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

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

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

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

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

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

Hmm, really?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The interview has been edited for length and clarity.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The results are mixed.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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But a fundamental question looms: Will they?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It Wednesday against New York’s statewide flavor ban.

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

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

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

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

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

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

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

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

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

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

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That’s the year America’s youngest baby boomers will reach retirement age.

The country already is feeling the effects of an aging population, but its most populous state is bracing for a hard hit as retirement collides with increasing poverty and the high cost of living. By 2030, an estimated 1 in 5 Californians will be 65 or older, representing a segment of the population growing , according to the Public Policy Institute of California.

“As we grow in the number of older Californians, we actually shrink in the number of younger Californians” who will make up the workforce, Dr. Mark Ghaly, secretary of California’s Health and Human Services agency, said Monday at a forum hosted by The SCAN Foundation, which advocates for the welfare of older adults. (Kaiser Health News, which publishes California Healthline, receives support for its coverage of aging and long-term care issues from .)

“We can’t just wait to watch it happen, but we have to plan ahead.”

The forum revolved around the creation of a statewide Master Plan for Aging, due in October 2020, that is intended to address how California must adapt to the needs of its aging residents. California Gov. Gavin Newsom issued in June calling for the plan, which would coordinate and improve the confusing web of existing programs — and create more, if necessary.

The committee that will formulate the master plan was set to meet for the first time Tuesday in Sacramento. is open to the public.

Newsom’s call for a master plan follows the lead of — Colorado, Connecticut, Minnesota and Washington — which have published similar plans, according to The SCAN Foundation. All document the changes needed in every aspect of daily life, from finances to transportation, to help aging people remain as active, mobile and independent as possible.

“The states that have something that looks like a master plan, or strategic plan around aging, perform better” on measures of , said Dr. Bruce Chernof, president and CEO of the foundation.

This may be because states with master plans tend to measure how their programs are improving the lives of older adults and their families, which means local and state governments are more accountable when they invest public money, Chernof said.

California Healthline interviewed state and local officials, researchers, advocates and older adults who attended Monday’s forum to ask what they’d like to see in the master plan.

A key issue for several participants was California’s affordable housing crisis.

Oakland resident Jerome McIntosh, 62, went on disability three years ago after suffering a massive heart attack. He survives on $1,070 a month, and lives with eight other people in a transitional home for seniors operated by St. Mary’s Center in Oakland. McIntosh is looking for an affordable place of his own that costs about one-third of his income. But in the past year, he has received only one callback on an apartment application. The monthly rent was $1,065.

“Housing is about the hardest thing,” McIntosh said. “Right now I’m in a transitional house, but I’m still homeless.”

Janny Castillo is an organizer and program coordinator at St. Mary’s Center, which serves about 1,000 low-income seniors in Oakland, including some who are homeless. Many of them, like McIntosh, get by on about $1,000 a month, which makes it almost impossible to afford housing in the Bay Area, Castillo said. She believes rent subsidies could help solve the problem.

“One of the things that is really critical right now is to address the seniors that are living outside,” Castillo said. “We’re losing them earlier than we need to, because of how hard it is to live outside.”

Even Californians who aren’t at risk of homelessness may not be able to remain in their homes if they get sick.

Almost one-third of seniors in the U.S. have nothing saved for retirement, while two-thirds of baby boomers are carrying an average of about $110,000 in credit card, student loan or mortgage debt, according to the .

If Californians don’t qualify for Medi-Cal, the state’s Medicaid program for low-income people, which funds some in-home care for eligible people, the high cost of in-home care falls on individuals and their families, said Lorna Van Ackeren, a marketing and community liaison at Hillendale Home Care, which hires out state licensed caregivers.

The business pays caregivers $15.50 to $19 per hour, based on experience, Van Ackeren said.

“But we charge the families $31 an hour, so it’s a real problem,” she said. The difference covers the agency’s legal obligations, such as maintaining their state licenses and insurance.

“It would be nice to have some kind of assistance for the middle class,” she said.

By 2030, more than 1 million seniors in California will require some in-home help, and more than 100,000 will need to live in a nursing home, according to the Public Policy Institute of California.

A severe labor shortage for caregivers also looms. By 2030, California will need as many as to care for seniors at home.

Richard Figueroa, a deputy Cabinet secretary in Newsom’s administration, said the governor wants the plan to include recommendations on how to help people age at home. “What can we do to help people stay in their homes as long as they can? Because there will be more and more folks in that situation, and our services and programs and opportunities are going to have to adapt to that,” he said.

California already has services for its aging population, but “people need to be able to navigate the system more easily without jumping through hoops,” said Christina Mills, executive director of the California Foundation for Independent Living Centers.

“Increasing the number of aging and disability resource centers across the state of California” could help, she said. “There are currently about eight, but there’s potential to be about 30,” she said.

State Assemblyman Joaquin Arambula (D-Fresno) said the needs of older Californians differ by region and cultural background. “I’d like to make sure that the needs and wishes of our immigrant and rural communities are taken care of,” he said. “We need to be both culturally and linguistically sensitive to the needs of various communities. We should make sure the surveys we are doing are reaching all communities and in languages they can understand.”

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Lucas McClain started smoking cigarettes in high school but switched to vaping after he heard e-cigarettes were a safer alternative.

His vape of choice became the Juul, the king of electronic cigarettes — which comes with a king-size nicotine hit.

Now 21, McClain wants to quit so badly that he’s turning back to the problem he fled in the first place: good old-fashioned cigarettes.

“Juul made my nicotine addiction a lot worse,” the Arlington, Va., resident said. “When I didn’t have it for more than two hours, I’d get very anxious.”

