigning this year for menthol bans in California’s Inland Empire, including the cities of Riverside, San Bernardino and Perris.

Some smokers understand the need to keep tobacco out of the hands of children, but they don’t think it’s fair to include menthol cigarettes.

“It’s stupid. Now they’re trying to act like menthol cigarettes are the problem. These have been around for a long time,” said April Macklin of Sacramento, who smokes Benson & Hedges menthols. She smoked when she was younger, quit, and started again three years ago.

The city of Sacramento will ban the sale of flavored tobacco, including menthol cigarettes, effective Jan. 1.

Macklin, 53, said she might just quit because she won’t smoke anything other than menthol. But even with a ban in place, she doubts menthol cigarettes will be gone for good. “I’m sure people will figure something out,” she said.

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California Governor’s Bill-Signing Marathon Offers Glimpse Of 2020 Issues

Ana B. Ibarra — Tue, 15 Oct 2019 09:00:40 +0000

Gov. Gavin Newsom wrapped up his bill-signing marathon Sunday, capping the end of a legislative session that will have a big impact on Californians’ health care and coverage.

Some of the most high-profile — and contentious — measures of the year were health care-related: Who hasn’t heard of the bill that spawned at the Capitol by anti-vaccine activists? After , Newsom signed SB-276 and an accompanying measure, which will give state public health officials authority to review and, in some cases, revoke questionable medical exemptions for childhood vaccinations.

In a blow to Big Pharma, the Democratic governor also signed what health advocacy groups deem this year’s biggest effort to lower prescription drug costs. AB-824 will give the state attorney general more power to go after pharmaceutical companies that engage in a practice in which makers of brand-name drugs pay off generic manufacturers to keep the lower-cost generic versions of their medications off the market.

And legislation adopted as part of the state budget this year will require Californians to have health insurance next year or . The budget also funded new state-based tax credits for Californians who purchase health insurance through Covered California, including some who earn too much to qualify for federal financial aid.

Also starting next year, young adults in the country illegally will be if their incomes qualify.

“This was a landmark year in health care,” said Anthony Wright, executive director of the consumer advocacy group Health Access California. “Over a million Californians will be getting help to access or afford coverage.”

But many lesser-known health care measures could also have a dramatic impact on Californians’ lives, including college students, dialysis patients, older adults and new moms. Some of the laws put California in the forefront nationally, such as a measure to expand access to HIV prevention drugs.

Most of these measures take effect Jan. 1:

HIV Prevention

California will be the first state to allow people to access HIV prevention drugs from pharmacies without a doctor’s prescription. Pre-exposure prophylaxis () is a once-a-day pill for HIV-negative people that may keep them from becoming infected, and post-exposure prophylaxis () is medication that can help prevent the virus from taking hold if they have been exposed to it. by state Sen. Scott Wiener (D-San Francisco) will allow pharmacists to dispense a 60-day supply of PrEP, or a 28-day course of PEP. Patients will need to see a physician to obtain more medication. The bill prohibits insurance companies from requiring patients to obtain prior authorization before obtaining the medication.

Abortion Pill

Students at California’s 34 California State University and University of California campuses will have access to medication-induced abortion — commonly known as the abortion pill — at on-campus student health centers by Jan. 1, 2023. Under by state Sen. Connie Leyva (D-Chino), students who are up to 10 weeks pregnant will be eligible. Initial costs, such as the purchase of medical equipment, will be paid for with private, not state, dollars.

Maternal Health

Black women are more likely to die during childbirth and from other pregnancy-related causes than white women, according to the Centers for Disease Control and Prevention. by state Sen. Holly Mitchell (D-Los Angeles) will require perinatal health care providers to undergo bias training with the goal of reducing preventable maternal deaths among black women. “The disproportionate effect of the maternal mortality rate on this community is a public health crisis and a major health equity issue,” Newsom said upon signing the bill.

Some new moms returning to their jobs who want to pump milk at work will face fewer barriers. by Wiener will require employers to provide new mothers with a private space that includes a table, chair, electric outlet and nearby access to running water and refrigeration. Businesses with fewer than 50 employees may be eligible for an exemption. “Too many new mothers are unable to express milk at work or are forced to do so in a restroom or other unsuitable space,” Wiener said.

