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

A group of employees at the Los Angeles region’s homelessness authority says hundreds of frontline workers will face layoffs as L.A. County transitions funding away from the agency.

Staffers from the L.A. Homeless Services Authority, or LAHSA, wrote an open letter to the county Board of Supervisors this week, demanding that no county-funded workers be displaced.

Its members say the transition would hit workers and unhoused clients harder than county officials have acknowledged.

“ A lot of the workers are in this because we care and we want to help our fellow neighbors and don't want to see see all kinds of people homeless on the street,” Jacqueline Beltran, a LAHSA employee who signed the letter, told LAist.

County officials said they are committed to “clearing pathways to employment” for county-funded LAHSA workers within the new Department of Homeless Services and Housing.

“We are continuing to explore all available options,” new department director Sarah Mahin said in a statement.

Mahin said funding and staffing will be finalized in the FY 2026-2027 Measure A spending plan for the fiscal year that ends in 2027. The county released a draft of that plan last month. 

County authorities have said they would fully integrate the services performed by LAHSA into the new Department of Homeless Services and Housing by next July.

The transition

In April, the county Board of Supervisors voted to pull more than $300 million from LAHSA and create a new county homelessness department to administer the funds.

That motion also directed county agencies to consult with Service Employees International Union 721, which represents county-funded LAHSA employees, to try to keep them employed — or prioritize them for transition into the new department’s workforce.

But the LAHSA Workers Coalition said that’s not happening.

The group demands in its letter that the county halt all staffing reductions at LAHSA and argues the county has a legal obligation to protect the workers. The group is made up of employees represented by SEIU 721, but the union’s leaders did not cosign the letter.

The union did not immediately respond to LAist’s questions about it Thursday.

In February, an L.A. County report said the agency had 900 staff positions and nearly 200 vacancies. More than half of the positions were funded by L.A. County, according to the report.

LAHSA reported last month that it employed 686 people.

Demands

Last year, county voters approved the Measure A sales tax to fund homeless services and affordable housing. The ordinance says that contracts funded with Measure A revenue "must not result in displacement of public employees.”

In the letter, the coalition argues the county is out of compliance with that requirement and is urging the board to discuss the matter at its next meeting.

Mahin said Measure A does not prevent the county from restructuring programs but instead “protects public employees from being displaced by outside service providers funded through Measure A.”

The county is facing a deficit of more than $300 million in funding for homeless services, Mahin said, adding that it must make “difficult but necessary decisions about how we invest our limited resources.”

The workers coalition is demanding that existing LAHSA employees be transferred directly to the new department, instead of having to reapply.

They’re also asking the board for a full public disclosure of staffing cuts related to the transition.

In addition to the Board of Supervisors, the coalition sent the letter to several other county and state oversight entities, including the county office of the inspector general, the civil grand jury, the state auditor and the attorney general.

When Terri Huerta called local winemakers about a problem with a meandering vine at Mission San Gabriel in the city of San Gabriel, she thought she'd get gardening help. Instead, she sparked a revival of L.A.'s oldest wine.

Mission San Gabriel's 250-year-old grapevine, one of the oldest living vines in California, continues to produce grapes for the Angelica wine revival.

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Brandon Killman

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LAist

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The vine in question isn't your typical grapevine. It's a 250-year-old beast with a trunk so massive two people can't wrap their arms around it. Because it served as the source for cuttings that spread throughout California's early vineyards, it’s now known as the Mother Vine.

For centuries, it just sprawled across the mission courtyard like some ancient, living pergola that refuses to quit, with no one taking any notice of the grapes flourishing each season.

But now, thanks to a group of determined local winemakers, that fruit is being transformed into Angelica, a sweet wine fortified with brandy that Franciscan missionaries made there in the 1700s — making it the city’s oldest wine.

A limited edition batch was launched Nov. 28 by the Angeleno Wine Company. There are fewer than 200 bottles for sale, and at $75, it's not cheap. But break that down by the vine's age, and you're paying 30 cents per year of history.

How it started

The collaboration began in 2020 when Huerta, director of mission development at Mission San Gabriel, reached out to the Los Angeles Vintners Association looking for help to manage the grapevine.

The association — a partnership among three L.A. wineries: Angeleno Wine Company, Byron Blatty Wines and Cavalletti Vineyards — sent winemakers Mark Blatty, Patrick Kelly, Jasper Dickson and Amy Luftig to assess the situation. They found something bigger than a courtyard cleanup project. They found grapes. A lot of them.

