The Brief

Worried that President-elect Donald Trump will curtail federal efforts to take on the nation's medical debt problem, patient and consumer advocates are looking to states to help people who can't afford their medical bills or pay down their debts.

"The election simply shifts our focus," said Eva Stahl, who oversees public policy at Undue Medical Debt, a nonprofit that has worked closely with the Biden administration and state leaders on medical debt. "States are going to be the epicenter of policy change to mitigate the harms of medical debt."

Good insurance is a defense against debt

New state initiatives may not be enough to protect Americans from medical debt if the incoming Trump administration and congressional Republicans move forward with plans to scale back federal aid that has helped millions gain health insurance or reduce the cost of their plans in recent years.

Comprehensive health coverage that limits patients' out-of-pocket costs remains the best defense against medical debt.

But in the face of federal retrenchment, advocates are eyeing new initiatives in state legislatures to keep medical bills off people's credit reports, a consumer protection that can boost credit scores and make it easier to buy a car, rent an apartment, or even get a job.

Several states are looking to strengthen oversight of medical credit cards and other financial products that can leave patients paying high interest rates on top of their medical debt.

Some states are also exploring new ways to compel hospitals to bolster financial aid programs to help their patients avoid sinking into debt.

New York out ahead on the issue

"There's an enormous amount that states can do," said Elisabeth Benjamin, who leads health care initiatives at the nonprofit Community Service Society of New York. "Look at what's happened here."

New York state has enacted several laws in recent years to rein in hospital debt collections and to expand financial aid for patients, often with support from both Democrats and Republicans in the legislature. "It doesn't matter the party. No one likes medical debt," Benjamin said.

Other states that have enacted protections in recent years include Arizona, California, Colorado, Connecticut, Florida, Illinois, Minnesota, Nevada, New Jersey, New Mexico, Oregon, Rhode Island, and Washington. Many measures picked up bipartisan support.

President Biden's administration has proved to be an ally in state efforts to control health care debt. Such debt burdens 100 million people in the United States, an NPR and KFF Health News investigation found.

Led by Biden appointee Rohit Chopra, the Consumer Financial Protection Bureau has made medical debt a priority, going after aggressive collectors and exposing problematic practices across the medical debt industry. Earlier this year, the agency proposed landmark regulations to remove medical bills from consumer credit scores.

The White House also championed legislation to boost access to government-subsidized health insurance and to cap out-of-pocket drug costs for seniors, both key bulwarks against medical debt.

Regulatory overreach?

Trump hasn't indicated whether his administration will move ahead with the CFPB credit reporting rule, which was slated to be finalized early next year. Congressional Republicans, who will control the House and Senate next year, have blasted the proposal as regulatory overreach that will compromise the value of credit reports.

And Elon Musk, the billionaire whom Trump has tapped to lead his initiative to shrink government, last week called for the elimination of the watchdog agency. "Delete CFPB," Musk posted on X.

If the CFPB withdraws the proposed regulation, states could enact their own rules, following the lead of Colorado, New York, and other states that have passed credit reporting bans since 2023. Advocates in Massachusetts are pushing the legislature there to take up a ban when it reconvenes in January.

"There are a lot of different levers that states have to take on medical debt," said April Kuehnhoff, a senior attorney at the National Consumer Law Center, which has helped lead national efforts to expand debt protections for patients.

Kuehnhoff said she expects more states to crack down on medical credit card providers and other companies that lend money to patients to pay off medical bills, sometimes at double-digit interest rates.

Under the Biden administration, the CFPB has been investigating patient financing companies amid warnings that many people may not understand that signing up for a medical credit card such as CareCredit or enrolling in a payment plan through a financial services company can pile on more debt.

If the CFPB efforts stall under Trump, states could follow the lead of California, New York, and Illinois, which have all tightened rules governing patient lending in recent years.

A focus on financial aid

Consumer advocates say states are also likely to continue expanding efforts to get hospitals to provide more financial assistance to reduce or eliminate bills for low- and middle-income patients, a key protection that can keep people from slipping into debt.

