“There are times where the water is so bad you can’t even wash dishes,” said Ruiz, who is advised not to drink the tap water, which is laden with nitrates — runoff from orange and nectarine fields surrounding the town of roughly 400. “We need help to fix our water problem.”

Tucked in a $10 billion climate bond on the November ballot is an earmark to improve drinking water quality for communities such as East Orosi. would allocate $610 million for clean, safe, and reliable drinking water and require at least 40% be spent on projects that benefit vulnerable populations or disadvantaged communities. But it’s a fraction of what the state says is needed.

While most Californians have access to safe water, roughly as of late October are served by 383 failing water systems, many clustered in remote and sparsely populated areas. A June assessment by the California State Water Resources Control Board pegged the cost of repairing failing and at-risk public water systems at about .

“We have communities in California that are served drinking water that has been out of compliance with regulatory standards for potent toxins like arsenic for years,” said Lara Cushing, an associate professor in UCLA’s Department of Environmental Health Sciences.

And climate change is eroding people’s access to clean water, she said. “There is kind of a perfect storm, if you will, of compounding hazards.”

Supporters say Proposition 4, to enact the Safe Drinking Water, Wildfire Prevention, Drought Preparedness, and Clean Air Bond Act of 2024, would jump-start upgrades by authorizing grants and loans for local governments to repair water systems contaminated with lead, arsenic, nitrates, or other chemicals tied to , and other serious health issues.

Water priorities vary by region, and the bond would give communities flexibility to address their needs, said MJ Kushner, a policy advocate at the Community Water Center, a statewide nonprofit. “It isn’t a one-size-fits-all solution,” Kushner said.

A taxpayer group opposing the bond says the state will go further into debt on piecemeal projects. It says the state is increasingly addressing its climate-related programs with bonds, which it calls the most expensive way for government to pay for things, rather than within the state budget.

Lawmakers added Proposition 4 to the ballot after Democratic Gov. Gavin Newsom, facing a , cut $6.6 billion in climate spending from the state budget, according to Department of Finance spokesperson H.D. Palmer. The reductions followed in climate cuts Newsom and lawmakers enacted in 2023.

Susan Shelley, a spokesperson for the Howard Jarvis Taxpayers Association, said the state has already borrowed billions and that now isn’t the time to add more debt given the deficit.

“If the legislature chose to cut these from the budget, they should not go on the credit card,” Shelley said. “It’s irresponsible.”

According to the nonpartisan Legislative Analyst’s Office, the state has routinely allocated state funds for climate-related programs, with about 15% coming from bonds. The office estimates it would cost taxpayers for the next 40 years to repay the bond — a total of $16 billion.

Since 2000, California voters have approved eight water bonds totaling , for projects involving flood management, habitat restoration, drought preparation, and drinking water improvement, according to the Public Policy Institute of California.

Scientists say climate change has led to more severe weather, including devastating floods and droughts; the spread of infectious diseases such as West Nile virus; and earlier deaths from respiratory illnesses. Public health experts add that as climate change worsens, its impact on people’s health will grow more severe and could cost the state more in the long run.

“If we quantify the damages associated with the do-nothing policy, you’ll see that typically, at the end of the day, the bill plus the interest costs are going to be less than the cost if we do nothing,” said Kurt Schwabe, an environmental economics and policy professor at the University of California-Riverside.

If approved, Ruiz hopes Proposition 4 can help East Orosi, a predominantly Latino and low-income community. Though she receives 25 gallons of drinking water twice a month, she sometimes runs out. The last time the 47-year-old drank tap water at home was when she was in high school.

“I don’t think any community anywhere in California should have to wait this long to get clean water,” Ruiz said.

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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 . 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 , 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 . 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 , 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 . 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, spent about $11 million across all 10 cities from February through the week before the election. 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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All three women sought abortion care at Northland Family Planning Center in Sterling Heights, a city in the metro Detroit area. And all told their stories to reporter Kate Wells as she embedded in the in August and September. Wells’ story, produced in partnership with KHN, ’s “Morning Edition” on Nov. 3. (The story includes audio of one woman’s abortion procedure that some listeners may find disturbing.)

Northland was started in 1976 by . She had undergone an illegal abortion at age 16, back in 1966, seven years before Roe v. Wade. In recent months, patients have been traveling to Northland’s three locations from Wisconsin, Indiana, Oklahoma, even as far as Florida and Texas.

But abortion rights in Michigan are far from certain. So far, courts have blocked enforcement of a 1931 law that bans the procedure with no exceptions for rape or incest. But the judicial wrangling has been confusing. On Aug. 1, for example, rapid-fire court rulings meant that was legal at breakfast, illegal at lunchtime, and legal once again by dinner.

Michigan voters decide Nov. 8 whether abortion stays legal in the state. What’s known as would explicitly enshrine in the Michigan Constitution the right to abortion, as well as other reproductive rights.

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From the heavily Armenian neighborhood of Tujunga in the foothills of the San Gabriel Mountains, Abramyan and other hookah shop and cafe owners began spreading the word that the ban, prompted by a burgeoning among teens, could put them out of business and extinguish a beloved social ritual that many feel is part of their heritage.

“We were going to be collateral damage,” said Abramyan, now president of the .

As their movement grew, the business owners hired a lobbyist and traveled to Sacramento to meet with lawmakers. They posted YouTube videos on “the history and centuries-old tradition” of smoking the popular in the Middle East. Their work paid off: State lawmakers passed the ban in August 2020, which outlawed the sale of flavored tobacco, including menthol cigarettes — but exempted premium cigars, loose pipe tobacco, and the “” used in hookah pipes.

It never went into effect. Big Tobacco quickly launched a referendum drive and gathered enough signatures to bring the issue to voters. This month, Californians will decide — — whether to uphold or block the law, which would make it illegal for brick-and-mortar retailers to sell flavored cigarettes, e-cigarettes, and other flavored tobacco products. Sales of gums or gummies that contain nicotine and are not approved by the FDA would also be prohibited.

If the law is upheld — indicates that a majority of likely voters support it — California would become the second state to rid stores of both flavored vapes and menthol cigarettes, which have and Latino smokers since tobacco companies began marketing them in inner-city neighborhoods half a century ago.

The question of why California has granted hookah smokers an exception while banning menthol cigarettes, the choice of smokers, has sparked a debate about which tobacco products — if any — merit protection. Until recently, menthols had failed in the face of aggressive tactics by tobacco companies, which have staved off billions in losses by and .

Anti-tobacco groups warn that this strategy has become a model for fending off government interference. They decry the hookah exemption as the latest example of business successfully using identity politics to keep profiting from a deadly product.

“Hookah has been given a pass for no scientific reason,” said Carol McGruder, co-founder of the . McGruder, who has spent years waging war against tobacco companies for their “predatory targeting” of Black communities with menthol cigarettes, said hookah smoking has become increasingly trendy among Black youths.

Many young people mistakenly believe that than other forms of smoking, but experts say tobacco smoked through water pipes is just as addictive as cigarette tobacco and tar, nicotine, and heavy metals.

“They bring out a beautiful antique hookah pipe and they say that hookah is all about family and community,” McGruder said. “But it’s all about money.”

Big Tobacco itself is assailing the hookah exemption, saying it proves that the law discriminates against Black and Latino smokers by banning menthol flavors, while giving “special treatment to the rich,” as an paid for by the industry argues.

“Prop. 31 will increase crime and expand illegal markets, cut revenue for critical services and could backfire on the very communities its proponents say they want to help,” said Beth Miller, a spokesperson for the “No on Prop 31” campaign.

, clustered primarily in California and Massachusetts, have restricted the sale of flavored tobacco products, including e-cigarette pods in — strawberry, chocolate milk, and pink punch — which health officials say have provided a gateway to teenage smoking. Roughly half of the ordinances restrict menthol, while fewer than 20 — nearly all of them in California — exempt hookah tobacco and/or hookah bars.

In 2021, and nearly 75% of middle school students who had used a tobacco product in the previous 30 days reported using flavored tobacco, the Centers for Disease Control and Prevention reported. In 2019 and 2020, an lung disease, known as EVALI, killed 68 people.

