In a sent Monday to the legislature, the California Department of Housing and Community Development recommended lawmakers set a maximum safe indoor air temperature of 82 degrees Fahrenheit for the Golden State’s estimated 14.6 million residential dwelling units.

“This is a big deal,” said C.J. Gabbe, an associate professor of environmental studies at Santa Clara University. “We’re seeing more and more concerns about the increase in heat-related morbidity and mortality in California, which is leading to these kinds of maximum indoor temperature guidelines.”

If the housing proposal is adopted, California could have the most comprehensive requirements in the nation, Gabbe said. Some local jurisdictions, including , , and , have set their own standards, and the and are exploring their own protections.

Last year was the planet’s warmest on record, and extreme weather is becoming more frequent and severe, according to the . Even though most heat deaths and illnesses are preventable, about 1,220 people in the United States are every year, according to the Centers for Disease Control and Prevention. Heat stress can cause heatstroke, cardiac arrest, and kidney failure, and it’s especially harmful to the very young and the elderly.

State law protects renters in the winter by requiring all rental residential dwelling units to include functioning heating equipment that can keep the indoor temperature at a minimum of , but there is no similar standard giving renters the right to cooling.

The release of this report is a key milestone, but it’s just the first step of a long road, vulnerable to legislative politics and an influential housing industry that has successfully delayed similar proposals in the past. , state lawmakers directed the housing department to issue cooling recommendations after proposed legislation stalled when landlords, real estate agents, and builders raised concerns such a standard would be cost-prohibitive.

Those concerns remain. Many California rental units are older homes, sometimes 90 to 100 years old, and installing air conditioning would require expensive changes, including upgrading the electrical system, said Daniel Yukelson, CEO of the Apartment Association of Greater Los Angeles.

“These types of government mandates, absent some kind of financing or significant tax breaks, would really put a lot of smaller owners out of business,” said Yukelson, who added that he’s concerned it would lead to housing getting bought by large corporations that would spike rent prices.

The report recommends lawmakers provide incentive programs for owners to retrofit residential units so the cost isn’t passed along to renters. It also suggested a variety of strategies that could be deployed to keep homes cool: central air conditioning, window units, window shading, fans, and evaporative room coolers.

For new construction, housing officials suggested new standards incorporating designs to keep indoor temperatures from topping 82 degrees, such as cool roofs and cool walls designed to reflect sunlight, or landscaping to provide shade.

Whether the legislature will take up the housing department’s recommendations is unclear. Spokespeople for Democratic Assembly Speaker Robert Rivas and Sen. Henry Stern, Democrats who co-authored the 2022 cooling standard bill, declined to comment.

Californians largely stand behind the idea, according to from the University of California-Berkeley Institute of Governmental Studies and co-sponsored by the Los Angeles Times. Sixty-seven percent of voters said they supported the concept of the state establishing cooling standards for residential properties.

As temperatures rise and heat waves become longer and more intense, the report cautions, deaths in California could rise to 11,300 a year by 2050. And deaths from all causes “may be up to 10% higher on hot nights compared with nights without elevated temperatures,” according to a by the Los Angeles County Department of Public Health.

That’s because it can be particularly dangerous when people can’t cool off at night during extended heat waves, said David Konisky, a professor of environmental policy at Indiana University.

“When you can’t count on evening cooling off and allowing the body to readjust,” he said, “that’s when things get really dangerous for people’s health.”

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At least one medical clinic burned down. Senior by ambulance from nursing facilities as embers swirled around them and their providers. Medical offices have closed, and routine appointments have been canceled. Some providers have lost homes or had to evacuate their neighborhoods, keeping them from work in many cases and making it a challenge for some health care centers to maintain sufficient staffing.

Amid the maelstrom, doctors, nurses, and other caregivers did their jobs.

On Tuesday night, Ravi Salgia, an oncologist at City of Hope National Medical Center in Duarte, saw the house above his Eaton Canyon home go up in flames. As debris and sparks fell, he, his wife, and their older daughter estimated they had no more than seven minutes to get out. In the middle of the night, Salgia got a call that the hospital had become an emergency command center and was at risk of evacuation, meaning he needed to help evaluate patients and make discharge preparations.

Salgia arrived at the hospital at 2:30 a.m. Wednesday. He was joined by colleagues, many of whom had also evacuated their homes.

“We all felt very strongly that we needed to take care of our patients — no matter what’s happening to us physically and emotionally, what’s happening to our houses — that we need to make sure that the people we serve were taken care of,” Salgia said in an interview.

He doesn’t know if his house is still standing.

In Pacific Palisades, , a primary care and pediatric clinic affiliated with Providence Health & Services, burned down, said Patricia Aidem, a spokesperson for the large Catholic hospital chain based in Renton, Washington.

Not far from the eastern edge of the Palisades Fire, Providence St. John’s Health Center in Santa Monica, one of the group’s major LA-area hospitals, was so close to evacuating that it called other hospitals in the area to find space for patients who would be displaced, Aidem said. USC Verdugo Hills Hospital, in Glendale, also faced potential evacuation, along with other hospitals in the region.

“All hospitals in close proximity to the fires remain on high alert and are prepared to evacuate if conditions worsen,” the Hospital Association of Southern California said in a statement. “The fires are creating significant operational hurdles,” the association added.

The association also said emergency services have been strained by high call volumes, while road closures have impeded the transport of patients, supplies, and health care workers. Some health facilities have been hit by power outages, the association said, while “many staff members are directly impacted by evacuations and fire-related disruptions, further complicating operations.”

The California Department of Managed Health Care on Thursday to ensure enrollees affected by wildfires have access to all needed medical services, including prescription drug refills.