Hospitals historically have not made this aid readily available, prompting states such as California, Colorado, and Washington to set stronger standards to ensure more patients get help with bills they can't afford. This year, North Carolina also won approval from the Biden administration to withhold federal funding from hospitals in the state unless they agreed to expand financial assistance.

In Georgia, where state government is entirely in Republican control, officials have been discussing new measures to get hospitals to provide more assistance to patients.

"When we talk about hospitals putting profits over patients, we get lots of nodding in the legislature from Democrats and Republicans," said Liz Coyle, executive director of Georgia Watch, a consumer advocacy nonprofit.

Many advocates caution, however, that state efforts to bolster patient protections will be critically undermined if the Trump administration cuts federal funding for health insurance programs such as Medicaid and the insurance marketplaces established through the Affordable Care Act.

Trump and congressional Republicans have signaled their intent to roll back federal subsidies passed under Biden that make health plans purchased on ACA marketplaces more affordable. That could hike annual premiums by hundreds or even thousands of dollars for many enrollees, according to estimates by the Center on Budget and Policy Priorities, a think tank.

And during Trump's first term, he backed efforts in Republican-led states to restrict enrollment in their Medicaid safety net programs through rules that would require people to work in order to receive benefits. GOP state leaders in Idaho, Louisiana, and other states have expressed a desire to renew such efforts.

"That's all a recipe for more medical debt," said Stahl, of Undue Medical Debt.

Jessica Altman, who heads the Covered California insurance marketplace, warned that federal cuts will imperil initiatives in her state that have limited copays and deductibles and curtailed debt for many state residents.

"States like California that have invested in critical affordable programs for our residents will face tough decisions," she said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF .

Copyright 2024 KFF Health News

On Nov. 3, Californians will vote on 14 statewide ballot measures on environment, taxation, election, housing and healthcare.

For months, interest groups sponsoring ballot initiatives spent heavily on ad blitzes and signature gathering to get on the ballot, but some agreed to withdraw high-profile proposals after striking deals with state leaders or other interest groups this week, ahead of Thursday’s deadline to finalize the November ballot.

Rideshare giant Uber and the state’s trial lawyers pulled rival measures in a deal with state lawmakers and healthcare labor unions and the California Hospital Association agreed to pull two measures that would have capped hospital executive pay and restricted spending by healthcare unions.

Here’s what’s on your November ballot:

Billionaire tax

What it does: This high-profile measure would apply a one-time 5% wealth tax on the assets of roughly 200 California billionaires, to be paid over five years. Ninety percent of the revenue would go to pay for healthcare for low-income Californians and 10% toward education and food assistance programs.

Supporters: Service Employees International Union–United Healthcare Workers West, independent U.S. Sen. Bernie Sanders, Teamsters California and AFSCME California

Opponents: Gov. Gavin Newsom, prominent billionaires including Google co-founder Sergey Brin and Ripple Labs co-founder Chris Larsen, the California Teachers Association, California Primary Care Association and California Medical Association

Audit new tax spending

What it does: This measure in response to the billionaire tax proposal would require state audits of programs funded by new taxes. It would also apply revenue from new taxes to the state’s spending cap, which requires that spiking revenue go back to taxpayers or toward education. That would effectively cancel out the wealth tax proposal. If voters approve both measures, the one with more votes will prevail.

Supporters: Building a Better California, primarily funded by Brin and venture capitalists John Doerr and Michael Moritz, and Reform California, led by GOP Assemblymember Carl DeMaio of San Diego

Opponents: Proponents of the billionaire tax initiative

Prohibit new personal property tax and retroactive taxes

What it does: This measure is also aimed at undercutting the wealth tax proposal. It would prevent new taxes on personal property, which would offset the wealth tax. If both pass, the one with more votes prevails.

Supporters: Building a Better California and Reform California

Opponents: Proponents of the billionaire tax initiative

Make high-earner income tax permanent

What it does: The measure seeks to make permanent a temporary income tax — up to 12% — on high earners that voters approved in 2012. The tax applies to household income over $721,000 for couples and over $360,000 for individuals. The tax generates between $5 billion and $15 billion each year for K-12 schools and community colleges. It is set to expire in 2031.

