Voters in Berkeley, Calif., have passed the nation’s first soda tax with a resounding 75 percent of the vote. The measure aims to reduce the effects of sugar consumption on health, especially increased rates of obesity and diabetes.

Across the bay in San Francisco, however, a similar proposal failed to get the two-thirds supermajority it needed.

More than 30 cities and states across the country have attempted but failed to enact such a tax, at least in part because of well-funded opposition from the soda industry.

Berkeley’s Measure D needed only a simple majority to pass. It will levy a penny-per-ounce tax on most sugar-sweetened beverages and is estimated to raise more than $1 million per year. Proceeds will go to the general fund; Measure D calls for the creation of a health panel to advise Berkeley’s City Council on appropriate health programs to receive funding.

Campaign Co-Chair Josh Daniels called Berkeley’s win a tipping point. “I think you will now see many, many other cities and communities around the country looking at this as a genuine public policy to address the diabetes and obesity crisis that we face,” he said.

While the San Francisco proposition did not pass, supporters there declared a victory of their own: More than half the voters approved the tax despite millions spent by the American Beverage Association to defeat it.

“So the fact that we were able to overcome $10 million,” said Proposition E coauthor Scott Wiener, a member of the San Francisco Board of Supervisors, “and it looks like a majority of San Franciscans – despite that $10 million – will vote ‘yes,’ is pretty extraordinary.”

The opposition campaigns, funded primarily by the beverage association, argued that the measures were riddled with loopholes and wouldn’t accomplish their health goals. Roger Salazar, a spokesman for the campaigns, pointed to the 30 failed measures from around the country and called Berkeley “an anomaly.” He said that to expect to pass such a tax elsewhere in California was “foolhardy.”

Advocates are convinced he’s wrong. Harold Goldstein, executive director of the California Center for Public Health Advocacy, called the measure’s passage “remarkable.”

“What we learned here in Berkeley,” he said, “is that when voters learn the truth about sugary beverages, when they learn that they are one of the central causes of the growing diabetes epidemic, they want to tax it, they want to regulate these products.”

Sodas are the primary source of added sugar in the American diet and that added sugar is linked to increasing rates of diabetes.

Berkeley has a history of being first to a new cause that’s later embraced more broadly, said Lori Dorfman, executive director for the Berkeley Media Studies Group. “In the mid-70s, Berkeley made the first ‘curb cut,’ and now people in wheelchairs all over the country are not trapped in their homes anymore.” She noted that Berkeley was also the first city to pass a clean indoor air ordinance.

Mexico enacted a national soda tax on January 1, and by summer, consumption had dropped 10 percent.

Kelly Brownell, dean of Duke University’s school of public policy first proposed a soda tax in the early 1990s. He called the votes in both Berkeley and San Francisco “historic” and, like other advocates, predicted other cities will soon follow suit and that soda companies are bracing for that.

“My guess is that inside their boardrooms, they know very well these taxes are the beginning of the future,” he said. “This is a wave starting to crest.”

Brownell said that half the costs of diabetes and obesity are born by taxpayers, through government health insurance programs Medicare and Medicaid. Those public costs “justify the government getting involved, just like tobacco taxes,” he said.

This story is part of a reporting partnership that includes KQED, NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The Affordable Care Act wasn’t directly on the ballot in any state, but voters did decide a host of health-related issues in Tuesday’s elections.  And there was no clear theme to what won and lost.

For example, voters in two states – North Dakota and Colorado – rejected so-called “personhood” amendments that would have recognized rights for unborn fetuses.

It was the third time since 2008 Colorado voters faced – and voted down – language to amend the state constitution to enshrine as a “person” those not yet born, sometimes from the moment of conception. This year’s version was slightly different. It would have written “unborn human beings” into the state’s criminal code and its Wrongful Death Act. As with the past two efforts, voters rejected this version 64 to 36 percent with 73 percent of the vote counted.

The North Dakota amendment, by contrast, would have added language to the state constitution stating, “The inalienable right to life of every human being at any stage of development must be recognized and protected.” It failed 64 to 36 percent.

Efforts to establish rights for the unborn have failed regularly even in very conservative places, as opponents have argued that such “personhood” measures could outlaw not only abortion, but some forms of birth control or in vitro fertilization.

Abortion opponents did not come away empty-handed, however. In Tennessee voters approved a measure that would effectively overturn a 2000 state Supreme Court decision that found the state’s constitution guaranteed a right to abortion and prohibited most state restrictions.

The amendment, stating that “Nothing in this Constitution secures or protects a right to abortion or requires the funding of an abortion,” was approved with 53 percent of the vote. It is expected to touch off a round of new restrictions when the Republican-dominated state legislature reconvenes next year.

In Arizona, voters, as expected, supported a “right to try” ballot measure that would allow, but not require, drug makers to provide not-yet-approved drugs to people with terminal illnesses. Colorado became the first state with a right-to-try law earlier this year.

The effort has been pushed by the Libertarian Goldwater Institute, based in Arizona. Critics have worried that the laws could give those with terminal illnesses false hope, particularly because drug makers are loathe to provide experimental drugs to those near death, since that could reflect badly on the drug.