The vaping epidemic has given anti-smoking activists an opening to lobby against menthol cigarettes. Invented in the 1920s, their cool, minty flavor helped new smokers adjust to them more easily than non-flavored cigarettes, and the industry marketed them as a healthier option. In the 1960s, tobacco companies turned to the Black community, to hip, young “communicators” in barbershops and bars. Menthol cigarettes account for more than a third of the $80 billion U.S. cigarette market.

Reynolds American, the country’s largest maker of menthol cigarettes, including Newport, has battled menthol bans by ’s National Action Network and other civil rights groups. When the a menthol cigarette ban in 2019, Sharpton cited the case of , a Black man who died in police custody in 2014 after he was stopped for allegedly selling single, untaxed cigarettes on the street.

But the success of these efforts came at a devastating price, public health experts say. African American men have the in America, according to the CDC.

Earlier this year, the FDA to ban sales of menthol-flavored cigarettes, a long-awaited move hailed by health officials and some Black leaders, even as they braced themselves for a protracted legal battle with the tobacco industry that .

For years, anti-smoking activists have been focused on menthol, said Valerie Yerger, an associate professor of health policy at the University of California-San Francisco. “Nobody was focused on hookah,” she said.

But water-pipe use among young people has been in recent decades.

At across the United States and Europe, contestants compete to build the most elaborate water pipe, often to a hip-hop soundtrack. Elaborate water pipes, with their billowing puffs of smoke, are often in rap videos.

“It’s just another way the industry has found to keep our young people addicted to these products,” Yerger said.

Hookah purveyors argue that blanket prohibitions endanger small-business owners, many of them immigrants, and threaten to erase a “” by effectively outlawing hookah pipes, which are often part of gatherings and celebrations for Arabs, Armenians, Persians, and others hailing from the Middle East. They reject the claim that their fight is only about money.

“Hookah lounges are a hallmark of community,” said Rima Khoury, general counsel for .

For Abramyan, smoking a hookah was an after-dinner, adult ritual his Iranian-born parents brought with them when they immigrated to America in the 1980s. The ornate water pipes are often several feet tall and take at least 20 minutes to set up.

“This is not something kids are smoking in the bathrooms at school,” he said. “We don’t want our kids to smoke, but why shouldn’t my grandpa be able to smoke his hookah in his backyard?”

Bible study groups and the local Rotary Club chapter regularly meet at his Tujunga hookah lounge, Garden on Foothill, which features outdoor gazebos for families and groups. “For Muslims who don’t drink alcohol, or people who don’t like to go to strip clubs, this is a safe space,” he said.

The shop he runs a few blocks away, Munchies Mart, sells handmade hookah pipes and tobacco in flavors such as Strawberry Lemonade, Orange Pop, and Agua Fresca, a far cry from the apple-soaked tobacco he remembers his Persian grandmother mixing in her kitchen.

Using cultural practices to argue for public policy exemptions is nothing new, said Arnab Mukherjea, an associate professor of public health at California State University-East Bay.

But he said that communities often suffer when corporate interests “use cultural identity to market a product for mass consumption.”

“You go to any college town,” he said, “and the hookah bars are filled not with practicing Muslims, but with college-age kids who are going there to socialize, consuming flavors in bubble gum and cotton candy.”

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The program that fed 50.6 million U.S. students expired in September, but some states are figuring out ways to extend it. and have both passed legislation to fund universal free lunch.

In Colorado, a coalition of parents, teachers, and anti-hunger advocates are pushing to make permanent universal free school lunches, and lawmakers in the Democratic-controlled legislature .

GlendaRika Garcia, a bilingual food assistance navigator for Hunger Free Colorado, strongly backs the idea.

“I think that the kids being able to eat for free at school is really important, for all families, all kids,” said Garcia, a widow and a single mom of four boys.

Two of them, Alonzo and Pedro, tossed a football around in front of their apartment building, as Garcia explained proposal on the ballot.

“Kids can’t learn if they don’t have good nutrition,” said Garcia, whose job entails signing up people for benefits and making sure they’re eligible.

The measure, known as , would use state funds to offer free meals for all public school students. It would also fund pay increases for school cafeteria workers, helping schools deal with staff shortages, and would incentivize schools to buy Colorado-grown food. That has some families, workers, and farmers cheering.

But critics point to a steep price tag for a new government program, which raises $100 million annually from a tax on households that make $300,000 or more a year.

School-aged members of a family of four making less than about $51,000 a year are eligible for free lunch. But that right now more than 60,000 Colorado kids can’t afford school meals yet aren’t eligible.

Garcia sees the proposal as a game changer, an equalizer. Depending on her job, Garcia at times qualified for her sons to get free lunches and at times didn’t, a blow to her budget.

Another issue, Garcia said, is that some kids bully others for getting a free lunch. It happened to her as a child when she also qualified for free lunch, and it happened to one of her sons.

“They know that people can identify if they can’t afford it. It hurts my heart,” she said.

Her son Alonzo said that at his high school some kids avoid the lunchroom rather than admit they qualify for free lunch.

“I think that they get embarrassed because they can’t afford it,” he said.

Many Colorado districts reported a clear uptick during the pandemic of provided for free at school.

“We were feeding kids that we have never fed before, and it was good to see them coming up, and not just buying junk food,” said Andrea Cisneros, the kitchen manager at West Woods Elementary School in Arvada.

Many students arrive at school without food, said Dan Sharp, the school nutrition director in Mesa County Valley School District 51 in Grand Junction.

The district saw a 40% year-over-year increase in meals served during the pandemic, said Sharp.

“I really believe there’s more households here and students that could qualify but don’t, due to the stigma that goes with applying for free and reduced meals,” he said.

Proponents said they did several throughout the pandemic and, according to a recent survey, 44% of respondents with kids at home reported struggling to have access to nutritious food.

Low-income students will keep receiving free meals through federal funding, whether the proposal passes or not. There’s no organized opposition to the measure, but it does have critics.

“Nobody wants to be evil enough to say it, but this is a really stupid idea,” said Jon Caldara, president of the , a libertarian think tank. “Most kids in Colorado do not need this. And in fact, those who do, already have this.”

The group’s voter’s guide .

“This proposal is, ‘Hey, let’s get the rich guys to buy our kids’ lunch,’” he said. “This is another expansion of state bureaucracy that is just not necessary.”

The governor told Colorado Public Radio’s he hasn’t made his mind up about how he’ll vote on it.

“I don’t have an objection to the funding mechanism, but at the same time I sort of ask myself, ‘If we had this, would it be better just to be able to pay teachers better, reduce class size?’” said Gov. Jared Polis, a Democrat. “Or is the best use of it lunches for upper-middle-income families?”

He added that the measure “doesn’t affect the state finances one way or the other because it’s effectively revenue-neutral with the mechanism.”

His Republican opponent seemed to lean toward supporting Proposition FF in .

“I haven’t had a chance to look at it, but I do want to make sure that every child has access to healthy food and lunches, so I’m certainly open to it,” said Heidi Ganahl.

The , a nonpartisan free-market think tank, analyzed the measure and raised several concerns, with modeling that showed it could be underfunded or raise more money than is needed.

“There needs to be some good oversight on the program so that costs are managed well, and also that they don’t develop a huge surplus,” said Steven Byers, the group’s senior economist.

Despite concerns about cost, universal free school lunch appears popular throughout the nation.

from its state budget to fund and support its universal free school meals program for the 2022-23 school year. Maine’s program was estimated by lawmakers to cost .

Washington, Minnesota, Wisconsin, Ohio, Pennsylvania, New York, Massachusetts, and North Carolina introduced bills similar to the one on the Colorado ballot, most of them during the current legislative session. All of them are still in committee and have yet to go up for a vote.

by the Urban Institute, a nonpartisan think tank focused on social and economic research, found that 76% of adults living with children enrolled in public school and 67% of adults not living with children enrolled in public school supported permanent free school meals.

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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 , 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 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 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 for .

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 , 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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Voters will decide on Proposal 3, which, if approved, would install protections for a woman’s right to have an abortion in the Michigan Constitution.

Kansas voted this year to keep abortion legal. Now Michigan is one of five states, along with California, Kentucky, Montana, and Vermont, asking voters next month to weigh in on abortion policy in the wake of the Supreme Court’s June ruling in Dobbs v. Jackson Women’s Health Organization. That ruling overturned the court’s 1973 Roe v. Wade decision and leaves states to set their own abortion policies.