Supporters: The California Teachers Association, California Federation of Teachers and California School Employees Association

Opponents: California Taxpayers Association

Higher threshold for local special taxes

What it does: This would raise the threshold for citizen-driven special tax ballot initiatives to pass from a simple majority to two-thirds, making it harder to impose or increase taxes. The measure, placed on the ballot at the last minute by state lawmakers, reflects a deal state leaders struck with Howard Jarvis Taxpayers Association.

Supporters: Howard Jarvis Taxpayers Association, California legislators, Newsom

Affordable housing bond

What it does: This would allow the state to borrow a record $11.25 billion for affordable housing, with $10 billion to buy, build, rehabilitate and preserve affordable homes and $1.25 billion to help veterans buy homes.

Supporters: Newsom, Democratic state lawmakers, the California Apartment Association and AFL-CIO California

Opponents: Republican state lawmakers

$25 billion homebuying loan

What it does: This would create a $25 billion mortgage loan program for home buyers who make less than 200% of the area median income. The measure would offer fixed-rate mortgages for up to 17% of the purchase price on homes priced under $1.5 million. Home buyers must pay at least 3% of their down payment.

Supporters: Former Senate Majority Leader Bob Hertzberg, Building a Better California, the California Association of Realtors, United Brotherhood of Carpenters and Joiners of America and Western States Regional Council of Carpenters

Rainy day fund

What it does: This constitutional amendment from top Democratic leaders would allow the state to deposit up to 20% of its general fund tax revenue into its rainy day fund each year, instead of the current 10%. The state could also spend some tax revenue to pay down its $20 billion federal unemployment insurance debt.

Supporters: Newsom and legislative Democrats

Opponents: Legislative Republicans

Expedited environmental review

What it does: This would amend the state’s landmark California Environmental Quality Act to create deadlines for environmental reviews of most housing, transportation, water, health and clean energy projects to speed up permitting and limit the court’s ability to stop or delay developments.

Supporters: California Chamber of Commerce, Building a Better California, the California Building Industry Association, PG&E and Edison

Opponents: Clean and Healthy California, a coalition of environmental advocates and the California State Building and Construction Trades Council

Voter ID

What it does: This constitutional amendment would require voters to present government-issued ID when voting in person or the last four digits of their ID number when voting by mail. Voters would be required to state under the penalty of perjury that they are U.S. citizens.

Supporters: Reform California, GOP U.S. Rep. Ken Calvert and state Sen. Tony Strickland of Huntington Beach

Opponents: League of Women Voters of California, ACLU California Action and California Donor Table

Public campaign financing

What it does: This measure would allow state and local political candidates to tap into public funds for their campaigns. Public campaign financing has been banned in California since 1988. State lawmakers approved the measure last year to send it to voters this November.

Supporters: California Common Cause, California Clean Money Campaign and ACLU California Action

Opponents: California Taxpayers Association

Recall election reform

What it does: After a recall, this constitutional amendment would eliminate the election to pick a successor immediately, such as when Gov. Arnold Schwarzenegger replaced the recalled Gov. Gray Davis, instead leaving the post vacant until it’s filled in a separate election. It would also allow the recalled official to run for the office again.

Supporters: League of Women Voters, California Common Cause and Secretary of State Shirley Weber

Opponents: Election Integrity Project California

Clinic funding

What it does: This measure would require federally qualified health centers to spend 90% of revenue on direct patient care and services that aid in providing care to low-income and underserved people. Clinics that don’t comply would be fined; the money would go into a state-operated account for worker training and staffing.

Supporters: Service Employees International Union-United Healthcare Workers West

Opponents: The California Primary Care Association, which represents clinics, the California Medical Association, Planned Parenthood Affiliates of California and the California Teachers Association

Immunology research bond

What it does: This would allow the state to borrow $8.4 billion in debt to research immune system-based technologies for treating conditions including cancer, heart disease and Alzheimer’s. The money would be divided between a University of California-affiliated nonprofit and a grant for public or nonprofit institutions. Any resulting technology and drugs from the research would be sold at 20% below the national average.

