Teens who land in emergency rooms with an opioid overdose generally receive naloxone to reverse the effects of dangerous drugs in their system and are sent home with a list of places they can go for follow-up care. But too often, those teens never seek additional help. They are left to suffer through the agony of withdrawal with no medications to ease their cravings. As a result, many, seeking relief, go back to opioids, often with tragic consequences.

Christian Thurstone, the director of behavioral health services at the Denver hospital, said six of his teen patients have died of fentanyl overdoses in the past two years. Denver Health has now opened what he believes to be the nation’s first adolescent inpatient detox unit.

“I’ve been doing adolescent substance treatment here in Denver for 20 years,” Thurstone said. “I wouldn’t know where to send somebody for adolescent detox.”

New research has found that most areas of the U.S. lack facilities that offer medically managed withdrawal for patients under 18. With adolescent overdoses continuing to rise along with the rapid growth of intentional and unintentional fentanyl use, there is a stark lack of options for teens.

Researchers at Oregon Health & Science University posed as an aunt or uncle of a teen who recently overdosed. The researchers called every U.S. teen addiction treatment facility they could find to ask if their niece or nephew could go there to detox and whether the facility offered medications to help with the process.

Of the 160 adolescent residential treatment facilities they contacted, only 63 said they would allow adolescents to detox on-site. Of those 63, only 18 offered buprenorphine — the one medication that’s FDA-approved to treat opioid use disorder in kids as young as 16 — and some of those offered no additional medications to manage withdrawal symptoms.

“I’m not sure if inhumane is too strong of a word,” said Caroline King, an emergency medicine resident at Yale University, who graduated from OHSU in 2023 and led the research. “Offering nothing, offering no additional medication, even nausea medication or really basic things, is really a travesty.”

Staff members at one facility told the researchers they don’t offer medications because kids are resilient, implying they don’t suffer as much as adults, or perhaps that they deserve to suffer, King said. Workers at another told researchers they “try to push Gatorade down them and just lay them down in a cot,” she said.

King said multiple locations responded that they couldn’t think of a single place in their state where kids could go to detox.

“It’s just really terrible to hear that that’s the case,” King said.

The American Society of Addiction Medicine is revising its standards for treating opioid use disorder in adults (this year) and children (in 2024). Sandra Gomez-Luna, the chief medical officer for psychiatry at the Yale School of Medicine, who is leading the pediatric effort, said most adolescents do not experience significant withdrawal symptoms and that, in general, withdrawal isn’t as intense for teens as it is for adults.

“That doesn’t mean that there isn’t a portion of teens with substance use disorders that will require medically monitored withdrawal management,” she said.

Because teens usually haven’t been using drugs for as long as adults, Gomez-Luna said, they may not suffer the consequences of chronic use or have as many accompanying health conditions that can make withdrawal more difficult, or more complex to treat.

But the rise in the more potent opioid fentanyl may be changing that thinking.

“As more and more teens will get involved in fentanyl use,” Gomez-Luna said, “there will be more adolescents that will require medically monitored withdrawal.”

Gomez-Luna said the addiction medicine group is also concerned there are too few facilities for teens and a lack of specialized personnel to treat them.

Scott Hadland, chief of adolescent and young adult medicine at Mass General for Children and Harvard Medical School, said there are fewer facilities for adolescents in part because many teens are never identified as needing help or connected to care, despite the growing number of overdoses.

“The patient volume is surprisingly not always there to support a program like this, even though we know that this is a huge public health problem,” Hadland said. “It becomes financially difficult to build a program whose sole service line is to provide detoxification services for young people.”

When no dedicated detox units are available, teens sometimes get admitted to a hospital, often to the intensive care unit, where more monitoring is available than on regular inpatient floors. But that also means teens are less likely to be cared for by a team specializing in adolescent addiction medicine.

“Our pediatric workforce has not traditionally received strong training in the management of addiction,” Hadland said. “When patients do go to general pediatric hospital settings, it’s possible that there isn’t someone there who has the expertise needed to manage that patient’s care.”

Thurstone said the biggest hurdle in getting Denver Health’s teen detox unit running was staffing. It took more than a year to find a certified addiction specialist to run the unit.

Addiction specialists stress that not all teens with opioid use disorder need inpatient detox. Withdrawal can be managed at home if teens have a stable family environment to support them and monitor their symptoms. Many adolescents with opioid use disorders, however, come from broken homes in which the parents may be struggling with addiction themselves. And coming out of the pandemic, specialists are also seeing more teens with opioid use disorders who have other psychiatric problems, such as depression, anxiety, attention-deficit/hyperactivity disorder, or eating disorders.

“All of these conditions have been on the rise in the wake of covid, alongside the rise in overdoses that we’re seeing,” Hadland said. “Part of the charge of our pediatric workforce right now is not just to address addiction, but also to tackle the underlying mental health conditions that young people are working through.”

Thurstone said that nationwide about half of all adolescents drop out of treatment, but that it’s worse in marginalized communities.

Denver Health repurposed beds from an inpatient psychiatric unit to get its teen detox program running. The unit saw its first patient this spring and has been admitting about one patient a week, mostly teens with a fentanyl dependence.

The teens start medication-assisted therapy, most often with buprenorphine, to address their cravings; get additional meds to manage any side effects of withdrawal; and receive cognitive behavioral therapy to help them with their recovery. Once they can be safely discharged, they are connected to addiction treatment programs in their communities. Thurstone believes providing that continuum of care will help reduce teen overdoses in the Denver region.

“We can do better than, you know, an ER visit and a list of resources to call,” he 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—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

The law, which goes into effect in October, will gut patients’ ability to take legal action if they believe they didn’t receive proper care due to a conscientious objection by a provider or an institution, such as a hospital.

So-called medical conscience objection laws have existed at the state and federal levels for years, with most protecting providers who refuse to perform an abortion or sterilization procedure. But the new Montana law, and others like it that have passed or been introduced in statehouses across the U.S., goes further, to the point of undermining patient care and threatening the right of people to receive lifesaving and essential care, according to critics.

“I tend to call them ‘medical refusal bills,’” said Liz Reiner Platt, the director of Columbia Law School’s Law, Rights, and Religion Project. “Patients are being denied the standard of care, being denied adequate medical care, because objections to certain routine medical practices are being prioritized over patient health.”

This year, 21 bills instituting or expanding conscience clauses have been introduced in statehouses, and two have become law, according to the nonprofit Guttmacher Institute. Florida lawmakers passed legislation that allows providers and insurers to refuse any health service that violates ethical beliefs. Montana’s law goes further, prohibiting the assignment of health workers to provide, facilitate, or refer patients for abortions unless the providers have consented in writing. South Carolina, Ohio, and Arkansas previously passed bills.

Supporters of the Montana law, called the Implement Medical Ethics and Diversity Act, say it fills gaps in federal law, empowering more medical professionals to practice medicine based on their conscience in circumstances beyond abortion and sterilization.

The bill applies to a wide range of practitioners, institutions, and insurers, encompassing just about any type of health care and anyone who could be providing it. The exception is emergency rooms, where the federal Emergency Medical Treatment and Labor Act takes precedence.

“We have technology that is pushing the limits of what is maybe ethical, and that is different in everybody’s minds,” said Republican state Rep. Amy Regier, who sponsored the Montana bill. “Having extra protections for people to practice according to their conscience as we continue down that path of innovation is important.”

