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New MLK hospital program brings amputations to zero for at-risk diabetic patients

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New MLK hospital program brings amputations to zero for at-risk diabetic patients

More than three decades after a diagnosis of Type 2 diabetes, Michelle Caldwell says her disease is better controlled than ever.

She keeps regular appointments with her endocrinologist, primary care provider, dietician and pharmacist at MLK Community Medical Group, the outpatient arm of MLK Community Healthcare.

She picks up weekly produce deliveries in the South Los Angeles hospital’s cafeteria and attends its occasional cooking classes. She has learned to decode nutrition labels and developed a taste for salads and nuts.

Just one hurdle remains: the shoes.

Diabetes can damage foot nerves, making it easier for patients to miss small scratches and wounds that could lead to serious infections. Her care team was gently urging her to switch to supportive, closed-toe footwear.

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But Caldwell loves a sandal, and the podiatrist-approved options were crimping her style.

“It doesn’t have to be, like, fashion fashion,” she said with a laugh during a recent visit with primary care provider Dr. Edward Cardenas at his East Compton office. But were there any options that didn’t look like “Frankenstein feet”?

That down-to-the-toes level of care is a feature of a program that has transformed the way MLK Community Healthcare treats diabetes, a chronic condition that affects one in every six South Los Angeles residents and nearly a quarter of MLK’s outpatients.

Four years after MLK launched an intensive management program for the most at-risk patients, more than 80% of enrollees have seen blood sugar levels decline. More than 70% have brought their blood pressure under control.

And diabetic-related amputations — which are painful and life-altering procedure that were the hospital’s most common surgery for years — have plummeted to zero for program patients.

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No novel medications or treatments are behind these results, said Dr. Jorge Reyno, MLK’s senior vice president for population health.

Dr. Edward Cardenas examines a patient with diabetes.

(Christina House / Los Angeles Times)

Rather, a relatively modest one-time grant has allowed the hospital system — whose service area includes some of L.A.’s poorest and most disadvantaged neighborhoods — to provide the same level of care for its diabetic patients that people in wealthier areas would expect as standard.

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“What we’ve demonstrated here is that we can get best-in-class care — we can even beat national benchmarks for care — if there’s the appropriate commitment and investment. And that people’s health doesn’t have to be determined just by their zip code,” Reyno said. “Because what we’ve created here is not necessarily incredibly innovative. It’s just what needs to be available — and is available in other locations.”

Some 1.3 million people live in MLK’s South Los Angeles service area. More than 90% are Black or Latino, and nearly 70% are either uninsured or have health coverage through Medi-Cal, Medicare or both.

Medi-Cal’s low provider payment rates is one reason South L.A. has only one-third of the full-time physicians necessary to treat a population of its size — a 1,500-doctor shortage, according to MLK’s research.

For many locals, MLK’s emergency department is about the only place they can see a doctor, given the challenge they face securing a timely appointment with a physician who accepts their health coverage.

Roughly 123,000 patients arrived last year at the hospital’s emergency department, which was designed to treat 40,000 people annually. About 40% were seeking primary care.

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Emergency room physicians were diagnosing diabetes in severely ill people who did not know they had the disease and treating life-threatening complications for those whose disease had long gone unmanaged.

Patients arrived with gangrenous foot wounds that harried providers elsewhere brushed off as athlete’s foot. Rates of diabetic ketoacidosis, a life-threatening complication that occurs when insulin levels are so low that cells can no longer convert glucose into energy, were three times that of the rest of Los Angeles County.

For many, care arrived too late to prevent one of the disease’s most serious complications: amputation.

Nerve damage means a blister or pebble in the shoe can go unnoticed until it creates a serious wound. High blood sugar impairs immune function and narrows vessels that carry oxygen-rich blood, making it harder for skin to heal. Once serious infection sets in, amputating a foot or limb may be the only option to save a patient’s life. Across the U.S., diabetes complications are responsible for roughly 80% of all non-trauma related amputations, according to the Centers for Disease Control and Prevention.

