Becerril earns about $52,000 a year at a nonprofit in California’s Central Valley, putting her and her husband, Armando, at more than double the limit to qualify for Medi-Cal, the state’s Medicaid program for people with low incomes and disabilities. Private insurance would cost $1,230 a month in premiums, money needed for their mortgage.

“We’ve been resorting to home remedies to get through the pain,” Becerril said through a Spanish translator. Her husband has needed hernia surgery for 20 years. “It’s frustrating because we pay our taxes, but we can’t reap any of the benefits of where our taxes are going,” she added.

While many Californians who earn too much to be eligible for Medi-Cal can get subsidized coverage through Covered California, an estimated 460,000 residents aren’t allowed to buy insurance through state-run insurance plans under the Affordable Care Act because they lack legal status. One Democratic lawmaker says it’s a small but glaring gap and is crafting a bill that could test Democratic Gov. Gavin Newsom’s commitment to reach universal health care.

“We’re going to need to figure out how to provide universal coverage for all who call this state home,” said the bill’s author, Assembly member Joaquin Arambula. “It’s an area our state has not leaned into enough, to provide coverage for those who are undocumented.”

Arambula’s bill would direct the state to ask the federal government to allow immigrants living in the state without authorization to get insurance through Covered California. Arambula sees the move as the critical first step to expand coverage. If approved, the Fresno lawmaker intends to push for state subsidies to help pay for insurance.

Both elements are essential for immigrants lacking legal status, said Jose Torres Casillas, a policy and legislative advocate with Health Access California, a consumer health group working with Arambula’s office on the measure.

“Access is one thing, but affordability is another,” Torres Casillas said.

Since taking office in 2019, Newsom has approved expanding Medi-Cal to all qualified residents regardless of immigration status. In doing so, the politician continuously rumored to be preparing for a presidential bid described the state as moving “one step closer” toward universal health care. But in January, Newsom announced a $22.5 billion state deficit and made no mention of new proposals for the state’s estimated 3 million uninsured residents.

Newsom’s health secretary, Dr. Mark Ghaly, acknowledged the pressure to go further but he would not commit to a timeline.

“Up until now we’ve had so many other things to focus on,” Ghaly said. “This will become, frankly speaking, one of the most important next issues that we take on.”

California needs permission from the federal government to open Covered California to immigrants without legal residency because it is currently closed to them, and Arambula said he is in talks with Newsom administration officials about how to structure the bill.

Once the federal government opens Covered California up to all migrants, the state could set aside funding for subsidies. About 90% of enrollees in Covered California qualify for financial assistance, which is paid for with both state and federal funds. Since 2020, the state has spent $20 million a year on those subsidies, a fraction of the cost, because Congress has given states an infusion of money during the pandemic.

Previously, lawmakers had allocated roughly $300 million to lower insurance premiums for Covered California enrollees. Any financial assistance to people living in the state without authorization would likely have to come from state funds, and the costs could vary widely.

For instance, Colorado enrolled 10,000 such immigrants into a new insurance program designed solely for them at a cost of $57.8 million in state funds, said Adam Fox, deputy director of the Colorado Consumer Health Initiative. The program covered the full cost of insurance for enrollees.

In Washington state, immigrants who lack legal status can take advantage of a state fund next year to help all income-eligible state residents pay for insurance, said Michael Marchand, chief marketing officer for the Washington Health Benefit Exchange. State lawmakers have added $5 million to the fund for immigrants without legal authorization.

“It would serve as an incentive for additional undocumented immigration into our country,” said Sally Pipes, president and CEO of the Pacific Research Institute, a think tank that advocated against Medi-Cal expansion to immigrants without legal standing. “And put taxpayers on the hook for additional government health care costs and the inevitable higher tax bills to pay for them.”

California officials have previously considered allowing all immigrants to buy insurance from its state-run program before, submitting a request to the federal government in 2016. But the state rescinded its application after President Donald Trump took office, given his anti-immigration rhetoric and policies.

The Biden administration in December approved an exception to federal law for Washington state — a game changer in the eyes of immigration advocates, said Rachel Linn Gish, a spokesperson for Health Access.

“Seeing what other states have done and the waivers that are happening under Biden, it makes a huge difference in our approach,” she said.

But even if lawmakers pass a plan to open California’s insurance marketplace to all immigrants regardless of status, advocates said the state will have to wait until Jan. 1, 2024, to ask the federal government for permission, and it could take half a year or longer to get a response.

That means it could be years before Becerril can get coverage. Instead, she’s preparing for the worst.

“I’m paying for funeral coverage,” she said. “It’s more economical than paying the health coverage premium.”

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Eggman, a licensed social worker, co-authored the novel law that allows families, clinicians, first responders, and others to petition a judge to mandate government-funded treatment and services for people whose lives have been derailed by untreated psychotic disorders and substance use. It was a win for Newsom, who proposed the Community Assistance, Recovery and Empowerment Act, or CARE Court, as a potent new tool to address the tens of thousands of people in California living homeless or at risk of incarceration because of untreated mental illness and addiction. The measure faced staunch opposition from disability and civil liberties groups worried about stripping people’s right to make decisions for themselves.

“We see real examples of people dying every single day, and they’re dying with their rights on,” Eggman said in an interview with KHN before the appointment. “I think we need to step back a little bit and look at the larger public health issue. It’s a danger for everybody to be living around needles or have people burrowing under freeways.”

Senate Pro Tem Toni Atkins announced Eggman’s appointment Thursday evening. Eggman replaces Dr. Richard Pan, who was termed out last year after serving five years as chair. Pan, a pediatrician, had prioritized the state’s response to the covid-19 pandemic and championed legislation that tightened the state’s childhood vaccination laws. Those moves made him a hero among public health advocates, even as he faced taunts and physical threats from opponents.

The leadership change is expected to coincide with a Democratic health agenda focused on two of the state’s thorniest and most intractable issues: homelessness and mental illness. According to federal data, California accounts for 30% of the nation’s homeless population, while making up 12% of the U.S. population. A recent Stanford study estimated that in 2020 about 25% of homeless adults in Los Angeles County had a severe mental illness such as schizophrenia and 27% had a long-term substance use disorder.

Eggman will work with Assembly member Jim Wood, a Santa Rosa Democrat who is returning as chair of the Assembly Health Committee. Though the chairs may set different priorities, they need to cooperate to get bills to the governor’s desk.

Eggman takes the helm as California grapples with a projected $24 billion budget deficit, which could force reductions in health care spending. The tighter financial outlook is causing politicians to shift from big “moonshot” ideas like universal health care coverage to showing voters progress on the state’s homelessness crisis, said David McCuan, chair of the political science department at Sonoma State University. Seven in 10 likely voters cite homelessness as a big problem, according to a recent statewide survey by the Public Policy Institute of California.

Eggman, 61, served eight years in the state Assembly before her election to the Senate in 2020. In 2015, she authored California’s End of Life Option Act, which allowed terminally ill patients who meet specified conditions to get aid-in-dying drugs from their doctor. Her past work on mental health included changing eligibility rules for outpatient treatment or conservatorships, and trying to make it easier for community clinics to bill the government for mental health services.

She hasn’t announced her future plans, but she has around $70,000 in a campaign account for lieutenant governor, as well as $175,000 in a ballot measure committee to “repair California’s mental health system.”

