Did he use drugs? Had he ever been in jail? How many times had he been to an emergency room? Had he been attacked on the streets? Tried to harm himself? Engaged in sex for money?

Clark didn’t feel comfortable being honest with the two surveyors he’d never met before, who were flanked by police officers as they recorded his responses from a questionnaire on a tablet.

“I’ve done some crazy things to survive, but I’m, like, I’m going to say no because there’s these officers right there,” he said, recalling the encounter on a fall afternoon outside his tent.

“I’m a Black man in America, so asking this stuff hits a little bit different.”

National homelessness experts and local leaders say such personal questions exacerbate racial disparities in the ranks of the nation’s unhoused, particularly as more people experiencing homelessness compete for scarce taxpayer-subsidized housing amid a deepening affordability crisis.

Vulnerability questionnaires were created to determine how likely a person is to get sick and die while homeless, and the system has been adopted widely around the country over the past decade to help prioritize who gets housing. The more a homeless person is perceived to be vulnerable, the more points they score on the questionnaire and the higher they move in the housing queue. The surveys are being singled out for worsening racial disparities by systematically placing homeless white people at the front of the line, ahead of their Black peers — partly because the scoring awards more points for using health care, and relies on trust in the system, both of which favor white people.

Black people make up 13.7% of the overall U.S. population yet account for 32.2% of the nation’s homeless population. White people, including some people of Hispanic descent, make up 75% of the country and represent 55% of America’s homeless.

“It’s racist in a systemic way,” said Marc Dones, a California-based policy director at the University of California-San Francisco and a lead researcher for one of the nation’s largest studies analyzing the Black homeless population. “If you’re a white person, the more likely you are to rank higher than if you’re a Black person, so you’re more likely to get selected for housing.”

Vulnerability surveys took off after President Barack Obama in 2009 signed into law sweeping rules requiring the country’s local homelessness agencies, known as Continuums of Care and currently numbering 381, to adopt a method to assess the vulnerability of homeless people to receive federal housing and homelessness funding. Cities and counties predominantly adopted a survey called VI-SPDAT, which is still used by an estimated two-thirds of homeless agencies, even as it has been found to favor white people and rank Black people lower.

Some experts argue it’s time to toss the vulnerability assessment altogether and look not only at health and social needs but also systemic racism, poverty, involvement in the criminal justice system, barriers to housing, and other economic drivers that influence, and in some cases cause, homelessness. Several U.S. communities are revamping their vulnerability assessment systems to reduce racial disparities and help more Black people get housing.

In Los Angeles, officials are launching an effort to use artificial intelligence to better assess whether someone should be prioritized for placement, in part by looking at overpolicing of Black people and discrimination in health care. In Las Vegas, officials are revamping their vulnerability assessment to give higher scores for systemic problems including incarceration. In Austin, Texas, officials are testing a system to account for people displaced by gentrification.

“We need to own the racism that is embedded in our systems,” said Quiana Fisher, vice president of homelessness response systems for the lead agency in Travis County, Texas, which includes Austin. “It’s not just about the tool — it’s about funding, and it’s about program outcomes. Even if it’s unintentional, we have created a homeless response system that is rooted in racism.”

The assessment tool was first tested in Boston, where members of the homeless population were more likely to be white, male, and have a severe mental illness or substance use disorder. Black people, meanwhile, are more likely to be homeless because of economic reasons, such as poverty or joblessness, and are less likely to have a record of medical care due to higher uninsurance and less use of health care.

“This whole system was piloted on this older white population in Boston, so it does a poor job of capturing the needs of Black folks, who don’t tend to be as sick as white folks — they’re more broke,” Dones said. “The initial thought was to prioritize these people because they’re going to die sooner. It was trying to tackle mortality, but it wound up in racism.”

As a result, white people are more likely to gain housing because they tend to score more points on vulnerability assessments that rank sickness higher, including histories of chronic disease, addiction, mental illness, and emergency room visits and hospitalizations, according to national surveys. Black people, meanwhile, are less likely to have health insurance or medical diagnoses and to reveal their ailments, and are more mistrustful due to biases in the health care system. “Black folks are less likely to seek care, even with coverage, due to medical racism,” Dones said.

Local leaders say part of the problem is becoming homeless in the first place and economic disadvantages that drive more Black people into homelessness, including placement in foster care and higher rates of eviction and joblessness. But once homeless, helping Black people get into stable housing becomes more elusive.

In Los Angeles County, home to more homeless people than any other county in the country, 31% of homeless people are Black, though the overall Black population accounts for 9%. In Austin, Black people account for nearly 32% of the homeless population, compared with 7.6% overall. And in Clark County, which includes Las Vegas, Black people represent 42% of the homeless population but just 12% of the overall population.

“We’ve failed to capture the complex vulnerabilities of our marginalized groups. We’re asking all these questions, but we created a waiting list to nowhere,” said Brenda Barnes, who leads the Southern Nevada Homelessness Continuum of Care.

Streets of Las Vegas

Grasping his toothbrush after cleaning up in his tent on a recent morning, Clark, 45, recalled taking his housing questionnaire this year. He ticked off responses to outreach workers that should rank him high in the queue — he lacked stable housing, has been homeless for nearly four years, and has no job or reliable income.

He’d frequented emergency rooms and had been to jail, pleading guilty to a felony theft crime he said he didn’t commit, and several times for possession of drugs and paraphernalia, he told them. He used methamphetamine, mostly to be alert at night when it became dangerous. Was he ever assaulted? Yes, especially in adulthood since becoming homeless in 2020.

