Healthcare workers in Washington State are fighting the coronavirus with knowledge gained from treating the flu. 

This article was first published on Wednesday, January 29, 2020 in Kaiser Health News.

By Will Stone

When the first U.S. case of a new coronavirus spreading throughout China was confirmed last week in Washington state, public health workers were well prepared to respond, building on lessons learned during the outbreak of measles that sickened 87 people in the state in 2019.

As of Monday, the Centers for Disease Control and Prevention had confirmed five cases of infection from the new coronavirus in the U.S., including two in California, one in Illinois and one in Arizona. All were linked to people who traveled to the Wuhan region in China. More than a hundred people are under investigation for the new coronavirus in 26 states, according to the CDC.

The first U.S. patient, an unidentified man in his 30s, had traveled to the Wuhan area at the end of last year. He fell ill shortly after flying back to the U.S., where he lives north of Seattle.

In Washington state, health agencies have identified more than 60 people who came in close contact with the infected man before he was hospitalized in Everett, a city in Snohomish County outside Seattle.

The case quickly grabbed national headlines, but it didn't rattle the local health clinic workers who had recently geared up to handle another infectious disease.

"The measles really kind of enlightened everybody about 'Wow, there are a lot of things out there that can be really contagious and can get you really sick, really fast,'" said Tové Skaftun, the chief nursing officer for the Community Health Center of Snohomish County.

Skaftun said she's glad that last year's outbreak forced them to improve how they approach these situations.

"We've recently grown our infection-control program so it's kind of at the forefront of a lot of what we do," said Skaftun.

She said that effort focused on educating staff about the correct precautions to take when faced with different kinds of infectious diseases — including wearing protective air-purifying respirators when in contact with patients who may be infected.

Measles is one of the most contagious viruses and can stay in the airspace of a room for up to two hours. In contrast, public health experts believe the new coronavirus requires close contact to spread between humans.

"Coronaviruses are generally transmitted through sneezing, coughing and close contact with individuals, so those are the types of criteria we use to identify people at risk," said Dr. Kathy Lofy, Washington's state health officer.

She said previous outbreaks and most recently the measles outbreak led to "a lot of preparation by our health care system partners around how to appropriately … protect themselves from highly infectious pathogens."

In Washington, public health workers are daily calling people who have come in contact with the confirmed case and asking about symptoms such as a fever or cough. Those being monitored are not required to be isolated unless they develop symptoms.

The patient in Seattle first went to a local health clinic when he started showing symptoms. Once it became clear he was at risk for coronavirus, he was transported to Providence Regional Medical Center in Everett, a hospital north of Seattle, where he was treated in isolation. He remains in "satisfactory" condition, according to the Washington State Department of Health.

Dr. Amy Compton-Phillips, the chief clinical officer at Providence St. Joseph Health, which runs that hospital, said it was set up to handle high-level infectious pathogens during the Ebola scare of 2014.

"All types of infrastructure had been put in place to ensure that when something came around we'd be ready," said Compton-Phillips.

Those include specialized gurneys to keep patients isolated while they're wheeled around the hospital, robots that can listen to patients' lungs and take blood pressure, and rooms with negative-pressure airflow so germs aren't circulated throughout the rest of the hospital.

In Snohomish County, health workers are on alert for signs that any patients could be at risk of carrying the new virus. At the Community Health Center of Snohomish County, signs posted in the waiting room tell patients to notify staff if there's any indication they could have been exposed.

"We do have patients that are calling in, and we do have patients that are talking about it with their provider staff," said head nurse Skaftun.

Skaftun said it's natural that some patients have been asking questions, but like other health providers in the area, her clinic had all the right protocols and infection-control gear at the ready when they first heard the news.

Last year, Clark County, Washington, which is in suburban Portland, Oregon, had an alarming outbreak of 71 cases of measles, mostly among unvaccinated children. In the Seattle area, the outbreak was smaller, and Snohomish County had just one case of measles. Still, the contagion containment efforts were statewide and can be drawn on now.

Federal health officials have been advising health care workers to take "airborne precautions" and wear protective gear if they are near a patient who is under investigation for the new coronavirus. At the moment, it appears considerably less dangerous than the flu.

"At this time in the U.S., this virus is not spreading in the community," said Dr. Nancy Messonnier, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, at a news conference.

The Washington patient was diagnosed after samples were sent to CDC headquarters in Atlanta. The CDC has developed a test to diagnose the new coronavirus.