Meanwhile, in California, two highly-publicized, health-related ballot measures went down to defeat.

One, Proposition 45, would have imposed the same public notice and transparency requirements for health insurance premium rates as voters approved for auto and homeowners insurance in 1988. It would also have given the state’s insurance commissioner the right to reject rate hikes deemed “excessive.”

The proposal was fiercely opposed by the health insurance industry, which raised more than $50 million to fight it. Opponents argued, among other things, that the proposal would have given too much power to the state’s elected insurance commissioner. With 95 percent of the votes counted, Proposition 45 was losing 60 to 40 percent.

California voters also turned back, 67 to 33 percent, an effort to raise the caps on damage awards for non-economic “pain and suffering” in medical malpractice cases. The $250,000 maximum had not been raised since the California malpractice law was originally written in 1975.

But Proposition 46 would also have made California the first state to require random drug and alcohol testing for physicians. That part of the proposal prompted many newspaper editorial boards to turn against it.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Tuesday’s re-election of Republican governors in closely contested races in Florida, Georgia, Wisconsin, Maine and Kansas dims the chances of Medicaid expansion in those states.
Advocates hoping for Democratic victories in those states were disappointed by the outcomes, but Alaska, which also has a Republican incumbent, remains in play as an independent challenger holds a narrow lead going into a count of absentee ballots.

“No one would say it was a good night for the prospects of Medicaid expansion,” said Joan Alker, executive director of the Center for Children and Families at Georgetown University.

Still, Alker said the playing field for Medicaid expansion didn’t shift dramatically. “The debate continues to be within the Republican party — with more pragmatic Republicans saying yes and ideologues driving the opposition. So what happens next is a good test case to see how Republicans will resolve these internal tensions.”

Even if Democrats had been victorious in governor races, they still faced a long shot getting Medicaid expansion through Republican-controlled legislatures. The one exception was Maine, where Gov. Paul LePage, who was re-elected, has five times vetoed efforts by his state’s Democratic-controlled legislature to expand the program.

In Florida, Republican Gov. Rick Scott has supported Medicaid expansion, but has done little to persuade state lawmakers to extend the program to 850,000 residents.

If Democratic challenger Charlie Crist had won, he would have faced strong opposition in the Republican-dominated state House, said Sean Foreman, associate professor of political science at Barry University in Miami Shores. “Scott’s victory means Medicaid expansion is dead the next four years,” he said.

Meanwhile, the future of Arkansas’ “private option” Medicaid expansion could be in trouble with the election of Republican Asa Hutchinson as governor and GOP gains in the state House and Senate. Hutchinson replaces Democratic Gov. Mike Beebe, who had championed the state’s expansion plan and who was barred by term limits from running.

Hutchinson has not taken a position on the program, saying he will assess its costs and benefits to “determine whether the program should be terminated or continued.” Arkansas’ expansion is vulnerable because by law, the legislature must reauthorize it every year with a 75 percent majority.

In Alaska, Bill Walker, an independent candidate who favors expansion, holds a small lead over incumbent Gov. Sean Parnell, who opposes it. Should Walker prevail after absentee ballots are counted, he still must get the support of his Republican-controlled legislature. About 26,000 Alaskans would gain coverage through expansion.

Since the Supreme Court made Medicaid expansion an optional part of the Affordable Care Act, 27 states and Washington, D.C. have extended the program to individuals with incomes under $16,100. While most of those states expanded eligibility at the beginning of 2014, Michigan and New Hampshire came on later this year and Pennsylvania’s expansion will start in January.

Nationally, Medicaid enrollment has increased by more than 8 million people since last October and has been seen as the biggest factor in reducing the number of uninsured Americans by about 25 percent this year.

State lawmakers have sometimes blocked Medicaid expansion even with a supportive executive. In 2013, Democrat Terry McAuliffe had campaigned on expanding Medicaid, but after he was elected Virginia governor he was unable to persuade state lawmakers who demanded the program be reformed first.

Carolyn Pearson, vice president of consulting firm Avalere Health, said expansion advocates will turn their attention to Utah, whose Republican governor hopes to take a plan to the GOP-controlled legislature, and Wyoming, where Gov. Matt Mead, also a Republican, has expressed interest in widening eligibility for Medicaid. Indiana is also negotiating with the Obama administration to expand Medicaid.

Pearson argued that Arkansas lawmakers are unlikely to unravel that state’s Medicaid expansion, which has helped more than 60,000 gain coverage. “It is incredibly difficult to take benefits away from state residents once they have been granted,” she said.

She said more Republican-led states could move ahead as the issue cools politically.

Sara Rosenbaum, professor of health policy at George Washington University, said it’s hard to tell how big an impact the election will have.

“One possibility is that now that a bitterly contested election is over, the governors may be open to discussion,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The American health care system is poorly equipped to care sensitively for patients at the end of life, a recent report from the Institute of Medicine found. But it is possible, through careful planning, for individuals to choose the kind of death they want. Consumer Reports has released a guide to end-of-life planning for families. The report offers tips for caregivers and individuals and profiles one man’s “beautiful death” at home.