In reality, he hustled sometimes for a dime, and he worried he’d be targeted for taking recyclables or engaging in prostitution. “I’ve done it to get a room for a night. It’s like a last resort,” he said.

And Clark wasn’t forthcoming with outreach workers about the details of his drug use or involvement with law enforcement, that he’d sold his body for sex, that he’d experienced abuse. He couldn’t recall all the details of his medical history either. Continually fleeing law enforcement sweeps with his tent, hauling it along busy train tracks, he’s high at times, and often in a state of chaos and fear that can scramble his memory or make him fearful of arrest. He didn’t share with them his occasional thoughts of suicide or his health concerns, including possibly having diabetes.

“They asked me about drugs, I was like, um, I don’t know,” Clark said. “Like I’m supposed to tell them I got addicted to meth or sold my body for a meal and hotel room? I had no idea where this information was going or what it was being used for.” After he took the survey, no housing came.

Even those who do answer honestly find themselves competing for a limited supply of affordable housing. John Harris was sleeping under a bridge on a recent October afternoon. He said he has taken the questionnaire twice. It led nowhere.

“They asked me, have I been incarcerated? And I said yes. I’ve been to prison too many times. And I have mental health struggles,” said Harris, 59, who has been in and out of sober living shelters but still uses methamphetamine. He has been a repeat visitor to emergency rooms, and on an October afternoon recorded a high blood pressure reading that put him at risk for a heart attack — factors that should score points for vulnerability.

“I called and asked what happened with my housing. They said I didn’t score high enough,” he said. After getting his blood pressure checked by a street medicine nurse, he shrugged, saying he may just wind up back in the emergency room, as he retreated under the bridge.

“No matter what society says today, things ain’t never going to change,” he said.

‘I Don’t Know What the Solution Is’

How communities assign points to homeless people and rank them for housing is the biggest problem.

The most common questionnaire deployed by communities around the country, the VI-SPDAT, assigns points meant to gauge the vulnerability of a person living on the streets. Experts say this model was never tested as a housing assessment tool, nor meant to determine whether someone gets into housing.

“This is not a reliable instrument, and Black men consistently score the lowest for vulnerability, so they are deprioritized for housing — to get housing, you really need to score high,” said Courtney Cronley, a University of Tennessee researcher who analyzed the vulnerability assessment. Her findings were published in 2020 in the Journal of Social Distress and Homelessness.

Cronley pointed to a range of questions that exacerbate racial bias and have little to do with qualifying for housing:

How many times have you received health care in an emergency room? Have you been attacked or beaten up? Have you threatened to harm yourself or anyone else in the last year?

Does anyone force you or trick you to do things that you do not want to do? Do you exchange sex for money? Run drugs?

Experts who study the vulnerability questionnaire also point out that the racial or ethnic background of surveyors often doesn’t reflect that of the people being questioned, which can lead to inaccurate results if a respondent doesn’t feel safe or understand the survey’s purpose.

Some cities and counties are creating surveys that local homeless agencies hope will narrow racial disparities.

Clark County deployed a new vulnerability assessment in June after a 2023 secret-shopper project found the system was not connecting homeless people with housing or services, especially people of color.

“We failed in every category,” Barnes said. Formerly homeless people fanned out on the streets and in the tunnels to test whether the housing questionnaire resulted in providing housing for the most vulnerable. “All we were doing is counting people.”

Clark County’s new weighted questionnaire now considers how likely a person is to exit homelessness on their own — instead of how likely they are to die on the streets or in the tunnels.

The new system assigns homeless people points in four categories to get higher in the queue for housing: whether someone is pregnant or a parent; whether they have a substance use disorder, chronic health condition, or mental health diagnosis; whether they’re 55 or older; and whether they have committed a felony or violent crime.

“Because you’re not going to get approved for a job or housing if they run a background check and there’s a criminal record,” she said, “so we want to address that in our housing system.”

Still, Barnes isn’t sure Clark County will get it right this time. As of mid-November, more homeless Black people were waiting for housing than white people. According to local data obtained through public records requests, nearly 1,500 Black people are in the county’s housing queue, compared with roughly 1,000 white people.

“I don’t know what the solution is,” Barnes said. “To be honest, the numbers may spike again.”

Los Angeles County, where an estimated 75,000 people experience homelessness, is creating a weighted tool to assign more points for factors that disproportionately affect people of color.

If someone has been incarcerated or detained by law enforcement, instead of getting one point, a homeless person would score five, moving them up on the housing list, said Eric Rice, a social scientist and professor at the University of Southern California.

“We are assigning more points to structural inequities,” said Rice, who is helping develop the new questionnaire.

Los Angeles County also plans to assign more points for drug use and for having HIV, which affects Black men more than any other group. New HIV diagnoses for Black adults were eight times those of white people, according to research by KFF, a health information nonprofit that includes KFF Health News.

Homelessness coordinators have also revamped their vulnerability assessment in Travis County, Texas, where a Black resident is six times as likely to fall into homelessness as a white person.

The county’s homelessness agency, according to Fisher, looked at historically Black neighborhoods in Austin that had been gentrified and scored homeless people higher if they’d lived in those areas but were now homeless.

“If you lived in a place that was previously redlined or now gentrified, you got a point for that,” Fisher said. The survey also gave points for involvement in the criminal justice system, because Black people are more likely to get arrested or jailed, she said.

Some experts say the idea of using a tool to rank people should disappear altogether.

Instead, communities should have flexibility to tailor their housing resources based on the local needs and demographic makeup of their homeless populations, said Mary Frances Kenion, vice president of training and technical assistance at the National Alliance to End Homelessness.