"We are refining the use of this test so we can provide optimal guidance to states and laboratoriums on how to use it," said Messonnier. The agency plans to distribute those to public health labs around the country "as fast as possible" in the coming weeks, she said.

"There are a lot of unknowns," said Janet Baseman, a professor of epidemiology at the University of Washington. "The best thing public health can do now is assume that it will be similar to other coronavirus outbreaks we have seen in recent years until proven otherwise."

"Being overprepared is the name of the game," she said.

With only one case of the coronavirus from China confirmed so far in Washington, Baseman said it's much easier for public health workers to do contact tracing than it was last year when they faced the measles outbreak, which included multiple cases.

"It was a really different situation because there were also a lot more exposed people," said Baseman.

This story is part of a partnership between NPR and Kaiser Health News.

Will Stone: @WStonereports

Influenza poses a far greater threat to Americans than the coronavirus from China that has made headlines around the world.

This article was first published on Friday, January 24, 2020 in Kaiser Health News.

By Liz Szabo

There's a deadly virus spreading from state to state. It preys on the most vulnerable, striking the sick and the old without mercy. In just the past few months, it has claimed the lives of at least 39 children.

The virus is influenza, and it poses a far greater threat to Americans than the coronavirus from China that has made headlines around the world.

"When we think about the relative danger of this new coronavirus and influenza, there's just no comparison," said Dr. William Schaffner, a professor of preventive medicine and health policy at Vanderbilt University Medical Center. "Coronavirus will be a blip on the horizon in comparison. The risk is trivial."

To be sure, the coronavirus outbreak, which originated last month in the Chinese city of Wuhan, should be taken seriously. The virus can cause pneumonia and is blamed for more than 800 illnesses and 26 deaths. British researchers estimate the virus has infected 4,000 people.

A second person in the U.S. who visited China has been diagnosed with the Wuhan virus, officials from the Centers for Disease Control and Prevention said Friday. Public health workers are monitoring 63 additional patients from 22 states.

Influenza rarely gets this sort of attention, even though it kills more Americans each year than any other virus, said Dr. Peter Hotez, a professor of pediatrics, molecular virology and microbiology at Baylor College of Medicine in Houston.

Influenza has already sickened at least 13 million Americans this winter, hospitalizing 120,000 and killing 6,600, according to the CDC. And flu season hasn't even peaked. In a bad year, the flu kills up to 61,000 Americans.

Worldwide, the flu causes up to 5 million cases of severe illness worldwide and kills up to 650,000 people every year, according to the World Health Organization.

And yet, Americans aren't particularly concerned.

Fewer than half of adults got a flu shot last season, according to the CDC. Even among children, who can be especially vulnerable to respiratory illnesses, only 62% received the vaccine.

If Americans aren't afraid of the flu, perhaps that's because they are inured to yearly warnings. For them, the flu is old news. Yet viruses named after foreign places — such as Ebola, Zika and Wuhan — inspire terror.

"Familiarity breeds indifference," Schaffner said. "Because it's new, it's mysterious and comes from an exotic place, the coronavirus creates anxiety."

Some doctors joke that the flu needs to be rebranded.

"We should rename influenza; call it XZ-47 virus, or something scarier," said Dr. Paul Offit, director of the Vaccine Education Center at Children's Hospital of Philadelphia.

Measles in the Democratic Republic of Congo has killed 5,000 people in the past year — more than twice as many as Ebola. Yet UNICEF officials have noted that the measles, which many Americans no longer fear, has gotten little attention. Nearly all the measles victims were children under 5.

Some people may worry less about the flu because there's a vaccine, whose protection has ranged from 19% to 60% in recent years. Simply having the choice about whether or not to receive a flu shot can give people an illusion of control, Schaffner said.

But people often feel powerless to fight novel viruses. The fact that an airplane passenger spread SARS to other passengers and flight crew made people feel especially vulnerable.

Because the Wuhan virus is new, humans have no antibodies against it. Doctors haven't had time to develop treatments or vaccines.

The big question, so far unknown, is just how easily the virus is transmitted from an infected person to others. The WHO this week opted not to declare the Wuhan outbreak an international health emergency. But officials warn the outbreak hasn't peaked. Each patient with the new coronavirus appears to be infecting about two other people.

By comparison, patients with SARS, or severe acute respiratory syndrome, spread the infection to an average of two to four others. Each patient with measles — one of the most contagious viruses known to science — infects 12 to 18 unvaccinated people.