Eggman said the CARE Court initiative seeks to strike a balance between civil rights and public health. She said she believes people should be in the least restrictive environment necessary for care, but that when someone is a danger to themselves or the community there needs to be an option to hold them against their will. A Berkeley Institute of Governmental Studies poll released in October found 76% of registered voters had a positive view of the law.

Sen. Thomas Umberg (D-Santa Ana), who co-authored the bill with Eggman, credited her expertise in behavioral health and dedication to explaining the mechanics of the plan to fellow lawmakers. “I think she really helped to put a face on it,” Umberg said.

But it will be hard to show quick results. The measure will unroll in phases, with the first seven counties — Glenn, Orange, Riverside, San Diego, San Francisco, Stanislaus, and Tuolumne — set to launch their efforts in October. The remaining 51 counties are set to launch in 2024.

County governments remain concerned about a steady and sufficient flow of funding to cover the costs of treatment and housing inherent in the plan.

California has allocated $57 million in seed money for counties to set up local CARE Courts, but the state hasn’t specified how much money will flow to counties to keep them running, said Jacqueline Wong-Hernandez, deputy executive director of legislative affairs at the California State Association of Counties.

Robin Kennedy is a professor emerita of social work at Sacramento State, where Eggman taught social work before being elected to the Assembly. Kennedy described Eggman as someone guided by data, a listener attuned to the needs of caregivers, and a leader willing to do difficult things. The two have known each other since Eggman began teaching in 2002.

“Most of us, when we become faculty members, we just want to do our research and teach,” Kennedy said. “Susan had only been there for two or three years, and she was taking on leadership roles.”

She said that Eggman’s vision of mental health as a community issue, rather than just an individual concern, is controversial, but that she is willing to take on hard conversations and listen to all sides. Plus, Kennedy added, “she’s not just going to do what Newsom tells her to do.”

Eggman and Wood are expected to provide oversight of CalAIM, the Newsom administration’s sweeping overhaul of Medi-Cal, California’s Medicaid program for low-income residents. The effort is a multibillion-dollar experiment that aims to improve patient health by funneling money into social programs and keeping patients out of costly institutions such as emergency departments, jails, nursing homes, and mental health crisis centers. Wood said he believes there are opportunities to improve the CalAIM initiative and to monitor consolidation in the health care industry, which he believes drives up costs.

Eggman said she’s also concerned about workforce shortages in the health care industry, and would be willing to revisit a conversation about a higher minimum wage for hospital workers after last year’s negotiations between the industry and labor failed.

But with only two years left before she is termed out, Eggman said, her lens will be tightly framed around her area of expertise: improving behavioral health care across California.

“In my last few years,” she said, “I want to focus on where my experience is.”

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Thomson lives about 50 yards from a busy freeway that bisects California’s capital city, one that has been increasingly used as a speedway for high-speed races, diesel-spewing big rigs, revving motorcycles — and cars that have been illegally modified to make even more noise.

About the only time it quiets down is Saturday night between 3 and 4 a.m., Thomson said.

Otherwise, the din is nearly constant, and most nights, he’s jolted out of sleep five or six times.

“Cars come by and they don’t have mufflers,” said Thomson, 54, who remodels homes for a living. “It’s terrible. I don’t recommend it for anyone.”

Thomson is a victim of noise pollution, which health experts warn is a growing problem that is not confined to our ears, but causes stress-related conditions like anxiety, high blood pressure, and insomnia.

California legislators passed two laws in 2022 aimed at quieting the environment. One directs the California Highway Patrol to test noise-detecting cameras, which may eventually issue automatic tickets for cars that make noise above a certain level. The other forces drivers of illegally modified cars to fix them before they can be re-registered.

“There’s an aspect of our society that likes to be loud and proud,” said state Sen. Anthony Portantino (D-Glendale), author of the noise camera law. “But that shouldn’t infringe on someone else’s health in a public space.”

Most states haven’t addressed the assault on our eardrums. Traffic is a major driver of noise pollution — which disproportionately affects disadvantaged communities — and it’s getting harder to escape the sounds of leaf blowers, construction, and other irritants.

California’s laws will take time and have limited effect, but noise control experts called them a good start. Still, they do nothing to address overhead noise pollution from circling police helicopters, buzzing drones, and other sources, which is the purview of the federal government, said Les Blomberg, executive director of the Noise Pollution Clearinghouse.

In October 2021, the American Public Health Association declared noise a public health hazard. Decades of research links noise pollution with not only sleep disruption, but also a host of chronic conditions such as heart disease, cognitive impairment, depression, and anxiety.

“Despite the breadth and seriousness of its health impacts, noise has not been prioritized as a public health problem for decades,” the declaration says. “The magnitude and seriousness of noise as a public health hazard warrant action.”

When there’s a loud noise, the auditory system signals that something is wrong, triggering a fight-or-flight response in the body and flooding it with stress hormones that cause inflammation and can ultimately lead to disease, said Peter James, an assistant professor of environmental health at Harvard University’s T.H. Chan School of Public Health.

Constant exposure to noise increases the risk of heart disease by 8% and diabetes by 6%, research shows. The European Environment Agency estimated in 2020 that noise exposure causes about 12,000 premature deaths and 48,000 cases of heart disease each year in Western Europe.

While California Highway Patrol officials will spend the next few years researching noise cameras, they acknowledge that noise from street racing and so-called sideshows — where people block off intersections or parking lots to burn out tires or do “doughnuts” — has surged over the past several years and disturbs people right now.

Cars in California are supposed to operate at 95 decibels — a little louder than a leaf blower or lawn mower — or less. But drivers often modify their cars and motorcycles to be louder, such as by installing “whistle tips” on the exhaust system to make noise or removing mufflers.

In 2021, the last full year for which data is available, the highway patrol issued 2,641 tickets to drivers for excessive vehicle noise, nearly double 2018’s 1,400 citations.

“There’s always been an issue with noise coming from exhausts, and it’s gained more attention lately,” said Andrew Poyner, a highway patrol captain. “It’s been steadily increasing over the past several years.”

The American Public Health Association says the federal government should regulate noise in the air, on roads, and in workplaces as an environmental hazard, but that task has mostly been abandoned since the federal Office of Noise Abatement and Control was defunded in 1981 under President Ronald Reagan.

Now the task of quieting communities is mostly up to states and cities. In California, reducing noise is often a byproduct of other environmental policy changes. For instance, the state will ban the sale of noisy gas-powered leaf blowers starting in 2024, a policy aimed primarily at reducing smog-causing emissions.

One of the noise laws approved in California in 2022, AB 2496, will require owners of vehicles that have been ticketed for noise to fix the issue before they can re-register them through the Department of Motor Vehicles. Currently, drivers can pay a fine and keep their illegally modified cars as they are. The law takes effect in 2027.

The other law, SB 1097, directs the highway patrol to recommend a brand of noise-detecting cameras to the legislature by 2025. These cameras, already in use in Paris, New York City, and Knoxville, Tennessee, would issue automatic tickets if they detected a car rumbling down the street too loudly.

Originally, the law would have created pilot programs to start testing the cameras in six cities, but lawmakers said they wanted to go slower and approved only the study.

Portantino said he’s frustrated by the delay, especially because the streets of Los Angeles have become almost unbearably loud.

“It’s getting worse,” Portantino said. “People tinker with their cars, and street racing continues to be a problem.”