Since the court’s ruling, abortion access in the U.S. has been evolving into a jumble of standards. In some states, decades-old laws lingering on the books could trigger dramatic shifts, while other states are eyeing new laws. But as the policy landscape forms, those on the front lines must operate in a state of uncertain limbo.

In Michigan, the politically deadlocked state government ensured that a 1931 law banning abortions was dusted off and then thrown to the courts, where judges temporarily blocked prosecutors from enforcing it. The ballot measure to protect abortion rights landed on ballots only after advocates submitted petitions bearing more than 735,000 valid signatures and Michigan Supreme Court justices ended a legal tug-of-war over petition technicalities.

Abortion policy has also spilled into both the attorney general race and the gubernatorial one, with Democratic incumbent Gov. Gretchen Whitmer, who supports abortion rights, running against Republican Tudor Dixon, an outspoken conservative who opposes abortion, even in cases of rape and incest.

When Whitmer urged Michigan voters to fight like hell to protect the right to abortion, Michigan Catholic Bishop urged Catholics to “” to stop the state constitutional amendment.

“There is a bit of a tennis match going on in Lansing right now,“ said Jim Sprague, CEO of the and a member of the coalition against Proposal 3.

Christen Pollo, executive director of , which works with students on campuses to end abortion, said that “overwhelmingly, voters oppose the extreme policies” in the measure. But according to a poll commissioned by the Detroit Free Press and its media partners, for the to codify abortion rights in the Michigan Constitution.

Meanwhile, the state’s abortion providers continue seeing patients amid the confusion around what will be legal in Michigan. At a full-service Planned Parenthood clinic in a bustling shopping plaza in Lansing, staffers still see a steady stream of women seeking services. And at a busy corner in front of the clinic’s parking lot, a continual flow of anti-abortion protesters still show up, holding signs, just as they have since this location opened decades ago.

It all looks much the same as before the Supreme Court’s historic decision, but behind the scenes, abortion providers and advocates are preparing for an uncertain future. Linda Goler Blount, president of the national in Atlanta, works with networks of activists around the country to support their efforts to make sure contraceptives are available. “Some of those groups are ordering medical abortion products, and stockpiling them,” she said.

And medical professionals worry about what happens if Michigan’s Proposal 3 doesn’t pass. Dr. , who works with medical residents at Michigan State University in East Lansing, said some of the emergency room and internal medicine residents worry they may be accused of causing an abortion as they provide care. Across the board, she said, physicians and other providers are concerned that their medical licenses could be in jeopardy, or they could find themselves locked up if the ballot measure fails.

The whole medical community is “in a wait-and-see moment,” she said.

But if Proposal 3 passes, Sprague said, it will cause a that protect women and children. He called it “a bad law for women” in Michigan that is too radical.

A ban on abortions in the state would likely have the greatest impact on Black women. According to the , Black women make up nearly 56% of patients who had abortions in the state in 2021.

“The disparity in the number of Black women who seek out abortion services speaks to the many health care inequities that they suffer across the board,” Goler Blount said.

So Black reproductive activist groups are among those on the ground making it clear to voters where elected officials stand, Goler Blount said. She added that they are working on massive voter registration and get-out-the-vote efforts.

Both sides in Michigan have invested millions in ads to make their case. In addition to neighborhood canvassing and phone trees, they are taking to social media, including , who is backing the measure. Signs for each side are sprouting in yards and anti-abortion groups have been assembling prayer rallies around the state.

The stakes are high and heated as the state awaits the vote. In September, a man shot in the shoulder in Ionia County while she was passing out anti-abortion pamphlets, and earlier this month, was sprayed outside a Roman Catholic Church in Lansing.

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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 at private hospitals, psychiatric facilities, and dialysis clinics. The Service Employees International Union-United Healthcare Workers West, which represents roughly 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 .

A 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 “.” An analysis commissioned by the California Hospital Association estimated that the change would raise costs for private facilities by , 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 and , 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 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 , 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 . 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.”

This story was produced by , which publishes , an editorially independent service of the .

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Legislative Referendum 131 was approved for next month’s election by state lawmakers in 2021, more than a year before the U.S. Supreme Court removed federal protections for abortion in June.

Abortion remains legal in Montana because of a that protects it under the state constitution’s . Three laws passed by the Republican-led legislature in 2021 to restrict abortion while a legal challenge proceeds, arguing that they violate the constitutional provision.

But lawmakers sent LR-131 directly to voters to decide whether it should become law.

Here are five key things to know about the ballot measure:

1. What would the initiative do?

would impose criminal penalties of up to 20 years in prison and up to a $50,000 fine on any health care worker who doesn’t try to save a “born-alive infant.” That term is defined as a legal person who breathes, has a heartbeat, or has voluntary muscle movement after an abortion or delivery.

The measure would require health care providers to “take medically appropriate and reasonable actions” to keep the fetus or infant alive, but it doesn’t define or give examples of such actions. The health care workers liable under the initiative would be doctors and nurses but also any “individual who may be asked to participate in any way in a health care service or procedure.”

The initiative includes a mandatory reporting requirement, which means that any employee or volunteer at a medical facility who is aware of a violation must report it to authorities.

2. Where did the initiative come from?

, the 2021 legislation that authorized the referendum, was sponsored by state Rep. (R-Kalispell), chair of the panel that oversees the state Department of Public Health and Human Services’ budget.

“We need to make it abundantly clear that here in Montana, the protection of all life is available,” while introducing the bill in January 2021.

The bill is very similar to in 2018 as a template for state lawmakers nationwide. So far, 18 states have provisions along those lines, and more are considering them, according to the group. Its president and CEO, Catherine Glenn Foster, during the 2021 legislative session.

The Montana measure does not include a provision in the model legislation that gives an infant’s parents the right to refuse medical intervention if the treatment isn’t necessary to save the infant’s life, would only temporarily prolong the infant’s death, or carries risks that outweigh the potential benefits to the infant.

The Montana measure also excludes a clause in the model legislation that exempts parents and guardians from criminal and civil liability. The Montana initiative doesn’t address parental liability.

Bradley Kehr, Americans United for Life’s policy counsel, described the ballot initiative as “well tailored to the needs of Montana.”

3. What does the initiative have to do with abortion?

Regier’s bill says the purpose of the referendum is to protect infants who have survived abortions from being denied medical care and being left to die.

The measure’s passage would move the Family Research Council’s classification of Montana’s “born-alive” protections from compared with the rest of the nation, according to Connor Semelsberger, director of federal affairs for life and human dignity for the nonprofit organization, which advocates for anti-abortion measures.

Montana is not among the nine states that require health providers to report when an infant is born alive during an abortion. The Family Research Council lists the states that do as Arkansas, Arizona, Florida, Indiana, Michigan, Minnesota, Ohio, Oklahoma, and Texas.

Instances of fetuses surviving abortions . In Minnesota, which the Family Research Council points to as having the strongest protections in the U.S., five of the 10,136 abortions performed in 2021 resulted in a live birth, . None of the five survived.

The number of abortions in which a fetus could survive is small, too: The point at which a fetus can survive outside the womb is generally considered to be after 22 weeks of pregnancy, and about .

The leaders of two Montana clinics that provide abortions said the initiative’s passage would not affect their operations, as Montana law restricts performing abortions after a fetus is viable. The law does not define viability.

Nicole Smith, executive director of Blue Mountain Clinic in Missoula, said her clinic provides dilation-and-evacuation abortions that would not result in a live birth. “We do not provide obstetric or labor-and-delivery care,” she said, adding that she would refer a patient who needed that kind of care to someone who specializes in high-risk pregnancies.

Helen Weems, director of All Families Healthcare in Whitefish, said her clinic does not perform abortions after 12 weeks. LR-131 “is designed to look like an anti-abortion measure, but it has no relevance” to her clinic, she said. “There would never be an occasion in my practice where there would be an infant born alive,” Weems said.

4. If clinics that provide abortions won’t be affected, who will?

The initiative also covers any natural birth, induced labor, or cesarean section.