She said communities can cultivate trust between homeless people and outreach workers through a one-on-one approach that can be more responsive to individual needs and local housing conditions, which can better determine whether someone should be moved to the top of the housing list.

Kenion also encouraged federal, state, and local governments to reimagine their approach to prioritizing people for housing based not on vulnerability but economic factors like income, history of eviction, or having a felony record. She argued communities should devote more resources to stem the flow of Black people into homelessness.

“If we don’t manage to stop that,” she said, “this is just going to keep getting exponentially worse.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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.

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The Chicago health care consultant contacted his physician at Northwestern Medicine, who referred him for a diagnostic colonoscopy, at least partly because Contos, 45, has a family history of colon issues.

“I work out a lot,” he said. “But my partner said this isn’t normal. My primary care physician said, ‘Given your family history, let’s get you in.’”

Northwestern Memorial Hospital asked him to prepay $1,000 out-of-pocket, and he underwent the procedure in June.

Then the bill came.

The Medical Procedure

Colonoscopies are performed in the United States more than 15 million times a year. Rates of colorectal cancer are on the rise, particularly among younger people.

The procedure, which is also a recommended screening for people 45 or older, involves examining the large intestine using a tube with a video camera that can also collect tissue samples.

It typically takes less than one hour, with another hour spent taking the patient’s history, administering anesthesia, and monitoring their recovery, said Glenn Littenberg, a physician who recently chaired the reimbursement committee of the American Society of Gastrointestinal Endoscopy.

According to Contos’ medical record, the gastroenterologist who performed his colonoscopy described it as “not difficult.” He biopsied and removed small growths called polyps from two spots and identified large internal hemorrhoids, which are swollen veins.

The biopsy samples were sent to pathology for testing and found to be precancerous. But the gastroenterologist reported finding no evidence of cancer, and after reviewing the pathology report, he concluded hemorrhoids were the likely cause of the bleeding.

The Final Bill

The hospital charged a total of $19,206 for the procedure, including physician fees. The insurer negotiated the price to $5,816 and paid $1,979, leaving a patient share of $4,047. (It wasn’t clear why the payments added up to slightly more than the negotiated price.) After Contos had paid $1,000 up front, plus $1,381 right after the procedure, the hospital said he still owed $1,666.

The Billing Problem: Colonoscopies That Find Polyps Cost More

Contos was shocked and angry when he received his itemized bill. “I said, ‘I don’t understand this.’ Then I started to research the cost.”

He asked the hospital what it charges for a diagnostic colonoscopy and was told he’d been sent a cost estimate through his online patient portal prior to the procedure.

The estimate, which took his deductible of $3,200 into account, listed a total price of $7,203, with an out-of-pocket bill of $2,381. He asked Northwestern why the charges were nearly three times the estimate and why his out-of-pocket share was nearly twice as high.

One big reason was revealed in an explanation of benefits (EOB) statement from Contos’ insurance company, Aetna: Northwestern had charged for two colonoscopies, at $5,466 each. And there were two fees for the gastroenterologist — $1,535 and $1,291.

The first procedure was listed as “colonoscopy and biopsy,” while the second was listed as “colonoscopy w/lesion removal.” Aetna’s negotiated member rate reduced the first $5,466 hospital charge to $3,425, while the charge for the second procedure was lowered to $1,787 — $1,638 less.

Neither the bill nor the EOB explained why there was a second procedure listed, at a reduced price.

After examining Contos’ bill, Littenberg said it’s standard for providers to bill for two colonoscopies if they remove two or more polyps in different ways, because of the extra work. As in this case, hospitals typically use a modifier code that reduces the amount charged for the second billed colonoscopy so they charge only for the extra work, he added.

“How do you explain that in sensible terms that anyone could understand?” Littenberg said.

Even with that reduction, Littenberg said, he thought Contos’ total out-of-pocket cost of $4,047 was “a lot, though not rare for large academic centers.”

Contos’ insurance documents show Aetna’s negotiated rate for his colonoscopy at Northwestern was more than twice the insurer’s median negotiated rate for the same procedure at other Chicago-area hospitals, according to Forrest Xiao, director of quantitative research at Turquoise Health, a company that gathers health care price data.

In exchanges with Northwestern and Aetna representatives, Contos asked why he was charged for two colonoscopies. A Northwestern representative said that because of the modifier code, he wasn’t actually being billed for two procedures, which Contos found bewildering.

“I told Northwestern, ‘I’m not paying that, and I don’t care if you send me to collections,’” he said. He filed appeals with the hospital and Aetna but was ultimately told the billing was correct.

The Resolution

In an email, Contos told the billing department that its charge was “ridiculously high.” A representative responded that Northwestern’s pricing is in line with other academic medical centers in Chicago and “non-negotiable” — and that his account would be turned over to a collections agency.

CVS Health spokesperson Phillip Blando said in a written statement to KFF Health News that the claims for Contos were “paid accurately” by Aetna, declining further comment. (CVS Health owns Aetna.)

Northwestern did not respond to multiple requests for comment.

Contos said he wrote to his physician that he was regretfully dropping him and leaving Northwestern entirely because of the health system’s high pricing.

He said he’s still experiencing periodic symptoms, which he relieves with over-the-counter Preparation H. A one-ounce tube of the ointment costs $10.99 at CVS.