Broaching amputation with a patient “is really tough,” Cardenas said. “You’re taking such a big part of them away. It’s identity, it’s confidence, it’s [the] ability to walk and do things for themselves. It’s a huge, huge thing.”

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It’s also costly. Diabetes cost $306.6 billion in U.S. direct medical spending in 2022, the most recent year for which numbers are available, and foot ulcer-related issues were responsible for about one-third of that, said Dr. David G. Armstrong, director of USC’s limb preservation program and the Southwestern Academic Limb Salvage Alliance.

Indirect costs are also steep. One study of post-surgery outcomes found that only about one-third of patients were able to return to work after the amputation surgery, despite an average age of 54.

“The economic ramifications aren’t just the fact that you’re not working. It’s also that people in your family are taking off of work to be able to help accommodate this, or having to provide extra resources that they previously weren’t having to, so it has sort of a multi-generational effect,” said Dr. Caitlin Hicks, a vascular surgeon and director of research at Johns Hopkins University’s Multidisciplinary Diabetic Foot and Wound Clinic.

In California, the households most likely to bear that cost are those that can least afford it.

Diabetic residents in MLK’s service area and other economically impoverished parts of California were more than 10 times more likely to have a toe, foot or leg amputated than diabetic people in more affluent areas, according to one 2014 UCLA study.

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“The finding that residents living in lower income areas bear a disproportionate share of disability and disfigurement from amputations is deeply disturbing in a society that espouses equality and outspends all other nations on health care for its more affluent citizens,” the paper’s authors wrote.

It was a problem MLK decided to do something about.

A health worker in a white lab coat talks with a patient.

Clinical Nutrition Manager Jackie Juarez, left, chats with Claudette Meeks, a member of the community and a hospital patient, following a cooking class at MLK Community Hospital.

(Christina House / Los Angeles Times)

The hospital secured a $2 million grant from the Good Hope Medical Foundation, a private foundation based in Pasadena, with additional funding from the Rose Hills Foundation and L.A. Care Health Plan.

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In October 2021, it began officially enrolling patients in its Diabetes Management Center of Excellence. Within this was an intensive-management program for a subset of high-risk patients, including those with Type 1 diabetes, gestational diabetes or hemoglobin A1C levels — an indicator of blood sugar — at 9.0% or more. (For people without diabetes, a level below 5.7% is considered normal.)

For the most part, the system already had the endocrinologists, nephrologists and primary care physicians it needed. The money let MLK build a network of dedicated support staff who could take care of diabetic patients outside the exam room.

Between visits, patients in the intensive-management program had access to a clinical care pharmacist who reviewed and coordinated medications; a diabetes educator who walked them through blood sugar monitoring, meal planning and other daily concerns; community health workers who could make home visits; and a nurse care manager who served as their primary advocate and point of contact.

Through the hospital’s Recipes for Health program, they could pick up weekly bundles of fresh produce and take bimonthly classes on diabetic-friendly recipes.

They were more likely to stick to their treatment plan, and had more time at doctor visits to discuss medical issues.

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A man holds a slice of cake on a plate.

Diabetes patient Jose Magallanes tries a cheesecake during a cooking class at MLK Community Hospital.

(Christina House / Los Angeles Times)

“We have multiple people reaching out and interacting with the patients in between physician visits,” said MLK endocrinologist Dr. Megan Jacobs. “They have someone reaching out to them [and] talking to them about the social aspects of things — how they have to take into account their diabetes when they go out to dinner and when they’re at a party.”

By year three, 66% of patients in the intensive-management program had lower blood sugar levels than they did at enrollment; by the fourth year, 81% did. In the third year 63% of patients had brought their blood pressure under control, rising to 71% the following year.

Four years after the program started, appointment compliance hit 84%, up from 50% at baseline. The hospital’s most severely diabetic patients were hospitalized for diabetes at less than half the rate of the area’s general population.

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Most significantly, amputations among the intensive-management group dropped to virtually zero.

Over the course of four years, only one of the 1,165 patients in the high-risk group required an amputation. The surgery took place less than a month after their enrollment, indicating they likely entered the program with a wound at critical levels.