Health officials worry that the new coronavirus could resemble SARS — which appeared suddenly in China in 2002 and spread to 26 countries, sickening 8,000 people and killing 774, according to the WHO.

The U.S. dodged a bullet with SARS, Schaffner said. Only eight Americans became infected, and none died, according to the CDC. Yet SARS caused a global panic, leading people to shutter hotels, cancel flights and close businesses.

Coronaviruses can be unpredictable, said Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. While some patients never infect anyone else, people who are "super spreaders" can infect dozens of others.

At Seoul's Samsung Medical Center in 2015, a single emergency room patient infected 82 people — including patients, visitors and staff — with a coronavirus called MERS, or Middle East Respiratory Syndrome. The hospital partly shut down to control the virus.

"This is one of the finest medical centers in the world, on par with the Cleveland Clinic, and they were brought to their knees," Osterholm said.

Yet MERS has never posed much a threat to the U.S.

Only two patients in the U.S. — health care providers who had worked in Saudi Arabia — have ever tested positive for the virus, according to the CDC. Both patients survived.

Hotez, who is working to develop vaccines against neglected diseases, said he worries about unvaccinated children. Most kids who die from the flu haven't been immunized against it, he said. And many were previously healthy.

"If you're worried about your health, get your flu vaccination," Hotez said. "It's not too late."

Liz Szabo: lszabo@kff.org, @LizSzabo

When it comes to where we die, the U.S. has reached a tipping point. Home is now the most common place of death.

This article was first published on Thursday, January 23, 2020 in Kaiser Health News.

By Blake Farmer, Nashville Public Radio

"I'm not anti-hospice at all," said Joy Johnston, who relocated to New Mexico years ago at age 40 to care for her dying mother.

"But I think people aren't prepared for all the effort that it takes to give someone a good death at home."

Surveys show dying at home is what most Americans say they want. But it's "not all it's cracked up to be," said Johnston, a caregiver advocate and writer from Atlanta.

She wrote an essay about her frustrations with the way hospice care often works in the United States. Johnston, like many family caregivers, was surprised that her mother's hospice provider left most of the physical work to her. She said that during the final weeks of her mother's life, she felt more like a tired nurse than a devoted daughter.

Hospice allows a patient deemed to have fewer than six months to live to change the focus of their medical care — from the goal of curing disease to a new goal of using treatments and medicines to maintain comfort and quality of life. It is a form of palliative care, which also focuses on pain management, but can be provided while a patient continues to seek a cure or receive treatments to prolong life.

According to a recent Kaiser Family Foundation poll, 7 in 10 Americans say they would prefer to die at home. And that's the direction the health care system is moving, as part of an effort to avoid unnecessary and expensive treatment at the end of life. (Kaiser Health News is an editorially independent program of the foundation.)

The home hospice movement has been great for patients and many patients are thrilled with the care they get, said Dr. Parul Goyal, a palliative care physician with Vanderbilt Health.

"I do think that when they are at home, they are in a peaceful environment," Goyal said. "It is comfortable for them. But," she noted, "it may not be comfortable for family members watching them taking their last breath."

When it comes to where we die, the U.S. has reached a tipping point. Home is now the most common place of death, according to new research, and a majority of Medicare patients are turning to hospice services to help make that possible. Fewer Americans these days are dying in a hospital, under the close supervision of doctors and nurses.

Hospice care is usually offered in the home, or sometimes in a nursing home. Since the mid-1990s, Medicare has allowed the hospice benefit to cover more types of diagnoses, and therefore more people. As acceptance grows among physicians and patients, the numbers continue to balloon — from 1.27 million patients in 2012 to 1.49 million in 2017.

According to the National Hospice and Palliative Care Association, hospice is now a $19 billion industry, almost entirely funded by taxpayers. But as the business has grown, so has the burden on families, who are often the ones providing most of the care. For example, one intimate task in particular — trying to get her mom's bowels moving — changed Joy Johnston's view of what hospice really means. Constipation plagues many dying patients.

"It's ironically called the 'comfort care kit' that you get with home hospice. They include suppositories, and so I had to do that," she said. "That was the lowest point. And I'm sure it was the lowest point for my mother as well. And it didn't work."

Hospice agencies primarily serve in an advisory role and from a distance, even in the final, intense days when family caregivers, or home nurses they've hired, must continually adjust morphine doses or deal with typical end-of-life symptoms, such as bleeding or breathing trouble. Those decisive moments can be scary for the family, said Dr. Joan Teno, a physician and leading hospice researcher at Oregon Health and Science University.