The Takeaway

To get a colonoscopy at a lower price, Littenberg said, patients should consider going to a freestanding endoscopy center or ambulatory surgery center not associated with a hospital. A 2023 study found that ambulatory surgery centers billed insurers an average of about $1,030 for a colonoscopy with biopsy or with removal of a polyp, compared with $1,760 at a hospital.

Bill of the Month

• A Toddler Got a Nasal Swab Test but Left Before Seeing a Doctor. The Bill Was $445. Nov 27, 2024
• Toddler’s Backyard Snakebite Bills Totaled More Than a Quarter Million Dollars Oct 30, 2024
• In Chronic Pain, This Teenager ‘Could Barely Do Anything.’ Insurer Wouldn’t Cover Surgery. Sep 25, 2024

To get a sense of how much a diagnostic colonoscopy could cost, patients can consult a hospital’s price website and an insurer’s cost-estimator website, both required by federal price transparency rules.

Patients also can look up a good-faith estimate of the cash price, which can be lower than the price for patients using insurance to pay for a procedure. In addition, they can check prices through websites such as Turquoise Health and Fair Health, which draw from federal price transparency data or claims data from insurers.

Still, the actual cost could be higher than the estimate if the colonoscopy finds one or more polyps that need to be removed and biopsied, which occurs in at least 40% of all colonoscopies, Littenberg said. Patients should ask whether the price includes those potentially extra services. After all, the point of a diagnostic colonoscopy is to find and, if necessary, treat lesions that could cause problems — regardless of the number found.

It all should be easier for patients, Xiao said: “You shouldn’t have to be a medical billing expert to know what you’re going to pay.”

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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.

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KFF Health News, partnering with researchers at the Johns Hopkins Bloomberg School of Public Health and Shatterproof, a national nonprofit focused on addiction, undertook a yearlong investigation to find out.

Dozens of interviews, thousands of pages of documents, an array of public records requests, and outreach to all 50 states resulted in a first-of-its kind database that catalogs more than 7,000 ways opioid settlement cash was used in 2022 and 2023. It’s the most comprehensive resource to date tracking some of the largest public health settlements in American history.

Among the findings:

• States and localities received more than $6 billion in opioid settlement funds in 2022 and 2023. According to public records, they spent or committed about a third of that amount and set aside about another third for future use. The final third was untrackable, as many jurisdictions did not produce public reports on the funds.
• Reports of spending tracked the minuscule to the monumental, from $11.74 to buy postage in Yavapai County, Arizona, to more than $51 million to increase the addiction treatment workforce in California.
• States allotted, on average, about 18% of their funds for addiction and mental health treatment; 14% for recovery services such as housing, transportation, and legal aid; 11% for harm reduction efforts such as overdose reversal medications; and 9% for prevention programs that aim to stop people from developing substance use disorders. States committed, on average, about 2% for syringe service programs, through which people can get sterile needles. (A variety of entities received this money, from law enforcement to nonprofit organizations to government agencies.)
• Governments reported spending more than $240 million on purposes that did not qualify as opioid remediation. (Most settlements allow states to spend up to 15% of their funds this way.) Most of this tranche went to legal fees, but several jurisdictions funneled money to their general fund. One county even sent funds to its road and bridge department.
• Several cities and counties reported expenditures they said addressed the overdose crisis but that would leave an average person scratching their head — such as $33.07 to an anti-abortion pregnancy center in Sandborn, Indiana, and $30,362 to screen first responders for heart disease in Oregon City, Oregon.

“When people know that people aren’t watching and there’s no accountability, then they can kind of do what they want,” said Tonja Myles, a community activist in Baton Rouge, Louisiana, who is in recovery. “That’s why we have to have some kind of database and accountability.”

Despite the recent decline in overall overdose deaths in the U.S., more than 90,000 people still died in the 12 months ending July 2024 and rates are rising in many Black and Native American communities.

“We can’t mess up or miss this moment,” Myles said.

Opioid settlement payouts are expected to total about $50 billion over nearly two decades, paid by more than a dozen companies that made or distributed prescription painkillers, including Johnson & Johnson, Walgreens, and Walmart. Although it’s a large sum, it’s dwarfed by the size of the crisis, making each dollar that’s spent critical.

KFF Health News and its partners reviewed hundreds of settlement spending reports, extracting expenditures line by line, and developed a methodology to sort the expenditures into categories like treatment or prevention. States were given an opportunity to review the data and comment on their spending.

To be sure, the database does not capture the full picture of opioid settlement spending nationwide. Some places do not publish spending reports, while others declined to engage with this project. The data presented here is a snapshot as of the end of 2023 and does not account for further spending in 2024. The differences in how states control, process, and report on the money make apples-to-apples comparisons nearly impossible. Still, the database helps fill a gap left by a lack of national reporting requirements and federal government inaction.

It is “a tool for those who want to objectively measure whether everything that can be done is being done,” said Matthew Myers, a former president of the Campaign for Tobacco-Free Kids, which compiles similar annual reports on tobacco settlement money.

Treatment a Clear Winner

The top priority to emerge from early opioid settlement spending was treatment, with more than $416 million spent or committed to residential rehabs, outpatient counseling, medications for opioid use disorder, and more.

The state of New York — which spent the most on treatment — allocated about $22 million of that for programs that make the gold standard for care as easy as possible for patients: providing same-day prescriptions for buprenorphine, a medication that decreases cravings for opioids.

The result was a program that John Greene said changed his life.

Greene, 57, used to live in the woods down the street from Family & Children’s Counseling Services in Cortland, New York. He cycled through jails and hospitals, overdosing half a dozen times and trying rehab just as many.

But now he has four months of recovery under his belt — the longest stint since he started regularly using drugs at 14.