That could present obstetricians and gynecologists with an ethical dilemma of having to choose between their obligation to provide the best available medical care to their patients or the potential of facing legal penalties, according to a by the American College of Obstetricians and Gynecologists opposing the Montana measure.

The organization said LR-131 could require an aggressive course of treatment in extremely complex and often tragic medical situations. It opposes the measure as government interference in the patient-physician relationship that would impose additional trauma on families.

Smith said the initiative would apply to miscarriages and to hospital deliveries in cases when parents know their child won’t live but want to complete the birth for a chance to hold the baby and say goodbye.

Opponents of the ballot initiative use the example . They say that rather than allowing the family to hold, say goodbye to, or baptize the baby before it dies, the measure would require health care workers to remove it in an attempt to save its life.

found that all 129 infants who were born before 22 weeks and were included in the study died. Two received active medical treatment. Of those born in the 22nd week, 5% survived. Most of the 24 hospitals in the study provided treatment to all infants born at 25 or 26 weeks. Those born at week 26 had an overall survival rate of about 81%, and 59% survived without moderate or severe impairment.

5. What does existing federal and state law say?

, it’s already a felony to purposely, knowingly, or negligently cause the death of a viable, premature infant. passed in 2002 says a person includes “every infant member of the species homo sapiens who is born alive at any stage of development.” It defines “born alive” as evidence of a heartbeat, breathing, or voluntary muscle movements, but does not include any additional provisions.

Opponents of the Montana measure point to those laws as evidence that LR-131 is unnecessary and is instead meant to drive conservative voter turnout. “This cruelty is being forced on already grieving families for the cold, calculated political gain of extreme-right politicians,” Weems said.

Regier, the legislator whose bill authorized the referendum, said current Montana law does not go far enough to protect infants.

Semelsberger, of the Family Research Council, said the same about the federal law and that it has lacked enforcement. The organization supports (R-Neb.) that would add requirements to save the life of an infant, though with up to five years of maximum prison time, instead of the 20 years in Montana’s measure.

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“They’ll get guaranteed earnings, health care benefits, personal protections, and they can maintain their flexible schedules.”

Political ad paid for by Lyft in favor of California’s Proposition 22. The ad was

on YouTube

on Oct. 8, and emailed by Lyft to its customers.

It can be republished for free.

[UPDATED at 1:15 p.m. ET]

App-based driving services such as Uber, Lyft, DoorDash and Instacart California’s Proposition 22, which would keep their drivers classified as independent contractors, not employees.

Leading into the Nov. 3 election, the ballot measure — which has become the — is mired in controversy and the subject of a from Uber drivers alleging that the company inappropriately pressured them to vote for the initiative.

But what’s occasionally lost in the debate over Proposition 22 are the claims about what it will mean for app-based drivers.

Detractors, like unions and driver advocacy groups, say Proposition 22 would strip drivers of the protections of , a 2019 California law delayed by legal challenges. The law requires drivers to be classified as employees, which would afford them the associated benefits like paid sick leave, workers’ compensation and access to unemployment insurance.

Supporters, such as ride-sharing companies and the California Chamber of Commerce, say Proposition 22 would give drivers benefits, like a guarantee of minimum earnings and compensation when they are hurt on the job, while allowing them to maintain the flexible schedule of independent contractors.

In an online ad paid for by Lyft, the company says “Prop. 22 will give them … health care benefits.”

That sounds like drivers with Uber, Lyft and other app-based companies will automatically get health insurance if Proposition 22 passes. The truth is a little more complicated.

What Does ‘Health Care Benefits’ Mean?

We reached out to Lyft to back up its claim, and the company directed us to the “Yes on 22” campaign. This is how the campaign explained “health care benefits”:

Under Proposition 22, drivers who qualify — more on that in a minute — would get a stipend they could use to buy an insurance plan from Covered California, the state’s health insurance marketplace.

That stipend would be calculated like this: App-based companies would look at the statewide average monthly premium of bronze-level plans sold on the Covered California exchange.

The companies would then give qualified drivers a stipend of 82% of the average premium, said Geoff Vetter, a spokesperson for the Yes on 22 campaign. (On average, U.S. employers covered for single coverage in 2019.)

So hypothetically, if bronze plans cost an average of $100 per month, Uber, Lyft or a similar company would provide qualifying drivers with $82 per month.

Drivers would be eligible for the full stipend — all $82 in the hypothetical case — if they average 25 hours per week of “engaged” time, which does not include time spent waiting between jobs.

“Most drivers work part time” and spend about one-third of their time waiting for rides and deliveries, according to the nonpartisan state . Using that equation, drivers would need to work an average of 37.5 hours per week for a single company in order to receive the full stipend.

A driver who averages at least 15 but less than 25 hours of engaged time each week would be eligible for 50% of the stipend — or $41 per month.

The stipend would be similar to employer-sponsored insurance because both employers and employees would contribute to the cost of insurance, Vetter said.

“For the people who do work closer to full time, it does give them that ability to receive health care coverage by getting a typical employer contribution for that coverage,” Vetter said.

Does a Stipend Equal Coverage?

But this stipend bears little resemblance to traditional employer-based insurance, which is what drivers would get if they were considered employees instead of gig workers, said Ken Jacobs, chair of the University of California-Berkeley Center for Labor Research and Education.

“It has very, very little relationship to what anyone would think of as job-based coverage,” Jacobs said. “It’s really wrong to think of this as health insurance.”

For instance, under Proposition 22, the stipends would be calculated and distributed quarterly, based on drivers’ hours. That could force drivers to periodically reassess what kind of coverage they would qualify for and could afford.

With traditional employer-sponsored insurance, a driver would enroll in a plan once per year and the premium wouldn’t change.

A vacation or illness could mean that drivers can’t maintain the hours required by the measure, costing them their stipend — and perhaps their insurance — for the quarter, and stripping them of the stability usually associated with job-based coverage, Jacobs said.

And getting money to buy an individual plan isn’t the same as participating in a large group plan offered by an employer, said Jen Flory, a policy advocate at the Western Center on Law & Poverty, a nonprofit organization that advocates for low-income Californians and opposes Proposition 22.

Covered California plans are typically less generous than the policies employees usually get through work, she said. And bronze-level plans, which have the lowest monthly premiums, also have the highest out-of-pocket costs for medical services.

Consider the deductible, which is how much a person needs to pay out-of-pocket before insurance starts paying for care.

In 2018, fewer than half of Californians who had work-based insurance had a deductible, and on average, that deductible was $1,402 for a single person, according to from the California Health Care Foundation. (California Healthline is an editorially independent service of the California Health Care Foundation.)

The deductible on a Covered California bronze plan for an individual in 2021 will be for medical services plus $500 for prescription drugs. Proposition 22 ties the stipend “to the highest deductible, highest out-of-pocket plans on the market,” Flory said. “And it’s for workers who aren’t making a whole lot of money.”

Drivers could use the stipend to buy a more generous plan, but the monthly premium would be higher and the stipend would cover less of it.

Depending on their incomes and other factors, drivers may also be eligible for tax credits and state and federal subsidies to help them afford plans on the individual market. But Flory said this amounts to the government subsidizing health insurance that employers should be paying for themselves.

It’s also problematic to base the stipends on a statewide average of bronze premiums because that doesn’t take into account the huge regional differences in the cost of care, said Gerald Kominski, a senior fellow at the UCLA Center for Health Policy Research.

“In the Bay Area, that contribution is going to buy a lot less than it would in Southern California,” Kominski said. “We’re a big state and have a lot of variation of health care costs.”

Our Ruling

The stipend offered under Proposition 22 is a “health care benefit,” but the wording is misleading and ignores critical information.

While neither Lyft nor the Yes on 22 campaign says the proposition will give drivers health insurance, saying that it will offer them “health care benefits” gives the impression that the stipend is similar to traditional job-based coverage. It’s not.

Drivers who value the ability to make their own schedules would have to figure out how to work an average of nearly 40 hours a week — essentially full time — to receive the full stipend. The stipend would cover a fraction of the premiums for health insurance that’s typically less generous than what they’d get as employees.

Moreover, because drivers’ stipends could change quarterly based on their driving time — which could be affected by vacation or illness — any coverage purchased with the stipend could carry a cloud of uncertainty.

We rate this claim as Half True.