Aidem said some doctors and other health workers at Providence St. John’s in Santa Monica and Providence Holy Cross Medical Center in the San Fernando Valley have lost homes or been evacuated, making them miss work and creating challenges to ensure adequate staffing.

Hospitals across the county said their emergency rooms had treated patients for burns, smoke inhalation, and eye irritation.

Over 700 people — and possibly far more — have from nursing homes and other care facilities, according to the California Department of Public Health.

On Wednesday, West Valley Health Center, operated by Los Angeles County’s Department of Health Services, closed due to a power outage, the department said. And UCLA Health said the closure of some of its clinics in Pasadena and on L.A.’s Westside was due partly to “utility shutoffs.”

Children’s Hospital Los Angeles said two of its specialty care clinics, in Encino and Santa Monica, “due to the impacts from the wind storm, power outages and wild fires.”

Providence also has shut several clinics this week.

The two biggest blazes, the Palisades Fire in the parched coastal hills of western L.A. County and the Eaton Fire on the Eastside, have together torched more than 50 square miles, burned thousands of structures, reduced beloved cultural landmarks to ashes, killed at least 10 people, and severely injured many more.

The monster winds that fueled the explosion of the fires on Tuesday and Wednesday have begun to quiet down, though significant gusts are still expected to complicate the task of firefighters for the next several days.

Routine medical care will likely be disrupted for thousands in the days ahead.

Kaiser Permanente, the giant HMO and medical provider, said it closed multiple medical sites Thursday due to the fires, including a pharmacy and laboratory and an eye clinic.

Huntington Hospital in Pasadena, close to the Eaton Fire, said some of its outpatient offices were affected by evacuation notices and heavy smoke.

Dignity Health, another large health system, said some of its hospitals were operating on generator power due to high winds, and some, including Glendale Memorial Hospital, had canceled elective surgeries. Other hospitals, including USC Verdugo Hills and Providence St. John’s, temporarily halted nonemergency surgeries due to the impact of the wildfires.

Christine Kirmsse, a registered nurse, evacuated her Santa Monica home on Wednesday night and is staying at a hotel an hour away. But she said she feels strongly that she needs to come into work.

“There’s obviously so much help that’s needed,” Kirmsse said. “And it’s important to me because I have the skills to be able to help. In times like this, this is when community is the most powerful.”

ºÚÁϳԹÏÍø News’ Chaseedaw Giles and Tarena Lofton contributed to this report.

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Lightbourne served as head of the state’s Department of Social Services for seven years before retiring in 2018 and had already returned to service once, as interim head of the Department of Health Care Services at the height of the covid-19 pandemic. On Nov. 4, he was tapped to lead the state’s Mental Health Services Oversight and Accountability Commission after executive director Toby Ewing announced he would step down.

Documents obtained by ºÚÁϳԹÏÍø News showed that Ewing took a trip to the U.K. funded by Kooth, a London-based company that the state contracted to build a youth mental health app. At the same time, he was working to protect Kooth’s $271 million contract.

During a public hearing the day he announced his resignation, advocates for mental health services accused the commission of favoring the interests of corporations over those of the people it is supposed to serve.

Lightbourne, 75, is now leading the commission, an independent body charged with ensuring that funds from a millionaires tax are used appropriately by counties for mental health services. He said he’ll focus on making the commission as open as possible, as a nationwide search for the next executive director begins.

He comes to the mental health commission at a moment of change. With the passage of the last year and its approval by voters this year as part of Proposition 1, the commission will be integrating 11 new members starting in January. And in July 2026, it will stop overseeing county funds for mental health innovation and will instead get its own bucket of up to $20 million a year to spend on innovation. Conversations are already underway about how to spend the funds.

Lightbourne directed social service agencies in Santa Clara, San Francisco, and Santa Cruz counties before being named director of the state social services department, where he launched an effort to move more foster children out of institutions and into family-based settings.

Lightbourne spoke to ºÚÁϳԹÏÍø News correspondent Molly Castle Work about his goals for state mental health services. The interview has been edited for length and clarity.

Q: You already came out of retirement once, to lead DHCS during the pandemic. How were you convinced to take this job?

A: Back when I was at DHCS, quite a bit of what is now the sort of health reconceptualization in California happened.

There’s a point where you feel a sense of paternal relationship for a lot of the initiatives. What the commission does in terms of the detailed finish work is really going to be important for this thing to work.

Q: Executive Director Toby Ewing resigned amid accusations of favoritism with the contracts. How can the public have faith that this won’t happen again?

A: I want to be very careful now, because the way you phrase the question implies that I accept the proposition, and I have no way of knowing. What I’ve always said in any setting that I’ve been in is always deal the cards face up. Just be transparent. Be open. When possible, use competitive processes.

There’s the famous three intersecting points of contracting: You can have speed, you can have quality, you can have a good price. Pick two. You can’t have three. And you know, my instinct is always to be a little bit more skeptical of urgency. I mean, there are huge human needs out there that we want to solve, but to say everything should go by the wayside because things have to happen yesterday — let’s take a beat.

Q: As the interim executive director, are there guardrails that you think need to be in place to ensure that taxpayer money is being spent wisely?

A: I don’t know that there’s anything that I am particularly worried about, but I think it’s my role to help the commission as it transitions into Prop 1, into BHSA, and into a permanent executive director — just make sure that they’ve got all the procedures that they think they need — and that we build a culture where we are sure that they are able to fully see things coming in front of them.

It’s going to be interesting that come January we’re going to add 11 commissioners. It’s a huge jump. And doing it in a way that everybody stays engaged — I don’t have an answer yet.