He said it’s because the counseling center’s new program — funded by a mix of state and local opioid settlement dollars — has a different approach. Counselors aren’t didactic and judgmental. They don’t force him to stop smoking marijuana. Several staff members have experienced addiction themselves. They drive Greene, who doesn’t have a car, to doctor appointments and the pharmacy for his buprenorphine prescription.

Now Greene lives and works with his brother, looks forward to weekly counseling sessions, and is notching small victories — such as buying his nephew toy cars as a stocking stuffer.

“It made me feel good to do something for somebody and not expect nothing back,” Greene said.

Emily Georgia, one of Greene’s counselors, said the center has worked with nearly 200 people like him in the past year. Without the settlements, “the program probably wouldn’t exist,” she said.

Across the country, the money supports other innovative treatment approaches:

• $21 million for a new program in Kentucky that diverts people with mental illness or addiction who face low-level charges away from incarceration and into treatment, education, and workforce training
• More than $3 million for, in part, three new mobile methadone programs in Massachusetts, to bring the medication to rural and underserved areas
• Tens of thousands of dollars each in Iowa and Pennsylvania to cover out-of-pocket treatment costs for people without insurance or those with high deductibles

Philip Rutherford, an expert on substance use disorder at the National Council for Mental Wellbeing, said these efforts “are really positive” and many have been “historically difficult or impossible to achieve with federal or state funding.”

But some funds are also flowing to treatment approaches that defy best practices, such as denying people medications for opioid use disorder.

Some in the recovery community consider methadone and buprenorphine a crutch. But study after study show that the medications help people stay in treatment and reduce the risk of overdose and death. Research even suggests that treatment without these medications can be more harmful than no treatment at all.

Although not everyone will want medication, settlement funds shouldn’t “prop up a system that doesn’t allow people to have that choice,” said Regina LaBelle, a professor of addiction policy at Georgetown University.

Babies, Forgotten Victims of the Epidemic

While treatment received a windfall in early opioid settlement spending, another aspect of the crisis was neglected: neonatal abstinence syndrome, a condition in which babies exposed to drugs in the womb experience withdrawal.

Nationwide, more than 59 newborns a day are diagnosed with it. Yet only about $8.4 million in settlement money was committed to the issue — less than 0.5% of all funds publicly reported as spent or committed in 2022 and 2023.

Experts in public health and addiction, as well as affected families, say it’s due to stigma.

“A mom using drugs and being a parent is a very uncomfortable reality to face,” said Ashley Grant, a 38-year-old mother of three in Mesa, Arizona. “It’s easier to just push it under the rug or let them fall through the cracks, as sad as that is.”

It almost happened to her.

Grant learned she was pregnant with her third child last year. At the time, her partner was in jail and she was using drugs after an eight-year period of recovery, was estranged from her family, and didn’t know how she’d survive the next nine months.

During a visit to a methadone clinic, she saw a booth about Jacob’s Hope, a specialty nursery that cares for substance-exposed newborns and their moms. Nursery staff connected her with a therapist, helped her enroll in parenting classes, and dropped off diapers and a playpen at her home.

After delivering at the hospital, Grant and her baby boy stayed at Jacob’s Hope for about a week. Nurses showed her how skin-to-skin contact calmed his withdrawal symptoms and more frequent feedings and burpings decreased gastrointestinal discomfort, which is common among substance-exposed newborns.

Today, Grant has roughly five months of recovery. She got certified as a peer recovery specialist and hopes to join Jacob’s Hope one day to help moms like her.

But the nursery’s future is uncertain.

After opening in 2019, Jacob’s Hope nearly shut down this summer due to low reimbursements and delayed payments from insurers, said Lyndsey Steele, its associate director. Community donations kept the nursery afloat, but “it’s still hanging on by a thread,” she said.

She’s hoping opioid settlement money can help.

In 2022, Jacob’s Hope received about $250,000 from Arizona’s opioid settlements. But this year, the legislature captured the state’s share of remaining funds and, in a controversial move, gave it to the Department of Corrections.

Jacob’s Hope has now turned to local governments, which control their own settlement dollars. Its home city of Mesa said a first round of grant applications should open in the spring.

Steele prays it won’t be too late for babies in need — the epidemic’s “forgotten victims,” she called them.

Heart Disease Screening, Robot Ambulances, and More

Some opioid settlement expenditures have sparked fierce disagreement. They generally fall into three buckets: money for law enforcement, funding for youth prevention programs, and purchases unrelated to the opioid crisis.

Settlement dollars nationwide have bought body scanners, K-9 units, bulletproof vests, patrol trucks, and laptops and printers for police and sheriffs.

Some spending strayed even further from the spirit of the settlement. In Oregon City, Oregon, more than $30,000 was spent on screening first responders for heart disease. Police Chief Shaun Davis said his staff respond to opioid-related emergencies and experience trauma that increases their risk of heart attack.

But some people question if settlement funds should be footing the bill.

“This looks to me like you’re trying to defray other costs” from the police budget, said Stephen Loyd, chair of Tennessee’s Opioid Abatement Council. “I don’t think that there’s any way that this opioid money was earmarked for stuff like that.”

A second area of contention is youth prevention.

Although most people agree that stopping children from developing addictions is important, the execution is tricky.

Nearly half a million settlement dollars have gone to the Drug Abuse Resistance Education program, commonly known as D.A.R.E. Decades of research suggest its original curriculum is ineffective.

