So, they routinely accept emergency calls during their meal and rest breaks — just as firefighters, policemen and other public emergency workers do.

But labor laws guarantee most California workers uninterrupted breaks, and multiple lawsuits are challenging whether private ambulance companies have the right to interrupt their employees’ breaks.

In November, voters will resolve the issue. — a measure backed and funded by American Medical Response (AMR), California’s largest private ambulance company — would require private-ambulance employees to remain on call during their breaks.

“If a dispatcher calls and the closest ambulance is only a few blocks away, they’ll be reachable and ready to respond,” said Marie Brichetto, spokeswoman for the campaign advocating the ballot measure. “In times of emergency, seconds will make a difference.”

Proposition 11 also would require private ambulance companies to provide their employees with mental health coverage and training to respond to natural disasters, mass shootings and other emergencies.

The ballot measure would apply to the state’s estimated 17,000 private ambulance employees, including dispatchers, emergency medical technicians (EMTs) and paramedics, who answer about three-quarters of the state’s emergency calls, according to a by the state Legislative Analyst’s Office. The initiative doesn’t affect public ambulance workers because the labor codes governing rest and meal breaks apply only to private-sector workers.

Opponents of the measure, including a California lawmaker who works part time as an EMT, call it a “misleading” effort by the industry to save money on staffing — and get out of potentially bank-breaking lawsuits.

The initiative isn’t about public safety, but rather “trying to extract machine-level work from human beings,” said Mike Diaz, an AMR employee in Antelope Valley and president of the International Association of EMTs and Paramedics Local 77.

For AMR, “the most efficient ambulance crew is one that is on a call for every hour of your 24-hour shift,” he said. “We’re not machines. We need rest.”

The initiative grew out of a 2016 state Supreme Court ruling in , which found that a California security company had failed to meet its legal obligation to provide breaks because its workers had to remain on call.

Given the similarities between the private security and ambulance industries, the case is likely to be applied to private EMTs and paramedics, the analyst’s Ìý³¦´Ç²Ô³¦±ô³Ü»å±ð»å.

AMR is already facing at least two lawsuits from employees who say they were denied breaks.

If the ambulance companies lose in court, they can no longer assume their employees are available during their breaks and would have to increase staffing — which could cost the industry around $100 million a year, the report said.

Proposition 11 is the industry’s effort to avoid that. The ballot measure also includes a provision that would effectively nullify the pending lawsuits.

So far, AMR is the only donor on either side of the measure. The company has poured about $3.6 million into a committee to support the measure, and the committee has used about $3 million of that, mostly to get the measure on the ballot. AMR declined to comment for this article and referred inquiries to Brichetto, the Proposition 11 campaign spokeswoman.

Some ambulance companies have offered muted support for the measure, while others have remained silent.

Edward Guzman, CEO and general manager of the nonprofit Sierra Ambulance Company in eastern Madera County, said he supports Proposition 11. But he acknowledged there are some private companies that overwork their employees.

“Some of the urban providers … were running their people into the ground and not providing adequate rest or breaks,” he said. “There are players that will continue to do that because they don’t want to add extra units into the mix.”

This summer, Sierra added an additional ambulance and paramedics to its daytime rotation to respond to higher demand, and employees have a strong collective bargaining agreement that protects them from overwork or abuse, Guzman said.

Still, he fears that his smaller company could get slammed with lawsuits if Proposition 11 doesn’t pass. The measure protects Sierra “from unnecessary and expensive litigation,” he said.

County officials across the state cannot take political positions, but some worry that if the measure fails and lawsuits against the companies succeed, the cost of hiring more ambulance workers could be passed on to them. Some counties hire private ambulance companies to supplement local fire departments and public ambulances.

“Somebody’s gonna have to pay for that,” said Cathy Chidester, director of Emergency Medical Services for Los Angeles County. “That [cost is] going to go back to the general public.”

Opposition to the ballot measure is largely unorganized but includes some unionized emergency response workers and lawyers representing the plaintiffs who are suing AMR. They argue that the proposition won’t change how private-ambulance employees operate, because their first instinct is to help people in distress.

“If I see something happen in front of me while I’m having my meal or rest break, I’m gonna respond. That’s our duty. That’s our calling,” said state Assemblyman Freddie Rodriguez (D-Pomona), who works part time as an EMT. “We’re not gonna sit there and watch somebody die just because we’re eating.”