The state is smart to target the loudest noises initially, the cars and motorcycles that bother people the most, Blomberg said.

“You can make every car coming off the line half as loud as it is right now and it would have very little impact if you don’t deal with all the people taking their mufflers off,” he said. “That outweighs everything.”

Traffic noise doesn’t affect everyone equally. In a 2017 paper, James and colleagues found that nighttime noise levels were higher in low-income communities and those with a large proportion of nonwhite residents.

“We’ve made these conscious or subconscious decisions as a society to put minority-race communities and lower-income communities who have the least amount of political power in areas near highways and airports,” James said.

Elaine Jackson, 62, feels that disparity acutely in her neighborhood, a low-income community in northern Sacramento sandwiched between freeways.

On weekends, sideshows and traffic noise keep her awake. Her nerves are jangled, she loses sleep, her dogs panic, and she generally feels unsafe and forgotten, worried that new development in her neighborhood would just bring more traffic, noise, and air pollution.

Police and lawmakers don’t seem to care, she said, even though she and her neighbors constantly raise their concerns with local officials.

“It’s hard for people to get to sleep at night,” Jackson said. “And that’s a quality-of-life issue.”

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Thomson vive a media cuadra de una transitada autopista que divide la ciudad capital de California, una vía que se ha utilizado cada vez más como pista de carreras de alta velocidad, y por donde pasan camiones grandes que arrojan diesel, motocicletas que aceleran y automóviles que han sido modificados ilegalmente para hacer aún más ruido.

Casi el único momento en que hay calma es el sábado por la noche entre las 3 y las 4 am, dijo Thomson.

El resto del tiempo el estruendo es casi constante y, la mayoría de las noches, se despierta cinco o seis veces.

“Los autos pasan y no tienen silenciadores”, dijo Thomson, de 54 años, quien trabaja remodelando casas. “Es terrible. No se lo recomiendo a nadie”.

Thomson es víctima de la contaminación acústica o sonora, que los expertos en salud advierten que es un problema creciente que no se limita a nuestros oídos, sino que causa condiciones relacionadas con el estrés, como la ansiedad, la hipertensión y el insomnio.

Los legisladores de California aprobaron dos leyes en 2022 destinadas a calmar el medio ambiente. Uno ordena a la Patrulla de Carreteras de California que pruebe las cámaras de detección de ruido, que eventualmente pueden emitir multas automáticas para los automóviles que hacen ruido por encima de cierto nivel. El otro obliga a los conductores de automóviles modificados ilegalmente a repararlos antes de que puedan renovar su registro.

“Hay un aspecto de nuestra sociedad al que le gusta ser ruidoso y orgulloso”, dijo el senador estatal Anthony Portantino (demócrata de Glendale), autor de la ley de cámaras de ruido. “Pero eso no debería afectar la salud de otra persona en un espacio público”.

La mayoría de los estados no han abordado el asalto a nuestros tímpanos. El tráfico es uno de los principales impulsores de la contaminación acústica, que afecta de manera desproporcionada a las comunidades desfavorecidas, y cada vez es más difícil escapar de los sonidos de los máquinas que recogen hojas, la construcción y otros irritantes.

Las leyes de California tomarán tiempo y tendrán un efecto limitado, pero los expertos en control del ruido las calificaron como un buen comienzo. Aún así, no hacen nada para abordar la contaminación acústica aérea de los helicópteros de la policía, los drones que zumban y otras fuentes de ruido, que son competencia del gobierno federal, dijo Les Blomberg, director ejecutivo de Noise Pollution Clearinghouse.

En octubre de 2021, la Asociación Estadounidense de Salud Pública declaró que el ruido es un peligro para la salud pública. Décadas de investigación vinculan la contaminación acústica no solo con la interrupción del sueño, sino también con una serie de afecciones crónicas, como enfermedades cardíacas, deterioro cognitivo, depresión y ansiedad.

“A pesar de la amplitud y gravedad de sus impactos en la salud, el ruido no ha sido priorizado como un problema de salud pública durante décadas”, dice la declaración. “La magnitud y la gravedad del ruido como peligro para la salud pública justifican la adopción de medidas”.

Cuando hay un ruido fuerte, el sistema auditivo señala que algo anda mal, desencadenando una respuesta de lucha o huida en el cuerpo e inundándolo con hormonas del estrés que causan inflamación y, en última instancia, pueden provocar enfermedades, dijo Peter James, profesor asistente de salud ambiental en la Escuela T.H. Chan de Salud Pública de la Universidad de Harvard.

La exposición constante al ruido aumenta el riesgo de enfermedad cardíaca en un 8% y de diabetes en un 6%, según muestra la investigación. En 2020, la Agencia Europea de Medio Ambiente estimó que la exposición al ruido causa alrededor de 12,000 muertes prematuras y 48,000 casos de enfermedades cardíacas cada año en Europa Occidental.

Si bien los funcionarios de la Patrulla de Carreteras de California pasarán los próximos años investigando las cámaras de detección de ruido, reconocen que el ruido de las carreras callejeras y los llamados espectáculos secundarios, donde las personas bloquean las intersecciones o los estacionamientos para quemar llantas o hacer “donas”, se ha disparado en últimos años y molesta a la gente ahora.

Se supone que los automóviles en California funcionan a 95 decibeles, un poco más alto que una cortadora de césped, o menos. Pero los conductores a menudo modifican sus automóviles y motocicletas para que sean más ruidosos, por ejemplo, instalando “silbatos” en el sistema de escape para hacer ruido o quitando los silenciadores.

En 2021, el último año completo del que hay datos disponibles, la patrulla de carreteras emitió 2,641 multas a conductores por ruido excesivo de vehículos, casi el doble de las 1,400 citaciones de 2018.

“Siempre ha habido un problema con el ruido de los caños de escape, y últimamente ha llamado más la atención”, dijo Andrew Poyner, capitán de la patrulla de carreteras. “Ha ido aumentando de manera constante en los últimos años”.

La Asociación Estadounidense de Salud Pública dice que el gobierno federal debería regular el ruido en el aire, en las carreteras y en los lugares de trabajo como un peligro ambiental, pero esa tarea se ha abandonado en su mayoría desde que, en 1981, bajo la presidencia de Ronald Reagan, se dejó de financiar a la Oficina Federal de Control y Reducción del Ruido.

Ahora, la tarea de silenciar a las comunidades depende principalmente de los estados y las ciudades. En California, la reducción del ruido suele ser un subproducto de otros cambios en la política ambiental. Por ejemplo, el estado prohibirá la venta de máquinas de hojas ruidosas a partir de 2024, una política destinada principalmente a reducir las emisiones que causan smog.

Una de las leyes de ruido aprobadas en California en 2022, AB 2496, requerirá que los propietarios de vehículos que hayan recibido multas por ruido solucionen el problema antes de que puedan volver a registrarlos a través del Departamento de Vehículos Motorizados. Actualmente, los conductores pueden pagar una multa y mantener sus autos modificados ilegalmente como están. La ley entra en vigor en 2027.

La otra ley, SB 1097, ordena a la patrulla de carreteras que recomiende una marca de cámaras detectoras de ruido a la legislatura para 2025. Estas cámaras, que ya se usan en París, la ciudad de Nueva York y Knoxville, Tennessee, emitirían multas automáticas a vehículos que retumban fuerte en la calle.