Diabetic-related amputations and wound care are now MLK’s third-most common type of surgical procedures, after holding the top spot since the hospital’s 2015 opening.

“This is absolutely, positively spectacular,” USC’s Armstrong said of MLK’s results. “This is life affirming stuff.”

The primary grant ends next year. After that, the program’s future is uncertain.

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MLK is eligible to reapply to the Good Hope Medical Foundation, which has been “very happy” with the program’s outcomes, said Howard A. Kahn, the foundation’s chair.

The hospital is also talking to L.A. Care, the largest publicly operated health plan in the U.S., about a potential partnership, Reyno said. It could be a win for both sides.

“The benefit of cost savings usually goes to the state Medicaid plan or to the insurance carrier, who doesn’t have as high a cost to pay,” Reyno said. “If a program like this could be replicated in other safety net communities and have a wider impact, then certainly the return on investment would be even greater.”

Care providers also said they see improvements the data doesn’t capture.

“I hear [patients] say, ‘Oh, I walked to the park with my grandchildren,’ or ‘I was able to move around because I’ve lost the weight’ … maybe they had a sore on their foot that was kind of questionable, [and] ‘Now it’s healed because my sugars are under control,” said nurse care manager Monica Garcia. “Just seeing the benefits when they are compliant is the satisfaction.”

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Back at the clinic office in East Compton — the shoe issue set aside for now — Cardenas examined Caldwell’s feet and lower limbs.

The doctor was optimistic that Caldwell’s recent discomfort came from tight muscles, rather than nerve damage, and recommended a stretching and strengthening regimen.

“It shouldn’t be painful, just like a tug,” he said, demonstrating a standing calf stretch. “If you like, I can refer you to physical therapy as well.”

Having providers take the time to explain her disease, rather than just scribbling out prescriptions, has made a world of difference for Caldwell, she said.

“It’s an awesome experience. I’ve changed my eating habits, I’m learning to read labels more clearly,” she said. “Even at my age, you think you know, but you don’t know.”

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14 propositions that could remake California taxes, housing, healthcare and elections

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14 propositions that could remake California taxes, housing, healthcare and elections

California voters will decide 14 statewide propositions in the Nov. 3 election, measures placed on the ballot mostly by either powerful interest groups or lawmakers that will affect the lives of millions of Californians.

While a proposed tax on state billionaires has dominated headlines, voters will also have a chance to weigh in on a number of consequential issues, from healthcare to voter identification requirements and more.

Californians are accustomed to legislating by the ballot and often face a list of propositions. But even by the standards of the state’s direct democracy process, the 2026 election stands out. The campaigns supporting and opposing the ballot measures have already collected more than $100 million in contributions, and are expected to use their money to inundate the television airwaves, livestreams and social media feeds and to flood mailboxes with glossy campaign mailers over the coming months.

Here are the measures on the Nov. 3 ballot:

Proposition 1: The Veterans and Affordable Housing Bond Act of 2026

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Spurred by the state’s affordable housing shortage, state lawmakers are asking voters to approve an $11.25-billion bond to boost affordable housing construction around the state.

Advocates say the funds would help build more than 40,000 shovel-ready affordable homes that are unable to move forward because of a financing gap and help preserve thousands of other existing units.

Proposition 1 includes specific funding for high-need groups, including $1.25 billion for a veterans’ home loan program, $1.15 billion for supportive housing for homeless people, $350 million for student housing at state universities, $450 million for farmworker housing and $200 million for Native American tribes.

“In California, we don’t turn away from the needs of our people — we meet them head-on,” said Gov. Gavin Newsom in a statement about the measure. “We are giving voters the power to help shape the future of housing in our state. This bond is about building communities, expanding access and affordability in California, where every family has a fair shot at a place to call home.”

Some Republicans took issue with the measure’s title — “The Veterans and Affordable Housing Bond Act of 2026” — arguing that it included veterans to have broader appeal while doing little to actually help homeless veterans.

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“It’s a sad thing to say that you have to use the veterans as bait to get the people of the state of California to approve an $11-billion bond, and I just think that’s shameful,” said Sen. Shannon Grove (R-Bakersfield), an Army veteran. “Call it what it is. It’s a homeless bond, and it does include some veterans’ benefits, but it is not a veterans bond.”