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“There are times where the water is so bad you can’t even wash dishes,” said Ruiz, who is advised not to drink the tap water, which is laden with nitrates — runoff from orange and nectarine fields surrounding the town of roughly 400. “We need help to fix our water problem.”

Tucked in a $10 billion climate bond on the November ballot is an earmark to improve drinking water quality for communities such as East Orosi. would allocate $610 million for clean, safe, and reliable drinking water and require at least 40% be spent on projects that benefit vulnerable populations or disadvantaged communities. But it’s a fraction of what the state says is needed.

While most Californians have access to safe water, roughly as of late October are served by 383 failing water systems, many clustered in remote and sparsely populated areas. A June assessment by the California State Water Resources Control Board pegged the cost of repairing failing and at-risk public water systems at about .

“We have communities in California that are served drinking water that has been out of compliance with regulatory standards for potent toxins like arsenic for years,” said Lara Cushing, an associate professor in UCLA’s Department of Environmental Health Sciences.

And climate change is eroding people’s access to clean water, she said. “There is kind of a perfect storm, if you will, of compounding hazards.”

Supporters say Proposition 4, to enact the Safe Drinking Water, Wildfire Prevention, Drought Preparedness, and Clean Air Bond Act of 2024, would jump-start upgrades by authorizing grants and loans for local governments to repair water systems contaminated with lead, arsenic, nitrates, or other chemicals tied to , and other serious health issues.

Water priorities vary by region, and the bond would give communities flexibility to address their needs, said MJ Kushner, a policy advocate at the Community Water Center, a statewide nonprofit. “It isn’t a one-size-fits-all solution,” Kushner said.

A taxpayer group opposing the bond says the state will go further into debt on piecemeal projects. It says the state is increasingly addressing its climate-related programs with bonds, which it calls the most expensive way for government to pay for things, rather than within the state budget.

Lawmakers added Proposition 4 to the ballot after Democratic Gov. Gavin Newsom, facing a , cut $6.6 billion in climate spending from the state budget, according to Department of Finance spokesperson H.D. Palmer. The reductions followed in climate cuts Newsom and lawmakers enacted in 2023.

Susan Shelley, a spokesperson for the Howard Jarvis Taxpayers Association, said the state has already borrowed billions and that now isn’t the time to add more debt given the deficit.

“If the legislature chose to cut these from the budget, they should not go on the credit card,” Shelley said. “It’s irresponsible.”

According to the nonpartisan Legislative Analyst’s Office, the state has routinely allocated state funds for climate-related programs, with about 15% coming from bonds. The office estimates it would cost taxpayers for the next 40 years to repay the bond — a total of $16 billion.

Since 2000, California voters have approved eight water bonds totaling , for projects involving flood management, habitat restoration, drought preparation, and drinking water improvement, according to the Public Policy Institute of California.

Scientists say climate change has led to more severe weather, including devastating floods and droughts; the spread of infectious diseases such as West Nile virus; and earlier deaths from respiratory illnesses. Public health experts add that as climate change worsens, its impact on people’s health will grow more severe and could cost the state more in the long run.

“If we quantify the damages associated with the do-nothing policy, you’ll see that typically, at the end of the day, the bill plus the interest costs are going to be less than the cost if we do nothing,” said Kurt Schwabe, an environmental economics and policy professor at the University of California-Riverside.

If approved, Ruiz hopes Proposition 4 can help East Orosi, a predominantly Latino and low-income community. Though she receives 25 gallons of drinking water twice a month, she sometimes runs out. The last time the 47-year-old drank tap water at home was when she was in high school.

“I don’t think any community anywhere in California should have to wait this long to get clean water,” Ruiz said.

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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 . 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 , 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 . 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 , 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 . 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, spent about $11 million across all 10 cities from February through the week before the election. 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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All three women sought abortion care at Northland Family Planning Center in Sterling Heights, a city in the metro Detroit area. And all told their stories to reporter Kate Wells as she embedded in the in August and September. Wells’ story, produced in partnership with KHN, ’s “Morning Edition” on Nov. 3. (The story includes audio of one woman’s abortion procedure that some listeners may find disturbing.)

Northland was started in 1976 by . She had undergone an illegal abortion at age 16, back in 1966, seven years before Roe v. Wade. In recent months, patients have been traveling to Northland’s three locations from Wisconsin, Indiana, Oklahoma, even as far as Florida and Texas.

But abortion rights in Michigan are far from certain. So far, courts have blocked enforcement of a 1931 law that bans the procedure with no exceptions for rape or incest. But the judicial wrangling has been confusing. On Aug. 1, for example, rapid-fire court rulings meant that was legal at breakfast, illegal at lunchtime, and legal once again by dinner.

Michigan voters decide Nov. 8 whether abortion stays legal in the state. What’s known as would explicitly enshrine in the Michigan Constitution the right to abortion, as well as other reproductive rights.

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From the heavily Armenian neighborhood of Tujunga in the foothills of the San Gabriel Mountains, Abramyan and other hookah shop and cafe owners began spreading the word that the ban, prompted by a burgeoning among teens, could put them out of business and extinguish a beloved social ritual that many feel is part of their heritage.

“We were going to be collateral damage,” said Abramyan, now president of the .

As their movement grew, the business owners hired a lobbyist and traveled to Sacramento to meet with lawmakers. They posted YouTube videos on “the history and centuries-old tradition” of smoking the popular in the Middle East. Their work paid off: State lawmakers passed the ban in August 2020, which outlawed the sale of flavored tobacco, including menthol cigarettes — but exempted premium cigars, loose pipe tobacco, and the “” used in hookah pipes.

It never went into effect. Big Tobacco quickly launched a referendum drive and gathered enough signatures to bring the issue to voters. This month, Californians will decide — — whether to uphold or block the law, which would make it illegal for brick-and-mortar retailers to sell flavored cigarettes, e-cigarettes, and other flavored tobacco products. Sales of gums or gummies that contain nicotine and are not approved by the FDA would also be prohibited.

If the law is upheld — indicates that a majority of likely voters support it — California would become the second state to rid stores of both flavored vapes and menthol cigarettes, which have and Latino smokers since tobacco companies began marketing them in inner-city neighborhoods half a century ago.

The question of why California has granted hookah smokers an exception while banning menthol cigarettes, the choice of smokers, has sparked a debate about which tobacco products — if any — merit protection. Until recently, menthols had failed in the face of aggressive tactics by tobacco companies, which have staved off billions in losses by and .

Anti-tobacco groups warn that this strategy has become a model for fending off government interference. They decry the hookah exemption as the latest example of business successfully using identity politics to keep profiting from a deadly product.

“Hookah has been given a pass for no scientific reason,” said Carol McGruder, co-founder of the . McGruder, who has spent years waging war against tobacco companies for their “predatory targeting” of Black communities with menthol cigarettes, said hookah smoking has become increasingly trendy among Black youths.

Many young people mistakenly believe that than other forms of smoking, but experts say tobacco smoked through water pipes is just as addictive as cigarette tobacco and tar, nicotine, and heavy metals.

“They bring out a beautiful antique hookah pipe and they say that hookah is all about family and community,” McGruder said. “But it’s all about money.”

Big Tobacco itself is assailing the hookah exemption, saying it proves that the law discriminates against Black and Latino smokers by banning menthol flavors, while giving “special treatment to the rich,” as an paid for by the industry argues.

“Prop. 31 will increase crime and expand illegal markets, cut revenue for critical services and could backfire on the very communities its proponents say they want to help,” said Beth Miller, a spokesperson for the “No on Prop 31” campaign.

, clustered primarily in California and Massachusetts, have restricted the sale of flavored tobacco products, including e-cigarette pods in — strawberry, chocolate milk, and pink punch — which health officials say have provided a gateway to teenage smoking. Roughly half of the ordinances restrict menthol, while fewer than 20 — nearly all of them in California — exempt hookah tobacco and/or hookah bars.

In 2021, and nearly 75% of middle school students who had used a tobacco product in the previous 30 days reported using flavored tobacco, the Centers for Disease Control and Prevention reported. In 2019 and 2020, an lung disease, known as EVALI, killed 68 people.