Claims the bill discriminates against patients frustrate Regier, who said it’s about protecting health care providers. “Because someone has a conscientious objection to a specific service, they should be able to practice that way,” she said.

In 1973, federal regulations known as the Church Amendments were implemented after the Supreme Court’s Roe v. Wade decision made abortion legal nationwide. Under the Church Amendments, any institution that receives funding from the federal Department of Health and Human Services may not require health care providers to perform abortion or sterilization procedures if doing so would violate their religious or moral principles. Additionally, providers who refuse to perform these services may not be discriminated against for their decision.

Since then, at least 45 states have enacted their own abortion conscience clauses, according to the Guttmacher Institute. Of those, only 17 mandate that patients be notified of the refusal or limit the clause’s use in the case of miscarriage or emergency.

A March 2020 article in the American Medical Association’s Journal of Ethics said, “Clinicians who object to providing care on the basis of ‘conscience’ have never been more robustly protected than today.” Legal remedies for patients who receive inadequate care as a result have shrunk significantly, the article said.

But the wave of medical conscience bills introduced in statehouses since that article was published go beyond abortion to include contraception, sterilization, gender-affirming care, and other services. Opponents such as the American Civil Liberties Union, Planned Parenthood, and the Human Rights Campaign have been vocal opponents of this trend, criticizing it as a backdoor way to restrict the rights of women, LGBTQ+ community members, and other individuals.

Still, lawmakers across the country insist the right of doctors, nurses, pharmacists, and other medical providers to practice medicine in alignment with their beliefs is being infringed.

Some health care practitioners would “just be done” practicing medicine if forced to perform certain procedures such as abortion, Regier said. “That, to me, is what limits patient care.”

Many of the most sweeping bills are backed by organizations that have made it their business to promote this “conscience” agenda nationwide, such as the Christian Medical Association, Catholic Medical Association, and National Association of Pro-Life Nurses. Other groups launched a joint effort in 2020 with the explicit purpose of advancing state legislation that makes it easier for health care providers to refuse to perform a wide range of procedures, including abortion and types of gender-affirming care.

The organizations that started the initiative are the Religious Freedom Institute in Washington D.C., an Arizona-based nonprofit called the Alliance Defending Freedom, and the Christ Medicus Foundation in Michigan. According to its website, the coalition bolsters efforts to pass more sweeping medical conscience legislation, using methods including print and digital media campaign strategy, grassroots organizing, and advocacy. After successes in Arkansas, Ohio, and South Carolina in 2021 and 2022, it turned to Montana and Florida. Regier said there are a “number of different organizations” pushing this type of legislation, including the Alliance Defending Freedom.

Most of these conscience laws are part of an “arsenal” to further social conservatism, and they are often religiously motivated, said Lori Freedman, a researcher and associate professor at the Bixby Center for Global Reproductive Health at the University of California-San Francisco.

Although federal law is meant to ensure people receive lifesaving care in an emergency, Freedman said, there are cases in which patients don’t receive the care they should simply because they don’t clear the bar of what a facility considers emergent.

While experts warn of the potential patient health consequences of these medical conscience bills, academics say placing a provider’s choice over their patient’s rights is itself a threat.

“These bills do not protect religious liberty because they make it impossible for people to follow their own religious and moral values in making major decisions,” Reiner Platt said.

About 1 in 6 patients in the U.S. are treated in Catholic health care facilities, according to Freedman. Many of those venues strictly regulate or prohibit certain procedures, such as abortion, but do not necessarily disclose that to patients. As of 2016, more than 25% of hospital beds in Montana were in such facilities, according to the ACLU. Freedman determined through her research that about one-third of people whose primary hospital was Catholic didn’t know of its religious affiliation and therefore were unaware of those limitations on their care.

The problem can extend to secular medical institutions, too. According to the AMA Journal of Ethics article, there are no rules requiring a patient be informed a provider is practicing conscientious objection, which means the patient might “unknowingly receive substandard care” and “even be harmed by” the provider’s refusals.

“As much as we like to think about these providers and their opinions, so much is determined at a larger, structural level,” Freedman said. “Abortion has been stigmatized, marginalized, and constrained,” and plenty of hospitals and physician groups have made great efforts to “make a very safe service somehow illegal to provide within their context.”

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—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Weaver, 70, knew that after he emerged from surgery, he’d want privacy. But because he and his wife drove more than 150 miles from Bend, Oregon, to Oregon Health & Science University Hospital in Portland, immediately returning home was not an option.

So, the couple brought their Escape 19 camping trailer, a small but comfortable home on wheels, and parked it in one of the hospital’s 17 on-site RV parking spaces.

“Leaving that hospital with the bandage, the scar, and the rest of it, there’s no way I wanted to be in a hotel,” he said. “Being able to go down and stay in the trailer there, jeez, it was so huge.”

Weaver was fortunate. OHSU Hospital, one of two Level I trauma centers in the state, is one of several medical centers in the United States that maintain parking spaces specifically for RVs, electric hookups included. The hospital has offered the free amenity to patients since 2009.

Medical and RV industry professionals say hospitals that offer RV parking are easing access to health care for some patients who drive long distances for care, like many rural residents.

Monika Geraci, a spokesperson for the RV Industry Association, said she could understand the appeal to patients who travel with campers. “It’s your home away from home on wheels,” she said. “You’re able to bring all of your creature comforts. It’s your bed, it’s your sheets, it’s your bathroom, it’s your kitchen.”

Many patients drive eight to 10 hours to receive care at OHSU Hospital, said Brett Dodson, who oversees the facility’s parking and transportation services.

“They’ve seen the rural clinics and they need to come to that next level,” he said. “When they do, I think they’re more comfortable with an RV than they are trying to find a hotel.”

The average stay for a patient in the RV spaces is about seven days, and the limit is 30 days at a time. If a patient depends on the hospital for a recurring treatment like kidney dialysis, they’ll stay every few months. Recently, spots were occupied by transplant patients and a family with a baby in the intensive care unit, Dodson said.

The spots help patients keep close to their medical providers and avoid paying for hotels. If patients don’t have access to an RV or would rather stay in a hotel, Dodson’s team refers them to the on-site lodging that OHSU runs in partnership with the local chapter of Ronald McDonald House Charities or a nearby hotel that gives patients a discounted rate.

In addition to improving patient comfort, Dodson said, the RV spaces set the hospital up to provide better care. People who previously would have driven through the night to get to Portland for a morning surgery can now arrive the night before, he said. “They can get a good night’s sleep, they’d be ready for a surgery, and they’re there on time.”

Accommodations hospitals offer RV travelers vary widely and many aren’t part of an official policy. Among those that do offer overnight RV spaces, not all offer designated spaces or utility hookups like OHSU Hospital.

In Montana, patients have been parking their campers at Bozeman Health Deaconess Regional Medical Center for years. It started informally, when tourists got hurt while adventuring or sick while passing through the mountain city of 56,000 people. This spring, Bozeman Health created a short-term RV parking program at the hospital, which so far has largely been used by Montana patients traveling for care they couldn’t receive closer to home.

Bozeman Health worked for years to turn itself into a medical hub in southwestern Montana, expanding into specialty services such as intensive care for infants and cancer treatment. Simultaneously, hotel prices in the destination town, one of the gateways to Yellowstone National Park, have skyrocketed, and competition to find a place to stay in peak tourist season is high.

“There are towns in Montana that just don’t have hospitals,” said Kallie Kujawa, the chief operating officer at Bozeman Health. “We had a couple who came who could not find anywhere to stay in town. This was the only place they could find to stay. And that was critical for them.”