Robeson County, North Carolina, spent about $10,000 in settlement money to buy “Andy the Ambulance,” a robot ambulance with big eyes and an audio system through which a human operator can discuss the dangers of drugs. EMS Director Patrick Cummings said his team has taken the robot to churches and elementary schools.

We “don’t have any studies that show it’s working,” he said, but educating kids seems like a good investment because “if they never try it, they don’t get addicted.”

Then there’s the chunk of money — up to 15% of each state’s funds — that’s a free-for-all.

Flint, Michigan, spent nearly $10,000 on a sign for a community service center. The city reported that the expense did not qualify as “opioid remediation.” In other words, it’s unrelated to addressing the crisis.

But Caitie O’Neill, a city spokesperson, said that “the building sign makes it possible for residents to find” the center, which houses city services, “including Narcan kits, fentanyl testing strips, and substance abuse referrals.”

Jurisdictions across 29 states reported non-remediation spending in 2022 and 2023. Most opioid settlements require such reports but operate on an honor system. No one is checking if the other 21 states and Washington, D.C., were truthful.

Jackie Lewis, an Ohio mother whose 34-year-old son, Shaun, died of an overdose in October 2022, finds that hard to stomach.

“This is blood money,” she said. Some people have “lost sight of that.”

Lewis is raising Shaun’s daughter, ensuring the 9-year-old receives counseling at school and can attend the hip-hop music classes she enjoys — all on Lewis’ Social Security payments. This year they moved to a smaller town with lower costs.

As settlement funds continue flowing, she wants officials in charge of the money to help families like hers.

“We still exist and we’re still struggling,” she said.

KFF Health News’ Henry Larweh and Megan Kalata, Johns Hopkins Bloomberg School of Public Health’s Sara Whaley and Vivian Flanagan, and Shatterproof’s Kristen Pendergrass and Sahvanah Prescott contributed to this article.

The Johns Hopkins Bloomberg School of Public Health has taken a leading role in providing guidance to state and local governments on the use of opioid settlement funds. Faculty from the school collaborated with other experts in the field to create principles for using the money, which have been endorsed by over 60 organizations.

Shatterproof is a national nonprofit that addresses substance use disorder through distinct initiatives, including advocating for state and federal policies, ending addiction stigma, and educating communities about the treatment system.

Shatterproof is partnering with some states on projects funded by opioid settlements. KFF Health News, the Johns Hopkins Bloomberg School of Public Health, and the Shatterproof team who worked on this report are not involved in those efforts.

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.

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“So, I don’t want to be dramatic,” she wrote on Sept. 27, “but we are gonna fly and rescue patients from the rooftop of Unicoi hospital.”

Earlier that day, Hurricane Helene roared into the Southern Appalachian Mountains after moving north through Florida and Georgia. The storm prompted a deadly flash flood that tore through Unicoi County in eastern Tennessee, trapping dozens of people on the rooftop of the county hospital.

The fast-moving floodwaters had made earlier rescue attempts by ambulance and boat impossible. Trees, trailers, buildings, caskets, and cars swept past the hospital in murky, brown rapids that overwhelmed the one-story structure with 12 feet of water on all sides.

No one knew how long the hospital’s frame would hold or if the rising water would breach the top of the 20-foot-tall building. Little more than a mile downstream, six people at a plastics plant in Erwin’s industrial park died in the flood.

“I do not feel good about this,” Boyd, a flight nurse for Ballad Health, texted her husband at 1:41 p.m., just before takeoff.

She wrote that she loved him. “If anything goes wrong,” she wanted him to tell her daughters “how much I love them,” too.

Her fears were well-founded.

In 2018, Unicoi County Hospital relocated from higher ground in the heart of Erwin to the southern edge of town, between Interstate 26 and the Nolichucky River. The new hospital was built in a known flood plain, but the facility wasn’t designed to accommodate helicopter landings on its roof. Boyd and her team weren’t sure the roof could bear the weight of their 7,200-pound Eurocopter in good weather, let alone during a flash flood.

“I had a horrible feeling about it,” she said.

By many accounts, the evacuation of 70 people, including 11 patients, by helicopter that day was a stunning success. The hospital was destroyed, but no one died. No one was even physically injured by the ordeal.

Yet, earth scientists, emergency management officials, and others who spoke to KFF Health News describe the narrow escape from Unicoi County Hospital as a cautionary tale. As climate change forces health care leaders and public officials to prepare for severe storms in landlocked parts of the country — where residents haven’t historically paid much attention to hurricane warnings — they must be strategic about both the infrastructure design and the locations selected for new projects, like hospitals.

The Biden administration finalized a rule this year designed to make the construction of such projects that receive funding from the Federal Emergency Management Agency more resilient to flooding. But a review by KFF Health News identified about 20 other Tennessee hospitals already built in, or near, flood plains.

Patrick Sheehan, director of the Tennessee Emergency Management Agency, said past weather patterns can lull people into a false sense of security. But, he added, “past is not always prologue. We’re going to experience novel, new ways of having disasters.”

Historically, the Southern Appalachian Mountains have been the place “where hurricanes go to die,” said Ryan Thigpen, an earth and environmental sciences professor at the University of Kentucky whose research focuses on flooding in the region. But as the Gulf of Mexico becomes warmer and storms, like Helene, that move northward into the mountains carry more moisture, weather events will become more severe.

“It’s apocalyptic,” said Thigpen, of the damage in Erwin. “The next storm may come before they are finished recovering from this. And that’s kind of scary.”

Hospitals in Flood Plains

All week, Michelle Matson had been worried about Unicoi County Hospital in the oncoming storm.