The value-add of this organization is that it’s got a commission of pretty damn committed people who take it very seriously and bring a lot of skill to it. And you wouldn’t want to see that lost.

Q: Our country has seen the mental health crisis spike over the past few years. Are there specific areas you want to focus on?

A: I always want to be a little careful about having one more bright idea. There is definitely initiative fatigue on the ground. People have got that glazed look. So if there are things that the commission can do to bring more resources, more players, more solutions that help, then that’s great. I just don’t want us to be piling on new ideas.

Some of the things the commission has already invested in, and I’m trying to get more familiar with this, like the early psychosis interventions — that could be a real game changer as I understand it.

Q: How do you think funding for mental health initiatives should be prioritized?

A: Certainly the old notion of full-service partnerships is important. It means whatever takes — put a team together, wrap it around the person, address their core needs, like housing.

Don’t think that with somebody sleeping under the bus shelter that you can address their needs while they’re still sitting there, you know? Move them into a setting where they can feel safe, they have dignity, they have their personal human needs met, and also whatever therapeutic needs or medication needs or medically assisted treatment needs.

Q: What are you most looking forward to in this role?

A: Because of where I’ve been previously, I think there are some obvious connections to make. We don’t want to subordinate the commission to the other systems. It’s got to have its own thing. But just knowing who to dance with can be helpful.

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Two years ago, Bonta, a Democrat who heads the state justice department, directed his staff to draft legal analyses against a possible national abortion ban after the U.S. Supreme Court overturned 50 years of abortion protections under Roe v. Wade. Bonta said they thought through arguments, even going so far as to decide in which court they would file suit.

Bonta said his team had a strategy in place starting from Election Day.

After the Dobbs decision, Trump boasted that he “” Roe v. Wade. He said he would veto any federal abortion ban after declining to say whether he’d veto one. And Project 2025’s Mandate for Leadership, a road map for the next conservative president that was crafted by many former Trump advisers, described the overturning of Roe as “.” It also calls for ending a requirement that Obamacare plans cover emergency contraceptives; the mailing of medication abortion pills; and federal funding of Planned Parenthood and other clinics that provide abortion.

By comparison, Californians have to abortion and contraception into the state constitution. The state in 2022 also and approved $200 million in new spending to expand abortion protections in the Golden State and make it easier for low-income and out-of-state patients to get care.

Bonta, who was appointed attorney general in 2021 by Gov. Gavin Newsom, a national anti-abortion group and a chain of anti-abortion crisis pregnancy centers for marketing unproven and potentially harmful “abortion pill reversal” procedures. In September, he sued Providence St. Joseph Hospital, a Catholic hospital that had allegedly denied a patient an emergency abortion, instead discharging her with an offer of a bucket and towels. Last week, Bonta reached a settlement with the city of Beverly Hills over its alleged blocking of an abortion clinic from opening.

He has joined other states in lawsuits over , , and for care. For Bonta, the issue of abortion is personal. His wife, Assembly member Mia Bonta, that she had an abortion when she was 21. As her boyfriend, Bonta held her hand when she made the decision.

Bonta spoke to ºÚÁϳԹÏÍø News correspondent Molly Castle Work about his passion to protect women’s reproductive health rights and how his upbringing influences his legal decisions. This interview, which took place Oct. 31, has been edited for length and clarity.

Q: How do you think your upbringing prepared you for this job?

A: It starts with inspiration from my parents. They learned that you can’t just hope and wait for the things that you want; you have to fight. They joined the United Farm Workers of America. My dad worked in the front office with Cesar Chavez, my mom with Dolores Huerta. They were fighting for the people that feed our state and our nation but weren’t being treated right.

I remember growing up, I would go with my mom … to protests and rallies and demonstrations. I was at her side, slogans in my throat and fist in the air, or placards in my hand, calling out the human rights abuses. There was that belief that everyday people cannot accept the unacceptable, and if something’s not right, we’ll fight, and can and do create the change that they seek.

I want to be the person that comes in with my positional power, my authority, the reach and the strength of this office behind me and on my side working together to protect those people who are being mistreated and wronged.

Q: You’ve been a longtime champion of reproductive rights. Why are you so passionate?

A: Some things you just feel in your gut. And you have your own personal story. My wife has told the story, and it’s her story to tell. She had an abortion, and I accompanied her and held her hand. It was her choice and her right and her decision and her bodily autonomy and self-determination. And every woman deserves that.

And I don’t like bullies. I don’t like people who attack others and try to take things away from them. It’s wrong and it’s my role to protect those rights. And these are not imagined rights — before Dobbs, they existed for 50 years for every woman in the United States of America.

We’re in a fight for freedom right now, certainly including reproductive freedom, and it’s something that I think the entire nation has some connection to, and it’s wrong for elected officials, presidential candidates, to make political decisions, to get in the way of a decision that should be made between a woman, her doctor, her faith.

Q: Tell me more about your wife’s decision to share her own abortion story after the U.S. Supreme Court issued the Dobbs decision. Why was it important for you both to share that story?

A: We talked about it, of course, but it was her decision. And it’s not something that’s easy to talk about, but I think it was important to talk about, especially given that moment.

It was painful to see that people lost faith and trust in the Supreme Court and it was important for people to know that their leaders are side by side with them, have experiences and passions and cares just like them, have worries and fears just like them.

And I think it was important to Mia to emphasize the impact of these decisions on women of color and vulnerable women, poor women. It was important for her to lift up her voice and, through her pain, own her power and show her strength and communicate with others about her own experience.

Q: You have joined and led multistate efforts to defend abortion in states such as Idaho and Texas. Why is it California’s place to push for access outside its borders?