Even though McClain knows the dangers of cigarettes — lung cancer runs in his family — he thinks it might be easier to kick cigarettes than his Juul. Plus, his mom keeps warning him about the mysterious vaping-related illnesses that have sickened hundreds across the country.

So last month, McClain bought his first pack of cigarettes in years. Then he tweeted about it.

“Bought a juul to quit smoking cigarettes,” he wrote, “now I’m smoking cigarettes to quit the juul.” He ended with this hashtag: #circleoflife.

Bought a juul to quit smoking cigarettes… now I’m smoking cigaretttes to quit the juul

— el mac (@ELMAC___)

One Juul pod, which provides about 200 puffs, contains as much nicotine as a pack of cigarettes. On stressful days, McClain could finish a pod in three hours — and as he and others figure out these and other e-cigarettes are, many want out.

Some are turning back to combustible cigarettes — or taking them up for the first time — in a dangerous bid to lower their nicotine intake and ultimately get off their vapes.

“Isn’t it ironic that to quit juul I bought cigarettes,” . Another points out that it’s “strange” that she used the device to quit smoking cigarettes but is now “far more than I ever was to cigs.”

“It sucks,” she said.

It isn’t a complete surprise that some young people are “going back to the product they were trying to quit in the first place,” said Pamela Ling, a professor of medicine at the University of California-San Francisco who studies tobacco and its marketing.

But it is worrisome because cigarettes contain toxins and chemicals that are dangerous to their health, she said.

Vaping may not be safe either. The Centers for Disease Control and Prevention is investigating at least — mostly among young people — possibly linked to vaping nicotine and marijuana. have died. California is investigating at least .

The back-to-smoke trend flies in the face of the e-cig industry’s most insistent PR pitch: Vaping helps people quit smoking cigarettes. In fact, San Francisco-based Juul Labs, which commands , says in its that the company aims to eliminate cigarettes by giving adult smokers “the tools to reduce or eliminate their consumption entirely.”

In an emailed statement, Juul didn’t directly address the decision by some of its users to revert to cigarettes, but again clung to the refrain that its products are “designed to help adult smokers switch from combustible cigarettes to an alternative nicotine delivery system.”

Ted Kwong, a Juul spokesman, said Juul is not designed to get people off nicotine or to treat nicotine dependence.

For those who criticize Juul’s high nicotine content, Kwong noted that pods come in two strengths — 5% and 3% nicotine concentrations — letting users customize their “switching journey.”

Monday, the Food and Drug Administration Juul for promoting its products as being safer than cigarettes without FDA permission. It gave Juul 15 business days to respond.

Vaping has become big business, with the global market projected to hit by 2023.

Smoke or vapor, cigarette makers win either way. Altria, which sells Marlboro and other tobacco brands in the U.S., invested in Juul for a 35% stake last year. Altria has proposed reuniting with Philip Morris International, a unit it sold off in 2008.

Even though the industry says vaping is intended for adults, Juul and other vaping pens took off among young people about two years ago when teens began taking the devices to school and teachers mistook them for flash drives. Students took hits in campus bathrooms and halls, and even in class when teachers weren’t looking.

The e-liquids inhaled from the devices contain nicotine and come in that appeal to kids.

Michigan last week became the first state to ban sales of flavored e-cigarettes in an attempt to end teen vaping. In June, the San Francisco Board of Supervisors banned the sale of all e-cigarettes, . Juul is fighting back with a November ballot measure, Proposition C, backed by millions of its own dollars.

Many former smokers attest that vaping was the only thing that , but the . Some studies have shown that many vapers continue to smoke cigarettes.

The FDA has approved seven treatments for smoking cessation, including patches, gums and lozenges. Vapes are not among them, said Dr. Elisa Tong, an associate professor of medicine at the University of California-Davis.

Tong said vapers may be using more nicotine than they realize. She understands why some choose to go back to cigarettes, but she doesn’t recommend it.

“What they’re doing is trying to taper down super high levels of nicotine,” she said. “Unfortunately, manufacturers don’t have a manual on how to quit their devices.”

Dr. Amanda Graham, senior vice president of innovations at the Truth Initiative, an anti-tobacco advocacy group, said she is seeing “desperation and misguided approaches” from teens and young adults trying to free themselves from nicotine.

“Young people are fumbling in the dark with what seems logical,” Graham said. “But there is no safe level of cigarette smoking.”

Early this year, Graham’s group launched a digital program to help teens and young adults quit their vaping devices. Since then, 41,000 people between 13 and 24 have enrolled in “,” which sends them tips and support via text messages.

Chris Gatus of Whittier, Calif., switched from traditional cigarettes to Juul because he thought the device would help him quit smoking, he said.

But because his Juul is always glued to his palm, he found himself using it everywhere and all the time.

“I’ve sort of forgotten what it’s like not to be on nicotine,” said Gatus, 21.

He switched back to cigarettes this year after noticing his growing addiction, but that only resulted in his using both. Now he’s trying different vaping pens, looking for something less harsh than the Juul or cigarettes, he said.

Last week, Ryan Hasson of New York City threw out his Juul after experiencing strong chest pains and labored breathing when exercising — and after hearing about the growing number of vape-related illnesses. He had never felt such strong symptoms when he smoked old-fashioned cigarettes, he said.

“I don’t plan on ever smoking again, but if I had to choose, I would much rather buy cigarettes over a Juul,” said Hasson, 25.

The same is true of his friends, he said.

“I think a lot of people are quitting completely or going back to cigarettes,” he said. “They’re waking up to the reality that maybe this isn’t as safe as we once thought.”

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