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

Hearings being held this week could decide whether California continues to have a say over what happens in federal waters off the state’s coast.

It’s part of the Trump administration’s efforts to supercharge industrial activities, including offshore drilling, rocket launches and desalination plants along California’s coast. At a hearing Monday at a Santa Monica hotel and at a news conference beforehand, speaker after speaker decried any effort that would allow the federal government to revoke California's ability to manage its coast.

A federal law called the Coastal Zone Management Act gives states with coastlines the right to review and veto projects that may conflict with state policies and economies. The law was signed by President Richard Nixon after a devastating oil spill off the coast of Santa Barbara and is credited with launching the modern environmental movement.

More than 50 years later, the federal government has called for a detailed review of California's compliance with the 1972 law.

In a May social media post, the Trump administration said California is standing in the way of economic progress and called the state’s coastal management practices “obstructionist” and “environmental extremism.”

California officials, including state Natural Resources Secretary Wade Crowfoot, dispute that, saying the state approves federal initiatives 96% of the time.

“ Never before in the five-decade history of this federal act has this sudden baseless review taken place on any state's coastal management program, and never before in the history of this act has a coastal management program ever been revoked,” Crowfoot said at a news conference in Santa Monica on Monday.  ”This federal administration is bent on industrializing our coast.”

The hearings, which are being administered by NOAA, could result in the federal government decertifying California’s rights under the Coastal Zone Management Act. A decision to do so would almost certainly be challenged in court, experts say.

That possibility has prompted Gov. Gavin Newsom to call on Californians to submit public comments on the issue.

“Give the Trump administration an earful,” Newsom said in a statement.

The hearings this week are solely for public comment. The review “seeks any new input from relevant stakeholders regarding spaceport infrastructure, offshore oil production, pipeline maintenance, desalination projects, and undersea cables,” according to a notice in the federal register. 

Such reviews have happened before — in 2024 a draft review by NOAA found the state’s coastal agencies had properly carried out the CZMA. The review, however, was not finalized due to the change in administration.

The latest review comes after the Trump administration gutted NOAA staff and funding. It has also aggressively worked to expand drilling off the California coast, while at the same time using taxpayer dollars to pay offshore wind companies to abandon their energy projects — something L.A. County Supervisor Lindsey Horvath highlighted at the Monday news conference.

“ L.A. County will soon achieve 100% renewable and reliable electricity. This is the change that we want to see,” she said. “Meanwhile, the Trump administration is recklessly starting foreign wars and skyrocketing the price at the pump.”

L.A. County Supervisor Lindsey Horvath also spoke Monday at the news conference ahead of the NOAA hearing in Santa Monica.

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Tina Calderon, Gabrielino Tongva and Chumash culture bearer, speaks at Monday's news conference.

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Horvath is part of a coalition of local, state, tribal, environmental, legal and business leaders who are calling the review a “takeover” of state and local rights.

Orange County resident Grant Bixby, who founded the Business Alliance for Protecting the Pacific Coast, pointed out at the news conference that offshore drilling makes up a tiny fraction of the state’s coastal economy, which generates between $44 billion and $50 billion a year, according to NOAA.

"Should we put 99% of the other employment at risk for the benefit of one dirty industry?” Bixby said.

Bixby recalled how the 2021 Huntington Beach oil spill turned the beaches into a “ghost town.”

The NOAA hearing was held in a ballroom at the Santa Monica Hilton.

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Among the speakers at the news conference and hearing, a clear theme emerged: The coast is an integral part of being a Californian, whether you’re lucky enough to live beachside or you live inland and have a favorite spot to call your own on hot summer days.

“The point is that we all love our beautiful saltwaters,” said Tina Calderon, Gabrielino Tongva and Chumash culture bearer, at the news conference. “These are sacred waters, and it's up to us to be the voice. It's up to us to cause no more human harm. We've done enough.”

Jackie, the bald eagle whose livestreamed life with her partner Shadow won the hearts of fans worldwide, has died, rescuers announced Monday.

The famous raptor, believed to be 14 years old, was receiving intensive care at the Ojai Raptor Center for severe anemia. She ultimately succumbed to her condition after a team of veterinarians struggled for weeks to figure out what was causing it.

Jackie remained critically ill despite receiving oxygen therapy, supportive treatment and around-the-clock monitoring. 

"We know this news will be deeply felt by the many thousands of people around the world who have followed her journey, hoped alongside us, prayed for her, and supported the people caring for her,” the Ojai Raptor Center said in an Instagram post. “Our team is heartbroken. It has been an extraordinary privilege to care for her."

Friends of Big Bear Valley, the nonprofit that launched the popular nest livestream in 2015, confirmed the news on social media.

“It is with great sadness and heavy hearts, to bring you the latest update from Ojai Raptor Center,” the nonprofit said to its roughly 1.3 million Facebook followers. “Please be kind to yourself, to others, to the FOBBV team and to those at the Ojai Raptor Center. Soar free Jackie…”

What happened to her?

The rescue center said on social media Sunday that she was “critically ill,” “unstable” and still in an "extremely serious” condition.

She was getting oxygen therapy, supportive treatment and around-the-clock care from vets and specialists across the country. But her red blood cell levels continued to drop well below normal after rebounding a bit after she was rescued.