A: We fight the fight wherever it is. We get involved in all sorts of different types of issues, supporting transgender and gender-nonconforming youth, supporting commonsense constitutionally lawful gun safety laws. And certainly when it comes to reproductive health care, we do the same. There are strategic, intentional, deliberate attacks, by design, in certain courts outside of California. And so it’s very important for us to bring our knowledge, our expertise, our legal insight into those fights.

Q: What happens if Trump wins the election? How does that change your job? And what type of preparations are you making?

A: We’ve been preparing since the Dobbs decision dropped. Shortly after that, I asked my team to start writing the brief for a national abortion ban: Just think it through, you know. Think through the arguments. Do we have a pathway to challenge it in court?

Hopefully we’ll never have to challenge it in court. There’s no national abortion ban, and maybe there never will be, but we want to be ready if there is. We want to have thought through it when we had time and been able to do the in-depth and the nuanced review.

I think the people of our state and the people of our country want us to have been doing that.

Q: So, I’m sure you know I have to ask: Are you considering a run for governor?

A: There will be a time to make that decision after the election. That time is not now. I am honored and grateful that I’ve gotten lots of encouragement from people. That gives me inspiration about the work that my team is doing.

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Toby Ewing, executive director of the Mental Health Services Oversight and Accountability Commission, will step down effective Nov. 22. Documents obtained by ºÚÁϳԹÏÍø News show that he tried in June to protect state funding for Kooth, a London-based digital mental health company with a contract to develop a virtual tool to help California tackle its youth mental health crisis.

He had been on pending since September.

Ewing’s resignation was announced after a four-hour closed session of the mental health commission. During a public hearing before the announcement, advocates for mental health services accused the commission of favoring corporations over serving people with mental health and substance use issues.

The commission is an independent body charged with ensuring that funds from a millionaires tax are used appropriately by counties for mental health services.

“You are being co-opted by big corporations,” said Susan Gallagher, executive director of Cal Voices, a mental health advocacy organization, during Thursday’s meeting. “You’re lobbying behind the scenes for these people to get money. That is not your job. You serve the people.”

Ewing declined to comment.

Kooth last year signed a four-year, with the Department of Health Care Services, which is separate from the commission, to , a free mental health app for California users ages 13 to 25.

The app, for younger users by the company Brightline, launched in January to fill a perceived need for young Californians and their families to access professional telehealth free of charge. It’s one component of Gov. Gavin Newsom’s youth mental health plan.

The apps have seen very slow uptake since their launch in January. In May, the Newsom administration proposed a $140 million budget cut for the apps. Both the state and budget committees proposed eliminating the entire program to save the state $360 million in the face of California’s $45 billion deficit.

But the funding for Kooth’s app wound up restored. It’s unclear why. Emails and calendars reviewed by ºÚÁϳԹÏÍø News showed Ewing pressed legislative staffers in June to restore the proposed cut.

About two weeks later, Ewing was accompanied by MHSOAC commissioners Mara Madrigal-Weiss, Bill Brown, and Steve Carnevale on a trip to London. show Kooth paid $15,000 in travel expenses for Ewing, Madrigal-Weiss, and Brown. The forms do not show the company paid for Carnevale’s travel.

While Ewing was in London, a colleague told him that the final state budget was approved with funding restored for Kooth’s app. Ewing ideas to improve its teletherapy app. About a week later he wrote, “We expect you to be involved in whatever we dream up.”

At Thursday’s commission meeting, Stacie Hiramoto, director of the Racial and Ethnic Mental Health Disparities Coalition, said the public will view the London trip as a serious conflict of interest.

“Maybe there was no wrongdoing, and maybe the company was good,” said Hiramoto, referring to Kooth. “But don’t you understand the appearance of the conflict?”

Carnevale said in Thursday’s meeting that the Newsom administration asked the commission to engage the legislature during budget negotiations.

“The governor’s office reached out to us to ask us to help them support the arguments and that’s what we did,” Carnevale said. “We went back and explained our positions on the digital solutions provided generally, without any particular comment on any company or any product in particular.”

Newsom’s office didn’t immediately respond.

Carnevale said the U.K. trip was not related to the budget. He said the trip “was very successful” for exchanging ideas with mental health policy leaders.

DHCS Director Michelle Baass that roughly 20,000 of the state’s more than 12.6 million children and young adults had registered on the apps. Together, they had been used for only about 2,800 coaching sessions. The department has not provided more recent figures to ºÚÁϳԹÏÍø News.

Madrigal-Weiss defended her support of the mental health apps, lauding the youth-led design. She cited data that a majority of Kooth’s users liked the virtual coaching sessions and more than half were from underserved communities.

According to , obtained through a records request early this year, its payment is partially contingent on how many people use its app. Kooth will not get a pay increase until it reaches 366,000 users.

Kooth’s stock price fell about 20% on Thursday after ºÚÁϳԹÏÍø News published an article about Ewing’s efforts to restore funding for its contract and the London trip.

Gabe Brison-Trezise contributed to this report.

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Emails and calendars reviewed by ºÚÁϳԹÏÍø News show Toby Ewing, executive director of the Mental Health Services Oversight and Accountability Commission, made efforts to protect funding for Kooth, a London-based digital mental health company the state hired to develop a virtual tool to help tackle its youth mental health crisis. Ewing pressed key legislative staffers to maintain its contract, even as Democratic Gov. Gavin Newsom and lawmakers proposed cuts in the face of California’s $45 billion deficit.

When Ewing and three commissioners — Mara Madrigal-Weiss, the commission chair; Bill Brown; and Steve Carnevale — left for London in June, Ewing wasn’t sure whether he had saved Kooth’s funding. On the second day of their trip, that lawmakers had .

