The Brief

Los Angeles County has launched one of the most ambitious efforts in the nation to tackle medical debt, targeting hospitals for their role in feeding a $2.9 billion problem. For over a year, the nation’s most populous county has worked on a comprehensive plan to track patient debt and hospital collection practices; boost bill forgiveness for low-income patients; and buy up and forgive billions in medical debt — an effort helmed by its Department of Public Health.

Though L.A. County isn’t the first government entity to confront this crisis, what sets it apart is how it casts medical debt not as a political issue, but as an urgent public health threat as prevalent as asthma and diabetes.

“Nobody in the county of L.A. who is facing economic limitations should have that impact their ability to get the kind of health care, the kinds of services and support that we all need and are essential to optimal well-being,” public health department director Barbara Ferrer said at a medical debt symposium April 10.

Mona Shah of Community Catalyst, a national health equity and policy organization, called the county’s efforts bold — tackling the root causes of medical debt, in addition to providing immediate debt relief, with input and participation from health plans, hospitals, community organizations, and government partners. Shah said the county’s population of about 10 million adds to the significance of its initiative.

But on the eve of the symposium, the local hospital association called on the county to revise its plan.

“We believe the proposed DPH [Department of Public Health] debt relief program and data collection effort will only burden hospitals with unnecessary requirements, without ultimately helping to address the underlying issue,” wrote George Greene, CEO of the Hospital Association of Southern California, in a letter to the LA County Board of Supervisors.

Many of the county’s recommendations would require hospitals to change their processes and add reporting duties. For instance, the county is asking hospitals to inform it when patient debt is sent to collections and pressing hospitals to improve access to financial assistance programs. Although state law requires hospitals to provide assistance, patient advocates say many don’t make it easy for patients to access.

Adena Tessler, L.A. County regional vice president for the hospital association, told KFF Health News the industry provides ample financial assistance and that the county is putting too much emphasis on hospitals’ role in the debt crisis, when other sectors of the health care system, such as insurers, should share the blame.

Tessler said the county plan should include all players, including health plans, provider groups, and ambulance providers.

“Medical debt is a problem, and we want to be a part of the solution,” Tessler said. “But hospitals are not the only source of medical debt.” Medical debt affects 4 in 10 adults in the U.S., according to a KFF Health News analysis. L.A. County found, in its own analysis this year, that about 785,000 residents were burdened in 2022 with a total of $2.9 billion in medical debt.

The county analysis shows that medical debt disproportionately affects people of color, low-income people, and families with children. Having medical debt more than doubled the likelihood that patients would delay or forgo health care or prescriptions or be at risk of losing housing or going hungry. Nationally, a handful of states have passed rules to limit medical debt collection or bolster hospital financial assistance policies. Some jurisdictions have relieved residents of debt. Connecticut, Colorado, and New York enacted laws in the last two years to ban medical debt on credit reports, which can depress credit scores and make it harder for patients to get a job, rent an apartment, or secure a car loan. California lawmakers have proposed similar legislation, and the federal Consumer Financial Protection Bureau is also developing a set of rules.

“It’s a huge public health problem,” said Naman Shah, medical and dental affairs director at the public health department. “We in public health try to shift the determinants of health. Those are things that impact health deeply and impact people widely. Medical debt fulfills both of those. It’s important that we see this as a health issue, and not just a regulatory issue.” The department made initial recommendations last spring, then further developed them with the backing of the Board of Supervisors, which described medical debt as “pervasive” and “causing financial, mental, and physical harm … especially to those from historically marginalized communities.”

Shah said that while the department continues to take hospital input and has addressed some of the association’s “misunderstandings,” officials are moving ahead with the plan. Tessler agreed the focus is on collaboration, not halting the county plan.

Over the next several months, the county plans to score hospitals based on financial assistance accessibility and provide them with templates and guidelines to make financial assistance less confusing and less burdensome for patients.

States such as Washington, Oregon, and Maryland have developed similar materials for hospitals.

The county’s goals also call for other debt prevention strategies, including working with plans and providers to better educate consumers to avoid surprise billing and out-of-network charges.

Shah said he was surprised by the timing of the hospital association’s letter, especially since county officials and hospital representatives met several times before the April symposium. He agreed it is important to tackle all sources of medical debt but said hospitals are a reasonable place to start. Nearly 75% of adults with medical debt owe some or all of it to hospitals, according to a 2023 Urban Institute analysis.