Patients can reserve a space for free for up to two weeks. Like at the hospital in Oregon, they need to bring their own water and lug their trash out. Bozeman Health has only two RV spaces; though, Kujawa said, the system could expand if demand increases.

Since it isn’t always clear whether a hospital will allow someone to park an RV on its property, publications and forums for RV owners have offered advice on the issue. An article in Family RVing, the Family Motor Coach Association’s magazine, encouraged readers to call ahead and ask for permission. The association does not, however, have specific guidelines for its members about RV parking at hospitals, said Robbin Gould, the magazine’s editor. Still, “from what various FMCA members have reported, hospital officials have granted permission for them to park their RVs on hospital property,” she said.

And it isn’t always patients who are looking to sort out a hospital’s RV parking situation. Staff also have an interest in on-site RV amenities.

In Salida, Colorado, an RV parking lot at Heart of the Rockies Regional Medical Center tends to get more use from hospital staff than from patients. Both patients and staff can stay at the six-spot, full-hookup lot for free.

One RV there recently was home to a new employee who was house hunting. Two nurses tend to use the lot while they work three straight days of 12-hour shifts, allowing them to avoid a commute over the mountains to their hometowns. A part-time general surgeon from Colorado Springs stays in the lot, too. A nurse comes down every week from Denver, a 2½-hour drive away.

“It’s been very popular, to say the least,” said the medical center’s CEO, Bob Morasko. “I just know that it works. And it helps us staff the hospital.”

KFF Health News Montana correspondent Katheryn Houghton and Colorado correspondent Rae Ellen Bichell contributed to this report.

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—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

During the early months of the covid-19 outbreak, Wangler and her colleagues had worked at a hospital in this former railroad hub of about 21,000 residents just a few miles from the Navajo Nation. The pandemic had been hard on Rehoboth McKinley Christian Hospital. Emergency federal funding was drying up and nearly a third of the staff — including Wangler, the chief medical officer — left after its board of trustees hired an out-of-state, for-profit management services firm to take over operations in August 2020.

The group of former hospital employees in Wangler’s backyard that afternoon in June 2022, including two OB-GYNs and a chaplain, knew the situation was dire and wondered what they could do.

Wangler said they realized “the most important thing we could do for the community is have good access to primary care.”

The health care cliff Wangler and her former colleagues confronted is one that has challenged dozens of rural communities over the past two decades.

By late 2022, the hospital had closed its labor and delivery unit and lost most of its primary care doctors. Gallup’s McKinley County was recording the largest primary care provider deficit in rural New Mexico — and local doctors knew that could lead to an increase in untreated conditions and patients seeking emergency rather than preventive care.

As of July 11, 195 rural hospitals have shuttered inpatient units or closed their doors altogether in the United States since 2005. Hundreds of others, like the one in Gallup, have cut services. Meanwhile, from 2006 to 2018, the combined number of Federally Qualified Health Centers and Rural Health Centers — outpatient clinics that receive federal funding to operate in medically underserved areas — increased by roughly 50%, according to a 2021 study from the University of North Carolina-Chapel Hill. By 2019, 20% of rural residents accessed care at such community health centers.

In response to the challenges facing their hospital, Wangler and the colleagues who’d gathered in her yard decided to open their own physician-led, nonprofit clinic, which is on its way to becoming an FQHC Look-Alike, an organization that meets the eligibility requirements of an FQHC but does not receive grant funding. That status will qualify the clinic for multiple types of federal aid including drug pricing discounts. Since it opened its doors last August, Gallup Community Health has treated about 3,000 patients in its stucco office space just a block from the historic U.S. Route 66. Many of GCH’s doctors came to Gallup from elsewhere and could have left town for more lucrative jobs. Instead, they decided to stay and attempt to fill primary care gaps.

“I’ve not seen [an FQHC] like this,” said Tim Putnam, a faculty member of the Medical University of South Carolina, a former hospital CEO, and a past president of the National Rural Health Association. Although it’s rare, if not a first, for physicians to lead their own FQHC, he said, it’s not uncommon to see FQHCs started by community groups, and in Gallup “the physicians are so dedicated to the community” that they’re like a community group themselves.

Unlike rural hospitals, which are increasingly being purchased by private equity firms and prioritizing lucrative specialties to increase profits, these health centers must offer primary care regardless of patients’ ability to pay and be overseen by a board made up primarily of patients. But while clinics provide important primary care services, researchers note that they struggle to fill the gaps in specialty and emergency care left by hospital closures.

Marcie Richmond, one of the clinic’s family medicine doctors, came to Gallup for the same reason that drew many of her colleagues: “to work with populations that might not be receiving much care.” She envisions a day when more of the Gallup area’s providers come from the local Navajo and Zuni communities, but until then she hopes to continue offering much-needed “care for people who are victims of chronic injustice.”

The clinic’s interior reflects that care: Indigenous children’s books like “Where Did You Get Your Moccasins?” and “We Sang You Home” fill the lobby, prints by Zuni artist Mallery Quetawki are going up in exam rooms, and watercolors of nearby Red Rock Park and photographs of Canyon de Chelly hang in the hallways.

On a Thursday morning in April, Renie Lente and her sister, Elsie, waited for their appointment.

Elsie has cerebral palsy and lives in a nursing home; Lente is her caregiver. Lente had called the night before after she noticed a fungal infection on Elsie’s foot, and the clinic was able to fit her in the next morning with the provider who treats her whole family. The community clinic is a “big change” from Rehoboth McKinley, where, Lente said, there was a backlog to be seen by primary care providers that left patients turning to the emergency room. After family medicine physician Neil Jackson treated Elsie, making space in the small exam room for both sisters and nursing home staffers, Lente noted that she appreciated how Jackson “treats you like family.”

“One of the things that the staff committed to from the beginning was doing what was right for the patient and figuring out finances later,” said Wangler, the clinic’s executive director.

The clinic opened its doors in large part thanks to contributions from the community: A statewide hospital system donated equipment, Gallup residents raised $30,000, and more than half the doctors volunteered their time or asked not to be paid until the clinic was operating in the black.

The team intended to offer some reproductive health care, but not prenatal care. Their clinic wasn’t a hospital, so patients would have to give birth elsewhere. But by the time the clinic opened, Rehoboth McKinley had closed its labor and delivery unit after every OB-GYN left the hospital, forcing pregnant patients to transfer their care to the local Indian Health Service facility — a sizable hospital where many Native Americans can seek care but which not all of them prefer — or to a hospital more than an hour’s drive away.

The doctors quickly started looking into what it would take to offer prenatal care. They wanted at least to save patients from having to choose between spending hours and gas money traveling for appointments and forgoing prenatal care entirely. By November, the community had raised $24,000 to pay for prenatal malpractice insurance. And during that time the clinic’s OB-GYNs and OB-trained family medicine doctors developed a plan for providing prenatal care while maintaining relationships with the more distant hospitals where their patients could deliver.

Clinic leaders intend to keep the doors open by applying for it to become a Federally Qualified Health Center Look-Alike. That would qualify it for higher Medicare and Medicaid payments.

Clinic staffers hope providing quality outpatient care can minimize hospitalizations and the need to travel for specialty care. One of the tools helping GCH doctors provide that care is the University of New Mexico Health System’s PALS, a hotline service that connects physicians anywhere in the state with specialists who can answer questions about care outside their area of practice.