Proposition 2: Save for California’s Future Act

Icon illustration of California in a crystal ball.

This measure would give California lawmakers more flexibility over state spending and allow them to save money that could otherwise go back to taxpayers.

The measure, supported by Newsom, seeks to exempt deposits into state savings accounts from a spending limit that voters adopted through a series of ballot measures dating back to the late 1970s, and to increase the share of tax revenue that can be put into the rainy day fund.

Under an existing state appropriations restraint, also known as the Gann Limit, lawmakers cannot spend more than an amount determined by a formula that takes annual tax proceeds, changes to the population and cost of living into consideration. Tax revenue above the limit must be divided between schools and refunds to taxpayers.

The measure could incentivize lawmakers to save more money because funds tucked away in the rainy day fund would no longer be considered expenditures counted toward the spending limit. By allowing lawmakers to set aside more money that is not subjected to state spending limits, it could also allow them to hold onto money that otherwise would be returned to taxpayers under current law.

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This proposed constitutional amendment was placed on the ballot by state lawmakers.

Proposition 3: Fund schools and healthcare

Icon illustration of books, an apple, a hospital and stacks of coins.

If passed, this proposition would make permanent an existing tax on high-income Californians.

The existing tax, passed by voters in 2012 and extended in 2016, is set to expire in 2031. It applies to people who earn more than $360,000 for single filers, $721,000 for joint filers, and $490,000 for heads of household. It adds between 1% to 3% to these high earners’ personal income tax rates.

According to the initiative text, the funds are largely earmarked for local school districts and community colleges, with some portion of the money going to California’s rainy day reserves — which the state uses to prevent cuts to healthcare and other services when revenues decline. The measure says revenues cannot be spent on state bureaucracy or administrative costs.

The state’s nonpartisan Legislative Analyst’s Office expects the measure to bring in between $5 billion and $15 billion annually, depending on how the stock market is performing, with the amount expected to grow over time.

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Proposition 4: Public financing of campaigns

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This measure would allow the state and local governments to offer public campaign financing to candidates running for elected office. Candidates receiving the funding must abide by expenditure limits and adhere to the criteria set by statute, ordinance or charter to demonstrate broad support, such as demonstrate a large number of small dollar contributions.

None of the public campaign financing can come from funds designated for education, transportation or public safety. The financing cannot discriminate based on party or whether a candidate is a challenger or an incumbent. The public funds cannot be used for legal costs, fines or to pay back personal loans to a campaign.

This measure was placed on the ballot by the California Legislature and governor.

Proposition 5: Recall elections

Icon illustration of a ballot box being yanked offstage by a large hook.

This measure would change the way recall elections are conducted in California. Under this proposed constitutional amendment, during a recall election, voters would decide solely whether a politician should be removed from their elected position. If the recall is successful, that office would remain vacant until it is filled in accordance with existing law — either by a separate election or by appointment.

Under current law, voters make two separate decisions during a recall election: Whether to remove the subject of the recall from office and, if they are booted, which candidate running to replace them should fill the position. The candidate who receives the most votes wins, even if they receive far less than 50% of the vote.

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The proposed constitutional amendment would also allow the recalled politician to run in the next election to fill the vacancy, though they cannot be appointed to their former post. Under the current system, office holders targeted in a recall are barred from being a candidate to replace themselves in that same election.

The proposal comes in the wake of the unsuccessful, Republican-led recall campaign against Gov. Gavin Newsom in 2021, which in part tested voter sentiment about his response to the COVID-19 pandemic. One of the sponsors of the recall-reform measure was Sen. Josh Newman (D-Fullerton), who was recalled from office in 2018 after he voted to increase gas taxes for road repairs, legislation pushed by then-Gov. Jerry Brown. Newman won back his seat in 2020.

This proposed constitutional amendment was placed on the ballot by the California Legislature.

Proposition 37: Homeownership loan program

Icon illustration of a home with magnifying glass, pen and contract.

Proposition 37 would create a down payment assistance program to help middle-class Californians buy a new home.