"The vine was full of fruit, and I told them it was just a nuisance every year," Huerta recalls. "They asked, 'What are you going to do with all this fruit?' and I said, 'I really don't know.'”

That's when the group offered to help take it off Huerta’s hands.

Grapes from Mission San Gabriel's 250-year-old grapevine used in the Angelica wine revival.

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Courtesy of John Pryor

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Wine history

Although the Napa Valley now reigns supreme as the region’s wine industry, L.A. once was the center for the entire state. Mission San Gabriel’s vine was planted by Franciscan friars after the establishment of the mission in 1775 to make sacramental wine to be used during mass. DNA analysis has since revealed its forebears: It's a hybrid of Spanish Listán Prieto grapes and native California Vitis girdiana.

This vine’s cuttings helped launch the many vineyards that began to crop up around the newly founded grape fields, which became numerous. By 1850, L.A. boasted over 100 vineyards. If you look carefully, even today, the city of L.A.’s seal has a bunch of grapes hanging at the top.

The official seal of the city of Los Angeles.

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Courtesy city of Los Angeles

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The wines were popular with fortune seekers headed north to the Gold Rush. The industry flourished until 1883, when an outbreak of Pierce's Disease destroyed thousands of acres of vines across SoCal. Urban sprawl replaced vineyards with housing through the mid-20th century.

Today, almost nothing remains of L.A. 's once-dominant wine industry — with the exception of the Mother Vine and a handful of its descendants scattered across the city.

Across from Union Station a direct descendant is still growing over tourist and vendor heads. It’s a 200-year-old vine at Olvera Street's Avila Adobe, the oldest standing residence in the city of L.A.

Storing up the grapes

The winemakers started picking the fruit at the Mission in 2020. But it wasn’t enough to make a substantial batch of wine, so the grapes were stored. For the past five years, the winemakers, joined with volunteers, have harvested the fruit each season, carefully packing it away.

In the meantime, they began to dig into mission records for mentions of grapes and winemaking. One day they came across a document from the 1800s, which outlined a recipe for Angelica, a fortified wine made from grape juice and brandy.

"Angelica is said to be made by mixing one gallon of grape brandy with three of grape juice, fresh from the press," it said. "It is a thick, sweet and strong drink, yet of very delicate flavor."

The fortification wasn't just about taste — it was a necessity. In an era before refrigeration, adding brandy preserved the wine, allowing it to survive California's heat and long journeys between missions.

Two of the winemakers, Dickson and Luftig, were especially interested. They’d been making wine from grapes grown locally in the SoCal region since 2018 at their winery Angeleno Wine Company, which produces everything on-site near Chinatown.

They became intrigued by the idea of recreating Angelica. Following the historical recipe, they pressed fresh Mission grapes and fortified the juice with brandy before fermentation. Then they used the solera system — a traditional Spanish method that blends wines across multiple vintages — aging the wine in oak barrels for years.

Initially, they made limited batches solely for the company’s wine club members, which quickly sold out.

This year’s Angelica is the group’s third batch but the first to go on sale to the public. It includes grapes that have been harvested from 2020, 2021, 2022, 2023 and 2024.

The wine pours a pale cherry color and has a syrup-like consistency. The brandy comes through right away, caramel and warm spices with refreshing acidity cutting through the sweetness. It's thick, decadent and undeniably strong — a small glass (or two) is all that’s needed after a warm holiday meal.

The harvest

Harvesting the grapes doesn't look like the romantic wine country fantasy you see in magazines.

Instead of long rows of vines with grapes easily accessed, harvesters have to pick the fruit from below the canopy.

"Everyone has to bring ladders because we're picking like this," Dickson says, gesturing upward in the Mission’s courtyard. "We're literally placing ladders on ancient monks' tombstones to reach the fruit above the graves."

This year the harvest happened in October.

Volunteers harvest grapes at Mission San Gabriel for the Angelica wine revival project.

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Amy Luftig

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Angeleno Wine Co.

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John Pryor, a volunteer, has done multiple harvests. He describes it plainly: "You're not in a vineyard. You're in a garden at a Catholic church. The vines are trellised 12 feet high and go on for a hundred yards."

For his daughter, 27 year-old Meg Pryor, seeing the massive trunk drove home what "old" actually means.

"Whenever we're there, I'm thinking, 'People were doing this a century ago, two centuries ago,'" she said.

John and Meg Pryor help harvest grapes from Mission San Gabriel's historic grapevine for the Angelica wine revival project.