A few days later, Kooth Chief Operating Officer Kate Newhouse suggestions he had shared with Assembly and Senate staff to improve Kooth’s youth teletherapy app. “We expect you to be involved in whatever we dream up,” Ewing wrote to Newhouse in another email.

It’s unclear why Kooth picked up a $15,000 tab for state officials to travel to London. It’s also unclear why Ewing pushed to protect its app from a spending cut. The commission is a 16-member independent body appointed by various elected officials to help ensure funds from a millionaires tax are used appropriately and effectively by counties for mental health services. Kooth’s contract is with the Department of Health Care Services, which is separate from the commission.

Kooth last year signed a four-year to , a free mental health app for California users ages 13 to 25. The app, , by the company Brightline, for younger users, launched in January to fill a need for young Californians and their families to access professional telehealth free of charge. It’s one component of Newsom’s youth mental health plan.

Ewing, who reports to the commission, started in 2015 and earned $175,026 in 2023, according to . He was placed on in September pending an investigation. Commission chief counsel Sandra Gallardo said the commission does not comment on personnel matters. Ewing did not respond to requests for comment.

Three commission employees filed whistleblower complaints against Ewing in September with the California State Auditor. They spoke with ºÚÁϳԹÏÍø News on the condition that their names not be used due to fears of workplace retaliation. They say Ewing’s conduct advancing a private company’s agenda as a public official crossed a line.

for Thursday’s commission meeting listed a personnel matter to be discussed in closed session. The whistleblowers said Ewing is the subject of the discussion.

Madrigal-Weiss said she couldn’t comment on Ewing’s actions. However, she said the commission supports virtual mental health resources for youth.

“These resources are less expensive and have proven valuable for youth, especially those who struggle to access services in typical brick-and-mortar spaces,” said Madrigal-Weiss, who is also executive director of student wellness and school culture for the San Diego County Office of Education.

Brown and Carnevale didn’t respond to requests for comment.

Kooth is committed to advancing youth access to behavioral health services, said Caroline Curran, of Metis Communications, a public relations firm representing Kooth.

“As a leader in youth behavioral health services with over 20 years of experience in the United Kingdom and the United States, we regularly convene sector-leading organizations to facilitate learning through sharing expertise and diverse perspectives on youth behavioral health,” Curran said.

As ºÚÁϳԹÏÍø News reported in April, the Kooth and Brightline app rollouts have been slow, with few children using them. In May, Newsom proposed a $140 million budget cut. DHCS Director Michelle Baass said in that it was due to low use but that the state expects more users to come on board over time, according to CalMatters’ Digital Democracy tool.

She told lawmakers on May 16 that roughly 20,000 of the state’s more than 12.6 million children and young adults had registered on the apps, and they had been used for only about 2,800 coaching sessions.

State Sen. Caroline Menjivar (D-Van Nuys) asked Baass at the hearing whether “there’s room to get out” of the contract altogether. Senators later to cut the entire platform budget to save the state $360 million.

Ewing on June 3: “Kooth is freaking out.  Is the cut coming from the Admin or the Leg.? Do we know if it’s a done deal?”

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Providence St. Joseph Hospital, in the small Northern California coastal city of Eureka, refused to provide the care she required because doctors could detect fetal “heart tones,” Nusslock said at a Monday. California Attorney General Rob Bonta against the Catholic hospital detailing Nusslock’s dangerous experience and alleging the hospital violated multiple state laws when it discharged Nusslock — with an offer of a bucket and towels — to go elsewhere for what he described as standard medical care.

Bonta also filed a in Humboldt County Superior Court, asking that it require Providence to treat anyone with an emergency medical condition. “The need for immediate relief is about to intensify,” the motion said. That’s because Mad River Community Hospital, where Nusslock ultimately got care 12 miles up the road, is slated to close its birth center this month.

Providence will be the only hospital within about 85 miles to offer labor and delivery, according to a ºÚÁϳԹÏÍø News analysis. When care is more than an hour away, academic researchers typically define the area as a .

“It begs the question, what happens next time someone in Anna’s situation shows up at Providence? There will be no Mad River for them to go to,” Bonta said at a news conference. “With a dire lack of services, even here in California, and an influx of patients from states with abortion bans, we need hospitals to follow the law.”

The case illustrates how even in California, where the right to an abortion is enshrined in state law, there’s a glaring loophole. Catholic hospitals, which restrict reproductive health care because they follow the church’s “,” are aggressively expanding nationally by acquiring secular hospitals. In swaths of the country, including parts of Northern California, they are the only choice. At the same time, maternity wards are closing rapidly, leaving more patients to contend with religious directives instead of accepted medical standards.

California’s lawsuit also comes amid uncertainty that emerged after the Supreme Court in 2022 overturned the constitutional right to an abortion: whether federal law requires hospitals to provide abortions as emergency medical care even in states that have banned the procedure. The high court punted on the question this summer. The its policy that the Emergency Medical Treatment and Labor Act requires hospitals to stabilize or treat any patient who shows up at an emergency room. Texas is suing the administration over the policy.

The issue is also playing out in the presidential election. During the Oct. 1 vice presidential debate, Democratic Minnesota Gov. Tim Walz noted a Georgia woman who died because a hospital delayed care. Sen. JD Vance (R-Ohio) answered, in part, by asking Walz if he wanted to force Catholic hospitals to perform abortions against their religious beliefs, saying that “Kamala Harris has supported suing Catholic nuns.”

With federal protections in limbo, Bonta said California must rely on its state laws to protect patients. Specifically, Bonta, who is widely expected to , alleges that Providence violated a that hospitals provide care “necessary to relieve or eliminate the emergency medical condition.”