The measure, spearheaded by former state Senate Majority Leader Bob Hertzberg, would allow middle-class California residents — defined as anyone who makes less than 200% of an area’s median income — borrow most of their down payment for a new home that they plan to live in. It is designed to boost construction of single-family homes.

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A down payment is traditionally about 20% of the purchase price of a home. If passed, the measure would create a state-administered loan program that offers qualified homebuyers a second mortgage of up to 17% of a home’s sale price.

The proposition would allow the California Housing Finance Agency to issue up to $25 billion in revenue bonds to administer the program.

The Legislative Analyst’s Office does not anticipate the measure to result in direct state or local costs because the costs are meant to be covered by homeowners’ mortgage payments.

Proposition 38: Immunology research bond

Icon illustration of several viruses and bacteria.

Proposition 38 asks voters to approve an $8.4-billion bond to support research in the burgeoning fields of immunology and immunotherapy, which study the human immune system and how it can be used to prevent, treat and cure diseases.

If approved, half of the funding would go toward the creation of a new immunology and immunotherapy research institute affiliated with the University of California. The other half would fund research grants for other California-based universities and nonprofit medical research institutions to study potential treatments for cancer, Alzheimer’s disease and heart disease.

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The measure has a built-in discount program for Californians — it requires that any technology or drugs developed from bond-funded research be sold to California patients for a price at least 20% below the national average.

Backers of the proposal include the Alzheimer’s Assn., National Multiple Sclerosis Society and other healthcare groups. Supporters argue the funding would facilitate research that could save lives and save patients “billions of dollars in health care costs by preventing and curing a range of debilitating diseases and illnesses,” according to the initiative text.

Proposition 39: Voter identification

Icon illustration of a California driver's license, photo and Real ID.

Proposition 39 would require Californians to show government-issued identification every time they vote at the polls.

Currently, Californians must affirm under penalty of perjury that they are U.S. citizens and provide information to verify their identity, such as their birth date, driver’s license or Social Security number, when registering to vote, but they don’t have to present identification when they cast their ballot.

Under this measure, voters would also need to present government-issued ID each time they vote in-person at the polls or, if voting by mail, provide the last four digits of a “unique identifying number from government-issued identification” that matches the one they provided when they registered to vote. California would be required to provide free voter ID cards on request, and state and county election officials would be required to verify registered voters are U.S. citizens by using government data.

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The voter ID measure has support from Assemblymember Carl DeMaio (R-San Diego), who has framed it as necessary to prevent voter fraud and restore trust. It comes as President Trump is pushing for stricter voter identification requirements and severe limits on voting by mail.

Democrats and voting rights groups, including the American Civil Liberties Union, oppose the measure, saying California’s elections are already secure — voter impersonation and noncitizen voting cases are rare — and that it would make voting harder for many eligible voters, including people who have changed names, move frequently or face housing instability.

According to the Legislative Analyst’s Office, the measure would make election administration more expensive, costing state and local governments anywhere from tens of millions to low hundreds of millions of dollars annually, plus tens of millions in upfront implementation costs.

Proposition 40: Billionaire tax

Icon illustration of a hand with cufflinks pinching a money coin.

This proposition, supported by a healthcare worker union, would impose a one-time tax of 5% on taxpayers and trusts with assets valued at more than $1 billion.

According to a state-prepared summary of the measure, 90% of the tax revenues would be spent on healthcare and 10% would fund food assistance or education-related programs. California’s richest residents would be able to spread the payments over five years.

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The Legislative Analyst’s Office estimates it would generate “tens of billions of dollars” spread over several years, but would lead to an annual decrease in state income tax revenues of “hundreds of millions of dollars or more.”

Newsom has publicly opposed the tax, arguing it would lead wealthy residents to leave the state and lead to future budget problems. Other opponents include Planned Parenthood, the California School Boards Assn. and a nonprofit called Building a Better California that is backed by tech execs and venture capitalists.

Some billionaires have already proactively moved themselves or their businesses out of the state because of the proposal, which as written would retroactively apply to residents of the state as of Jan. 1.