Originalmente, la ley habría creado programas piloto para comenzar a probar las cámaras en seis ciudades, pero los legisladores dijeron que querían ir paso a paso, y aprobaron solo el estudio.

Portantino dijo que se siente frustrado por la demora, especialmente porque las calles de Los Ángeles se han vuelto insoportablemente ruidosas.

“Está empeorando”, dijo Portantino. “La gente juega con sus autos y las carreras callejeras continúan siendo un problema”.

El estado es inteligente al apuntar inicialmente a los ruidos más fuertes, los automóviles y motocicletas que más molestan a las personas, dijo Blomberg.

“Puedes hacer que cada automóvil que sale de la línea sea la mitad de ruidoso que ahora y tendría muy poco impacto si no lidias con todas las personas que quitan los silenciadores”, dijo. “Eso supera todo”.

El ruido del tráfico no afecta a todos por igual. En un artículo de 2017, James y sus colegas encontraron que los niveles de ruido nocturno eran más altos en las comunidades de bajos ingresos y aquellas con una gran proporción de residentes de color.

“Hemos tomado estas decisiones conscientes o subconscientes como sociedad para colocar comunidades de razas minoritarias y comunidades de bajos ingresos que tienen la menor cantidad de poder político en áreas cercanas a carreteras y aeropuertos”, dijo James.

Elaine Jackson, de 62 años, siente esa disparidad de manera aguda en su vecindario, una comunidad de bajos ingresos en el norte de Sacramento ubicada entre autopistas.

Los fines de semana, los espectáculos en las calles y el ruido del tráfico la mantienen despierta. Sus nervios están alterados, pierde el sueño, sus perros entran en pánico y, en general, se siente insegura y olvidada, preocupada de que el nuevo desarrollo en su vecindario solo traerá más tráfico, ruido y contaminación del aire.

A la policía y los legisladores no parece importarles, dijo, aunque ella y sus vecinos constantemente plantean sus preocupaciones a los funcionarios locales.

“Es difícil para la gente conciliar el sueño por la noche”, dijo Jackson. “Y ese es un problema de calidad de vida”.

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Inglewood residents were poised to approve a ballot measure that would boost the minimum wage to $25 at private hospitals, psychiatric facilities, and dialysis clinics. The latest vote count showed Measure HC leading 54% to 46%, according to Los Angeles County election officials. In Duarte, roughly 35 miles away, voters were on track to decisively reject a similar proposal, Measure J, 63% to 37%.

Los Angeles County election officials plan to release final results Dec. 5.

The contests were the first ballot-box fight in what seems likely to be a multiyear battle between a powerful labor union and the influential hospital industry. Similar proposals are scheduled to go before voters in Los Angeles, Downey, Long Beach, and Monterey Park in 2024.

All were spearheaded by the Service Employees International Union-United Healthcare Workers West, which represents roughly 100,000 workers, including medical assistants, food service workers, and custodial staff.

Suzanne Jimenez, the union’s political director, said the union still plans to pursue a $25 minimum wage in other cities and, eventually, statewide.

“We’re still moving forward on all fronts,” she said.

George Greene, president of the Hospital Association of Southern California, said in a statement that hospitals support “fair wages” for health workers but that their pay should be discussed at a “state or regional level.”

“Deeply flawed” local ordinances, he said, are “bad policy and the wrong approach.”

The union used Inglewood and Duarte, both in Los Angeles County, as test cases for raising wages, particularly for some of the lowest-paid health facility workers, such as nursing assistants, security guards, and janitors. Because the measures are city ordinances, they wouldn’t apply to state- and county-run medical facilities, just private hospitals and clinics.

Union officials argue that a $25 minimum wage is necessary to retain and attract workers in a sector that has been understaffed and overworked throughout the covid-19 pandemic.

The minimum wage in most of Los Angeles County is $16.04 per hour. But for a single adult with no children, the living wage — the amount that person would need to cover typical expenses such as food, housing, and transportation in the county — is $21.89 hourly, or about $45,500 a year, according to a tool from the Massachusetts Institute of Technology. Occupations such as “healthcare support” generally pay around $33,000 annually in the county, according to the same tool.

Hospitals campaigned heavily against the union’s proposal and argued it would create “unequal pay” for staff at private and public facilities. An analysis commissioned by the California Hospital Association estimated that instituting a $25 minimum wage in the 10 cities originally targeted by the union would have raised costs for private facilities in those communities by $392 million a year, a 6.9% increase.

In Inglewood — a working-class city of about 107,000 people southwest of Los Angeles — Measure HC will apply to Centinela Hospital Medical Center and several for-profit dialysis clinics if it prevails. About 315 employees of the hospital would see their wages rise, according to Jimenez, who said she doesn’t know how many dialysis clinic employees would be affected.

In Duarte, a wealthier suburb of about 21,000 people east of Los Angeles, Measure J would have applied only to City of Hope, a cancer hospital.

Jimenez said the differences between those communities, and their residents’ experiences with the health care system, could account for how the measures fared. She said she noticed that Inglewood voters had more direct experience with Centinela — they may have visited the emergency room or had a baby — than Duarte voters had with City of Hope.

The union has taken two approaches to seeking a $25 minimum wage. It attempted to secure a statewide minimum wage during negotiations with hospitals this year in Sacramento. But the negotiations were complicated by competing hospital and union priorities, and the deal fell apart in August. The union has also pursued a city-by-city strategy, targeting 10 communities in Los Angeles and Orange counties, including Inglewood and Duarte, where internal polling showed minimum wage proposals could pass.

Earlier this year, city councils in Los Angeles, Downey, Monterey Park, and Long Beach adopted $25 minimum-wage ordinances for private facility health workers, but hospitals and health care facilities challenged them, pushing the issue to the 2024 ballot. Meanwhile, the union dropped its effort in Anaheim and failed to gather enough signatures in Culver City, Lynwood, and Baldwin Park to place measures before voters this year.

Both sides spent heavily. According to state campaign finance filings, the union spent about $11 million across all 10 cities from February through the week before the election. Hospitals and health care facilities spent $12 million during the same time frame.

Many labor economists said that the health care workforce deserves higher wages and better working conditions but that increasing the minimum wage could cause ripple effects.

Neighboring towns or facilities that aren’t subject to the new minimum wage and other sectors of the local economy might have to compete for workers, said Joanne Spetz, director of the Philip R. Lee Institute for Health Policy Studies at the University of California-San Francisco. And facilities that increase pay may have to do more with fewer staffers, she said.

“To have a minimum wage that is specific to a limited category of workers, in a limited set of organizations, in a single city is really unusual,” Spetz said. “I cannot think of any other circumstances where this has happened.”

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Tres veces a la semana, Sherwin, de 71 años, conduce hasta una clínica de diálisis en Elk Grove, California, el suburbio al sur de Sacramento donde vive, y permanece conectada a una máquina durante unas cuatro horas mientras ésta filtra su sangre. El tratamiento la agota, pero se siente bien atendida y sabe que los trabajadores de la clínica llamarán a la policía si no se presentara a la cita y no pudieran contactarla directamente.

“Se lo toman muy en serio”, dijo Sherwin.

Ahora Sherwin teme que no le permitan acudir a esta clínica. Un cartel en la ventana del centro pide a los pacientes y visitantes que voten “no” a la Propuesta 29, la tercera iniciativa estatal sobre diálisis en cinco años que impondría nuevos requisitos a las clínicas de diálisis, como exigir la presencia de un médico durante los tratamientos.