The vaping epidemic has given anti-smoking activists an opening to lobby against menthol cigarettes. Invented in the 1920s, their cool, minty flavor helped new smokers adjust to them more easily than non-flavored cigarettes, and the industry marketed them as a healthier option. In the 1960s, tobacco companies turned to the Black community, to hip, young “communicators” in barbershops and bars. Menthol cigarettes account for more than a third of the $80 billion U.S. cigarette market.

Reynolds American, the country’s largest maker of menthol cigarettes, including Newport, has battled menthol bans by ’s National Action Network and other civil rights groups. When the a menthol cigarette ban in 2019, Sharpton cited the case of , a Black man who died in police custody in 2014 after he was stopped for allegedly selling single, untaxed cigarettes on the street.

But the success of these efforts came at a devastating price, public health experts say. African American men have the in America, according to the CDC.

Earlier this year, the FDA to ban sales of menthol-flavored cigarettes, a long-awaited move hailed by health officials and some Black leaders, even as they braced themselves for a protracted legal battle with the tobacco industry that .

For years, anti-smoking activists have been focused on menthol, said Valerie Yerger, an associate professor of health policy at the University of California-San Francisco. “Nobody was focused on hookah,” she said.

But water-pipe use among young people has been in recent decades.

At across the United States and Europe, contestants compete to build the most elaborate water pipe, often to a hip-hop soundtrack. Elaborate water pipes, with their billowing puffs of smoke, are often in rap videos.

“It’s just another way the industry has found to keep our young people addicted to these products,” Yerger said.

Hookah purveyors argue that blanket prohibitions endanger small-business owners, many of them immigrants, and threaten to erase a “” by effectively outlawing hookah pipes, which are often part of gatherings and celebrations for Arabs, Armenians, Persians, and others hailing from the Middle East. They reject the claim that their fight is only about money.

“Hookah lounges are a hallmark of community,” said Rima Khoury, general counsel for .

For Abramyan, smoking a hookah was an after-dinner, adult ritual his Iranian-born parents brought with them when they immigrated to America in the 1980s. The ornate water pipes are often several feet tall and take at least 20 minutes to set up.

“This is not something kids are smoking in the bathrooms at school,” he said. “We don’t want our kids to smoke, but why shouldn’t my grandpa be able to smoke his hookah in his backyard?”

Bible study groups and the local Rotary Club chapter regularly meet at his Tujunga hookah lounge, Garden on Foothill, which features outdoor gazebos for families and groups. “For Muslims who don’t drink alcohol, or people who don’t like to go to strip clubs, this is a safe space,” he said.

The shop he runs a few blocks away, Munchies Mart, sells handmade hookah pipes and tobacco in flavors such as Strawberry Lemonade, Orange Pop, and Agua Fresca, a far cry from the apple-soaked tobacco he remembers his Persian grandmother mixing in her kitchen.

Using cultural practices to argue for public policy exemptions is nothing new, said Arnab Mukherjea, an associate professor of public health at California State University-East Bay.

But he said that communities often suffer when corporate interests “use cultural identity to market a product for mass consumption.”

“You go to any college town,” he said, “and the hookah bars are filled not with practicing Muslims, but with college-age kids who are going there to socialize, consuming flavors in bubble gum and cotton candy.”

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The program that fed 50.6 million U.S. students expired in September, but some states are figuring out ways to extend it. and have both passed legislation to fund universal free lunch.

In Colorado, a coalition of parents, teachers, and anti-hunger advocates are pushing to make permanent universal free school lunches, and lawmakers in the Democratic-controlled legislature .

GlendaRika Garcia, a bilingual food assistance navigator for Hunger Free Colorado, strongly backs the idea.

“I think that the kids being able to eat for free at school is really important, for all families, all kids,” said Garcia, a widow and a single mom of four boys.

Two of them, Alonzo and Pedro, tossed a football around in front of their apartment building, as Garcia explained proposal on the ballot.

“Kids can’t learn if they don’t have good nutrition,” said Garcia, whose job entails signing up people for benefits and making sure they’re eligible.

The measure, known as , would use state funds to offer free meals for all public school students. It would also fund pay increases for school cafeteria workers, helping schools deal with staff shortages, and would incentivize schools to buy Colorado-grown food. That has some families, workers, and farmers cheering.

But critics point to a steep price tag for a new government program, which raises $100 million annually from a tax on households that make $300,000 or more a year.

School-aged members of a family of four making less than about $51,000 a year are eligible for free lunch. But that right now more than 60,000 Colorado kids can’t afford school meals yet aren’t eligible.

Garcia sees the proposal as a game changer, an equalizer. Depending on her job, Garcia at times qualified for her sons to get free lunches and at times didn’t, a blow to her budget.

Another issue, Garcia said, is that some kids bully others for getting a free lunch. It happened to her as a child when she also qualified for free lunch, and it happened to one of her sons.

“They know that people can identify if they can’t afford it. It hurts my heart,” she said.

Her son Alonzo said that at his high school some kids avoid the lunchroom rather than admit they qualify for free lunch.

“I think that they get embarrassed because they can’t afford it,” he said.

Many Colorado districts reported a clear uptick during the pandemic of provided for free at school.

“We were feeding kids that we have never fed before, and it was good to see them coming up, and not just buying junk food,” said Andrea Cisneros, the kitchen manager at West Woods Elementary School in Arvada.

Many students arrive at school without food, said Dan Sharp, the school nutrition director in Mesa County Valley School District 51 in Grand Junction.

The district saw a 40% year-over-year increase in meals served during the pandemic, said Sharp.

“I really believe there’s more households here and students that could qualify but don’t, due to the stigma that goes with applying for free and reduced meals,” he said.

Proponents said they did several throughout the pandemic and, according to a recent survey, 44% of respondents with kids at home reported struggling to have access to nutritious food.

Low-income students will keep receiving free meals through federal funding, whether the proposal passes or not. There’s no organized opposition to the measure, but it does have critics.

“Nobody wants to be evil enough to say it, but this is a really stupid idea,” said Jon Caldara, president of the , a libertarian think tank. “Most kids in Colorado do not need this. And in fact, those who do, already have this.”

The group’s voter’s guide .

“This proposal is, ‘Hey, let’s get the rich guys to buy our kids’ lunch,’” he said. “This is another expansion of state bureaucracy that is just not necessary.”

The governor told Colorado Public Radio’s he hasn’t made his mind up about how he’ll vote on it.

“I don’t have an objection to the funding mechanism, but at the same time I sort of ask myself, ‘If we had this, would it be better just to be able to pay teachers better, reduce class size?’” said Gov. Jared Polis, a Democrat. “Or is the best use of it lunches for upper-middle-income families?”

He added that the measure “doesn’t affect the state finances one way or the other because it’s effectively revenue-neutral with the mechanism.”

His Republican opponent seemed to lean toward supporting Proposition FF in .

“I haven’t had a chance to look at it, but I do want to make sure that every child has access to healthy food and lunches, so I’m certainly open to it,” said Heidi Ganahl.

The , a nonpartisan free-market think tank, analyzed the measure and raised several concerns, with modeling that showed it could be underfunded or raise more money than is needed.

“There needs to be some good oversight on the program so that costs are managed well, and also that they don’t develop a huge surplus,” said Steven Byers, the group’s senior economist.

Despite concerns about cost, universal free school lunch appears popular throughout the nation.

from its state budget to fund and support its universal free school meals program for the 2022-23 school year. Maine’s program was estimated by lawmakers to cost .

Washington, Minnesota, Wisconsin, Ohio, Pennsylvania, New York, Massachusetts, and North Carolina introduced bills similar to the one on the Colorado ballot, most of them during the current legislative session. All of them are still in committee and have yet to go up for a vote.

by the Urban Institute, a nonpartisan think tank focused on social and economic research, found that 76% of adults living with children enrolled in public school and 67% of adults not living with children enrolled in public school supported permanent free school meals.

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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 , 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 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 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 for .

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 , 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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Voters will decide on Proposal 3, which, if approved, would install protections for a woman’s right to have an abortion in the Michigan Constitution.

Kansas voted this year to keep abortion legal. Now Michigan is one of five states, along with California, Kentucky, Montana, and Vermont, asking voters next month to weigh in on abortion policy in the wake of the Supreme Court’s June ruling in Dobbs v. Jackson Women’s Health Organization. That ruling overturned the court’s 1973 Roe v. Wade decision and leaves states to set their own abortion policies.