Supporters: Gary Michelson, philanthropist and funder of the California Institute for Immunology and Immunotherapy, Meyer Luskin, philanthropist and institute board member,The ALS Association, The Alzheimer’s Association and Blood Cancer United

Opponents: Robert Kaplan, former associate director of the National Institutes of Health

CalMatters’ Ben Christopher contributed reporting.

The L.A. region’s lead homelessness agency is moving to take the Trump administration to court over a recent suspension that has potentially frozen up to $150 million in federal homelessness funds and complicated how millions more will flow to Los Angeles County.

The U.S. Department of Housing and Urban Development suspended the Los Angeles Homeless Services Agency from federal grant activity in a June 11 letter pending an investigation into alleged mismanagement at the agency.

On Monday, LAHSA's governing body, the LAHSA Commission, voted unanimously to authorize legal action challenging that suspension. The agency has not said what a lawsuit would specifically target or when it might be filed.

LAHSA officials were initially unclear which funds the suspension reached — money already under contract with HUD, federal grants awarded but not yet signed, or the coming year's application for regional homelessness grants.

“ The wording in this initial letter was quite vague and left a lot of uncertainty about which funds would be impacted by suspension,” Gita O’Neill, LAHSA’s interim CEO, said at Monday’s commission meeting.

LAHSA officials estimated about $115 million in grants awarded for fiscal year 2025 are awaiting HUD's final signature and in limbo.

O'Neill put the agency's broader exposure higher, warning of “$150 million in award funding at risk if HUD chooses to restrict LAHSA from distributing current funds from grants that have been awarded but not yet executed.”

The larger figure includes executed and unexecuted contracts spanning fiscal years 2022 through 2025, LAHSA’s deputy chief financial officer said.

HUD looks to bypass LAHSA

Following LAHSA’s request for clarity, according O’Neill, HUD sent another letter on June 18 explaining that as a result of the suspension, LAHSA would be barred from performing one of its key functions: applying to HUD on behalf of the entire region in the federal housing agency’s main homelessness grant competition.

The biggest pot of federal homelessness dollars flow to regions like Los Angeles through HUD’s Continuum of Care grant program.

In 2024, HUD awarded more than $220 million to the Los Angeles Continuum of Care, including more than $77 million to LAHSA directly. HUD has awarded $944 million to the L.A. Continuum of Care since 2021, according to the federal agency.

In each region, a lead agency applies for those funds as what HUD calls a “collaborative applicant” and passes them along to local providers. In Los Angeles, that agency is LAHSA.

In HUD’s June 18 letter, Ronald Kurtz, assistant secretary for community planning and development, wrote that LAHSA is “no longer eligible” to fulfill that role.

HUD may “designate another body as a collaborative applicant or permit eligible entities to apply directly for grants,” Kurtz wrote.

Absent a different decision based on LAHSA's response, the letter said HUD has determined “it would be in the public interest to allow eligible entities to submit their grant requests directly to HUD.”

Allowing individual shelter and housing operators to seek federal money on their own rather than through LAHSA would be a major structural change.

HUD did not respond to repeated inquiries about the June 18 letter.

The application for the next round of Continuum of Care funding, covering fiscal year 2026, is due Aug. 26. LAHSA officials estimate about $241 million is at stake for the L.A. region in that funding cycle.

President Donald Trump greets Secretary of Housing and Urban Development Scott Turner during the congressional picnic on the South Lawn of the White House on May 19 in Washington, D.C.

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LAHSA's problems

LAHSA is a joint-powers authority created by the city of Los Angeles and Los Angeles County, which elected leaders appointed to coordinate the region's response to homelessness.

It administers a mix of federal, state and local money — applying for the funds and passing them to the nonprofit and government agencies that run shelters and housing programs.

LAHSA's city, county and state funding — which makes up the majority of the agency's budget — is not affected by the federal suspension.

The June 18 letter gives LAHSA and the Continuum of Care 30 days to respond to its findings. HUD said that action is separate from the June 11 suspension, which carries its own 30-day window to contest.

LAHSA declined to comment on a potential lawsuit Thursday.