Sherwin y otros votantes de California también han sido bombardeados por anuncios de televisión, en los que pacientes en sillas de ruedas y médicos advierten que “la 29 cerraría las clínicas de diálisis en toda California”.

“Estamos aterrorizados”, dijo Sherwin. “Si las cierran, ¿a dónde vamos a ir? Simplemente moriremos”.

Sherwin es una de los aproximadamente 80,000 californianos que dependen de 650 clínicas de diálisis ubicadas en centros comerciales y médicos por todo el estado.

Los pacientes llegan en furgonetas de transporte médico, minivans y algún vehículo de alquiler, porque después del tratamiento están demasiado cansados y hambrientos como para conducir a casa. Llevan bolsas de lona y almohadas, preparados para estar sentados durante cuatro o cinco horas seguidas, normalmente tres días a la semana, mientras su sangre se limpia y se filtra a través de una máquina porque sus riñones ya no pueden realizar esas funciones.

La Propuesta 29 exigiría a las clínicas reportar al estado sobre las infecciones e informar a los pacientes cuando los médicos tengan una participación financiera en una clínica, normas que son similares a las regulaciones federales existentes.

El punto más contencioso es la exigencia de que haya un médico, una enfermera o un asistente médico presente en cada clínica mientras se trata a los pacientes.

Exigir la presencia de un médico en cada clínica aumentaría los costos de cada centro en “varios cientos de miles de dólares anuales”, según un análisis de la Oficina del Analista Legislativo del Estado, una institución no partidista. Para hacer frente a los costos adicionales, el análisis concluye que las clínicas tienen tres opciones: negociar tarifas más altas con las aseguradoras, perder beneficios o cerrar las instalaciones.

El sindicato Service Employees International Union-United Healthcare Workers West, que patrocina la Propuesta 29, señaló que las reformas son necesarias para mantener a los pacientes seguros durante el arduo proceso de diálisis.

El sindicato —que ha intentado organizar a los trabajadores de diálisis, pero no lo ha conseguido— argumenta que el tratamiento es peligroso y que los pacientes necesitan tener acceso a profesionales médicos altamente capacitados para hacer frente a las emergencias en lugar de depender del 911.

El sindicato también estuvo detrás de las dos iniciativas de votación anteriores sobre diálisis, que fracasaron por amplios márgenes. La Propuesta 8 en 2018 habría puesto un tope a los beneficios de la industria, mientras que la Propuesta 23 en 2020 era casi idéntica a la medida de este año. Ambas batieron récords de gastos de campaña.

La campaña de oposición a la Propuesta 29, financiada en su mayor parte por la industria de la diálisis, sostiene que mantener a un médico o enfermera en todo momento es costoso e innecesario.

Las clínicas emplean a enfermeras que cuidan a los pacientes y a directores médicos, en trabajos de supervisión pero que a menudo solo están presentes a tiempo parcial. Aproximadamente tres cuartas partes de las clínicas de diálisis de California son propiedad de dos empresas o están gestionadas por ellas: DaVita y Fresenius Medical Care.

Hasta ahora, ambas partes han recaudado al menos $94 millones, según Los Angeles Times, de los cuales aproximadamente el 85% procede de DaVita y Fresenius.

Joe Damian, de 71 años, no se cree la afirmación de que las clínicas cerrarían si se aprueba la Propuesta 29. Por supuesto que se sentiría más cómodo si un médico estuviera presente cuando su esposa, Yolanda, tiene sus tratamientos, explicó. También cree que las empresas de diálisis seguirían ganando dinero a manos llenas.

“¿Cómo no va a ser mejor?”, preguntó. “Simplemente no quieren renunciar a ninguno de sus beneficios”.

Damian lleva a su mujer a sus tratamientos en Elk Grove. Comprende que muchos pacientes y sus familias estén preocupados por el posible cierre de las clínicas, pero cree que el sector está generando alarma.

“Cerrar instalaciones es una amenaza que nunca ejecutarán”, afirmó. “¿Por qué iban a cerrar un negocio que genera dinero?”.

La propuesta 29 incluye normativas destinadas a proteger contra el cierre de clínicas, como la exigencia de que los centros obtengan la aprobación del estado antes de finalizar o reducir los servicios, pero los opositores argumentan que esas normativas no se sostendrán en los tribunales.

Casi todos los pacientes entrevistados que iban o venían de sus citas de diálisis en cinco clínicas del área de Sacramento habían sido testigos de cómo los trabajadores llamaban al 911 por otro paciente. La mayoría dijo que los trabajadores y el personal de emergencias habían manejado bien estas situaciones. En general, afirmaron sentirse bien cuidados por las clínicas de diálisis.

La mayoría de los pacientes había interiorizado el lenguaje de los anuncios de la oposición que advertían sobre el cierre de las clínicas.

Norbie Kumagai, de 65 años, pasó el último Día de Acción de Gracias en el Centro Médico de la Universidad de California-Davis, y a su familia se le dijo que no sobreviviría. Pero Kumagai, que padece una enfermedad renal en fase 4 y tiene hipertensión, salió adelante y tuvo que esperar meses para que se abriera una plaza de diálisis en una clínica de West Sacramento, a unas 13 millas de su casa en Davis.

En general, Kumagai está de acuerdo en que el sector de la diálisis necesita reformas. Por ejemplo, le gustaría que a los técnicos que lo ayudan cada semana les aumentaran el sueldo.

Pero le preocupa lo que la Propuesta 29 pueda significar para los tratamientos que lo mantienen con vida.

“Le he dicho a mis amigos y vecinos que estoy muerto de miedo si se aprueba”, afirmó Kumagai. “Esta clínica podría cerrar”.

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Three times a week, Sherwin, 71, drives to a dialysis clinic in Elk Grove, California, the suburb south of Sacramento where she lives, and lies tethered to a machine for about four hours while it filters her blood. The treatment exhausts her, but she feels well cared for and knows the clinic workers will call the police if she doesn’t show up for an appointment and they can’t get in touch with her directly.

“They don’t play games,” said Sherwin.

Sherwin fears her access to the clinic is in jeopardy. A sign in the clinic’s window tells patients and visitors to vote “no” on Proposition 29, the third statewide dialysis initiative in five years. It would impose new requirements on dialysis clinics, such as requiring a doctor to be on hand during treatments.

She and other California voters have also been bombarded by TV ads, in which patients in wheelchairs and doctors in scrubs warn that “29 would shut down dialysis clinics throughout California.”

“We’re terrified,” said Sherwin. “If they stop it, where are we going to go? We just die.”

Sherwin is among roughly 80,000 Californians who rely on 650 dialysis clinics tucked into strip malls and medical centers around the state. Patients arrive in medical transport vans, minivans, and the occasional ride-hailing vehicle and are often too tired and hungry after treatment to drive themselves home. They drag duffel bags and pillows into clinics, prepared to sit for four or five hours at a time, typically three days a week, as their blood is cleaned and filtered through a machine because their kidneys can no longer perform those functions.

Proposition 29 would require clinics to report infections to the state and tell patients when doctors have a financial stake in a clinic, rules that are similar to existing federal regulations.