Proposition 41: Requires limits and audits on new state special taxes

Icon illustration of scissors cutting a document in half with stacks of coins nearby.

This is one of two ballot measures crafted by opponents of the proposed initiative to impose a new tax on California billionaires, and it would in effect undercut or curtail that wealth tax.

This proposed ballot measure would also prohibit any new state taxes from being excluded from the state’s current voter-approved spending limit. The proposed billionaire tax would have such an exclusion. If the billionaire tax proposal is approved by voters but this proposal receives more votes, the billionaire tax measure would be voided.

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The measure would require the state auditor to conduct a financial and performance audit of proposed ballot initiatives and of the programs they fund. The measure would require audits of any program that would receive funding from the special tax in the proposed initiative to assess the efficiency of the program and recommend who ought to reduce its annual costs by 10%. If the measure passes, the costs of the audits would be paid via the revenues generated by the special tax.

This ballot initiative is one of two so-called poison pills to sink the billionaire tax that is being bankrolled by Building a Better California, which has raised well over $100 million from the state’s most affluent. The largest donor is Sergey Brin, a co-founder of Google, who has reportedly moved out of California because of the tax proposal. He donated at least $82 million to the group as of late June.

Proposition 42: Ban on new state personal property taxes

Icon illustration of scissors cutting a document in half with a house symbol. Stacks of coins nearby.

This is one of two ballot measures created by opponents of the proposed initiative to impose a tax on California billionaires, and it would in effect void that wealth tax.

This proposed ballot measure would prohibit new taxes on personal property, intellectual property, retirement accounts and other assets and would limit situations in which a ballot measure or state lawmakers can impose or raise taxes retroactively — both of which are essential parts of the billionaire tax initiative.

If the billionaire tax proposal is approved by voters but this proposal receives more votes, the billionaire tax ballot measure would be voided.

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This ballot initiative is one of two so-called poison pills to sink the billionaire tax that is being bankrolled by Building a Better California, which has raised well over $100 million from the state’s most affluent. The largest donor is Sergey Brin, a co-founder of Google, who has reportedly moved out of California because of the tax proposal. He donated at least $82 million to the group as of late June.

Proposition 43: Voting thresholds for special taxes

Icon illustration of two dollar bills with checkmarks and one dollar bill with a red X.

The measure would prohibit local governments from imposing new special taxes unless the proposed tax receives approval from two-thirds of voters. The restriction also applies to citizen initiatives, which currently only need a simple majority vote to be approved.

The Howard Jarvis Taxpayers Assn. supports Proposition 43. The advocacy group has characterized the measure as an effort to “save” 1978’s Proposition 13, the landmark initiative that capped California property tax increases and required a super-majority of votes to approve most future tax increases.

Assemblymember Buffy Wicks (D-Oakland), who authored the legislation that became Proposition 43 — ACA 22 — opposes the measure and has urged Californians to vote against it. She said the only reason she crafted the bill was because it was a necessary bargaining chip to torpedo another ballot measure backed by the Howard Jarvis Taxpayers Assn. that would have devastated revenues for local governments and retroactively rescinded some local tax increases.

“I authored ACA 22 not because I wanted it to become law — but because it was the only path left to get the more dangerous initiative off the ballot before time ran out,” Wicks posted on social media.

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Proposition 44: Regulate health clinic spending

Icon illustration of a stethoscope encircling stacks of coins.

If passed, Proposition 44 would require federally qualified health centers to spend 90% of their revenue on “program services advancing their charitable purpose” rather than management and overhead. Community clinics that fail to comply would be penalized, with fines placed in a state-managed fund to be spent on clinic workforce programs.

Advocates say clinics spend too much on executive pay and other administrative costs and not enough on patient care. The measure, which would dictate how clinics spend money, is designed to fix that. The measure is backed by the Service Employees International Union-United Healthcare Workers West, an influential healthcare workers union, which argues it will help hold clinics accountable.

In May, the California Primary Care Assn., which represents more than 2,300 community health clinics, sued to block the ballot measure. The state’s powerful doctors’ lobby, the California Medical Assn., also opposes the measure, arguing it would ban clinics from keeping funding in reserves and hamper their ability to upgrade equipment or expand to new locations.