“There’s a physician shortage everywhere and a real understanding that it is challenging for people to get in from the rural setting,” said Wangler, who added that specialists have been amenable to partnering and offering guidance.

Doctors like Jackson say the tight-knit community in Gallup made them want to stay and try to fill the primary care void. “All of the folks that I’m working with here are truly rooted in the community and going to be here for better or worse.”

This article was supported by the Journalism and Women Symposium Health Journalism Fellowship, with the support of The Commonwealth Fund.

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—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Beard, a Republican from the rural town of Elliston, ushered a bill through the GOP-controlled legislature this spring. The proposal would have moved more than 200 people off waiting lists for government-supported care and saved the state money by accessing more federal Medicaid money to cover their costs and the cost of those already in assisted living.

The bill had broad support from assisted living facility owners whose facilities eventually would accept more of these patients covered by Medicaid, the state-federal program that pays medical and other health-related bills for low-income and disabled people. In Montana, the federal government pays about 65% of the cost of most Medicaid-covered services, and the state pays for the rest.

But Republican Gov. Greg Gianforte vetoed the measure May 18, two weeks after the legislature adjourned. A post-session vote in June by Montana’s 150 lawmakers to override the veto failed by 10 votes.

Gianforte’s veto disappointed and mystified the bill’s supporters.

“I don’t see where there is any negative impact, financially for the state, for the residents, or to us as providers,” said Mike White, who co-owns seven assisted living facilities across Montana. “I thought, of all the bills out there, this would be the last one to get vetoed.”

Gianforte said the bill, by creating another Medicaid entitlement program, could have ended up costing the state much more in the long run. He also said it would have restricted the state’s ability to serve Medicaid-funded residents “in a community setting.”

Supporters of the bill said that the governor is simply wrong — and that Montana missed an opportunity to tackle a long-standing problem: the lengthy waiting lists for people on Medicaid who need assisted living or in-home care, to keep them out of more expensive nursing homes.

An analysis by Gianforte’s own budget office said the bill would have saved the state $1 million during its first two years by using more federal money. Some supporters also pointed to the state’s $2.4 billion surplus, saying the state could certainly afford this small change to its Medicaid plan, if it ended up costing the state.

“This administration has shown that they don’t care about poor people, about people who are struggling,” said state Rep. Mary Caferro, a Democrat. “They simply don’t care, because we had the money to do it.”

The Gianforte administration insisted that there is no accurate way to estimate the long-term costs of placing assisted living under a Medicaid option called Community First Choice, and that doing so would complicate management of in-home and assisted living services.

Beard’s Senate Bill 296 would have required the state to place Medicaid funding for assisted living under Community First Choice starting in 2026, instead of a “waiver” program, where it’s been for many years.

States must ask the feds for Medicaid waivers to offer services or cover populations not covered under federal law. Like many other states, Montana asked for a waiver decades ago to cover nonmedical services that help keep older or disabled people out of nursing homes or other institutional settings. About 2,700 Montanans use these waiver-covered services each year, including about 900 in assisted living facilities.

But funding for Montana’s Big Sky Waiver program is capped by the legislature, so it has a waiting list for covered services. As of this spring, about 160 people who’d qualified for Medicaid coverage were on the waiting list for an assisted living spot.

An additional 150 people were waiting for other Medicaid services, such as in-home care that helps with daily chores like eating, dressing, and bathing. Those spots open only if lawmakers approve more funding or if a person getting the services dies or no longer qualifies for Medicaid.

Community First Choice, however, has no waiting list because it’s an entitlement, with no funding cap. A person who qualifies for Medicaid gets whatever services are covered under the program.

CFC was created as a state Medicaid option by the 2010 Affordable Care Act, in hopes of expanding coverage of services that help older and disabled people who have little income and few assets live independently, staying out of pricey facilities.

To encourage states to incorporate CFC into their Medicaid plans, the Affordable Care Act offered a higher federal match, of 6 additional percentage points.

Only nine states, however, have adopted CFC, and only three — Washington, Oregon, and California — have chosen to cover assisted living under the program.

Montana is one of the nine states that applied for the program, 11 years ago under Democratic Gov. Brian Schweitzer. But the state did not include assisted living as a covered service under CFC.

Rose Hughes, executive director of the Montana Health Care Association, which represents nursing homes and assisted living facilities, said states apparently worry that making these services an entitlement will increase their Medicaid budgets.

But she argued that expanding assisted living coverage under Medicaid saves states money because it can keep people out of more expensive nursing homes and, in some cases, costs less than in-home care.

Assisted living “is an extremely cost-effective service, and it’s one that seniors like,” Hughes said.

She also noted that anyone who qualifies for assisted living under CFC or the waiver is eligible for nursing home-level care.

“The day they get put on a waitlist, they could go to a nursing home, and the state would pay for that,” Hughes said.

And getting rid of the waiting list simply is the humane thing to do, bill supporters said.

The waiting list, managed by the state, rates people’s level of need and can seem incredibly arbitrary, bill supporters said. There are separate waiting lists for different locales; if you’re on the list in one town and move elsewhere, you must get on another waiting list.

“These systems are designed to protect people when they run out of resources. These people did their part, and we owe it to them,” said Michael Coe, director of operations for Caslen Living Centers, the company co-owned by White.

Beard eventually found her 82-year-old mother a spot at a Helena senior living facility that her mother pays for herself, without help from Medicaid.

Beard said the experience drove home the difficulty many Montanans face in finding such services if they can’t afford to pay.

She said she shares the concerns of her fellow conservatives about the state budget, but on this issue, she thinks paying for more assisted living slots is both fiscally sound and the right thing to do — and she’ll pursue it again in the 2025 legislature.

“This is a real need, and we’re not done with it,” Beard said. “I’m not giving up on this.”

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—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Jones, who is 31 and lives in Belgrade, Montana, said she had “zero control over what was going on” during her hospital birth. Jones wanted a midwife to help deliver her third child, and after finding one she clicked with, she decided to go with a home birth.

“I felt like I was in control of everything and she was there to listen to what I needed from her,” Jones said.

The only downside, from Jones’ perspective, was that her insurance didn’t cover home births attended by a midwife as an in-network service. Jones paid about $5,500 out-of-pocket.

Home births surged nationally during the pandemic. In Montana, they accounted for 2.85% of all births in 2021, behind Idaho’s nation-leading 3.56% but still the sixth-highest rate in the country. Women who choose home births say they can provide a more familiar setting and a more natural experience than a hospital birth, along with the greater control cited by Jones. Doctors say hospital births are generally safer but that home births can also be a safe choice for many low-risk pregnancies.

Montana’s Republican-dominated legislature this year moved to support home births with a measure requiring they be covered by Medicaid and another that expands the types of drugs midwives can administer. Republican Gov. Greg Gianforte signed the bills into law in April.

Montana Republicans touted the moves as evidence of their commitment to women and families at a time when they were passing strict abortion limits. Since the legislative session ended in May, Gianforte has signed into law bills limiting abortion access, including a ban on dilation and evacuation procedures after 15 weeks. The governor also extended postpartum care for new mothers on Medicaid to 12 months in the state budget, and approved an adoption tax credit.

“Advancing his pro-life, pro-child, pro-family agenda, the governor supported extending Medicaid coverage for mothers to 12 months postpartum, and proudly introduced an adoption tax credit and a child tax credit in his Budget for Montana Families,” Gianforte spokesperson Kaitlin Price said via email.

The child tax credit has not been signed into law.