The biggest flashpoint is the requirement to have a doctor, nurse practitioner, or physician assistant present at every clinic while patients are being treated.

Requiring a clinician on-site would increase each facility’s costs by “several hundred thousand dollars annually on average,” according to an analysis by the nonpartisan state Legislative Analyst’s Office. To deal with the additional costs, the analysis concluded, clinics have three options: negotiate higher rates with insurers, lose profits, or close facilities.

The Service Employees International Union-United Healthcare Workers West, which is sponsoring Proposition 29, said reforms are necessary to keep patients safe during the physically arduous dialysis process. The union — which has tried but failed to organize dialysis workers — argues that the treatment is dangerous and that patients need access to highly trained medical professionals to deal with emergencies instead of relying on 911.

The union was also behind the two previous dialysis ballot initiatives, which failed by wide margins. Proposition 8 in 2018 would have capped industry profits, while Proposition 23 in 2020 was nearly identical to this year’s measure. Both broke records for campaign spending.

The Proposition 29 opposition campaign, funded mostly by the dialysis industry, says keeping a doctor or nurse practitioner around at all times is both costly and unnecessary. Clinics employ registered nurses who check on patients and medical directors — physicians who oversee facilities but are often on-site only part time. About three quarters of California’s dialysis clinics are owned or operated by two companies: DaVita and Fresenius Medical Care.

So far, both sides have raised at least $94 million, according to the Los Angeles Times, with roughly 85% coming from DaVita and Fresenius.

Joe Damian, 71, doesn’t buy the claim that clinics would close if Proposition 29 passed. Of course, he said, he’d feel more comfortable if a doctor were on-site when his wife, Yolanda, has her treatments. He also believes dialysis companies would continue to make money hand over fist.

“How could it not be better?” he asked. “They just don’t want to give up any of their profits.”

Damian drives his wife to her treatments in Elk Grove. He understands why other patients and their families are worried about clinics closing but thinks the industry is fearmongering.

“Closing facilities is a threat they’ll never do,” he said. “Why would they close a moneymaking business?”

Proposition 29 includes provisions intended to protect against clinic closures, such as requiring facilities to get approval from the state before they end or reduce services, but opponents argue the provisions won’t hold up in court.

Nearly all the patients interviewed going to or from dialysis appointments at five Sacramento-area clinics had witnessed workers call 911 for another patient. Most said the emergencies had been handled well by the workers and emergency personnel. Overall, they said, they felt the dialysis clinics took good care of them.

The majority of patients had internalized the language of the opposition ads that warned of clinic closures.

Norbie Kumagai, 65, spent last Thanksgiving at University of California-Davis Medical Center, and his family was told it was time to say goodbye. But Kumagai, who has stage 4 kidney disease and high blood pressure, pulled through and had to wait months for a dialysis chair to open up at a clinic in West Sacramento, about 13 miles from his home in Davis.

Kumagai generally agrees that the dialysis industry needs reforms. For instance, he said, he’d like the technicians who help him each week to get pay raises.

But he’s worried about what Proposition 29 might mean for the treatments that keep him alive.

“I’ve told my friends and neighbors I’m scared to death if it passes,” Kumagai said. “This facility will probably close.”

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Tony Ramirez, 39, a critical care technician at Garfield Medical Center in Monterey Park, California, finds more fulfillment in helping people in need than he once did editing technical documents for Disneyland. Before the pandemic, he would reposition and bathe patients and sometimes monitor their vital signs. After covid struck, he took on more duties, providing CPR or grabbing medications during an emergency, placing leads to monitor heart rhythms, and conducting post-mortem work. “We started doing that,” Ramirez said, “because of the influx of covid patients running very ill and in very intense situations.”

Through it all, his $19.40-an-hour pay hasn’t changed.

In Southern California, one labor union is trying to help by pushing for a $25 minimum wage at private hospitals, psychiatric facilities, and dialysis clinics. The Service Employees International Union-United Healthcare Workers West, which represents roughly 100,000 health care workers in California, says a raise would help the providers retain workers who could land comparable positions at Amazon or fast-food restaurants amid labor shortages. It would also allow Ramirez to give up one of the three jobs he works just to make rent.

What began as a 10-city campaign by the union has been winnowed to November ballot measures in just two cities in Los Angeles County, reflecting expensive political jockeying between labor and industry. And the $25 minimum wage isn’t the only campaign being waged by SEIU-UHW this cycle — the union is also trying for the third time to get dialysis industry reforms passed.

A ballot issue committee called the California Association of Hospitals and Health Systems — with funding from Kaiser Permanente of Northern California, Adventist Health, Cedars-Sinai, Dignity Health, and other hospitals and health systems — opposes a $25 minimum wage because it raises costs for private, but not public, hospitals and health care facilities. Opponents have latched on to this disparity by calling it the “unequal pay measure.” An analysis commissioned by the California Hospital Association estimated that the change would raise costs for private facilities by $392 million a year, a 6.9% increase, across the 10 cities.

“No one in hospitals and no one in health care is opposed to a living wage,” said George Greene, president and CEO of the Hospital Association of Southern California. “But we believe that this should be a statewide conversation that is measured and thoughtful.”

Earlier this year, city councils in Los Angeles, Downey, Monterey Park, and Long Beach adopted similar $25 minimum wage ordinances for health workers, but they were challenged by hospitals and health facilities, which pushed the issue to the ballot in 2024. Meanwhile, the union dropped its effort in Anaheim and failed to gather enough signatures in Culver City, Lynwood, or Baldwin Park to get a minimum wage measure on the fall ballot. As a result, only voters in Inglewood and Duarte will cast their votes — on Measure HC and Measure J, respectively — this November.

Spending on the fight over the minimum wage proposals in Southern California has reached nearly $22 million. According to state campaign finance filings, SEIU-UHW has spent nearly $11 million across all 10 cities. Hospitals and health facilities have also spent almost $11 million to defeat minimum wage proposals.

Unions have long agitated for across-the-board minimum wage increases. In 2016, labor played a key role in successfully lobbying then-Gov. Jerry Brown to make California the first state to set a $15 minimum wage, a graduated measure that as of this year applies to all employers with 26 or more workers. About 40 local governments set their own minimum wages above the state minimum. The federal minimum wage remains $7.25.

SEIU-UHW contemplated a statewide scope, as well as the current piecemeal strategy of targeting cities in and around Los Angeles. “At first we were looking at city by city,” said the union’s political director, Suzanne Jimenez. “And then a conversation around doing it statewide came up but ultimately didn’t move forward.”

That’s partly because a deal to set a statewide minimum wage at public and private hospitals fell apart at the end of the last legislative session, and wins like that are harder to pull off than they once were, said Bill Sokol, a labor lawyer who has worked with SEIU-UHW.

“It’s not about what we wish we could do, but about where can we win,” Sokol said. “The answer is in one city at a time.”

Union leaders said they targeted cities where internal polling showed support among residents. Jimenez said the proposal has majority support in Inglewood but Duarte is too small to sample. The measures need a majority vote in each city to pass, and if that happens, they will take effect 30 days after the results are certified.

Should the approach prove successful in Los Angeles County, the union will consider taking the proposal to other parts of the state, including the Inland Empire and Sacramento, Jimenez said. That could eventually build momentum for statewide change.