Rodriguez and other opponents say the Proposition 11 campaign’s emphasis on public safety masks its true intentions: to maximize private companies’ profit margins.

“It’s a little misleading,” Diaz said.

EMT and paramedic workloads vary greatly depending on the county and employers. Diaz, who works in the Antelope Valley region of Los Angeles County, said his area is chronically understaffed. But Dandy Mendoza and Esther Nungaray, who work for American Ambulance in Fresno County, said they take an average of six to seven calls during a 12-hour shift — a number they consider reasonable.

“I don’t really have a strong opinion because I really like my job. I show up to take care of people,” Mendoza said. “I try to stay out of politics.”

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The results of Tuesday’s primary have set up general-election contests between candidates — for governor, attorney general, insurance commissioner and some congressional seats — with sharply differing views on government’s role in health care.

The outcome in the Golden State could help shape the fate of the Affordable Care Act and influence whether Republicans in Washington take another shot at dismantling the landmark law.

“For the Affordable Care Act, California is a bellwether state,” said David Blumenthal, president of the Commonwealth Fund, a New York-based health policy research organization. If California voters don’t elect more Democrats to Congress, it will be harder for the party to gain legislative control and “the Affordable Care Act will continue, as it has been, to be under attack from an empowered Republican majority,” he said.

Despite being targeted for voting last year to repeal the ACA and cut Medicaid funding, several Republican incumbents performed well at the polls in California.

“California was supposed to lead the blue wave, but that’s not what we saw” in the primary, said Ivy Cargile, an assistant professor of political science at California State University-Bakersfield.

In the California governor’s race, Democratic front-runner Gavin Newsom quickly sought to cast the November contest as a referendum on Trump and his effort to undo much of President Barack Obama’s legacy, particularly on health care.

endorsing Republican candidate John Cox, a multimillionaire real estate investor, helped propel the political outsider to the general election.

“It looks like voters will have a real choice — between a governor who will stand up to Donald Trump and a foot soldier in his war on California,” Newsom said Tuesday night to supporters in San Francisco.

California has embraced the federal health law enthusiastically and stands to lose more than any other state if the ACA is gutted. About 1.5 million Californians buy coverage through the state’s Obamacare exchange, Covered California, and nearly 4 million have joined Medicaid as a result of the program’s expansion under the law.

Newsom, a former San Francisco mayor and the current lieutenant governor, has the coverage gains made under the ACA. He has vowed to go even further by pursuing a state-run, single-payer system for all Californians.

Newsom won the primary with 33 percent of the vote and Cox placed second with 26 percent. Some mail-in votes and provisional ballots .

Cox has slammed Newsom and fellow Democrats for imposing government controls on health care that he says make coverage too expensive for families. He said he isn’t interested in defending the Affordable Care Act and that, if the law is scrapped, millions of Californians can go into high-risk insurance pools — an idea that predates the health law.

Andrew Busch, a government professor at Claremont McKenna College, said the political divide over health care has grown even wider this year as single-payer has gained support from mainstream Democrats in California.

“I’d say the Republican candidates are pretty much where the Republicans have been, but the Democratic candidates have shifted to the left, so the choice is starker than it has been,” Busch said.

Heading into Tuesday’s primary, it wasn’t clear that California voters would face such drastically different choices on the November ballot. Under the state’s primary system, the top two vote-getters, regardless of party affiliation, advance to the general election. That left many experts predicting single-party matchups across the state.

But that scenario also didn’t pan out in the race for attorney general, a position that has played a key role in California’s resistance politics since Trump was elected. Democratic incumbent Xavier Becerra, who has become a national leader against Trump’s agenda, will face off against Republican Steven Bailey in the fall.

Becerra has filed on health care and other issues since taking office in January 2017.

Bailey, a criminal attorney and former judge, has blamed the Affordable Care Act for driving up health care costs, and he favors less industry regulation. He also has criticized Becerra for fixating too much on Trump.

“Just because a tweet comes out of Washington, it doesn’t require a lawsuit to be filed the next day,” Bailey said.

Health care could also play a role in several of California’s congressional races. Democrats are trying to win back control of the House, in part to better block Republican efforts to roll back the ACA.

“The actions of the Trump administration, the elimination of the individual mandate and its impact on markets will become more of an issue,” said Chris Jennings, a former health care adviser in the Obama administration. “The conservative caucus has been forcefully advocating for another aggressive return to the repeal effort.”

nationally is in a district of California’s San Joaquin Valley where Republican incumbent Jeff Denham drew several Democratic opponents after voting to repeal the health law last year — as did .