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Courtesy of John Pryor

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Understanding who most of those workers were centuries ago means confronting some difficult issues. Huerta of Mission San Gabriel acknowledges the mission system relied on Indigenous labor, and the vine's hybrid nature suggests native plant knowledge may have contributed to its development.

But she doesn't shy away from the complexity.

"You can't tell Mission history without including all the parts," she says. "You can't tell one story without telling another story. Winemaking has always been a part of L.A. history. The grapes were brought by the Franciscans. They didn't just start here in California. They started in Mexico, so its complexity makes it interesting, but it also makes it controversial."

Going forward, Angeleno Wine Company plans to release a limited batch of Angelica as a seasonal offering each year, as long as the Mother Vine continues to produce fruit.

The Supreme Court has cleared the way for Texas to use a new congressional map that could help Republicans win five more U.S. House seats in the 2026 midterm election.

The decision released Thursday boosts the GOP's chances of preserving its slim majority in the House of Representatives amid an unprecedented gerrymandering fight launched by President Donald Trump, who has been pushing Texas and other GOP-led states to redraw their congressional districts to benefit Republicans.

The high court's unsigned order follows Texas' emergency request for the justices to pause a three-judge panel's ruling blocking the state's recently redrawn map.

After holding a nine-day hearing in October, that panel found challengers of the new map are likely to prove in a trial that the map violates the Constitution by discriminating against voters based on race.

In its majority opinion, authored by a Trump nominee, the panel cited a letter from the Department of Justice and multiple public statements by key Republican state lawmakers that suggested their map drawer manipulated the racial demographics of voting districts to eliminate existing districts where Black and Latino voters together make up the majority. For the next year's midterms, the panel ordered Texas to keep using the congressional districts the state's GOP-controlled legislature drew in 2021.

But in Texas' filing to the Supreme Court, the state claimed the lawmakers were not motivated by race and were focused instead on drawing new districts that are more likely to elect Republicans.

In November, after the panel blocked the new map, Justice Samuel Alito allowed Texas to temporarily reinstate it while the Supreme Court reviewed the state's emergency request.

The mid-decade redistricting plan Texas Republicans passed in August sparked a counter response by Democratic leaders in California, where voters in a special election in November approved a new congressional map that could help Democrats gain five additional House seats. A court hearing for a legal challenge to that map is set for Dec. 15.

The rest of the redistricting landscape remains unsettled as well. Lawsuits are challenging new gerrymanders in places like Missouri, where there is also a contested referendum effort. And other states, including Florida, Indiana and Virginia, may also pursue new districts prior to the midterms.

Last week, a federal court ruled to allow North Carolina's midterm election to be held under a recently redrawn map that could give Republicans an additional seat.

Another wave of congressional redistricting may be coming soon depending on what — and when — the Supreme Court decides in a voting rights case about Louisiana's congressional map. After the court held a rare rehearing for that case in October, some states are watching for a potential earlier-than-usual ruling that may allow Republican-led states to draw more GOP-friendly districts in time for the 2026 midterms.

Edited by Benjamin Swasey
Copyright 2025 NPR

Growing up in Whittier, tamales have always been part of who I am — whether from local bakeries like La Moderna, where my mother always orders the day after Thanksgiving, or our annual tamalada with family friends, where we churn out hundreds in slightly drunken assembly-line fashion.

Over the years, I've explored beyond the traditional Mexican versions: El Salvadoran styles from What's That You're Cooking in Orange County to the Chinese lo mai gai found at dim sum spots across the city. My pursuit of new tamal variations is relentless, especially this time of year.

So when I heard about a $27 lamb neck tamal in Venice, I had to know: could an elevated, chef-driven approach ever justify that price? Since a few other restaurants are also recreating the humble dish with a high-end approach, I decided to go and try them.

What I discovered was that these aren't replacements for traditional tamales — they're explorations of what happens when fine dining ambition meets this centuries-old form.

Si! Mon (Venice)

Si! Mon opened in 2023 in the former James Beach space, a collaboration between chef José Olmedo Carles Rojas and restaurateurs Louie and Netty Ryan, known for Venice-adjacent mainstays Hatchet Hall and Menotti's Coffee Stop. Si! Mon offers Carles Rojas' take on Panamanian fine dining, drawing on Panama's melting pot of Chinese, French, Spanish, African and Caribbean influences.

For the holidays, Carles Rojas is offering a $27 lamb neck tamal — a clear departure from the Mexican versions most Angelenos know. And while the price might cause some sticker shock, it’s worth considering what goes into it and how much food there is.