If voters in Inglewood and Duarte pass the $25 minimum wage, the effect would be limited. Workers at state- and county-run medical facilities aren’t covered by city ordinances, so the local measures wouldn’t apply. That means it excludes workers who do the same jobs at public hospitals, clinics, and health care facilities.

In Inglewood, the measure would apply only to Centinela Hospital Medical Center and several for-profit dialysis clinics. In Duarte, it would apply to City of Hope, a private cancer hospital.

Many labor economists agree that something must improve for this workforce: They need higher wages and better work conditions. But that comes at a cost to the health system, said Joanne Spetz, director of the Philip R. Lee Institute for Health Policy Studies at the University of California-San Francisco.

“In the end, who ends up paying for that? Consumers do,” Spetz said. “Maybe you’ll cut into the profit margins of a publicly traded company a little bit, but the reality is those companies have been pretty good at figuring out how to keep their revenues and profitability up.”

Still, the union says a $25 minimum wage would help members of the lowest-paid sector of the health care workforce, who are disproportionately women, immigrants, and people of color.

Andrew Kelly, assistant professor of public health at Cal State East Bay, said raising wages at one facility could have a cascade effect because surrounding facilities would then need to raise wages to compete.

Currently, a living wage in L.A. County for a single adult with no children is $21.89 hourly, or a little more than $45,500 a year, according to a tool from the Massachusetts Institute of Technology. Occupations like “healthcare support” generally pay around $33,000 annually in the county, according to the same tool.

Come Election Day, most Southern California health workers will have to watch from the sideline.

In Monterey Park, where Ramirez works, the city council approved the $25 minimum wage, but opponents got the vote invalidated by arguing that the council lacked a quorum at the time. The council ended up placing the question on the ballot in 2024, two years from now. Ramirez said that new hires at his medical center start at $15.30 an hour doing the dirtiest jobs in the hospital and that five workers have left his department this year.

“It’s disheartening, I’m not going to lie,” Ramirez said. “These elected officials know what’s going on.”

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California Together, No on Proposition 1, on its website, Aug. 16, 2022

California Together, a campaign led by religious and anti-abortion groups, is hoping to persuade voters to reject a ballot measure that would cement the right to abortion in the state’s constitution. The group is warning that taxpayers will be on the hook for an influx of abortion seekers from out of state.

Proposition 1 was placed on the ballot by the Democratic-controlled legislature in response to the U.S. Supreme Court’s decision to overturn Roe v. Wade. If passed, it would protect an individual’s “fundamental right to choose to have an abortion,” along with the right to birth control.

California Together’s website says: “With Proposition 1, the number of abortion seekers from other states will soar even higher, costing taxpayers millions more.”

The campaign raised similar cost concerns in a voter information guide that will be mailed out to every registered voter ahead of the Nov. 8 election. One prominent argument is that Proposition 1 will turn California into a “sanctuary state” for abortion seekers, including those in late-term pregnancy — and that would be a drain on tax dollars.

We decided to take a closer look at those eye-catching statements to see how well they hold up when broken down.

We reached out to California Together to find out the basis for its arguments against the measure. The campaign cited an analysis from the pro-abortion rights Guttmacher Institute, which estimated before Roe was overturned that the number of women ages 15 to 49 whose nearest abortion provider would be in California would increase 3,000% in response to state abortion bans. The Guttmacher analysis said most of California’s out-of-state patients would likely come from Arizona because it’s within driving distance.

California Together does not cite a specific cost to taxpayers for the measure. Rather, it points to millions of dollars the state has already allocated to support abortion and reproductive health services as an indication of how much more the state could spend if the proposed amendment passes.

Sources indicate that people are already coming to the state for abortion services.

Jessica Pinckney, executive director of Oakland-based Access Reproductive Justice, which provides financial and emotional support for people who have abortions in California, said the organization had experienced an increase in out-of-state calls even before the high court ruled in June. Pinckney anticipates handling more cases as more states restrict abortion — regardless of Proposition 1’s outcome.

Will It Cost Taxpayers Millions?

In its fiscal year 2022-23 budget, California committed more than $200 million to expanding reproductive health care services, including $20 million for a fund to cover the travel expenses of abortion seekers, regardless of what state they live in. Once it’s up and running in 2023, the fund will provide grants to nonprofit organizations that help women with transportation and lodging.

However, none of that spending is connected to Proposition 1, said Carolyn Chu, chief deputy legislative analyst at the nonpartisan Legislative Analyst’s Office. It’s already allocated in the budget and will be doled out next year regardless of what happens with the ballot measure.

In the end, the Legislative Analyst’s Office found “no direct fiscal effect” if Proposition 1 passes because Californians already have abortion protections. And people traveling from out of state don’t qualify for state-subsidized health programs, such as Medi-Cal, the state’s Medicaid program, Chu added in an interview. “If people were to travel to California for services, including abortion, that does not mean they’re eligible for Medi-Cal,” she said.

Still, Proposition 1 opponents see the cost argument playing out in a different way.

Richard Temple, a campaign strategist for California Together, said a “no” vote will send lawmakers a mandate to stop the support fund. “Defeat Prop. 1, and you send a loud signal to the legislature and to the governor that you don’t want to pay for those kinds of expenses for people coming in from out of state,” Temple said.

What About an Influx of Abortion Seekers?

A key element of California Together’s argument is pegged to the idea that California will become a sanctuary state for abortion seekers. Opponents assert that Proposition 1 opens the door to a new legal interpretation of the state’s Reproductive Privacy Act. Currently, that law allows abortion up to the point of viability, usually around the 24th week of pregnancy, or later to protect the life or health of the patient.

An argument made in the voter guide against the constitutional amendment is that it would allow all late-term abortions “even when the mother’s life is not in danger, even when the healthy baby could survive outside the womb.”

Because the proposition says the state can’t interfere with the right to abortion, opponents argue that current law restricting most abortions after viability will become unconstitutional. They contend that without restrictions, California will draw thousands, possibly millions, of women in late-term pregnancy.

Statistically, that’s unlikely. The state doesn’t report abortion figures, but nationwide only 1% of abortions happen at 21 weeks or later, according to the Centers for Disease Control and Prevention.

Whether there will be a new interpretation if Proposition 1 passes is up for debate.

UCLA law professor Cary Franklin, who specializes in reproductive rights, said that just because Proposition 1 establishes a general right to abortion doesn’t mean all abortion would become legal. Constitutional language is always broad, and laws and regulations can add restrictions to those rights. For example, she said, the Second Amendment to the U.S. Constitution grants the right to bear arms, but laws and regulations restrict children from purchasing guns.

“The amendment doesn’t displace any of that law,” Franklin said.

But current law was written and interpreted under California’s current constitution, which doesn’t have an explicit right to abortion, said Tom Campbell, a former legislator who teaches law at Chapman University. If Proposition 1 passes, courts might interpret things differently. “Any restriction imposed by the state on abortion would have to be reconsidered,” Campbell said.

The Legislative Analyst’s Office concluded that “whether a court might interpret the proposition to expand reproductive rights beyond existing law is unclear.”

California voters will soon have their say.

Polling has found widespread support for the constitutional amendment. An August survey by the Berkeley IGS Poll found 71% of voters would vote “yes” on Proposition 1. A September survey by the Public Policy Institute of California pegged support at 69%.

Our Ruling

California Together warns voters: “With Proposition 1, the number of abortion seekers from other states will soar even higher, costing taxpayers millions more.”