"Imagine if you're the caregiver, and that you're in the house," Teno said. "It's in the middle of the night, 2 o'clock in the morning, and all of a sudden, your family member has a grand mal seizure."

That's exactly what happened with Teno's mother.

"While it was difficult for me to witness, I knew what to do," she said.

In contrast, Teno said, in her father's final hours, he was admitted to a hospice residence.

Such residences often resemble a nursing home, with private rooms where family and friends can come and go and with round-the-clock medical attention just down the hall.

Teno called the residence experience of hospice a "godsend." But an inpatient facility is rarely an option, she said. Patients have to be in bad shape for Medicare to pay the higher inpatient rate that hospice residences charge. And by the time such patients reach their final days, it's often too much trouble for them and the family to move.

Hospice care is a lucrative business. It is now the most profitable type of health care service that Medicare pays for. According to Medicare data, for-profit hospice agencies now outnumber the nonprofits that pioneered the service in the 1970s. But agencies that need to generate profits for investors aren't building dedicated hospice units or residences, in general — mostly because such facilities aren't profitable enough.

Joe Shega is chief medical officer at the for-profit VITAS Healthcare, the largest hospice company in the U.S. He insists it is the patients' wishes, not a corporate desire to make more money, that drives his firm's business model.

"Our focus is on what patients want, and 85 to 90% want to be at home," Shega said. "So, our focus is building programs that help them be there."

For many families, making hospice work at home means hiring extra help.

'I Guess I've Just Accepted What's Available'

On the day I visit her home outside Nashville, hospice patient Jean McCasland is at the kitchen table refusing to eat a spoonful of peach yogurt. Each morning, nurse's aide Karrie Velez pulverizes McCasland's medications in a pill crusher and mixes them into her breakfast yogurt.

"If you don't, she will just spit them out," Velez said.

Like a growing share of hospice patients, McCasland has dementia. She needs a service that hospice rarely provides — a one-on-one health attendant for several hours, so the regular family caregiver can get a break each day. When Velez is not around, John McCasland — Jean's husband of nearly 50 years — is the person in charge at home.

"I have said from the beginning that was my intention, that she would be at home through the duration, as long as I was able," John said.

But what hospice provided wasn't enough help. So he has had to drain the couple's retirement accounts to hire Velez, a private caregiver, out-of-pocket.

Hospice agencies usually bring in a hospital bed, an oxygen machine or a wheelchair — whatever equipment is needed. Prescriptions show up at the house for pain and anxiety. But hands-on help is scarce. According to Medicare, hospice benefits can include home health aides and homemaker services. But in practice, that in-person help is often limited to a couple of baths a week. Medicare data reveals that, on average, a nurse or aide is only in the patient's home 30 minutes, or so, per day.

Jean McCasland's husband hasn't complained. "I guess I've just accepted what's available and not really thought beyond what could be," he said. "Because this is what they say they do."

Families often don't consider whether they're getting their money's worth because they're not paying for hospice services directly: Medicare gets the bills. John keeps his monthly statements from Medicare organized in a three-ring binder, but he had never noticed that his agency charges nearly $200 a day, whether there is a health provider in the home that day or not.

That daily reimbursement covers equipment rentals and a 24-hour hotline that lets patients or family members consult a nurse as needed; John said it gives him peace of mind that help is a phone call away. "There's a sense of comfort in knowing that they are keeping an eye on her," he said.

The rate that hospice charges Medicare drops a bit after the patient's first two months on the benefit. After reviewing his paperwork, John realized Medicare paid the hospice agency $60,000 in the first 12 months Jean was on hospice.

Was the care his wife got worth that?

"When you consider the amount of money that's involved, perhaps they would provide somebody around the clock," he said.

Sue Riggle is the administrator for the McCaslands' hospice agency and said she understands how much help patients with dementia need. Her company is a small for-profit business called Adoration; she said the agency can't provide more services than what Medicare pays for.

"I think everybody wishes we could provide the sitter-service part of it," said Riggle. "But it's not something that is covered by hospices."

I checked in with John and Velez (Jean's longtime private caregiver) this winter. The two were by Jean's side — and had been there for several days straight — when she died in October. The hospice nurse showed up only afterward, to officially document the death.

This experience of family caregivers is typical but often unexpected.

'It's A Burden I Lovingly Did'

"It does take a toll" on families, said Katherine Ornstein, an associate professor of geriatrics and palliative medicine at Mount Sinai Hospital in New York, who studies what typically happens in the last years of patients' lives. The increasing burden on loved ones — especially spouses — is reaching a breaking point for many people, her research shows. This particular type of stress has even been given a name: caregiver syndrome.