HUD’s suspension comes as LAHSA is under increased local scrutiny.

An L.A. County auditor-controller report in November 2024 found LAHSA paid contractors late and failed to secure repayment agreements for some. A March 2025 court-ordered review found Los Angeles failed to properly track billions in homelessness spending, largely because of dysfunction at LAHSA.

Last year, L.A. County officials voted to pull more than $300 million a year from LAHSA and manage its own homelessness dollars through a new homelessness department at the county.

HUD has cast its actions as overdue accountability.

“Taxpayers will no longer bankroll an organization that puts its own self-interests ahead of the Americans it was created to serve,” HUD Secretary Scott Turner said when announcing LAHSA’s suspension this month.

HUD has accused LAHSA of repeatedly certifying financial controls and conflict-of-interest safeguards it did not have.

The agency said it has hired accounting firm KPMG to overhaul its finances, with recommendations to be presented publicly in July, according to O’Neill.

Local leaders, including L.A. Mayor Karen Bass, have called HUD’s suspension counterproductive.

Along a discreet stretch of Hewitt Street, in the Arts District, there’s an unassuming brick facade with a glowing vertical neon sign that says BAR, the downtown skyline visible in the background — like a still from a futuristic sci-fi noir film.

Lynx's moody exterior.

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Step inside and the room opens up — exposed wood beam ceilings, oversized globe pendants, deep crimson slatted walls, banquettes packed with people leaning into each other. It pulls you in before you even take your seat.

This is LYNX, which opened in March and has already earned a Bib Gourmand — Michelin's designation for exceptional food at a reasonable price — from the Michelin Guide for California.

Built backwards

On paper, the menu at LYNX is deceptively casual — pizza and cocktails. Beverage director Brandyn Tepper says it's because the math is simple: good margins on flour, water, and alcohol. But Tepper and his partner Chef Joshua Skenes are attempting something far more intentional. The cocktail program is built around a single-ingredient philosophy, and the pizza, in Skenes' words, is designed "backward — from the bite, from the way it eats."

It's rare in L.A. to find a place with such high aspirations, in such an unassuming location.

The craft — pizza

The pizza at LYNX doesn't hold back. The Napoletana: whole anchovy fillets laid across tomato, glistening and curled at the edges from the heat, two kinds of olives, scattered capers, basil leaves wilting into the crust beneath them.

The mushroom pie, covered with an avalanche of mushrooms and parmesan.

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On the other end of the spectrum, the mushroom pie arrived as an avalanche — paper-thin fungi and Parmesan piled so thick the crust completely disappears. You're handed a slice of lemon to squeeze over it, as if given your own participation trophy. Pizzas run $25 to $29.

Skenes describes the dough as a "thin, shattering exterior that crackles like an eggshell, giving way to a very open, airy, and tender interior at the point of fermentation where the dough reaches maximum aromatic complexity."

The result, in his words, is "a style of pizza that feels weightless yet very satisfying."

Both pizzas are daring, texturally and visually, the kind of thing that pushes the format to a place you hadn't considered. That's what the best food does. It meets you somewhere comfortable, then quietly moves the walls.

The craft — beverage

Whether seated at a banquette or any of the high tops, the bar anchors the room — LYNX is intimate enough that it's always in view. The open kitchen visible in the background, bottles and prep material to the left, and off to the right, a rotovap — a distillation machine that allows Tepper to extract the pure essence of an ingredient, from banana peels to grapefruit.

Lynx aims to extract the pure essence of its cocktail ingredients.

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Take the Paloma. Before it was ever served to a guest, Tepper tested roughly 30 iterations just to get the carbonation right. Too much and the drink turns acidic. Too little and it falls flat.

The Sudachi daiquiri tells a similar story. Sudachi is a small Japanese citrus — tart, floral, intensely aromatic — and Tepper wanted the drink to taste purely of the fruit. No lime, which would overpower it. Just the peel, shaken directly into the rum, strained, then scraped fresh over the top. You sense the acid on your palate, but what you actually taste is Sudachi in full — its aroma, its character. Cocktails are a flat $20 across the board.