Jackie was rescued in July by Big Bear’s Dana Point Park after a brief fight with two other eagles. Jackie was weak, vulnerable, underweight and unable to fly, according to the Ojai Raptor Center.

The center said the fight is likely what left her grounded, but her condition suggests she had been sick for some time.

How Jackie’s Big Bear saga started

Jackie was the matriarch of the famous Big Bear bald eagle nest since around 2017. She’s believed to be the first bald eagle chick hatched in Big Bear Valley in recent history, according to the nonprofit.

The pair believed to be her parents, Ricky and Lucy, left the area around 2016. The young Jackie then started hanging out in their old nest, where the livestream camera had been installed.

Jackie took on her first mate, a bald eagle known as Mr. B, and laid her first clutch of eggs in the nest the following season. Shadow came into the picture in the summer of 2018, refusing to leave until Mr. B eventually flew away from the area, according to Friends of Big Bear Valley.

Jackie and Shadow were mates ever since. They successfully raised six chicks together — Sandy and Luna this season, Sunny and Gizmo last year, Spirit in 2022 and Simba in 2019.

Amid growing frustration with both major political parties, voters are open to some big changes.

A new poll, commissioned by supporters of election reforms and shared with NPR, shows there is significant support for upending winner-take-all U.S. House elections and single-member congressional districts and instead moving toward proportional representation, a system that elects multiple representatives in a single district in rough proportion to a party's vote share.

Earlier this summer, about 500 democracy and legal experts sent a letter to Congress urging members to consider proportional representation as a solution to the redistricting brinksmanship set off by President Donald Trump last year.

"There should be little doubt that the single-member district system is failing to deliver fair and representative outcomes," they wrote. "We urge Congress to adopt a proportional system of representation, solving the gerrymandering problem at its source."

According to the poll conducted by the advocacy group Fix Our House and liberal think tank New America, half of 1,000 respondents said they support proportional representation, with nearly a quarter opposed. A third of those who participated said they were not sure whether they supported it or not.

Lee Drutman, a senior fellow at New America, said he was surprised to see how much backing there is for proportional representation, despite the idea being fairly obscure in the United States.

"It really did shock me how supportive people were of the various principles of proportional representation across the board," he told NPR.

While support was highest among younger, more educated, more left-leaning voters, Drutman found that 6 in 10 Trump voters who have an opinion on proportional representation said they back it, too.

American voters want more political parties

Pollsters also walked respondents through some of the tradeoffs of proportional representation — including that it can lead to multiple parties having to find a way to work together.

"For every one of those questions, people prefer the proportional system with multiple parties," Drutman said, "even if it leads to a coalition government that is maybe not quite as efficient."

He said voters also weren't very concerned when asked about the possibility of proportional representation leading to some more extreme political parties.

"One thing people said is they already think the parties are pretty extreme right now," Drutman explained. "So that's not quite the fear that some in the political class think it would be."

Jocelyn Kiley, director of political research at the Pew Research Center, said voters writ large have been in a "prolonged period of disaffection with politics and the political system."

She said Pew has found there is a lot of openness to reform, with nearly 70% of respondents to its polls saying they wish, at least somewhat, there were more political parties to choose from.

Kiley said detailed knowledge of what any election reform would look like is rare among voters. And she said that when many reforms "move from theory to practice," they often hit some resistance.

"People want to understand exactly how that reform will impact them," she said.

Room for a national conversation

Drutman told NPR the new poll numbers mark a starting point for what could be a national conversation about how to break out of the country's two-party system.

"People are dissatisfied," he said. "People are frustrated. People don't have a language for how to talk about alternatives because they haven't really heard all that much about the alternatives, because we haven't had a national conversation about the alternatives yet. So, there's a lot of room to have that conversation."

Drutman said only about a quarter of the respondents were aware that there are alternatives to a two-party system, and even fewer people could name an alternative when pressed.

In fact, only about 2% of the participants in the poll could name proportional representation off the top of their heads, said Dustin Wahl, executive director of Fix Our House,

"But when asked about the kind of underlying values beneath it and the component parts, there was widespread support from all across the political spectrum," Wahl said. "And that's not something we would have expected to see necessarily four years ago, for instance. But as the problems grow, the desire for solutions grows, as well."

Proportional representation is currently the most widely used electoral system among the world's democracies. Wahl points out that the U.S., along with the likes of Canada and Australia, has a system that was abandoned long ago by other countries.

"Arguably the only reason we don't use proportional representation is because it wasn't used anywhere in the world at the time of [America's] founding," he said. "And we just kept doing elections the same way."

The poll also found a majority support (54%) for expanding the House, with 150 new members.

There are bills in Congress, with all Democratic co-sponsors, that would study or move the U.S. to a system of proportional representation, but Wahl said any bill that doesn't include expanding the House is "politically dead in the water" because without expansion, lawmakers have to choose to potentially vote themselves out of office.

"That [150-seat expansion] gives you enough of a cushion so that members, incumbents know that they're very likely to hold on to their seats," he said. "It wouldn't run into the problem, at all, of candidates or of sitting members of Congress thinking that they're going to lose their seats because their elections would be totally untouched."
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