The Legislative Analyst’s Office estimates that enforcing the measure would cost the government up to the low tens of millions annually, and that much of the cost would be paid for through penalties and fees charged to affected clinics. The office says the measure has “uncertain” impacts and could lead to clinic closures.

Proposition 45: CEQA reform

Icon illustration of half of the Earth and half of a mechanical gear.

This proposition would amend the California Environmental Quality Act, or CEQA, and speed up the process for projects deemed “essential,” including certain housing, water, health, public safety, energy and transportation projects.

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Jails, detention facilities and oil or natural gas production facilities would not be considered “essential” projects, according to the measure text.

If passed, the measure would set deadlines for public agencies to complete environmental review, allow expedited review of a project’s environmental impacts — currently, public agencies are required to consider a range of feasible alternatives to reduce environmental impacts — and establish deadlines for filing and resolving lawsuits.

CEQA lawsuits have often been used to block construction of housing in the state. For instance, in Berkeley, neighbors used CEQA — citing potential noise impact from partying students — to delay, for years, UC Berkeley’s construction of student dorms on People’s Park.

The Legislative Analyst’s Office estimates that the state and local government implementation will cost in the tens of millions of dollars for the first several years. It notes the legislation would probably result in net savings in the long term due to reduced administrative and legal workload.

Times staff writers Seema Mehta and Phil Willon contributed to this report.

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July Fourth fireworks may bring ‘hazardous’ air quality to Southern California. What you need to know

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July Fourth fireworks may bring ‘hazardous’ air quality to Southern California. What you need to know

L.A.’s love of fireworks makes for a colorful Fourth of July, with dozens of official celebrations and countless illicit explosions expected for the holiday.

But as each sparkler, Roman candle, palm and peony dissipates, it leaves behind a cloud of noxious gases, soot and finely ground toxic metals — some of which ends up in the lungs of revelers and passersby below.

Hazardous levels of air pollution are expected across central and southern Los Angeles County, northern Orange County, and Riverside and San Bernardino counties from 5 p.m. Saturday evening through 3 p.m. Sunday, according to the South Coast Air Quality Management District. Unhealthy air quality is also expected in northern Los Angeles County and southern Orange County.

Pollution levels are expected to build from dusk onward Saturday, as light winds and increased firework activity lead to an increase in smoke, a South Coast AQMD advisory said. Soot and particulates will likely linger through Sunday afternoon before being dispersed by the wind.

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Firework-related pollution can trigger coughs, breathing problems, asthma flares and heart attacks, according to Los Angeles County Public Health, and anyone experiencing severe or worsening cardiovascular symptoms like chest pain or difficulty breathing should seek medical attention immediately.

Pyrotechnics set off at home are even more likely to trigger cardiovascular problems, the American Lung Assn. says, as the burst of pollutants takes place closer to the ground.

July 4 and 5 are traditionally two of the worst days of the year for the region’s air quality, according to South Coast AQMD. This year’s celebration comes on the heels of a late June warehouse fire in Boyle Heights that released extraordinary amounts of soot and smoke across the county, on par with pollution generated by the previous year’s wildfires.

To limit negative health effects, the L.A. County public health department recommends avoiding strenuous physical activity and keeping doors and windows closed. As whole house fans and swamp coolers can suck additional pollutants inside, the department recommends using air purifiers or air conditioners as alternatives when possible.

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Contributor: Alcohol should be stigmatized like smoking

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Contributor: Alcohol should be stigmatized like smoking

Few substances are as deeply woven into everyday life as alcohol. It is a fixture at holiday celebrations, work-related social gatherings, sporting events, airports, and brunch or dinner tables. All demonstrate how deeply alcohol has become embedded in social customs and cultural traditions.

Yet alcohol contributes to millions of deaths globally each year and is linked to cancer, liver disease, unintentional accidents, violence and, importantly, dependence and addiction. Despite this, the disconnect between alcohol’s cultural role and its serious health burden is striking. An estimated 2.3 billion people worldwide consume alcohol.