Nusslock’s case isn’t an isolated incident, the lawsuit said. “One to two women per year receive abortion care at Mad River, after being refused care at Providence Hospital,” the lawsuit said. “These individuals, like Anna Nusslock, had all been discharged from Providence Hospital with instructions to go somewhere else.” Bonta said his office is investigating how widespread cases are in California, where Catholic hospitals represent .

In an Oct. 1 letter to employees that was obtained by ºÚÁϳԹÏÍø News, Providence Northern California Service Area Chief Executive Garry Olney said the hospital is “heartbroken” about Nusslock’s experience, which “did not meet our high standards for safe, quality, compassionate care.” He added the hospital is revisiting its training, education, and escalation processes to ensure it doesn’t happen again.

Providence spokesperson Bryan Kawasaki said its abide by applicable federal and state laws, including EMTALA. Kawasaki declined to comment specifically on Nusslock’s case.

More women are running into barriers to obtaining care as Catholic health systems have gained market power, a ºÚÁϳԹÏÍø News investigation found. Four of the 10 largest hospital chains by number of beds are Catholic, according to federal data from the Agency for Healthcare Research and Quality.

Many Americans don’t have a choice — ambulances may take patients to a Catholic-run health system without giving them a say. Non-Catholic hospitals could be out of their insurance networks or too far to reach in an emergency. In the U.S, nearly 800,000 people have only Catholic or Catholic-affiliated birth hospitals within an hour’s drive, including pockets of Northern California.

Pregnant women who must drive farther to a delivery facility are at higher risk of harm to themselves or their fetus, .

“It’s really concerning, especially in a state like California, where people expect to have comprehensive access to care,” said Debra Stulberg, a family medicine physician at the University of Chicago. “The growth of Catholic hospitals, especially in this post-Dobbs era, continues to constrain the quality of care people get.”

The directives guiding care at Catholic-based health systems are issued by the U.S. Conference of Catholic Bishops. They state that abortions are “intrinsically evil” and “never permitted.”

The document does offer this guidance as an exception: Treatments that could cure “a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.”

“The church, I would say, helps Catholic hospitals to apply some of our deepest beliefs and moral principles to very, very complex situations,” said John Brehany, executive vice president of The National Catholic Bioethics Center, an ethics authority for Catholic health institutions. “And one of those beliefs is that you can never directly intend to end the life of a developing human being.”

Brehany wouldn’t comment on Nusslock’s case but gave the example that if a woman needed cancer treatment, the church would allow her to proceed with the treatment even if it “results in the death of an unborn child.” He added that some situations are “more debatable” than others.

As Catholic-based systems have consolidated and acquired more medical facilities, their care denials have been compounded by other hospitals closing their labor and delivery wards at alarming rates across the country. In California, 56 hospitals have shuttered their maternity wards in the past 12 years, according to by CalMatters. Nationwide, at least 267 hospitals between 2011 and 2021, representing about 5% of the country’s hospitals, according to Chartis, a health analytics and consulting firm.

With each closure, patients could lose options for abortion care, contraceptives, tubal ligations, and gender-affirming care, said Mona Shah, senior policy and strategy director with Community Catalyst, a national health equity organization.

Nusslock’s 12-mile trip for care at Mad River cost her, according to the lawsuit and her public statement. She had passed an “apple-sized blood clot” and was hemorrhaging in “blinding pain,” she said, by the time she reached the operating room. In the lawsuit, Nusslock said her doctor told her later that her test results showed she most likely had an infection.

It’s a trip Bonta described as “patient dumping” and one Nusslock should never have made.

Seven months later, Nusslock said, she has trouble sleeping, recalling how Providence sent her away.

“I’ll never forget looking at my doctor, tears streaming down my face, my heart shattered into a million pieces, and just pleading with her, ‘Don’t let me die,’” she said.

ºÚÁϳԹÏÍø News data editor Holly K. Hacker contributed to this article.

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Democratic challenger Will Rollins also called out his rival, Rep. Ken Calvert, and “MAGA extremists” in an for their backing of a bill that could criminalize medical practitioners who provide abortions.

A few blocks from state Route 14 in Lancaster, about 70 miles north of downtown Los Angeles, Rep. Mike Garcia’s Democratic opponent, George Whitesides, planted promising to protect reproductive health care, a jab at the Republican congressman, who has voted to cut taxpayer funding of abortions for service members and other Americans.

As Election Day approaches, Democratic hopefuls are doing all they can to tie Republican opponents in contested congressional districts to their anti-abortion records. Aggressive ads are going up in , , , , , and , as Democrats see an opportunity to take control of the House by engaging voters who might not vote straight-ticket — or at all. Republicans currently control the House by a slim margin.

“What we all need to do is to make sure we look at her record, and that record is contrary to what she’s putting out there in her ads,” Tran said in an interview about Steel. “We’re making sure that we educate and remind the voters of who she really is.”

Democrats are also linking Republican incumbents to former President Donald Trump, who has taken credit for the 2022 Supreme Court decision overturning Roe v. Wade. Democrats are warning voters that more restrictions could come. During the Sept. 10 presidential debate, Trump dodged a question about whether he would veto a national abortion ban if elected.

A majority of voters support restoring a federal right to abortion, according to a . And 1 in 14 voters say abortion is the most important issue in determining their choice. Those voters have the potential to make a difference in the close races, said David McCuan, a political science professor at Sonoma State University.

“The politics of abortion and reproductive health can get voters to participate at higher rates,” McCuan said. “It’s going to be a defining issue.”

Democrats are hoping the issue plays to their favor in California. Voters two years ago codified abortion rights into state law. In May, Planned Parenthood Affiliates of California launched a seven-figure campaign targeting seven Republican seats and Democrat Katie Porter’s open seat.