Financial Abuse Of Older Adults

Investment advisers and broker-dealers will be required to report suspected financial abuse of elder or dependent adults. by state Sen. John Moorlach (R-Costa Mesa) allows these financial experts to temporarily delay requested transactions, such as stock trades and disbursement of funds, when they suspect potential abuse. “With growing Alzheimer’s and dementia concerns, it is critical that we provide safeguards to prevent financial abuse for those in the beginning stages of a difficult life journey,” Moorlach said in a statement.

Smoking In State Parks

Californians will be prohibited from smoking or vaping at state beaches and parks, except for paved roads and parking areas. Violations of -8 by state Sen. Steve Glazer (D-Orinda) will carry a fine of up to $25. Similar efforts were vetoed by former Gov. Jerry Brown.

Nurse Staffing

State health officials who make unannounced inspections of hospitals will start reviewing nurse staffing levels. Some California hospitals disregard the state’s current nurse-to-patient ratio requirements, Leyva, the bill’s author, argued. establishes penalties for violations: $15,000 for the first offense and $30,000 for each subsequent violation.

Medical Marijuana On School Grounds

Even though medicinal cannabis has been legal for years in California, it has not been allowed on school grounds. by state Sen. Jerry Hill (D-San Mateo), will allow school boards to adopt policies that authorize parents or guardians of students with severe medical and developmental disabilities to administer medicinal , as long as it is not via smoking or vaping. This allows students to “take their dose at school and then get on with their studies,” Hill said.

Dialysis Industry Profits

One new law could disrupt the dialysis industry’s business model. Dialysis companies often get higher reimbursements from private insurers than they do from public coverage. One way low-income patients remain on private insurance is by getting financial assistance from the American Kidney Fund, a nonprofit that receives most of its donations from the two largest dialysis companies, Fresenius Medical Care and DaVita Inc. , by Assemblyman Jim Wood (D-Santa Rosa), will limit the private-insurance reimbursement rate that dialysis companies receive for patients who get assistance from groups such as the American Kidney Fund.

Health Care In Jails And Prisons

County jails and state prisons will be prohibited from charging inmates copays — usually $3 to $5 — for medical and dental services with the passage of , by state Assemblyman Mark Stone (D-Scotts Valley). Some states already prohibit copays in prison, but California is the first to eliminate copays in county jails.

Cancer Patients

Some Californians undergoing cancer treatment such as radiation or chemotherapy will have insurance coverage for fertility preservation treatments. Under by state Sen. Anthony Portantino (D-La Cañada Flintridge), private health plans regulated by the state must cover procedures such as the freezing of eggs, sperm or embryos for patients who want to try to have children in the future.

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States Target Vaping With Bans. In California, The Action Is Local.

Ana B. Ibarra — Mon, 30 Sep 2019 09:00:03 +0000

States are piling on.

took the first statewide shot at vaping early this month when it announced a ban on the sale of flavored e-cigarette products. It was soon joined by , and jumped in Wednesday. went further, announcing Tuesday that it would prohibit the sale of all vaping flavors and devices for four months.

But in California — which prides itself on progressive policies — lawmakers this year punted on a proposal for a statewide ban on flavored tobacco products.

California Gov. Gavin Newsom this month added that he didn’t have the authority to enact a flavor ban, as others states have, funding for a new public awareness campaign and increased enforcement of the sale of e-cigarettes.

In the absence of a statewide ban — and as the number of people getting sick or dying from vaping mounts — California cities and counties are stepping in, including major population centers such as San Francisco and Los Angeles.

Local governments are taking the lead because they have to, said Tom Butt, the mayor of Richmond, Calif., which recently adopted a sweeping ordinance that bans the sale of all vaping products starting Jan. 1. The ban was modeled after the one San Francisco adopted in June.

“That’s where change happens first, in the cities,” Butt said. “Some states and particularly Congress are really slow to act on things like this.”

Livermore’s City Council approved a similar ban, and the San Joaquin County District Attorney’s Office expects to present one to county officials for consideration within the next few months.

California jurisdictions prohibit or restrict the sale of flavored tobacco products or are considering ordinances. E-liquids, which are heated in vaping devices and can contain nicotine or marijuana, come in like strawberry-pineapple and sweet desserts. Health officials are concerned that the flavors appeal to teens and preteens.

On Tuesday, the Los Angeles County Board of Supervisors is expected to hold a final vote on a proposal to ban the retail sale of all flavored tobacco products in the county’s unincorporated communities, home to about 1 million people.