“We want to get the most bang for our buck,” Shah said. “The largest bill that a patient receives is not a dental bill. It’s not an office bill. It’s a hospital bill.”

The Democratic National Committee on Wednesday sued President Donald Trump’s administration for recent television advertisements that promoted his political message while costing taxpayers millions of dollars.

The complaint, filed in the U.S. District Court for the District of Columbia, alleges that the ads are illegal government-sponsored propaganda and accuses Trump of personally directing them. It asks the court to declare the ads illegal and stop the use of federal funds to pay for them.

Trump has faced bipartisan backlash for the ads, which glorify him and echo his campaign pitch as voters cast early ballots with the midterm elections less than a month away.

The spots, which began airing in September, already have cost more than $12 million to run, according to the media tracking firm AdImpact, and a total of $20 million in Homeland Security Department funding has been tapped to pay for them.

Responding Monday to the criticism, Trump defended the ads as “positive promotion for our Great U.S.A.” but said he’d pay for them using his MAGA Inc. super PAC going forward.

But on Tuesday, the fifth ad in the campaign began airing with the notice “paid for by the U.S. Government,” promoting Trump’s military actions in Venezuela earlier this year. The same day, Trump made it clear he hasn’t committed to reimbursing any money that has already been spent, telling reporters “we’ll decide.”

DNC Chair Ken Martin said in a statement that Trump is misusing taxpayer dollars in “a last-ditch attempt to save Republicans in November.”

“Americans deserve better than to have their hard-earned tax dollars used for Trump’s illegal schemes,” he added.

Legal experts have suggested the ads run afoul of a federal statute against congressionally appropriated money being used for “publicity or propaganda,” and potentially other federal laws. The Homeland Security money tapped for the ads comes from a $175 million package Congress gave to the department as part of Trump’s immigration enforcement agenda.

The White House has defended the ads as public service announcements akin to what past administrations have done to promote various policies. Legal experts have said the recent ads differ from many past public service announcements because they aren’t aimed at helping members of the public benefit from specific government programs.

The defendants in the lawsuit — Trump, the White House, DHS and the Office of Management and Budget — didn’t immediately respond to requests for comment.

Fall has only just begun, but it's already time to start thinking about the quintessential winter bug: the flu.

The annual flu season usually starts in October or November. But this year, it looks like the flu started to pick up in early September.

"There are enough signs pointing in the same direction to make me think, 'OK, yes. This is the start of flu season,'" says Caitlin Rivers, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health.

The percentage of people testing positive for the flu in the West has been rising steadily since around the beginning of September, she says. And the number of people showing up in emergency departments because of the flu has also been rising for weeks, she adds.

"It's very uncommon to see flu activity rising this early. It's activity that we might normally see more like November or December," she says.

The timing of the flu season isn't the only thing that's odd. It's also unusual that flu activity seems to have started in Western states, such as California, Washington, Hawaii and Alaska.

"It typically starts in the South and then expands from there," Rivers says. "So two uncommon developments there."

Rivers stresses that the amount of flu activity is still very low in most parts of the country. But that's starting to change as the flu picks up nationwide.

It's unclear why flu activity would have started so early, and in such an unusual part of the country. But one clue might be a new variant that evolved a mutation, which appears to make it better at evading existing immunity, especially among teenagers.

"That's our best argument for what's going on right now in terms of this early flu season," says Dr. Alex Greninger, a virologist who heads infectious disease diagnostics at the University of Washington. Doctors there are seeing as much flu right now as they usually would around Christmas, and the mutated variant appears to be common, he says.

So Greninger, Rivers and others are urging people to think about getting their flu shot earlier than usual.

"It's crucial that people get an influenza vaccine," says Scott Hensley, a virologist at the University of Pennsylvania. "And this might be a year that people might want to get a vaccine early."

But the Centers for Disease Control and Prevention hasn't been promoting flu shots as it usually does. Health Secretary Robert F. Kennedy Jr., who oversees the CDC, is a long-time vaccine skeptic.

"It is disappointing that CDC is quiet given that flu kills of hundreds of kids a year and can result in tens of thousands of hospitalizations and tens of thousands of deaths," says Dr. Demetre Daskalakis, who resigned last year as the director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention to protest what he called political interference at the agency.

The CDC declined to make an official available to NPR for this story. In a statement, a CDC spokesperson said, "CDC is developing a communications strategy to provide clear, accessible information about influenza vaccination and other critical steps people can take to protect themselves during respiratory virus season. This includes information about the benefits and risks of vaccination to support informed decision-making."
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