"Our long-term-care system in this country is really using families — unpaid family members," she said. "That's our situation."

A few high-profile advocates have even started questioning whether hospice is right for everybody. For some who have gone through home hospice with a loved one, the difficult experience has led them to want something else for themselves.

Social worker Coneigh Sea has a portrait of her husband that sits in the entryway of her home in Murfreesboro, Tennessee. He died of prostate cancer in their bedroom in 1993. Enough time has passed since then that the mental fog she experienced while managing his medication and bodily fluids — mostly by herself — has cleared, she said.

But it was a burden.

"For me to say that — there's that guilt," she said. "But I know better. It was a burden that I lovingly did."

She doesn't regret the experience but said it is not one she wishes for her own grown children. She recently sat them down, she said, to make sure they handle her death differently.

"I told my family, if there is such a thing, I will come back and I will haunt you," she said with a laugh. "Don't you do that."

Sea's family may have limited options. Sidestepping home hospice typically means paying for a pricey nursing home or dying with the cost and potential chaos of a hospital — which is precisely what hospice care was set up to avoid. As researchers in the field look to the future, they are calling for more palliative care, not less — and, at the same time, they are advocating for more support for the spouses, family members and friends tasked with caring for the patient.

"We really have to expand — in general — our approach to supporting caregivers," Ornstein said, noting that some countries outside the U.S. pay for a wider range and longer duration of home health services.

"I think what we really need to do is be broadening the support that individuals and families can have as they're caring for individuals throughout the course of serious illness," Ornstein said.

"And I think that probably speaks to the expansion of palliative care, in general."

This story is part of a partnership that includes Nashville Public Radio, NPR and Kaiser Health News.

Blake Farmer, Nashville Public Radio: bfarmer@wpln.org, @flakebarmer

Healthcare bills and budget initiatives are heavy on ideas and dollars — and on opposition from powerful industries.

This article was first published on Tuesday, January 21, 2020 in Kaiser Health News.

By Ana B. Ibarra

California is known for progressive everything, including its health care policies, and, just a few weeks into 2020, state leaders aren't disappointing.

The politicians' health care bills and budget initiatives are heavy on ideas and dollars — and on opposition from powerful industries. They put California, once again, at the forefront.

The proposals would lower prescription drug costs, increase access to health coverage, and restrict and tax vaping. But most lawmakers agree that homelessness will dominate the agenda, including proposals to get people into housing while treating some accompanying physical and mental health problems.

"This budget doubles down on the war on unaffordability — from taking on health care costs and having the state produce our own generic drugs to expanding the use of state properties to build housing quickly," Gov. Gavin Newsom said in a letter to the legislature, which accompanied the $222.2 billion budget proposal he unveiled last Friday. About a third of that money would be allocated to health and human services programs.

But even with a Democratic supermajority in the legislature, these proposals aren't a slam-dunk. "There are other factors that come into play, like interest groups with strong presence in the Capitol," including Big Pharma and hospitals, said Shannon McConville, a senior researcher at the nonpartisan Public Policy Institute of California.

Newsom's plan to create a state generic drug label is perhaps his boldest health care proposal in this year's budget, as it would make California the first state to enter the drug-manufacturing business. It may also be his least concrete.

Newsom wants the state to contract with one or more generics manufacturers to make drugs that would be available to Californians at lower prices. Newsom's office provided little detail about how this would work or which drugs would be produced. The plan's cost and potential savings are also unspecified. (Sen. Elizabeth Warren of Massachusetts, who is seeking the Democratic presidential nomination, proposed a similar plan at the federal level.)

Because the generics market is already competitive and generic drugs make up a small portion of overall drug spending, a state generic-drug offering would likely result in only modest savings, said Geoffrey Joyce, director of health policy at USC's Leonard D. Schaeffer Center for Health Policy & Economics.

However, it could make a difference for specific drugs such as insulin, he said, which nearly doubled in price from 2012 to 2016. "It would reduce that type of price gouging," he said.

Representatives of Big Pharma said they're more concerned about a Newsom proposal to establish a single market for drug pricing in the state. Under this system, drug manufacturers would have to bid to sell their medications in California, and would have to offer prices at or below prices offered to any other state or country.

Californians could lose access to existing treatments and groundbreaking drugs, warned Priscilla VanderVeer, vice president for the Pharmaceutical Research and Manufacturers of America, the industry's lobbying arm.