Proposition 1 would protect an individual’s “fundamental right to choose to have an abortion.”

While it could lead to more people coming to California for abortion services, that’s already happening, even before voters decide on the measure.

In addition, Proposition 1 doesn’t allocate any new spending. So the $20 million state fund to cover travel expenses for abortion seekers would exist regardless of whether the constitutional amendment is adopted. Bottom line: A nonpartisan analyst found there will be no direct fiscal impact to the state, and out-of-state residents don’t qualify for state-subsidized health programs.

It’s speculative that Proposition 1 would expand abortion rights beyond what’s currently allowed or that the state would allocate more money for out-of-state residents.

Because the statement contains some truth but ignores critical facts to give a different impression, we rate the statement Mostly False.

Sources

California Together, No on Proposition 1, “Q&A: What You Should Know About Prop 1,” accessed Aug. 22, 2022

Legislative Analyst’s Office, Analysis of Proposition 1, accessed Aug. 22, 2022

Email interview with Kelli Reid, director of client services at McNally Temple Associates, Aug. 24, 2022

Phone interview with Carolyn Chu, chief deputy legislative analyst, Legislative Analyst’s Office, Sept. 12, 2022

CalMatters, “California Fails to Collect Basic Abortion Data — Even as It Invites an Out-of-State Influx,” June 27, 2022

California Health Benefits Review Program, “Analysis of California Senate Bill 245 Abortion Services: Cost Sharing,” accessed Sept. 12, 2022

SB 1142, Abortion Services, accessed Sept. 12, 2022

Phone interview with Richard Temple, campaign strategist for California Together, Sept. 12, 2022

Phone interview with Cary Franklin, law professor at UCLA School of Law, Sept. 13, 2022

Phone interview with Luke Koushmaro, senior policy analyst, Legislative Analyst’s Office, Sept. 13, 2022

Gov. Gavin Newsom, remarks in Sacramento, California, June 27, 2022

Public Policy Institute of California, “PPIC Statewide Survey: Californians and Their Government,” accessed Sept. 13, 2022

California state budget, Health and human services summary document, accessed Sept. 14, 2022

Phone interview with Jessica Pinckney, executive director of Access Reproductive Justice, Sept. 15, 2022

Phone interview with Tom Campbell, law professor at Chapman University, Sept. 15, 2022

SB 1301, Reproductive Privacy Act, accessed Sept. 19, 2022

Email interview with H.D. Palmer, deputy director for external affairs at the California Department of Finance, Sept. 20, 2022

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SACRAMENTO — California is trying to ease the pain of vasectomies by making them free for millions of residents.

Federal law and state law require most health insurers to cover prescription contraceptives at no cost to the patient. But those provisions apply to only 18 FDA-approved birth control options for women, so anyone with testicles is out of luck.

California lawmakers are now considering a bill that would expand that requirement to male sterilization. If the Contraceptive Equity Act of 2022 passes, commercial insurance plans regulated by the state won’t be allowed to impose out-of-pocket costs, like copays, coinsurance, and deductibles, for vasectomies.

“It’s pretty groundbreaking in that way — it’s a whole new framework to think about contraception as something that is relevant for people of all genders,” said Liz McCaman Taylor, a senior attorney with the National Health Law Program, a group that advocates for the health rights of low-income people.

A vasectomy is an outpatient surgical procedure in which the patient’s supply of sperm is cut off from his semen by sealing or snipping the tubes that transport sperm from the testes to the penis. Most men need to recover on the couch with an ice pack for a day or two, and a test a few months later determines whether the procedure worked.

Because vasectomies are elective procedures and usually not urgent, price can be a deciding factor.

For Nathan Songne, cost was the most stressful part of the procedure. For several years, the 31-year-old had known he didn’t want to have kids biologically. Better to adopt a 4-year-old and skip the diaper stage, he thought. He was adopted by his stepfather as a child and knew he didn’t need to be genetically related to his children to love them.

“My only concern was that I had no idea how much it was going to cost me because nobody told me,” said Songne, who lives in Mission Viejo, in Orange County. If the procedure cost $1,000, as he expected, he wouldn’t be able to afford it, he said.

Songne’s insurance, which he gets through his work assembling guitars, covered 70% of the Aug. 8 procedure, leaving him with a bill of just under $200. “Cost did affect my decision, but because it was only $200, it made me feel a lot more relieved about continuing on with the vasectomy,” he said.

There are two hot times of year in the vasectomy business, according to Dr. Mary Samplaski, an associate professor of urology at the USC Keck School of Medicine. First, she sees an uptick during the March Madness college basketball tournament, when men choose to recover on the couch watching hoops.

The end of the year is also busy, she said, because many patients have finally met their annual insurance deductible and can afford the procedure.

Patients discuss out-of-pocket costs in about 20% of her vasectomy consultations. “It’s obviously a nerve-wracking procedure,” Samplaski said. “And on top of that, if your copay is high, there’s even less reason to want to do it.”

In April, Jacob Elert comparison-shopped for a vasectomy near his home in Sacramento because his health plan doesn’t cover the procedure. He had hoped to schedule one with his regular urologist, he said, but that would have come with a $1,500 price tag.

Instead, he found a chain of vasectomy clinics where he could get the procedure for $850. Three months later, a test confirmed the vasectomy was a success.

Elert has no regrets, but had price not been a factor, he would have preferred to go to his regular urologist. “That’s the doctor I trust,” Elert said. “But it was just way too expensive.”

In November, California voters will decide whether to lock rights to abortion and contraception into the state constitution. But Proposition 1 doesn’t address issues such as cost and coverage, said Amy Moy, a spokesperson for Essential Access Health, a group that runs California’s Title X family planning program.

“The constitutional amendment is kind of the long-term protection, and we are still working to reduce barriers for Californians on the short-term and day-to-day level regardless of their gender,” she said.

SB 523 has sailed through preliminary votes in the state legislature, which faces an end-of-August deadline to act on bills. If the measure passes, it would take effect in 2024, and California would join a handful of states that require plans they regulate to completely cover vasectomies.

The California Association of Health Plans is still evaluating the measure, which may be amended in the final days of the legislative session. But the association generally opposes bills that require additional insurance benefits because they could lead to higher premiums, spokesperson Mary Ellen Grant said.

SB 523 applies to more than 14 million Californians who work for the state, have a student health plan through a university, or have state-regulated commercial health plans. The bill would not apply to the millions of Californians whose health insurance plans are regulated by the federal government.

Women aren’t completely left out by the bill. They would become eligible to receive free over-the-counter birth control — such as emergency contraception, condoms, spermicide, and contraceptive sponges.

The specifics of how the benefit would work, including the frequency and amount of birth control that insurers must cover and whether patients would have to pay upfront and be reimbursed later, would be hammered out after the measure is adopted. McCaman Taylor said allowing people to simply present their insurance card at a pharmacy counter and walk away with the birth control they need would be preferable.

“We kind of learned from the national experiment with covid over-the-counter tests that reimbursement wasn’t the best model,” she said. “If people can’t afford to pay out-of-pocket for it, they’re just not going to get it.”

The California Health Benefits Review Program, which analyzes legislation, projected that roughly 14,200 people with state-regulated commercial insurance would get vasectomies in California this year. Eliminating cost sharing would increase the number of vasectomies by 252 in the law’s first year, the program estimated.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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