Since the court’s ruling, abortion access in the U.S. has been evolving into a jumble of standards. In some states, decades-old laws lingering on the books could trigger dramatic shifts, while other states are eyeing new laws. But as the policy landscape forms, those on the front lines must operate in a state of uncertain limbo.

In Michigan, the politically deadlocked state government ensured that a 1931 law banning abortions was dusted off and then thrown to the courts, where judges temporarily blocked prosecutors from enforcing it. The ballot measure to protect abortion rights landed on ballots only after advocates submitted petitions bearing more than 735,000 valid signatures and Michigan Supreme Court justices ended a legal tug-of-war over petition technicalities.

Abortion policy has also spilled into both the attorney general race and the gubernatorial one, with Democratic incumbent Gov. Gretchen Whitmer, who supports abortion rights, running against Republican Tudor Dixon, an outspoken conservative who opposes abortion, even in cases of rape and incest.

When Whitmer urged Michigan voters to fight like hell to protect the right to abortion, Michigan Catholic Bishop urged Catholics to “” to stop the state constitutional amendment.

“There is a bit of a tennis match going on in Lansing right now,“ said Jim Sprague, CEO of the and a member of the coalition against Proposal 3.

Christen Pollo, executive director of , which works with students on campuses to end abortion, said that “overwhelmingly, voters oppose the extreme policies” in the measure. But according to a poll commissioned by the Detroit Free Press and its media partners, for the to codify abortion rights in the Michigan Constitution.

Meanwhile, the state’s abortion providers continue seeing patients amid the confusion around what will be legal in Michigan. At a full-service Planned Parenthood clinic in a bustling shopping plaza in Lansing, staffers still see a steady stream of women seeking services. And at a busy corner in front of the clinic’s parking lot, a continual flow of anti-abortion protesters still show up, holding signs, just as they have since this location opened decades ago.

It all looks much the same as before the Supreme Court’s historic decision, but behind the scenes, abortion providers and advocates are preparing for an uncertain future. Linda Goler Blount, president of the national in Atlanta, works with networks of activists around the country to support their efforts to make sure contraceptives are available. “Some of those groups are ordering medical abortion products, and stockpiling them,” she said.

And medical professionals worry about what happens if Michigan’s Proposal 3 doesn’t pass. Dr. , who works with medical residents at Michigan State University in East Lansing, said some of the emergency room and internal medicine residents worry they may be accused of causing an abortion as they provide care. Across the board, she said, physicians and other providers are concerned that their medical licenses could be in jeopardy, or they could find themselves locked up if the ballot measure fails.

The whole medical community is “in a wait-and-see moment,” she said.

But if Proposal 3 passes, Sprague said, it will cause a that protect women and children. He called it “a bad law for women” in Michigan that is too radical.

A ban on abortions in the state would likely have the greatest impact on Black women. According to the , Black women make up nearly 56% of patients who had abortions in the state in 2021.

“The disparity in the number of Black women who seek out abortion services speaks to the many health care inequities that they suffer across the board,” Goler Blount said.

So Black reproductive activist groups are among those on the ground making it clear to voters where elected officials stand, Goler Blount said. She added that they are working on massive voter registration and get-out-the-vote efforts.

Both sides in Michigan have invested millions in ads to make their case. In addition to neighborhood canvassing and phone trees, they are taking to social media, including , who is backing the measure. Signs for each side are sprouting in yards and anti-abortion groups have been assembling prayer rallies around the state.

The stakes are high and heated as the state awaits the vote. In September, a man shot in the shoulder in Ionia County while she was passing out anti-abortion pamphlets, and earlier this month, was sprayed outside a Roman Catholic Church in Lansing.

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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 at private hospitals, psychiatric facilities, and dialysis clinics. The Service Employees International Union-United Healthcare Workers West, which represents roughly 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 .

A 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 “.” An analysis commissioned by the California Hospital Association estimated that the change would raise costs for private facilities by , 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 and , 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 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 , 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 . 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.”

This story was produced by , which publishes , an editorially independent service of the .

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Legislative Referendum 131 was approved for next month’s election by state lawmakers in 2021, more than a year before the U.S. Supreme Court removed federal protections for abortion in June.

Abortion remains legal in Montana because of a that protects it under the state constitution’s . Three laws passed by the Republican-led legislature in 2021 to restrict abortion while a legal challenge proceeds, arguing that they violate the constitutional provision.

But lawmakers sent LR-131 directly to voters to decide whether it should become law.

Here are five key things to know about the ballot measure:

1. What would the initiative do?

would impose criminal penalties of up to 20 years in prison and up to a $50,000 fine on any health care worker who doesn’t try to save a “born-alive infant.” That term is defined as a legal person who breathes, has a heartbeat, or has voluntary muscle movement after an abortion or delivery.

The measure would require health care providers to “take medically appropriate and reasonable actions” to keep the fetus or infant alive, but it doesn’t define or give examples of such actions. The health care workers liable under the initiative would be doctors and nurses but also any “individual who may be asked to participate in any way in a health care service or procedure.”

The initiative includes a mandatory reporting requirement, which means that any employee or volunteer at a medical facility who is aware of a violation must report it to authorities.

2. Where did the initiative come from?

, the 2021 legislation that authorized the referendum, was sponsored by state Rep. (R-Kalispell), chair of the panel that oversees the state Department of Public Health and Human Services’ budget.

“We need to make it abundantly clear that here in Montana, the protection of all life is available,” while introducing the bill in January 2021.

The bill is very similar to in 2018 as a template for state lawmakers nationwide. So far, 18 states have provisions along those lines, and more are considering them, according to the group. Its president and CEO, Catherine Glenn Foster, during the 2021 legislative session.

The Montana measure does not include a provision in the model legislation that gives an infant’s parents the right to refuse medical intervention if the treatment isn’t necessary to save the infant’s life, would only temporarily prolong the infant’s death, or carries risks that outweigh the potential benefits to the infant.

The Montana measure also excludes a clause in the model legislation that exempts parents and guardians from criminal and civil liability. The Montana initiative doesn’t address parental liability.

Bradley Kehr, Americans United for Life’s policy counsel, described the ballot initiative as “well tailored to the needs of Montana.”

3. What does the initiative have to do with abortion?

Regier’s bill says the purpose of the referendum is to protect infants who have survived abortions from being denied medical care and being left to die.

The measure’s passage would move the Family Research Council’s classification of Montana’s “born-alive” protections from compared with the rest of the nation, according to Connor Semelsberger, director of federal affairs for life and human dignity for the nonprofit organization, which advocates for anti-abortion measures.

Montana is not among the nine states that require health providers to report when an infant is born alive during an abortion. The Family Research Council lists the states that do as Arkansas, Arizona, Florida, Indiana, Michigan, Minnesota, Ohio, Oklahoma, and Texas.

Instances of fetuses surviving abortions . In Minnesota, which the Family Research Council points to as having the strongest protections in the U.S., five of the 10,136 abortions performed in 2021 resulted in a live birth, . None of the five survived.

The number of abortions in which a fetus could survive is small, too: The point at which a fetus can survive outside the womb is generally considered to be after 22 weeks of pregnancy, and about .

The leaders of two Montana clinics that provide abortions said the initiative’s passage would not affect their operations, as Montana law restricts performing abortions after a fetus is viable. The law does not define viability.

Nicole Smith, executive director of Blue Mountain Clinic in Missoula, said her clinic provides dilation-and-evacuation abortions that would not result in a live birth. “We do not provide obstetric or labor-and-delivery care,” she said, adding that she would refer a patient who needed that kind of care to someone who specializes in high-risk pregnancies.

Helen Weems, director of All Families Healthcare in Whitefish, said her clinic does not perform abortions after 12 weeks. LR-131 “is designed to look like an anti-abortion measure, but it has no relevance” to her clinic, she said. “There would never be an occasion in my practice where there would be an infant born alive,” Weems said.

4. If clinics that provide abortions won’t be affected, who will?

The initiative also covers any natural birth, induced labor, or cesarean section.