As a result, political analysts say, Republicans have shied away from their votes on abortion and some incumbents — such as Steel, Garcia, and Central Valley U.S. Rep. David Valadao — have moderated their stances to appeal to voters.

, like and , has said she supports exceptions to abortion bans in cases of rape, incest, or threats to the life of the mother. All three co-sponsored a bill amounting to a blanket abortion ban in the previous Congress. Garcia and Valadao left their names off the bill last year, but Steel signed on again as a co-sponsor — briefly.

She withdrew her support after she won her March primary, explaining that it could create confusion because the three-page bill could threaten in vitro fertilization. In a , Steel shared that she had used IVF to have children and reiterated her support for the procedure. Steel spokesperson Lance Trover said she opposes a national abortion ban.

None of the Republican incumbents who represent a California “toss-up” district, as determined by the nonpartisan , granted ºÚÁϳԹÏÍø News an interview. Those who did respond said they do not support a national abortion ban.

Rep. John Duarte added that he opposes a ban because he’s “pro-choice,” and Calvert said “the issue is best decided with the states and their voters directly.” Both voted for a bill to limit medication abortion and supported a measure that would have for medical providers who don’t resuscitate babies born after an attempted abortion.

Tim Rosales, a political strategist who has represented Republican candidates, said these incumbents shouldn’t get heat for changing their minds over time, noting that Democratic former Presidents Bill Clinton and Barack Obama reversed their positions on same-sex marriage.

“There has to be some allowance for evolution on a variety of issues,” Rosales said.

Ben Petersen, a spokesperson for the National Republican Congressional Committee, said Democrats who have called out Republicans for inconsistencies want to move the conversation away from other topics, such as the “disastrous cost of living crisis hurting women and families caused by their one-party control of Sacramento.”

This political dance is playing out on the national stage, especially in battleground races where Republicans find themselves on defense in states where abortion is on the ballot. Roughly two dozen races are considered toss-ups.

In a March post on the social platform X, Republican Nebraska Rep. , “I’ve always defended the life of the mother,” after his Democratic rival, Tony Vargas, called him out for supporting a , which makes no exceptions for cases in which the mother’s life is at risk. That same month, that the Omaha-area congressman had deleted some anti-abortion endorsements from his website. Nebraskans will vote this November on .

In Arizona, where voters will also be asked whether to enshrine abortion rights into the state constitution, Republican incumbent David Schweikert this year did not support a national abortion ban, which he had co-sponsored at least six times from 2012 to 2021. In April, that he opposed an abortion ban in Arizona, calling on the state legislature to “address this issue immediately.”

On the airwaves, on their websites, and on the campaign trail, Republican candidates are pivoting to convince voters that they have voted to protect women. For example, Steel this month released an in which the Orange County sheriff says Steel has “worked tirelessly to protect victims of domestic violence and sexual abuse.”

Trover, the Steel spokesperson, said she voted two years ago to reauthorize the Violence Against Women Act. That vote was on a larger , which included the measure.

The year before, Steel .

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The (D-Santa Barbara) and backed by Democratic Attorney General Rob Bonta, will block health care providers, as well as any contracted collection agency, from sharing a patient’s medical debt with credit reporting agencies. At least eight states have banned medical bills from consumer credit reports in the past two years. In June, the Biden administration proposed similar federal protections, but it’s unclear when the rules will be enacted — or, if former President Donald Trump is elected again, if they will be at all.

“Nobody chooses to get sick, and then your credit gets ruined,” said Chi Chi Wu, a senior attorney with the National Consumer Law Center. “That’s why we encourage states to keep adopting laws. In case something goes wrong at the federal level, the states could protect their own consumers.”

When California’s new law goes into effect in January, it will extend these protections to credit reports used for employment and tenant screening, Wu said. This is in addition to the proposed federal ban on reporting to credit agencies that inform credit card companies and mortgage lenders.

California lawmakers noted that medical debt — unlike other kinds of debt — of credit risk, and its inclusion can depress credit scores and make it hard for people to get a job, rent an apartment, or secure a car loan.

But California lawmakers have left a glaring loophole. Patients who pay hospital bills using medical credit cards or medical specialty loans — which can come with interest rates — won’t get that debt taken off their credit report, as residents of , , and do. It’s a through late-in-the-game “hostile” amendments, which “influential entities opposed to the measure prevailed” in including, Limón said. In a 2022 , 15% of adults said they had used a medical credit card.

Kelly Parsons-O’Brien, legislative chair of the California Association of Collectors, which represents collection agencies, said the exemptions were essential because medical credit card holders can buy nonmedical items and medical loans can be refinanced with nonmedical debt, making it “impossible” for creditors to know what’s actually a medical charge.

“More consumers will get into situations where they cannot afford to pay, and lenders will be operating in the dark,” Parsons-O’Brien said.

The three largest U.S. credit agencies — Equifax, Experian, and TransUnion — said they would stop listing some medical debt, including paid-off debts and those less than $500, but millions of patients were left with bigger medical bills on their credit reports. The Consumer Financial Protection Bureau that 15 million Americans still had medical bills on their credit reports.

About report carrying some type of medical debt, which disproportionately affects low-income, Black, and Latino patients, according to the California Health Care Foundation.

have enacted legislation to protect consumers from surprise billing and medical debt, according to the National Conference of State Legislatures. Newsom, a Democrat, also signed legislation on Tuesday on all real property owned by Californians who typically earn less than 400% of the federal poverty level. It expands current state law that protects a patient’s home from debt collectors.