KHN staff reporter Jenny Gold interviewed author Nancy Metcalf about the report. What follows is an edited transcript of their conversation.

Q: You called your report “A Beautiful Death.” What does a beautiful death look like?

Metcalf: A beautiful death is probably different for each person. The gentleman whom we focused on – Paul Sheier, a retired dentist from a suburb of Buffalo — was very clear about what he wanted. He wanted to die at home. He had terminal lung cancer. He preferred to be kept comfortable, to forgo what he believed would be futile chemo, so he could spend his last months of life with his family and friends playing golf rather than at the hospital hooked up to an IV drip.

We also did a national survey along with this article, and we found that 86 percent of adults said they would like to spend their final days at home. Fifty percent preferred pain management and comfort care over other medical treatments. Yet even among adults age 65-plus, only 47 percent had completed an advanced directive or living will, and overall only about 20 percent of adults had done that. So they haven’t really taken steps to assure what they want to happen will happen.

Q: How can we give ourselves the best chance for a beautiful death?

Metcalf: The Institute of Medicine report that came out a few months ago made very clear that we have a very medicalized way of death in the United States. And I think anyone who has gone through the loss of an older family member has probably experienced that.

Everybody over the age of 18 should have a living will or advanced directive, including young people, and very few of them have it. Bad stuff can happen anytime. You want to have those documents, and you want to think about what you want to put in them. You don’t have to go to a lawyer or do anything expensive. You can download these documents online. There’s a site called Caringinfo.org that has state-specific living will forms.

You need to make your documents accessible. The one thing you should not do is put it in a safe deposit box. That’s really hard for people to get to. You should make many copies of it and make sure your family members know where it is. You should probably give one to your regular doctor as well.

You also should designate a health care proxy –somebody you want to make medical decisions for you if you can’t make them yourself. And you need to have a conversation with that person about your preferences and values, even if it’s general. It’s something you can revisit as your health status changes and you get older.

And you need to have the conversation with everybody in your family. Because a big source of problems at the end of life is when family members have disagreements about how someone’s care should proceed, if someone isn’t able to express their own wishes. It freaks doctors out and makes them very reluctant. Those are often the situations where people can end up in court and get guardianship. You don’t want that to happen. It’s so much better if everyone is on the same page.

One of the interesting results in our survey was that 42 percent of people had provided end-of-life care for a friend or relative. That’s a big, big number — so many of us have experienced the chaos that can come with end-of-life care.

Q: How can families make sure that their loved ones have the death they want?

Metcalf: It’s very typical at the end of life for people to be demented, in and out of nursing homes, assisted living and hospitals. It’s often not even clear when the end of life is near. That can be extremely difficult.

One resource that’s hugely important is palliative care. It can work with hospice, but it can also be offered to people who have not entered hospice. These are doctors who specialize in managing [care of the] whole person, talking to them about what their values are and finding out what’s important to them in their day-to-day lives. Do they want to be treated in such a way that they can survive to see a grandchild’s college graduation, or a wedding, or one last Christmas? Or do they want to maximize feeling good and [being] unmedicated as they spend time with their family members?

There’s no wrong answer here. But the palliative care specialist is trained to listen for that and work out ways that it can happen, either in conjunction with ongoing treatment or in conjunction with end-of-life care.

It was a little upsetting, frankly, that our survey found that 61 percent of adults had never even heard of palliative care, and only 10 percent had a really good understanding of what it does. And that’s really too bad because it’s a tremendous resource for people.

If you do feel chaos surrounding you, and you don’t feel you’re getting the right stuff from your health care providers, you need to make some noise and say, “I’m having a hard time here.” And ask for a palliative care consult. Almost every decently sized hospital has that option now. You don’t have to wait for a doctor to refer you to someone — you can pick up the phone and ask for one.

Q: How do you know when it’s time for hospice?

Metcalf: It’s hard to tell. There’s a formal definition that Medicare has created which is that you can be put in hospice if, in the opinion of your provider, you have less than 6 months to live. But people usually go in much too late. It’s a fine line—you don’t want to put people in there too soon because one you go into hospice, you’ve said you’re not going to get any more treatment to cure your illness. But hospice workers are very, very oriented towards a good end-of-life care experience for the patient and they also offer enormous resources for families.

You have to ask the doctors – how much longer? And if they guess wrong, and the person lasts longer but is still on a terminal track, they can be recertified. And the amount of care hospice gives isn’t always the same. It might be very little at the beginning of a person’s terminal course and very intense at the end. Hospice care can be delivered in all kinds of settings. A great many people get it at home. You can also get it in assisted living, nursing homes or in a hospital. And many hospices have their own inpatient units.

You don’t have to wait for a doctor to refer you to hospice. If you feel like you’re pretty sure that medical treatment isn’t going to help anymore from your conversations with medical providers, you can refer yourself. You can pick up the phone and call.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.