Kelly Baden, vice president for public policy at the Guttmacher Institute, a national research and policy organization that studies reproductive rights, said the new home-birth laws and postpartum care expansion are among the supports reproductive safety professionals have been pushing for decades.

“Anything a state can do that helps improve the economic or health care coverage of people is important,” Baden said, adding that those things don’t need to be done as political cover for abortion restrictions.

The new laws would not have helped Jones: Whether insurance covers home births in Montana varies by policy, and Jones’ insurance declined to cover her home birth because it was out of network.

But the passage of House Bill 655, which adds most home births to Medicaid-covered services, is a boost for women enrolled in the federal-state health coverage program for low-income residents. The average cost of having a baby in a hospital in Montana is $11,938.

Lindsey Erin Ellis, co-founder of the Montana Birth Collective, is a doula, or someone who provides emotional support during pregnancy rather than the medical care of a midwife. She said while the cost of giving birth outside a hospital is less, the out-of-pocket expense for a patient can be more if they lack insurance coverage.

“Having Medicaid is huge because those midwives can then accept those clients and be paid for their work,” Ellis said.

The legislation on the medications midwives can administer brings Montana into alignment with the nearby states of Idaho, Colorado, and Washington, and enhances patient safety, said Amanda Osborne, vice president of the board of the Montana Midwifery Association.

That measure, House Bill 392, allows midwives to administer IVs, antibiotics to prevent infections in babies, oxygen, and prescription drugs that help stop hemorrhaging, all of which Osborne described as the “standard of care for pregnant women” and which midwives have the training to administer. The bill does not address pain medications.

Prior to the 2023 law, Osborne said, midwifery laws in Montana were last updated in the 1990s and midwives were not able to administer basic, lifesaving medications.

“I think women and babies deserve safe care no matter where they decide to give birth,” Osborne said.

Home births are a safe option for low-risk pregnancies and healthy babies, Osborne said. If a pregnancy becomes higher-risk, the patient is transferred to a physician’s care. High-risk indicators include high blood pressure, gestational diabetes, and carrying twins, Osborne said.

Recent trends suggest home births will continue to tick up. And while some practitioners praised the new laws, issues of cost and access aren’t going away.

Averee Chifamba, who has a midwifery practice in Bozeman called Saddlepeak Birth, was the midwife for Jones’ home birth. Of the roughly three dozen licensed midwives in Montana, there are eight — soon to be nine — in Bozeman, Chifamba said, and most of the home-birth practices there are full.

Chifamba said HB 392 increases midwives’ drug prescribing privileges to the standard of care for other health care professionals. But HB 655 is a “hard one” for her because the Medicaid reimbursement rate is so low, Chifamba said.

“We love the idea that it opens up the availability, that if we want to serve Medicaid families as a small business, we can now; it’s just whether that’s going to be worth the hit the midwife is going to take financially,” Chifamba 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—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

The travel ban, which took effect May 5, created the crime of “abortion trafficking,” punishable by a minimum of two years in prison. It forbids helping a person under 18 years old obtain abortion pills or leave the state for abortion care without parental permission.

The complaint, filed in federal court in Boise, Idaho, says the ban infringes on the right to interstate travel and on First Amendment rights to speak about abortion and “engage in expressive conduct, including providing monies and transportation (and other support) for pregnant minors traveling within and outside of Idaho.”

The suit also says the travel ban “lacks clarity” and “invites arbitrary enforcement,” raising the specter of traffic stops of girls of reproductive age, and infringes on the right of people to cross the border into neighboring states, including Washington, where minors can legally obtain abortion care without parental consent.

Wendy Heipt, senior reproductive health and justice counsel at Legal Voice, an advocacy group representing the plaintiffs, said Idaho’s law prohibits “recruiting or harboring a minor, but what constitutes recruiting? Giving information? You can’t stop [my clients] from providing information about conduct that is legal in another state.”

She added, “If we want to give money to a minor to go to another state, we should be able to do that.”

In a statement, Idaho’s Office of the Attorney General said, “While we don’t comment on pending litigation, our office is always prepared to vigorously defend the constitutionality of statutes duly passed by the legislature.”

Legal experts say the ban, based on a model bill written by National Right to Life, one of the country’s largest anti-abortion groups, is drafted to sidestep implied constitutional protections for interstate travel.

“This National Right to Life proposal was designed to chip away at travel in a way that is less politically and legally risky,” said Mary Ziegler, a professor of law at the University of California-Davis and an abortion historian. “It’s easier to package this as a Republican parental rights initiative, and it’s easier legally because courts have been willing to countenance limits on minor rights that they wouldn’t countenance on adults.”

She added, “The idea is to stop people from traveling to other states,” and teen travel bans “could be a steppingstone to limit an adult’s right to travel.”

The plaintiffs include the Indigenous Idaho Alliance, a nonprofit that has helped pregnant minors access abortion care outside the state; the Northwest Abortion Access Fund, which provided financial assistance to 166 Idahoans in 2022, including 18 minors; and Lourdes Matsumoto, an attorney who works with victims of domestic and sexual violence, many of whom are minors.

Domestic violence advocates “don’t know what advice they can give people,” Matsumoto said. “In the shelters, they are confused about what information they can and cannot give out without putting themselves in legal jeopardy.” She said the teen travel ban has had a chilling effect on her work with teenagers dealing with the trauma of sexual assault.

Idaho’s law, the first in the nation to describe “abortion trafficking,” requires a minimum two-year prison sentence for any adult who acts “with the intent to conceal an abortion from the parents or guardian of a pregnant, unemancipated minor.”

But Matsumoto, who has two teenage nieces, said the law fails to detail what constitutes parental consent. “If my niece comes to me and says, ‘My mom says this is OK; can you take me to Oregon?’ — is that enough that the mom consented? Am I going to have to come back, get arrested, lose my law license, then go to court and say, ‘The mom said it’s OK’? Is it a nod? A thumbs-up in a text message?”

Courts are usually suspicious of laws that are overbroad and vague, said I. Glenn Cohen, a Harvard Law School professor. But he said abortion bans around the country, including Idaho’s teen travel ban, have been written in a “fuzzy” way so that they “will deter ever more conduct because people don’t know where the line is.”

The lawsuit cites a legal opinion dated March 27 from Labrador that “stated that medical professionals who refer pregnant patients across state lines for either medical or chemical abortions violate Idaho’s Total Abortion Ban,” a separate law that went into effect after the Supreme Court overturned federal abortion rights last year in Dobbs v. Jackson Women’s Health Organization. Labrador withdrew the opinion on April 7, facing a legal challenge over constitutional rights of speech and movement.

“It is unconstitutional to forbid citizens from traveling because you disapprove of the reasons they are driving to another state,” Heipt said. “Idahoans, like all people, should be free to travel within and between states without the specter of prison, even if they are traveling for a reason other people disagree with.”

Idaho patients, including teenagers, have long crossed into Washington state to legally end their pregnancies. But fewer than 5% of patients at Planned Parenthood clinics in Washington who come for abortion care are minors, according to Karl Eastlund, CEO of Planned Parenthood of Greater Washington and North Idaho.

Most of those patients, he said, do involve their parents in the process, even though parental consent is not mandatory in Washington. Those who don’t, Eastlund said, have good reason not to. Some are in dangerous, abusive situations in which disclosing a pregnancy could put them at risk of further harm.

The lawsuit in Idaho cites Associate Justice Brett Kavanaugh’s concurring opinion in Dobbs, in which he claimed states could not bar residents from going to other states for abortions.