As a district coordinator for the Tennessee Emergency Management Agency, Matson works with local officials to plan for worst-case scenarios.

Leading up to Hurricane Helene, she’d been in regular communication with the county’s emergency management director. The hospital’s vulnerability next to the river kept coming up.

“That was the only place we were worried about,” Matson said.

But concern over the hospital’s location wasn’t new.

In November 2013, Unicoi County Memorial Hospital, which opened in 1953, was acquired by Mountain States Health Alliance on the condition that Mountain States would construct a hospital in Erwin to replace the old one.

Two years later, Mountain States purchased a 45-acre tract of land next to a bend in the Nolichucky River, just off Interstate 26. A hospital system press release at the time explained that due diligence had been conducted to ensure, among other things, that the hospital building would not be in a flood plain. It also presented the location as desirable because it was near the interstate and the landscape would provide “a healing environment by taking advantage of the natural beauty of Unicoi County, with the river running along the east side of the property.”

Dating back decades, though, flood maps published by FEMA put the entire property in a flood plain. The building itself was in a 500-year flood plain (meaning a 0.2% chance of flooding in any given year), while the only road on and off the property was in a 100-year flood plain (meaning a 1% annual risk).

But it wasn’t only FEMA maps that forecast this possibility. In 2001, a report published by Unicoi County marked this land as being in a “flood hazard” area. The report warned of “considerable pressure” to develop flood hazard areas across the county “due to population increase and the need for vacant land.”

The same report acknowledged a history of destructive flooding in the county and the risks it faced being situated along “three major streams,” including the Nolichucky River, which flows northward out of the Blue Ridge Mountains of western North Carolina straight through Erwin.

“If you start looking at the river’s history, there are a number of these notable flood events, and quite a few in the 20th century. They just did not reach this magnitude,” said Philip Prince, a geologist with Appalachian Landslide Consultants. His YouTube videos about mountain flooding during Helene have been viewed hundreds of thousands of times. “People should have been expecting more than they did. But again, we have not seen anything like this.”

Matthew Rice, a former Unicoi County commissioner, served as chair of the Hospital Visioning Committee for the new hospital in 2015. He said some committee members raised questions during the planning process about the location, but he conceded there weren’t many large, flat places to build a hospital in Erwin.

Amid a wave of rural hospital closures across the United States, Erwin residents celebrated when the new hospital opened in 2018. One lawmaker told the Johnson City Press it was “the most modern facility on the planet.”

Alan Levine was CEO of Mountain States Health Alliance during that time and later became the head of Ballad Health, when Mountain States merged with a competing hospital system in 2018 to form the largest state-sanctioned hospital monopoly in the country.

Levine said Mountain States was aware the property carried flood risk but noted that the hospital system added levees to protect the building from river flooding at the recommendation of outside consultants. One levee already existed along the river’s edge. And the hospital itself was deliberately constructed on a high point of the land, at the same elevation as the interstate, Levine said.

“I feel like everything we did when we built it was done the right way,” said Levine, a former health care leader in Louisiana and Florida.

Even so, Matson, who lives in Kingsport, about 45 minutes northwest of Erwin, said some residents were quietly critical of the new hospital’s location.

“We all thought that it was a stupid idea to build a hospital in a flood plain. It’s like, who does that?” Matson said. She said her opinion doesn’t represent an official position of the Tennessee Emergency Management Agency.

But Unicoi isn’t the only Tennessee hospital built in a flood plain. Eight others across the state were built in moderate- or high-risk flood zones, and a dozen other hospitals are situated just outside them, KFF Health News found.

The hospitals at risk span the length of the state, from Memphis on the western edge to Knoxville in the east, and include big-city general hospitals, smaller rural hospitals, and behavioral health facilities.

Some of the hospitals are decades old. Parkridge East Hospital in Chattanooga, for example, was built in the 1970s inside a high-risk flood zone. Others are more recent — like Creekside Behavioral Health in Kingsport. That building, which opened in 2018, straddles high- and moderate-risk flood zones.

Then there are facilities like Pinewood Springs in Columbia. The 60-bed mental health facility, which opened in 2020, is in a low-risk area, but the main road leading in and out of the hospital lies in a high-risk flood area.

To identify these hospitals, KFF Health News looked for licensed facilities in or near areas that, according to FEMA, have either a high flood risk (with a 1-in-100 chance of flooding in any given year) or moderate risk (a 1-in-500 chance in any given year).

But FEMA’s maps likely underestimate the true flood risk, researchers and government watchdogs agree, because they’re largely outdated and don’t account for current or future conditions, including more frequent and more intense storms and flooding associated with climate change.

Those maps are updated on an ongoing but slow and piecemeal basis. Meanwhile, the federal regulation finalized this year to expand areas considered at risk for current and future flooding also sets more stringent building standards for critical infrastructure projects located in 100-year flood plains and funded by federal taxpayers.

The rule became effective on Sept. 9, less than three weeks before Hurricane Helene ravaged the Southern Appalachians, but it is unclear whether the incoming Trump administration will preserve it.

After he took office in 2017, President Donald Trump revoked federal flood protection standards set up under the Obama administration. Karoline Leavitt, a spokesperson for the incoming Trump administration, did not respond to emailed questions for this article.

An ‘Antiquated and Broken’ System

On Sept. 24, three days before the hospital evacuation, the National Hurricane Center issued the first of several warnings predicting significant river flooding and landslides in the Southern Appalachians. Two days before the flood in Erwin, a satellite office of the National Weather Service in Morristown, Tennessee, predicted “life-threatening flash flooding” near the Tennessee-North Carolina state line.