That could present obstetricians and gynecologists with an ethical dilemma of having to choose between their obligation to provide the best available medical care to their patients or the potential of facing legal penalties, according to a by the American College of Obstetricians and Gynecologists opposing the Montana measure.

The organization said LR-131 could require an aggressive course of treatment in extremely complex and often tragic medical situations. It opposes the measure as government interference in the patient-physician relationship that would impose additional trauma on families.

Smith said the initiative would apply to miscarriages and to hospital deliveries in cases when parents know their child won’t live but want to complete the birth for a chance to hold the baby and say goodbye.

Opponents of the ballot initiative use the example . They say that rather than allowing the family to hold, say goodbye to, or baptize the baby before it dies, the measure would require health care workers to remove it in an attempt to save its life.

found that all 129 infants who were born before 22 weeks and were included in the study died. Two received active medical treatment. Of those born in the 22nd week, 5% survived. Most of the 24 hospitals in the study provided treatment to all infants born at 25 or 26 weeks. Those born at week 26 had an overall survival rate of about 81%, and 59% survived without moderate or severe impairment.

5. What does existing federal and state law say?

, it’s already a felony to purposely, knowingly, or negligently cause the death of a viable, premature infant. passed in 2002 says a person includes “every infant member of the species homo sapiens who is born alive at any stage of development.” It defines “born alive” as evidence of a heartbeat, breathing, or voluntary muscle movements, but does not include any additional provisions.

Opponents of the Montana measure point to those laws as evidence that LR-131 is unnecessary and is instead meant to drive conservative voter turnout. “This cruelty is being forced on already grieving families for the cold, calculated political gain of extreme-right politicians,” Weems said.

Regier, the legislator whose bill authorized the referendum, said current Montana law does not go far enough to protect infants.

Semelsberger, of the Family Research Council, said the same about the federal law and that it has lacked enforcement. The organization supports (R-Neb.) that would add requirements to save the life of an infant, though with up to five years of maximum prison time, instead of the 20 years in Montana’s measure.

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“They’ll get guaranteed earnings, health care benefits, personal protections, and they can maintain their flexible schedules.”

Political ad paid for by Lyft in favor of California’s Proposition 22. The ad was

on YouTube

on Oct. 8, and emailed by Lyft to its customers.

[UPDATED at 1:15 p.m. ET]

App-based driving services such as Uber, Lyft, DoorDash and Instacart California’s Proposition 22, which would keep their drivers classified as independent contractors, not employees.

Leading into the Nov. 3 election, the ballot measure — which has become the — is mired in controversy and the subject of a from Uber drivers alleging that the company inappropriately pressured them to vote for the initiative.

But what’s occasionally lost in the debate over Proposition 22 are the claims about what it will mean for app-based drivers.

Detractors, like unions and driver advocacy groups, say Proposition 22 would strip drivers of the protections of , a 2019 California law delayed by legal challenges. The law requires drivers to be classified as employees, which would afford them the associated benefits like paid sick leave, workers’ compensation and access to unemployment insurance.

Supporters, such as ride-sharing companies and the California Chamber of Commerce, say Proposition 22 would give drivers benefits, like a guarantee of minimum earnings and compensation when they are hurt on the job, while allowing them to maintain the flexible schedule of independent contractors.

In an online ad paid for by Lyft, the company says “Prop. 22 will give them … health care benefits.”

That sounds like drivers with Uber, Lyft and other app-based companies will automatically get health insurance if Proposition 22 passes. The truth is a little more complicated.

What Does ‘Health Care Benefits’ Mean?

We reached out to Lyft to back up its claim, and the company directed us to the “Yes on 22” campaign. This is how the campaign explained “health care benefits”:

Under Proposition 22, drivers who qualify — more on that in a minute — would get a stipend they could use to buy an insurance plan from Covered California, the state’s health insurance marketplace.

That stipend would be calculated like this: App-based companies would look at the statewide average monthly premium of bronze-level plans sold on the Covered California exchange.

The companies would then give qualified drivers a stipend of 82% of the average premium, said Geoff Vetter, a spokesperson for the Yes on 22 campaign. (On average, U.S. employers covered for single coverage in 2019.)

So hypothetically, if bronze plans cost an average of $100 per month, Uber, Lyft or a similar company would provide qualifying drivers with $82 per month.

Drivers would be eligible for the full stipend — all $82 in the hypothetical case — if they average 25 hours per week of “engaged” time, which does not include time spent waiting between jobs.

“Most drivers work part time” and spend about one-third of their time waiting for rides and deliveries, according to the nonpartisan state . Using that equation, drivers would need to work an average of 37.5 hours per week for a single company in order to receive the full stipend.

A driver who averages at least 15 but less than 25 hours of engaged time each week would be eligible for 50% of the stipend — or $41 per month.

The stipend would be similar to employer-sponsored insurance because both employers and employees would contribute to the cost of insurance, Vetter said.

“For the people who do work closer to full time, it does give them that ability to receive health care coverage by getting a typical employer contribution for that coverage,” Vetter said.

Does a Stipend Equal Coverage?

But this stipend bears little resemblance to traditional employer-based insurance, which is what drivers would get if they were considered employees instead of gig workers, said Ken Jacobs, chair of the University of California-Berkeley Center for Labor Research and Education.

“It has very, very little relationship to what anyone would think of as job-based coverage,” Jacobs said. “It’s really wrong to think of this as health insurance.”

For instance, under Proposition 22, the stipends would be calculated and distributed quarterly, based on drivers’ hours. That could force drivers to periodically reassess what kind of coverage they would qualify for and could afford.

With traditional employer-sponsored insurance, a driver would enroll in a plan once per year and the premium wouldn’t change.

A vacation or illness could mean that drivers can’t maintain the hours required by the measure, costing them their stipend — and perhaps their insurance — for the quarter, and stripping them of the stability usually associated with job-based coverage, Jacobs said.

And getting money to buy an individual plan isn’t the same as participating in a large group plan offered by an employer, said Jen Flory, a policy advocate at the Western Center on Law & Poverty, a nonprofit organization that advocates for low-income Californians and opposes Proposition 22.

Covered California plans are typically less generous than the policies employees usually get through work, she said. And bronze-level plans, which have the lowest monthly premiums, also have the highest out-of-pocket costs for medical services.

Consider the deductible, which is how much a person needs to pay out-of-pocket before insurance starts paying for care.

In 2018, fewer than half of Californians who had work-based insurance had a deductible, and on average, that deductible was $1,402 for a single person, according to from the California Health Care Foundation. (California Healthline is an editorially independent service of the California Health Care Foundation.)

The deductible on a Covered California bronze plan for an individual in 2021 will be for medical services plus $500 for prescription drugs. Proposition 22 ties the stipend “to the highest deductible, highest out-of-pocket plans on the market,” Flory said. “And it’s for workers who aren’t making a whole lot of money.”

Drivers could use the stipend to buy a more generous plan, but the monthly premium would be higher and the stipend would cover less of it.

Depending on their incomes and other factors, drivers may also be eligible for tax credits and state and federal subsidies to help them afford plans on the individual market. But Flory said this amounts to the government subsidizing health insurance that employers should be paying for themselves.

It’s also problematic to base the stipends on a statewide average of bronze premiums because that doesn’t take into account the huge regional differences in the cost of care, said Gerald Kominski, a senior fellow at the UCLA Center for Health Policy Research.

“In the Bay Area, that contribution is going to buy a lot less than it would in Southern California,” Kominski said. “We’re a big state and have a lot of variation of health care costs.”

Our Ruling

The stipend offered under Proposition 22 is a “health care benefit,” but the wording is misleading and ignores critical information.

While neither Lyft nor the Yes on 22 campaign says the proposition will give drivers health insurance, saying that it will offer them “health care benefits” gives the impression that the stipend is similar to traditional job-based coverage. It’s not.

Drivers who value the ability to make their own schedules would have to figure out how to work an average of nearly 40 hours a week — essentially full time — to receive the full stipend. The stipend would cover a fraction of the premiums for health insurance that’s typically less generous than what they’d get as employees.

Moreover, because drivers’ stipends could change quarterly based on their driving time — which could be affected by vacation or illness — any coverage purchased with the stipend could carry a cloud of uncertainty.

We rate this claim as Half True.

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