“May a State bar a resident of that State from traveling to another state to obtain an abortion?” Kavanaugh wrote. “In my view, the answer is no based on the constitutional right to interstate travel.”

But Kavanaugh represents only one vote on the court, Cohen said, and “it remains to be seen what the other justices have to say on the matter.”

Rather than settle the question of whether states can prohibit traveling for an abortion, Heipt said, “Dobbs unleashed chaos. What’s next?”

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—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

The takeover by Tower Health meant the 219-bed Pottstown Hospital no longer had to pay federal and state taxes. It also no longer had to pay local property taxes, taking away more than $900,000 a year from the already underfunded Pottstown School District, school officials said.

The district, about an hour’s drive from Philadelphia, had no choice but to trim expenses. It cut teacher aide positions and eliminated middle school foreign language classes.

“We have less curriculum, less coaches, less transportation,” said Superintendent Stephen Rodriguez.

The school system appealed Pottstown Hospital’s new nonprofit status, and earlier this year a state court struck down the facility’s property tax break. It cited the “eye-popping” compensation for multiple Tower Health executives as contrary to how Pennsylvania law defines a charity.

The court decision, which Tower Health is appealing, stunned the nonprofit hospital industry, which includes roughly 3,000 nongovernment tax-exempt hospitals nationwide.

“The ruling sent a warning shot to all nonprofit hospitals, highlighting that their state and local tax exemptions, which are often greater than their federal income tax exemptions, can be challenged by state and local courts,” said Ge Bai, a health policy expert at Johns Hopkins University.

The Pottstown case reflects the growing scrutiny of how much the nation’s nonprofit hospitals spend — and on what — to justify billions in state and federal tax breaks. In exchange for these savings, hospitals are supposed to provide community benefits, like care for those who can’t afford it and free health screenings.

More than a dozen states have considered or passed legislation to better define charity care, to increase transparency about the benefits hospitals provide, or, in some cases, to set minimum financial thresholds for charitable help to their communities.

The growing interest in how tax-exempt hospitals operate — from lawmakers, the public, and the media — has coincided with a stubborn increase in consumers’ medical debt. KFF Health News reported last year that more than 100 million Americans are saddled with medical bills they can’t pay, and has documented aggressive bill-collection practices by hospitals, many of them nonprofits.

In 2019, Oregon passed legislation to set floors on community benefit spending largely based on each hospital’s past expenditures as well as its operating profit margin. Illinois and Utah created spending requirements for hospitals based on the property taxes they would have been assessed as for-profit organizations.

And a congressional committee in April heard testimony on the issue.

“States have a general interest in understanding how much is being spent on community benefit and, increasingly, understanding what those expenditures are targeted at,” said Maureen Hensley-Quinn, a senior director at the National Academy for State Health Policy. “It’s not a blue or red state issue. It really is across the board that we’ve been seeing inquiries on this.”

Besides providing federal, state, and local tax breaks, nonprofit status also lets hospitals benefit from tax-exempt bond financing and receive charitable contributions that are tax-deductible for the donors. Policy analysts at KFF estimated the total value of nonprofit hospitals’ exemptions in 2020 at about $28 billion, much higher than the $16 billion in free or discounted services they provided through the charity care portion of their community benefits.

Federal law defines the sort of spending that can qualify as a community benefit but does not stipulate how much hospitals need to spend. The range of community benefit activities, reported by hospitals on IRS forms, varies considerably by organization. The spending typically includes charity care — broadly defined as free or discounted care to eligible patients. But it can also include underpayments from public health plans, as well as the costs of training medical professionals and doing research.

Hospitals also claim as community benefits the difference between what it costs to provide a service and what Medicaid pays them, known as the Medicaid shortfall. But some states and policy experts argue that shouldn’t count because higher payments from commercial insurance companies and uninsured patients paying cash cover those costs.

Bai, of Johns Hopkins, collaborated on a 2021 study that found for every $100 in total spending, nonprofit hospitals provided $2.30 in charity care, while for-profit hospitals provided $3.80.

Last month, another study in Health Affairs reported substantial growth in nonprofit hospitals’ operating profits and cash reserves from 2012 to 2019 “but no corresponding increase in charity care.”

And an April report by the Lown Institute, a health care think tank, said more than 1,350 nonprofit hospitals have “fair share” deficits, meaning the value of their community investments fails to equal the value of their tax breaks.

“With so many Americans struggling with medical debt and access to care, the need for hospitals to give back as much as they take grows stronger every day,” said Vikas Saini, president of the institute.

The Lown Institute does not count compensating for the Medicaid shortfall, spending on research, or training medical professionals as part of hospitals’ “fair share.”

Hospitals have long argued they need to charge private insurance plans higher rates to make up for the Medicaid shortfall. But a recent state report from Colorado found that, even after accounting for low Medicaid and Medicare rates, hospitals get enough from private health insurance plans to provide more charity care and community benefits than they do currently and still turn a profit.

The American Hospital Association strongly disagrees with the Lown and Johns Hopkins analyses.

For many hospitals — after dozens of closures over the past 20 years — “just keeping your doors open is a clear community benefit,” said Melinda Reid Hatton, general counsel for the AHA. “You can’t focus entirely on charity care” as a measure of community benefit. Hospitals deliver nine times the community benefit for every dollar of federal tax avoided, Hatton said.

The 2010 Affordable Care Act, she noted, imposed additional community benefit mandates. Tax-exempt hospitals must conduct a community health needs assessment at least once every three years; establish a written financial assistance policy; and limit what they charge individuals eligible for that help. And they must make a reasonable attempt to determine if a patient is eligible for financial assistance before they take “extraordinary collection actions,” such as reporting people to the credit bureaus or placing a lien on their property.

Still, the Government Accountability Office, a congressional watchdog agency, argues that community benefit is poorly defined.

“They’re not requirements,” said Jessica Lucas-Judy, a GAO director. “It’s not clear what a hospital has to do to justify a tax exemption. What’s a sufficient benefit for one hospital may not be a sufficient benefit for another.” The GAO, in a 2020 report, said it found 30 nonprofit hospitals that got tax breaks in 2016 despite reporting no spending on community benefits.

The GAO then recommended Congress consider specifying the services and activities that demonstrate sufficient community benefit.

The tax and benefit question has become a bipartisan issue: Democrats criticize what they see as scant charity care, while Republicans wonder why nonprofit hospitals get a tax break.

In Georgia, Democratic lawmakers and the NAACP spearheaded the filing of a complaint to the IRS about Wellstar Health System’s nonprofit status after it closed two Atlanta-area hospitals in 2022. The complaint noted the system’s proposed merger with Augusta University Health, under which Wellstar would open a new hospital in an affluent suburban county.

“I understand you pledged over $800 million” in the deal with AU Health, state Sen. Nan Orrock, an Atlanta Democrat, told Wellstar executives at a recent legislative hearing, citing the system’s disinvestment in Atlanta. “Doesn’t sound like a nonprofit. It sounds like a for-profit approach.”

Wellstar said it provides more uncompensated health care services than any other system in Georgia, and that its 2022 community benefit totaled $1.2 billion. Wellstar attributed the closures to chronic financial losses and an inability to find a partner or buyer for the inner-city hospitals, which served a disproportionately large African American population.

In North Carolina, a Republican candidate for governor, state Treasurer Dale Folwell, said many hospitals “have disguised themselves as nonprofits.”

“They’re not doing the job. It should be patients over profits. It’s always now profits over patients,” he said.