Denham led a crowded primary field with 38 percent of the vote Tuesday. Democrat Josh Harder is holding on to second place with nearly 16 percent, just ahead of a Republican challenger. until late-arriving ballots are counted.

Harder said the Republicans’ repeal-and-replace effort on health care was a major reason he decided to run. He made it a centerpiece of his campaign and ran ads criticizing Denham for voting to take away coverage from thousands of his constituents. About 40 percent of residents in this Modesto-area district are enrolled in Medicaid, the government insurance program for the poor and disabled.

Denham has defended his repeal vote, saying that patients’ access to doctors has only gotten worse since coverage was expanded under the ACA. In a statement last year, Denham said, “coverage does not necessarily equal care and families must resort to overflowing emergency rooms to be seen.”

But Dan Schnur, a Republican political strategist who teaches at the University of Southern California and the University of California-Berkeley, said health care has gone from a negative to a positive for Democratic candidates, who have spent the past several elections defending Obamacare.

“As a result, they’re doing everything they can to emphasize the health care debate rather than run away from it,” he said.

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More than 300,000 cases of gonorrhea, chlamydia and syphilis — the most common sexually transmitted bacterial infections — were reported in 2017. That represents a 45 percent increase since 2013 and the highest number since at least 1990, state Department of Public Health numbers show.

Some of those cases had tragic endings: Thirty of the 278 babies affected by congenital syphilis in 2017 were stillbirths, the highest number in 22 years. occurs when syphilis passes from a pregnant woman to her fetus.

California has the second-highest rate of congenital syphilis in the country after Louisiana, according to the .

“We’re getting a lot of … younger pregnant women infected with syphilis and not getting prenatal care,” said Mario Alfaro, regional program director for education at Planned Parenthood Mar Monte in Fresno.

Fresno County accounted for 60 of the state’s congenital syphilis cases last year, including seven stillbirths, said Joe Prado, a division manager at the county Department of Public Health.

Fresno County participates in a pilot program run by the U.S. Centers for Disease Control and Prevention (CDC) and the state public health department to address congenital syphilis. Officials say the program has already increased outreach and screening but that the number of diagnoses is still rising.

Newborns with congenital syphilis may suffer from deformed bones, severe anemia, blindness, deafness or other symptoms. According to the CDC, to women with untreated syphilis may be stillborn or die from the infection as a newborn.

Alfaro cited lack of access to health care, insurance and education as contributing factors to the rise in congenital syphilis. “All of those things are a deadly combination,” he said.

Prado also pointed to a rise in syphilis among methamphetamine users.

“We’re just seeing this is a more difficult population to get a hold of, to reach and really be able to get them to consent and agree to treatment,” he said.

Chlamydia has increased 9 percent in California since 2016. Chlamydia is more prevalent in women, while gonorrhea, which has increased 16 percent since 2016, is more common in men.

“Half of chlamydia and a third of gonorrhea cases are folks under age 25,” said Dr. Heidi Bauer, the state public health department’s chief of the Sexually Transmitted Diseases Control Branch.

Her division released this preliminary data this week, a few months before the final numbers become available, because the increases are so dramatic, she said.

Rates of both chlamydia and gonorrhea are nearly five times higher among blacks than whites. And men who have sex with men also have much higher rates of infection than the general population. Their rates of syphilis are more than 20 times the overall rate, and their rates of gonorrhea are more than 15 times the overall rate.

The state’s data did not include HIV, a viral STD. New HIV infections fell in both California and nationwide from 2012 to 2016, in part because of and increased use of the .

While there’s of the other STDs, Bauer pointed to “very high rates of folks who are not accessing sexual health services and aren’t getting screened frequently.”

If left untreated, chlamydia and gonorrhea can lead to infertility, ectopic pregnancy and chronic pelvic pain. Syphilis can cause permanent vision and hearing loss, and other neurological problems.

Once diagnosed, doctors can often cure these sexually transmitted diseases with antibiotics, said Dr. Karen Smith, the state’s public health director.

Because these infections often appear without symptoms, San Francisco County wants to make sure the hardest-hit populations have access to regular screenings, said Dr. Susan Philip, a division director at the county Department of Public Health.

“Making sure that there are culturally appropriate and sensitive services … where young people would be willing to seek care becomes really important,” she said.

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