As a physician working in addiction medicine, I regularly care for patients whose alcohol use affects nearly every organ system. It is often not until these patients end up admitted to the hospital that they learn the effects of alcohol on various parts of their body besides their liver.

Newer evidence challenges assumptions about what was long considered “safe drinking.” Even moderate drinking carries risk and is not as harmless as people, including experts, once thought.

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Many people associate alcohol risk primarily with addiction or dangerous behaviors such as driving while intoxicated. However, its effects extend far beyond this, into nearly every aspect of a person’s well-being.

While alcohol may transiently improve mood and ease social anxiety, long-term alcohol use can lead to a worsening of mood, cognition and sleep, which can further compound use.

A 2021 literature review found that consuming approximately two standard drinks roughly doubles the odds of sustaining injuries — with or without a vehicle involved. The review also found that heavy episodic (binge) drinking can increase the risk of injury by 50-fold, depending on the amount of alcohol consumed and the type of injury. While alcohol’s effects on the liver are well known, it can also lead to gastrointestinal complications and heart disease

The World Health Organization estimates that 2.6 million deaths each year are attributable to alcohol, accounting for nearly 1 in every 20 deaths worldwide.

While many people recognize the risks of alcohol addiction, people are generally much less aware of the links between alcohol use and cancer risk.

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The World Health Organization classifies alcohol as a Group 1 carcinogen — the same category as tobacco and asbestos. In 2025, the U.S. surgeon general emphasized that alcohol increases the risk of at least seven cancers, including cancers of the breast, colorectal, liver, oral, esophagus and larynx. An advisory called for updated warning labels.

Yet fewer than half of Americans recognize alcohol as a risk factor for cancer, particularly for cancers such as breast cancer that are not commonly associated with alcohol use.

Throughout the 1990s and early 2000s, observational studies suggested that moderate alcohol consumption might offer cardiovascular benefits. Over the past decade, however, higher-quality studies have challenged these findings, suggesting that much of the apparent benefit may have reflected differences in the health and lifestyles of moderate drinkers rather than a protective effect of alcohol itself.

Current evidence increasingly suggests that even low levels of alcohol may increase cancer risk.

Federal guidelines acknowledge that adults should “consume less alcohol for better overall health.” However, the most recent version of the “Dietary Guidelines for Americans,” updated in January, removed the previous recommendation to limit intake to no more than one drink per day for women and two for men. It also omitted explicit discussion of alcohol’s links to cancer.

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These changes have drawn criticism from public health experts, who argue that the revised language plays down the growing evidence of alcohol-related harms and provides less specific guidance to consumers. The current administrator of the Centers for Medicare & Medicaid Services characterized alcohol as a “social lubricant” that brings people together, rather than emphasizing its well-established health risks.

This may be true physiologically, at least temporarily, but obscures the fact that relying on it as a social lubricant can lead to chemical and psychological dependency. In my view, statements to that effect are shortsighted, prioritizing short-term social effects over more insidious and long-term issues, including addiction.

While many dangerous mind-altering substances are hidden from public perception, alcohol is often placed at the center of it – a trend that shows no sign of changing imminently.

Further, large companies often profit from ads that appeal to young people.

Looking back at the history of tobacco smoking provides some helpful insights. In 1965, 42.4% of the U.S. population smoked. By 2022, that figure had dropped to 11.6%.

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This steep decline did not happen because of a single intervention, but through decades of accumulating scientific evidence, public education campaigns, warning labels, restrictions on advertising, smoke-free policies, higher tobacco taxes and shifts in social norms. Together, these efforts transformed smoking from a widely accepted social behavior into one broadly recognized as a major health risk and correspondingly, less socially accepted.

Although alcohol consumption has modestly declined in recent years, it remains deeply embedded in social life in ways cigarette smoking no longer is.

People often assume that if a substance is legal, common and widely socially accepted — even encouraged — it must also be safe. But public health history suggests those assumptions can and should change.

Emma Fenske is an addiction medicine fellow and internal medicine physician at Oregon Health & Science University. This article was produced in partnership with the Conversation.

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