Ideas for reforms, though, have run up against powerful hospital opposition.

Montana’s state health department proposed developing standards for community benefit spending after a 2020 legislative audit found nonprofit hospitals’ reporting vague and inconsistent. But the Montana Hospital Association opposed the plan, and the idea was dropped from the bill that passed.

Pennsylvania, though, has a unique but strong law, Bai said, requiring hospitals to prove they are a “purely public charity” and pass a five-pronged test. That may make the state an easier place to challenge tax exemptions, Bai said.

This year, the Pittsburgh mayor challenged the University of Pittsburgh Medical Center over the tax-exempt status of some of its properties.

Nationally, Bai said, “I don’t think hospitals will lose tax exemptions in the short run.”

But, she added, “there will likely be more pressure from the public and policymakers for hospitals to provide more community benefit.”

Mountain States editor Matt Volz contributed to this report.

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—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

In 14 states, these councils have the ultimate say on the money, which comes from companies that made, distributed, or sold opioid painkillers, including Purdue Pharma, Johnson & Johnson, and Walmart. In 24 other states, plus Washington, D.C., the councils establish budget priorities and make recommendations. Those will affect whether opioid settlement funds go, for example, to improve addiction treatment programs and recovery houses or for more narcotics detectives and prisons.

KFF Health News, along with Johns Hopkins University and Shatterproof, a national nonprofit focused on the addiction crisis, gathered and analyzed data on council members in all states to create the first database of its kind.

The data shows that councils are as unique as states are from one another. They vary in size, power, and the amount of funds they oversee. Members run the gamut from doctors, researchers, and county health directors to law enforcement officers, town managers, and business owners, as well as people in recovery and parents who’ve lost children to addiction.

“The overdose crisis is incredibly complex, and it demands more than just money,” said Rollie Martinson, a policy associate with the nonprofit Community Education Group, which is tracking settlement spending across Appalachia. “We also need the right people in charge of that money.”

That’s the $50 billion question: Are the right people steering the decisions? Already, criticism of the councils has been rife, with stakeholders pointing out shortcomings, from overrepresentation to underrepresentation and many issues in between. For example:

• Council membership doesn’t always align with the states’ hardest-hit populations — by race or geography.
• Heavy presence of specific professional groups — treatment providers, health care executives, or law enforcement officials, for example — might mean money gets directed to those particular interests at the expense of others.
• Few seats are reserved for people who’ve dealt with a substance use disorder themselves or supported a family member with one.

Admittedly, no one can design a perfect council. There’s no agreement on what that would even look like. But when a pile of money this big is at stake, everyone wants in on the action.

More than $3 billion of opioid settlement funds has already landed in government coffers, with installments to come through 2038. The money is meant as restitution for the hundreds of thousands of Americans who have died from drug overdoses in recent decades.

But what restitution looks like depends on whom you ask. People running syringe service programs might suggest spending money immediately on the overdose reversal medication naloxone, while hospital officials might advocate for longer-term investments to increase staffing and treatment beds.

“People naturally want money to go toward their own field or interest,” said Kristen Pendergrass, vice president of state policy at Shatterproof.

And that can trigger hand-wringing.

In many parts of the country, for instance, people who support syringe service programs or similar interventions worry that councils with high numbers of police officers and sheriffs will instead direct large portions of the money to buy squad cars and bulletproof vests. And vice versa.

In most states, though, law enforcement and criminal justice officials make up fewer than one-fifth of council members. In Alaska and Pennsylvania, for instance, they’re not represented at all.

Outliers exist, of course. Tennessee’s 15-member council has two sheriffs, one current and one former district attorney general, a criminal court judge, and a special agent from the state Bureau of Investigation. But like many other councils, it hasn’t awarded funds to specific groups yet, so it’s too soon to tell how the council makeup will influence those decisions.

Pendergrass and Johns Hopkins researcher Sara Whaley, who together compiled the list of council members, say criticism of councils drawing too heavily from one field, geographic area, or race is not just a matter of political correctness, but of practicality.

“Having diverse representation in the room is going to make sure there is a balance on how the funds are spent,” Pendergrass said.

To this end, Courtney Gary-Allen, organizing director for the Maine Recovery Advocacy Project, and her colleagues chose early on to ensure their state’s 15-member council included people who support what’s known as harm reduction, a politically controversial strategy that aims to minimize the risks of using drugs. Ultimately, this push led to the appointment of six candidates, including Gary-Allen, to the panel. Most have personal experience with addiction.

“I feel very strongly that if these six folks weren’t on the council, harm reduction wouldn’t get a single dollar,” she said.

Others are starting to focus on potential lost opportunities.

In New Jersey, Elizabeth Burke Beaty, who is in recovery from substance use disorder, has noticed that most members of her state’s council represent urban enclaves near New York City and Philadelphia. She worries they’ll direct money to their home bases and exclude rural counties, which have the highest rates of overdose deaths and unique barriers to recovery, such as a lack of doctors to treat addiction and transportation to faraway clinics.

Natalie Hamilton, a spokesperson for New Jersey Gov. Phil Murphy, a Democrat who appointed the members, said the council represents “a wide geographic region,” including seven of the state’s 21 counties.

But only two of those represented — Burlington and Hunterdon counties — are considered rural by the state’s Office of Rural Health needs assessment. The state’s hardest-hit rural counties lack a seat at the table.

Now that most of the council seats nationwide are filled, worries about racial equity are growing.

Louisiana, where nearly a third of the population is Black, has no Black council members. In Ohio, where Black residents are dying of overdoses at the highest rates, only one of the 29 council members is Black.

“There’s this perception that this money is not for people who look like me,” said Philip Rutherford, who is chief operating officer of Faces & Voices of Recovery and is Black. His group organizes people in recovery to advocate on addiction issues.

Research shows Black Americans have the fastest-rising overdose death rates and face the most barriers to gold-standard treatments.

In several states, residents have lamented the lack of council members with firsthand knowledge of addiction, who can direct settlement dollars based on personal experiences with the treatment and criminal justice systems. Instead, councils are saturated with treatment providers and health care organizations.

And this, too, raises eyebrows.

“Service providers are going to have a monetary interest,” said Tracie M. Gardner, who leads policy advocacy at the New York-based Legal Action Center. Although most are good people running good treatment programs, they have an inherent conflict with the goal of making people well and stable, she said.

“That is work to put treatment programs out of business,” Gardner said. “We must never forget the business model. It was there for HIV, it was there for covid, and it’s there for the overdose epidemic.”

Councils in South Carolina and New York have already seen some controversy in this vein — when organizations associated with members pursued or were awarded funding. It’s not a particularly surprising occurrence, since the members are chosen for their prominent work in the field.

Both states’ councils have robust conflict-of-interest policies, requiring members to disclose professional and financial connections. New York also has a law precluding council members from using their position for financial gain, and South Carolina uses a rubric to objectively score applications.

That these situations cause alarm regardless shows how much hope and desperation is tied up in this money — and the decisions over who controls it.

“This is the biggest infusion of funding into the addiction treatment field in at least 50 years,” said Gardner. “It’s money coming into a starved system.”

Database Methodology

The list of council members’ names used to build the database was compiled by Johns Hopkins University’s Sara Whaley and Henry Larweh and Shatterproof’s Kristen Pendergrass and Eesha Kulkarni. All council members, even those without voting power, were listed.