In the city of Los Angeles — with a population of about 4 million people — City Attorney Mike Feuer is also calling for action.

“Enacting a citywide ban on the sale of all flavored tobacco products is the best way to safeguard our youth and protect the general public from significant health risks,” Feuer said.

Ana Ibarra discussed the ongoing outbreak of vaping-related respiratory illnesses, and the state and local response to it, with KPCC’s on Sept. 26.

Can’t see the audio player? Click here to download.

Dr. Tony Kuo, director of the division of chronic disease and injury prevention at Los Angeles County’s Department of Public Health, said the ban on flavored tobacco products is needed in response to the growing outbreak of vaping-related respiratory illnesses.

The Centers for Disease Control and Prevention is investigating of vaping-related lung illnesses in 46 states, including at least 12 deaths, that have been linked to both nicotine and cannabis vaping products. California officials are investigating . They have not yet been able to connect the illnesses to a particular flavor or chemical.

Of the two deaths related to the illnesses in California, one occurred in Los Angeles County.

“Even before that, we were monitoring the expansion of the e-cigarette epidemic among youth,” Kuo said.

Recent funded by the National Institute on Drug Abuse show that 25% of this year’s high school seniors and 20% of 10th graders reported vaping nicotine in the past month. That’s more than double the use reported in 2017.

In addition to cities and counties that already adopted ordinances, a handful of California communities are considering flavor bans, while a few others are looking to follow San Francisco with an outright ban on all vapes.

A — which already has a ban in place for the sale of flavored tobacco in unincorporated areas — now wants to ban all e-cigarettes. A San Jose City Council member a similar measure.

But these communities must brace themselves for an inevitable fight with Big Tobacco and the vaping industry.

Door hangers supporting Juul-backed Proposition C can be found across San Francisco with language like “Stop Youth Vaping.” (Hannah Norman/KHN)

San Francisco-based Juul Labs, the manufacturer of the most popular e-cigarette, has already to promote Proposition C, a measure on the November ballot that would overturn the city’s e-cigarette ban. San Francisco’s Board of Supervisors approved the ban in June but it doesn’t take effect until early next year.

Meanwhile, Livermore has to place its ban on e-cigarette sales before voters after Juul successfully to keep the ban from taking effect. Residents will vote in March.

The Vapor Technology Association, a Washington, D.C.-based lobbying group, said it advocates for sensible regulation in local governments, but wants to keep flavors as an option for adult consumers.

It Wednesday against New York’s statewide flavor ban.

“We stand ready to work with individual cities and counties on thoughtful and effective regulations that restrict youth access, preserve flavored alternatives for adult smokers seeking to quit, and allow legal and responsible vape small business owners the ability to continue to operate in a regulated market,” Tony Abboud, executive director of the Vapor Technology Association, said in a statement.

Joseph Ditre, an associate professor of psychology at Syracuse University, said it makes sense that local governments and states are seeking solutions, but added that they should consider potential consequences.

“One concern would be a rise in the underground market and bootleg products,” he said. “It doesn’t take long to search the internet and find recipes to making nicotine juices that can be used in almost any vaping device,” Ditre said.

Butt, the mayor of Richmond, acknowledged the possibility of a rise in black-market products, but “the alternative is to do nothing,” he said.

“What we’re doing is not perfect, it’s not going to solve all the problems, but it’s better than doing nothing.”

State Sen. Jerry Hill (D-San Mateo) said statewide action would be more effective and harder for the industry to battle than local efforts. In the state legislative session that just ended, Hill introduced that would have prohibited the sale of flavored tobacco products across California.

Strong opposition from the vaping and tobacco industries resulted in amendments that watered down the bill to exclude menthol-flavored tobacco, flavors for hookahs and any other flavored products that existed before 2000. Disappointed with the changes, Hill decided to pull his bill from consideration this year.

Even a moderate proposal by state Assemblyman Adam Gray (D-Merced), which would have added restrictions on the sale and advertisement of vaping products, could not make it out of the legislature this year.

Hill plans to come back with a stronger version, one that will include all flavors —with no exceptions.

“The crisis is becoming more evident,” he said. “Addiction is more real and the deaths are becoming almost a daily event, so we have to take some action or we’re not responsible legislators.”

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