A ºÚÁϳԹÏÍø News analysis found that credit reporting is the most common collection tactic used by hospitals to get patients to pay their bills. A credit score ban might make it more difficult for hospitals to collect.

When Sacramento resident Sonia Hayden and her boyfriend applied for a home loan last year, she discovered her credit score had dropped about a hundred points. It had been downgraded because of an approximately $200 emergency room charge after a car accident years ago.

The 44-year-old said her insurance covered tens of thousands of dollars in medical bills but that the hospital miscoded the $200 charge and she never received a bill for it. That, she said, should also have been charged to insurance.

Hayden tried unsuccessfully for over a year to resolve the issue with her health insurer. It’s still on her credit report. She was eventually able to get a home loan, but her interest rates were higher because of her credit score.

“Medical bills, they’re not on purpose, you know?” said Hayden, who testified in support of the legislation. “It was already a super traumatic accident. I almost died. And then to have this super stressful medical bill — nobody’s asking for that. It shouldn’t affect your credit.”

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Nine counties have begun rolling out the , which Gov. Gavin Newsom (D) signed into law in 2022 to get people with untreated schizophrenia or other psychotic disorders, many of them incarcerated or homeless, into treatment. But often those skilled clinicians have been pulled by counties from other understaffed behavioral health programs.

“There’s just so much change coming with a limited workforce, limited treatment resources, and high expectations for counties to solve things like homelessness,” said Scott Kennelly, director of the Butte County Behavioral Health Department. “It’s like I’m turning on a fire hose and saying, ‘Start drinking.’”

by state Sen. Tom Umberg would create an annual scholarship fund for students who pursue a mental health profession provided they work for three years with CARE Court. Umberg $10 million for the program, but it’s unclear how many students would receive the scholarship, said Jackie Koenig, a spokesperson for the senator. The bill sailed through the legislature without a single lawmaker voting against it.

Umberg, a Democrat from Orange County, said CARE Court deserves targeted funding because it’s a new program, and he noted other are available for students pursuing a behavioral health degree. For instance, the state announced in March 2023 that it $118 million in grants to support behavioral health providers at 134 nonprofit community-based organizations.

“CARE Court is new, and it is in a unique space that requires unique behavioral health skills, dealing with schizophrenics,” Umberg said. “So, we want to encourage folks to go into that space, because it is a challenge.”

But local behavioral health administrators say shifting experts into CARE Court may create shortages in other programs or thrust mental health specialists into multiple demanding programs.

The CARE Act allows patients or others, such as their , or roommates, to petition their county court for help. Individuals who agree to participate can receive up to 24 months of treatment, which can include outpatient substance use disorder treatment, stabilization medication, connection to social services, and housing. It is one of Newsom’s experimental initiatives intended to get some of the state’s off the streets and into housing without resorting to mandatory conservatorships.

Only Californians are estimated to be eligible for treatment, according to the Judicial Council, which helps oversee the program.

The state has to staff and launch the CARE program through the current budget year, including $122 million in grants to counties, according to the state Legislative Analyst’s Office. At the same time, counties have been directed to implement a host of other behavioral health programs, such as mobile crisis teams, and boost mental health services for Medi-Cal patients. Last year, Newsom also signed legislation that broadened the number of Californians who could be involuntarily committed.

“As a high-profile mandate, counties are largely moving existing, skilled, experienced staff over to launch and staff the CARE Court teams,” said Michelle Cabrera, executive director of the County Behavioral Health Directors Association of California, which supports the bill.

It’s why critics, including ACLU California Action, Mental Health America of California, and some counties, say a CARE Court scholarship should also support other county programs that treat individuals with serious mental illness and housing instability.

“Restricting workforce development initiatives solely to one of the many new behavioral health initiatives will not solve the issues of staffing across the continuum of behavioral health services,” said Alexandra Pierce, an assistant director at the Merced County Behavioral Health and Recovery Services Department.

County behavioral health departments are in the midst of a massive behavioral health workforce shortage — running 25% to 30% below full staff capacity, on average, according to an internal 2023 survey conducted by the county behavioral health director association and the University of California-San Francisco’s Healthforce Center, Cabrera said.

More than a dozen rural and urban county behavioral health directors told ºÚÁϳԹÏÍø News that hiring challenges are widespread and not unique to CARE Court, pointing to burnout since the start of the covid-19 pandemic and steep competition from schools, correctional facilities, and the private sector, which can offer skilled clinicians higher pay, work-from-home telehealth jobs, and generous vacation.

Michelle Funez, division director of Marin County Behavioral Health and Recovery Services, said a CARE Court scholarship could incentivize students to pursue county jobs that support vulnerable individuals in the community.

Finding the right clinician for CARE Court can be tricky because the job requires skilled individuals to work in homeless encampments and other nontraditional environments, Funez said.

“It can feel like we’re looking for the needle in the haystack,” Funez said, drawing from “an already smaller body of staff who have the requisite skills for this type of work, who are also up for the challenge.”

The nine counties that have launched the specialized courts have received more than 600 petitions in the first 10 months of the program, said Leah Myers, a spokesperson for the state Department of Health Care Services, which helps oversee the program. The remaining 49 counties are slated to launch their programs by Dec. 1.

There have been early successes with the program. A year in, San Diego County is already beginning to “graduate” patients, meaning they have received treatment and have made enough progress to transition out of the court system.

As more counties roll out CARE Courts, they will need more clinicians. A scholarship program, some counties said, could help. But the bill’s price tag could be its downfall. In June, Newsom signed a state budget closing an estimated , and last year he vetoed hundreds of bills, many of them over cost. Newsom spokesperson Elana Ross declined to comment on the measure.

Newsom has until the end of the month to sign or veto the bill.

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