Although many states have councils to address the opioid crisis generally, the database focused specifically on councils overseeing the opioid settlement funds. A council’s scope of power was classified as “decision-making” if it directly controls allocations. “Advisory” means the council provides recommendations to another body, which makes final funding decisions.

The data is current as of June 9, 2023.

KFF Health News’ Aneri Pattani, Colleen DeGuzman, and Megan Kalata analyzed the data to determine which categories council members represent, based on the following rules:

— Each council member can be counted in only one category. There is no duplication.

— People should be given the most descriptive categorization possible. For example, attorneys general are “elected officials,” but it is more specific to say they are “law enforcement and criminal justice” officials.

— A “government representative” is typically a government employee who is not elected and does not fit into any other descriptive category — for example, a non-elected county manager.

— People who provide direct services to patients or clients, such as physicians, nurses, therapists, and social workers, are classified as “medical and social service providers.” People with more administrative roles are typically classified as “public” or “private health and human services,” based on their organization’s public or private affiliation.

— “Lived or shared experience” refers to someone who has personally experienced a substance use disorder, has a family member with one, or has lost a loved one to the disease. Because people’s addiction experiences are not always public, only individuals explicitly appointed because of their firsthand connection or to fill a seat reserved for someone with that experience were categorized as such.

KFF Health News’ Colleen DeGuzman and Megan Kalata contributed to this report.

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—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

The change comes after state lawmakers, in the midst of a national upsurge in maternal deaths, decided not to extend a sunset date for the panel set in 2019, when they established the state’s Maternal Mortality Review Committee, or MMRC.

The committee was composed of a family medicine physician, an OB-GYN, a midwife, a coroner, and a social worker, in addition to others who track deaths in Idaho that occur from pregnancy-related complications. Wyoming studies its maternal deaths through a shared committee with Utah. All other states, as well as Washington, D.C., New York City, Philadelphia, and Puerto Rico, have an MMRC, according to the Guttmacher Institute, a reproductive rights research group.

A majority of the state committees were established within the past decade as federal officials scrambled to understand state and local data to address gaps in maternal care. The committees review deaths that occur within a year of pregnancy and identify trends, share findings, and suggest policy changes.

Liz Woodruff, executive director of the Idaho Academy of Family Physicians, said she was “incredibly disappointed” by the legislature’s decision to scuttle the committee. “It seems relevant that the state of Idaho supports a committee that works toward preventing the deaths of pregnant women,” she said. “This should be easy.”

The committee disbanded despite a high rate of maternal mortality in the United States that exceeds those of other high-income countries. The U.S. recorded 23.8 maternal deaths per 100,000 live births in 2020, compared with 8.4 in Canada and 3.6 in Germany, according to the Organization for Economic Cooperation and Development and the Centers for Disease Control and Prevention.

And the U.S. rate is sharply rising. In March, a few weeks before Idaho lawmakers adjourned their 2023 session, the CDC released data that showed the maternal mortality rate in the U.S. climbed in 2021 to 32.9 deaths per 100,000 live births.

Idaho has a particularly acute problem. Its pregnancy-related mortality ratio was 41.8 pregnancy-related deaths per 100,000 live births in 2020, according to the Maternal Mortality Review Committee report from that year.

Hillarie Hagen of Idaho Voices for Children, a nonprofit focused on low- and moderate-income families, said that the committee used the Idaho-specific data to do deep-dive analyses and that an information void would be left by shuttering the board.

“How do we make decisions and policy decisions to improve the health of mothers and their babies if we’re not tracking the data?” she asked. “From our perspective, having consistent data and trends shown over time helps make more sound policy decisions.”

The decision to disband the board came as two hospitals that serve rural areas announced they would stop providing services for expectant mothers. One of the hospitals cited trouble recruiting and retaining OB-GYNs after the state last summer enacted one of the strictest abortion bans in the country.

The committee, tasked with investigating deaths both individually and collectively, found that almost half of the maternal deaths in Idaho in 2020 occurred after delivery.

Amelia Huntsberger, an OB-GYN and a member of the committee, noted also that patients covered by Medicaid during pregnancy are overrepresented in maternal death rates, which led the panel to recommend expansion of postpartum Medicaid coverage to 12 months rather than the current 60 days.

Huntsberger made national headlines this year when she announced plans to leave both her job and the state, citing the state’s abortion ban and the move to dissolve the MMRC.

But in their legislative session, Idaho lawmakers decided not to advance a bill that would have embraced the committee’s recommendation to expand postpartum Medicaid coverage.

The legislation creating the review committee included a “sunset clause” to dissolve the committee on July 1, 2023. Following a contentious session of the Health and Welfare Committee of the Idaho House of Representatives in February, House Bill 81, which would have renewed the committee, failed to advance.

Republican state Rep. Dori Healey said she sponsored the bill because of her work as an advanced practice registered nurse when the legislature is out of session. “For me, being in the health care field, I think it’s always important to understand the why behind anything. Why is this happening? What can we do better?” Healey said. “I feel like in health care we can only improve with knowledge.”

Healey said she hadn’t anticipated the strong opposition to the bill. In declining to advance it, lawmakers cited costs of running the panel, although some, like Huntsberger, say its operation was covered by a federal grant.

The MMRC was funded by the federal Title V Maternal and Child Health Block Grant program, aimed at improving the health of mothers, infants, and children. Idaho has received more than $3 million annually in Title V funds in recent years, according to statistics cited by Huntsberger.

The MMRC, whose members say annual operation costs stand at about $15,000, was deemed budget-neutral, running at no cost to the state.

In an interview with KFF Health News, Marco Erickson, vice chair of the Health and Welfare Committee, said Idaho’s Republican Party has been focused on reducing government spending. He said the same maternal data could be adequately culled through epidemiology reports already published by the Department of Health and Welfare.

“Anytime that there is a death of a mother and child, there is value in evaluating why it occurred,” Erickson said. “The whole committee saw the importance but saw there was another way to do it. It wasn’t that they didn’t think it was valuable.”

Erickson, who previously oversaw elements of maternal and child health in his role as a health program manager for Nevada’s Division of Public and Behavioral Health, said that information could become siloed in government, but it was worthwhile to improve existing bodies, rather than creating a committee anew.

“I think it could be covered elsewhere, and if it’s not being done, they need to make a loud voice to cover it in the existing programs,” he said. “We’re happy to sit down together to find a solution that works.”

The lobbying group Idaho Freedom Foundation celebrated the end of the committee, contending it was a “vehicle to promote more government intervention in health care,” and citing the group’s recommendation to extend Medicaid coverage to mothers for 12 months postpartum.

Elke Shaw-Tulloch, public health administrator at the Department of Health and Welfare, said the department would “continue to collect raw data on maternal deaths and gather as much data as possible through limited, existing sources.” But, she said, it will not have the ability to compel reporting on cases or convene committee members to investigate deaths.

“We are currently assessing what actions we can take and working with stakeholders to address solutions moving forward,” she said.

A group to do so has not yet convened since the legislative session ended in April, although stakeholders say they will focus on bringing another bill before the Idaho Legislature to reinstitute the committee in the 2024 session.

Stacy Seyb, a maternal-fetal specialist who grew up in rural western Kansas and chaired the committee until its dissolution, said that supporting medical providers in more rural areas was part of his lifelong mission and that the work won’t necessarily stop.

“We knew once it didn’t get out of committee that ‘Oh, well, we’re sunk,’” Seyb said. “I know one thing we want to do is collect as much information as we can over the year. Whether it will get reviewed or not, I don’t know.”

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—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).