Every glass arrives frosted, chilled with liquid nitrogen before the drink goes in. How a drink feels in your hand, Tepper says, matters as much as what's inside it — from the specifically sourced glassware for each cocktail to the temperature itself. It sounds like a flourish, but at LYNX, the details are far from decorative.

Working with a cheat code

Tepper and Skenes have history. The two worked together in San Francisco — first at Saison, Skenes' three-Michelin-star restaurant, and later at Angler, where Tepper served as corporate beverage director.

Working with a chef of that caliber, Tepper says, is a "cheat code", because of the access it provides to his palate, his instincts, his sense of how flavors relate to each other. When Tepper was developing the Shanghai Pistachio, a bourbon-and-pistachio cocktail, a few words from Skenes — bourbon, pistachio, milky oolong, honey — gave him the architecture. The rest was technique.

The zero-proof ambition

LYNX is also quietly building toward something less common: a zero-proof menu that matches the ambition of the cocktail list. Of the 12 drinks on the menu, 10 already have non-alcoholic counterparts — not juice and ginger, but technique-driven alternatives made with the same rotovap behind the bar. The goal isn't to replicate the alcoholic versions. It's the same philosophy applied differently: find the purest expression of an ingredient, and build from there.

Understated celebration

When LYNX earned its Michelin Guide mention earlier this year, the staff celebrated. Tepper celebrated too, but his framing of it is grounded. "There are literal lives at stake," he says — people on paychecks, livelihoods depending on the bar's ability to execute every service. The Michelin mention is good for morale. But if a bartender's car breaks down, Tepper's calling the Uber. The mention, in that light, isn't a goal. It's what happens when you show up and do the work at a certain standard, every service, regardless of who's watching.

Kaan Ayhan scored on the final kick of the match, and Turkey beat the United States 3-2 Thursday night for its only win of the World Cup.

Auston Trusty scored in the third minute and Sebastian Berhalter got a tying goal early in the second half for the Americans, who had already won Group D with victories over Paraguay and Australia. Coach Mauricio Pochettino’s team will meet Bosnia-Herzegovina in the Round of 32 on Wednesday.

Pochettino fielded nine new starters for this low-stakes game, but Christian Pulisic entered in the 58th minute. He hadn’t played since the first half of the Americans’ opener due to a calf injury.

Arda Güler and Orkun Kökçü scored in the first half of a resilient performance by Turkey, which had already been eliminated after losing its first two matches despite largely dominating both statistically.

Turkey improbably won in the eighth minute of stoppage time when Can Uzun got the ball in space on the back post and pushed it past sprawling goalkeeper Matt Turner to Ayhan, who slid to knock it home.

The game’s meaninglessness didn’t matter to the raucous sellout crowd that packed SoFi Stadium. The American team’s fan base has been energized by its strong start to this home World Cup -- and this Los Angeles-area crowd was still chanting and standing when Berhalter airmailed a long corner to Trusty, who made the stadium shake when he banged it home inside the back post.

Trusty’s goal was the Americans’ seventh of the tournament, tying their scoring record for any World Cup before knockout play even begins. It was also the 173rd goal of this tournament, breaking the record for the most combined goals scored in a World Cup set in Qatar four years ago — and doing it in four fewer matches.

Turkey evened it in the 10th minute with an excellent two-man game from Baris Alper Yilmaz and Güler, the 21-year-old Real Madrid rising star.

Berhalter tied it in the 49th minute by running on to a loose ball about 20 yards from the net for a vicious strike.

Pulisic replaced Tim Weah in the 58th minute for his first game action since the first half of their 4-1 victory over Paraguay nearly two weeks ago.

Pulisic said this week that he is ready to play again after coming out at halftime with a calf injury in the Americans’ home World Cup opener. The AC Milan midfielder entered the 2-2 game to an enormous roar, and he created a scoring opportunity just a couple of minutes later with a dynamic run down the left side.

Pulisic nearly scored again in the 63rd minute, but his quick shot off a nice pass from Berhalter was knocked off the goalpost by Turkey goalkeeper Ugurcan Cakir, and Brenden Aaronson botched the resulting sitter.