This proposal could "let the government decide what drugs patients are going to get," she said. "When the governor sets an artificially low price for drugs, that means there will be less money to invest in innovation."

Newsom's drug pricing proposals build on his executive order from last year directing the state to negotiate drug prices for the roughly 13 million enrollees of Medi-Cal, the state's Medicaid program for low-income residents. He also ordered a study of how state agencies could band together — and, eventually, with private purchasers such as health plans — to buy prescription drugs in bulk.

Homelessness

California has the largest homeless population in the nation, estimated at more than 151,000 people in 2019, according to the U.S. Department of Housing and Urban Development. About 72% of the state's homeless slept outside or in cars rather than in shelters or temporary housing.

Newsom has asked for $1.4 billion in the 2020-21 state budget for homelessness, most of which would go to housing and health care. For instance, $695 million would boost health care and social services for homeless people via Medi-Cal. The money would fund programs such as recuperative care for homeless people who need a place to stay after they've been discharged from the hospital, and rental assistance if a person's homelessness is tied to high medical costs.

A separate infusion of $24.6 million would go to the Department of State Hospitals for a pilot program to keep some people with mental health needs out of state hospitals and in community programs and housing.

Surprise Bills

California has some of the strongest protections against surprise medical bills in the nation, but millions of residents remain vulnerable to exorbitant charges because the laws don't cover all insurance plans.

Surprise billing occurs when a patient receives care from a hospital or provider outside of their insurance network, and then the doctor or hospital bills the patient for the amount insurance didn't cover.

Last year, state Assembly member David Chiu (D-San Francisco) introduced legislation that would have limited how much hospitals could charge privately insured patients for out-of-network emergency services. The bill would have required hospitals to work directly with health plans on billing, leaving the patients responsible only for their in-network copayments, coinsurance and deductibles.

But he pulled the measure because of strong opposition from hospitals, which criticized it as a form of rate setting.

Chiu said he plans to resume the fight this year, likely with amendments that have not been finalized. But hospitals remain opposed to the provision that would cap charges, a provision that Chiu says is essential.

"We continue to fully support banning surprise medical bills, but we believe it can be done without resorting to rate setting," said Jan Emerson-Shea, a spokesperson for the California Hospital Association.

Medi-Cal For Unauthorized Immigrants

California is the first state to offer full Medicaid benefits to income-eligible residents up to age 26, regardless of their immigration status.

Now Democrats are proposing another first: California could become the first to open Medicaid to adults ages 65 and up who are in the country illegally.

Even though Medicaid is a joint state-federal program, California must fund full coverage of unauthorized immigrants on its own.

Newsom set aside $80.5 million in his 2020-21 proposed budget to cover about 27,000 older adults in the first year. His office estimated ongoing costs would be about $350 million a year.

Republicans vocally oppose such proposals. "Expanding such benefits would make it more difficult to provide health care services for current Medi-Cal enrollees," state Sen. Patricia Bates (R-Laguna Niguel) said in a prepared statement.

Vaping

Dozens of California cities and counties have restricted the sale of flavored tobacco products in an effort to curb youth vaping.

But last year, state legislators punted on a statewide ban on flavored tobacco sales after facing pressure from the tobacco industry.

Now, state Sen. Jerry Hill (D-San Mateo) is back with his proposed statewide flavor ban, which may have more momentum this year. Since last summer, a mysterious vaping illness has sickened more than 2,600 people nationwide, leading to 60 deaths, according to the Centers for Disease Control and Prevention. In California, at least 199 people have fallen ill and four have died.

Hill's bill would ban retail sales of flavored products related to electronic cigarettes, e-hookahs and e-pipes, including menthol flavor. It also would prohibit the sale of all flavored smokable and nonsmokable tobacco products, such as cigars, cigarillos, pipe tobacco, chewing tobacco, snuff and tobacco edibles.

Newsom has also called for a new tax on e-cigarette products — $2 for each 40 milligrams of nicotine, on top of already existing tobacco taxes on e-cigarettes. The tax would have to be approved by the legislature as part of the budget process and could face heavy industry opposition.

Tobacco-related bills are usually heard in the Assembly Governmental Organization Committee, "and that is where a lot of tobacco legislation, quite frankly, dies," said Assembly member Jim Wood (D-Healdsburg), who supports vaping restrictions.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Ana B. Ibarra: aibarra@kff.org, @ab_ibarra