The warnings kept coming. The National Weather Service in upstate South Carolina forecast on Sept. 26, a Thursday, that Helene would amount to one of the region’s most significant weather events “in the modern era.”

“I don’t think people knew what that meant,” said Prince, the geologist. “We just didn’t have a precedent.”

Ballad Health didn’t anticipate that Unicoi would flood during the storm, Levine said, even though a hazard vulnerability assessment conducted annually for the hospital identifies external flooding as the second-highest risk facing Unicoi County Hospital, behind only a civil disturbance. The same 2024 assessment rated the hospital’s preparedness for a flood as a “3” or “low,” the worst possible score.

But a document outlining the hospital’s emergency alert procedures makes no mention of flood risk. If anything, hospital leaders said they were anticipating a surge of patients during Hurricane Helene if Erwin and the surrounding area experienced widespread power outages.

“There was no conversation I had with anybody, anywhere about the risk of flooding before Friday morning,” Levine said.

The day before, Jennifer Harrah, the hospital’s administrator, had called a meeting to discuss the storm. Sean Ochsenbein, an emergency medicine physician and the hospital’s chief medical officer, recalled that the group gathered “just to kind of circle the wagons, make sure everybody was on the same page.”

Later that day, Harrah spoke to Unicoi County’s emergency management director. But “let me be very clear,” Ochsenbein said. “Nobody gave us — as Ballad or our hospital — any kind of indication that we would have floodwaters.”

And yet little more than 24 hours after their planning meeting, both Harrah and Ochsenbein were stranded on the hospital roof, literally praying to God for their rescue.

“I called my husband, and I called my sons,” Harrah said. “I told them that I loved them.”

One reason the impact of the storm seemed to catch people off guard was a disconnect between the strong warnings issued by the federal agencies and the low expectations that many people in the region, including Ballad Health leaders, had of the potential flood risk.

It was sunny outside when people were evacuated from the hospital roof, Thigpen pointed out. It had rained about 5 inches in Erwin over several days, but that was nothing compared with places in the North Carolina mountains that received more than 20 inches over the same period. Rainfall at those higher altitudes eventually drained into the rivers and streams that ultimately destroyed places like Erwin.

But residents in Unicoi County had no clue what was coming their way, Thigpen said, because there weren’t river gauges upstream to sound alarms about dangerous water levels.

“I think that our warning systems are antiquated and broken,” he said. “These people in Erwin have seen floods — and a lot of big floods — and it’s never been anywhere close to this.”

Tennessee state climatologist Andrew Joyner is one of several experts now calling for more river gauges to monitor water levels and a network of weather stations in every county designed to collect live precipitation data.

Thirty-eight states already operate similar systems, he said, estimating that setting up and staffing weather stations across Tennessee would cost less than $4 million in the first year.

But the state has failed to act before. Following a catastrophic flood in Waverly, Tennessee, that killed 20 people and destroyed hundreds of homes and businesses in 2021, the Tennessee General Assembly denied a $200 million request to relocate 14 public schools across the state that had been deemed vulnerable to future flooding.

‘Might Not Make It Back’

On the morning of the flood, Matson had stood with the county’s emergency management director behind Unicoi County Hospital and watched the rising river. “We both had this, like, sick feeling in our stomach that said we’ve got to evacuate,” she remembered. “I said to him, worse comes to worst, we evacuate, nothing happens. Just blame it on me.”

They made the call to start moving patients out of the hospital just before 9:45 a.m. Less than 30 minutes later, the river had breached its banks, cutting a new channel in front of the hospital and eliminating access to the only road on or off the property.

When an ambulance evacuation became untenable, the Tennessee Emergency Management Agency called in swift-water teams, specially designed to rescue people in turbulent waters. But the flash flood had become so violent and the river was so full of debris that the boats couldn’t safely carry patients away. Meanwhile, dangerous wind conditions prevented helicopters located to the east or west from immediately flying that morning to rescue everyone by air.

“To be honest, I really thought we may not make it back” from the rescue mission, Boyd, the flight nurse, said.

When the wind started to die down that afternoon, Virginia State Police deployed two helicopters to rescue patients. Eventually, three Black Hawk helicopters from the Tennessee National Guard assisted in the effort. Pilots were required to make multiple round trips between the hospital and the local high school to evacuate four or five people at a time who had been stranded by the flood. Some patients stranded in boats near the hospital were hoisted into helicopters, while those who were stranded on the roof were either carried onto the aircraft or climbed aboard while the helicopters lightly touched down on their skids.

As the afternoon wore on and the evacuation was nearing its completion, pilot Jeff Bush with the Virginia State Police said he learned that the hospital building was weakening. They weren’t sure how much longer it would hold.

“It was intense,” he said. “The fact that the building is still standing is, I think, kind of amazing.”

Ballad Health evacuated two other hospitals and one nursing home by ambulance within 24 hours of the flood in Erwin, but none of those sustained damage. Meanwhile, what’s left of Unicoi County Hospital stands next to the Nolichucky in a field of mud and displaced river rocks.

For now, Ballad Health has opened a temporary urgent care center and plans to establish an emergency department at the site of the former Unicoi County Memorial Hospital in downtown Erwin.

Levine said Ballad Health will eventually rebuild a full-service hospital, but he estimated the project would cost $50 million, roughly twice as much as it did in 2018. It remains unclear where it would be built.

Probably not in a flood plain, Levine said. “I would avoid it if I could.”

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“That’s all a recipe for more medical debt,” said Stahl, of Undue Medical Debt.

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

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

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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