Wrapped in a banana leaf, the tamal uses a lighter, softer masa enriched with the lamb neck’s braising liquid. Rojas pulls the meat, tosses it with sofrito until it takes on a sauce-like consistency, then adds Indian-style quick-pickled dates for sweetness and olives for brine. Finally, the tamal is finished in Si! mon's wood-fired oven, adding subtle smokiness.

My verdict? After taking that first bite, I can tell you… it’s worth the splurge. One tamal is meant to be shared between two people, which partly explains the price point (though I had no problem finishing mine solo). I’ve had plenty of Central American tamales over the years — Salvadoran versions with their silky masa, Nicaraguan nacatamales loaded with vegetables and pork — but Carles’ take pulls out all the stops. This is a deluxe, bells-and-whistles vision: sweet, salty, and deeply savory all at once, comforting yet unlike anything I’ve tasted before.

Yes, it is a high price, but I’d say it reflects the time, technique and premium ingredients behind it.

KOMAL (South L.A.)

A Guatemalan-style chuchito tamal from KOMAL at Mercado de Paloma in South L.A.

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Frank WonHo

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Courtesy KOMAL

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KOMAL is L.A.'s first craft molino (mill), founded by Fátima Júarez and Conrado Rivera, former employees of Michelin-rated Holbox, who opened this masa-centric counter inside South L.A.'s Mercado La Paloma. The name is Nahuatl for "comal," the traditional flat griddle used to cook tortillas.

I wanted to try the chuchito ($11), a regular menu staple at KOMAL. Júarez refers to the dish as a gift — both for the unwrapping it requires and the labor of love behind it. Each one takes more than 22 hours to make, starting with nixtamalizing heirloom corn to create the masa. (Nixtamalization, an ancient Mesoamerican process, involves soaking and cooking corn in an alkaline solution to improve its flavor, texture, and nutrition).

The result is a fluffy steamed tamal filled with tender pork and crowned with roasted pepper and tomato sauce, pickled cabbage and vegetables, and crema. The dish honors her kitchen team, most of whom are from Guatemala, and it's KOMAL's way of putting their heritage front and center on the menu.

KOMAL’s strawberry tamal dulce comes bright red and crowned with pineapple and fruit compote.

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Frank WonHo

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Courtesy KOMAL

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Komal’s tamal verde at Mercado de Paloma comes stuffed with tender chicken and topped with zippy green salsa.

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Frank WonHo

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Courtesy KOMAL

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Beyond the chuchito, Júarez is offering three special tamales as holiday pick-ups for Christmas and New Year's: a deep, complex tamal rojo filled with sweet corn and squash calabacita, a vibrant tomatillo-based tamal verde filled with chicken, and a tamal de leche made with oranges and strawberry jam, a sweet version that hints at the pre-Hispanic tasting menu they're developing.

After the holidays, these tamales will transition to appearing exclusively at Komal's planned ancestral and ceremonial dinners in 2026 — making this a rare chance to try them before they become part of a more formal dining experience.

Available by the half-dozen ($45) or the dozen ($90), they can be ordered for pick-up at KOMAL on Tuesday, Dec. 23, or Tuesday, Dec. 30.

Campesino Café at The Ecology Center (San Juan Capistrano)

Aaron Zimmer, head chef of Campesino Café at The Ecology Center, works within a unique constraint: everything on his menu comes from the 28-acre regenerative organic farm surrounding the restaurant. That includes the corn he grows, dries, harvests and processes into masa for his tamales.

For the winter season, Zimmer is offering two versions that reflect what's abundant on the farm right now. The shelling bean and cheese tamal ($21) features beans from one of four varieties they grow on-site — shelling beans are harvested before they're thoroughly dried, prized for their creamy texture and delicate, earthy flavor. The cooked-down beans are incorporated into the fresh masa with cheese, then topped with chili con queso made with pickled giardiniera from their summer harvest.

Campesino Café’s tamal duo pairs winter squash in walnut mole with a shelling-bean-and-cheese tamal topped with chile con queso.

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Gab Chabrán

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LAist

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The winter squash tamal ($21) features squash finished with a walnut mole sauce. The sweet, nutty texture, combined with the squash's sweet, earthy flavors and soft, fresh-tasting masa, creates a highly multidimensional bite.

Both are wrapped in masa and steamed in corn husks, then topped with whatever's available in the larder at any given moment, such as freshly grown cilantro or pickled onion.

It's a hyperlocal, intensely seasonal approach that makes each tamal a snapshot of what the farm is producing — versatile, sustainable, and entirely tied to the land it comes from.