PRESQUE ISLE, Maine — Outside the Mi’kmaq Nation’s health department sits a dome-shaped tent, built by hand from saplings and covered in black canvas. It’s one of several sweat lodges on the tribe’s land, but this one is dedicated to helping people recover from addiction.

Up to 10 people enter the lodge at once. Fire-heated stones — called grandmothers and grandfathers, for the spirits they represent — are brought inside. Water is splashed on the stones, and the lodge fills with steam. It feels like a sauna, but hotter. The air is thicker, and it’s dark. People pray and sing songs. When they leave the lodge, it is said, they reemerge from the mother’s womb. Cleansed. Reborn.

The experience can be “a vital tool” in healing, said Katie Espling, health director for the roughly 2,000-member tribe.

She said patients in recovery have requested sweat lodges for years as a cultural element to complement the counseling and medications the tribe’s health department . But insurance doesn’t cover sweat ceremonies, so, until now, the department couldn’t afford to provide them.

In the past year, the Mi’kmaq Nation received more than $150,000 from settlements with companies that made or sold prescription painkillers and were accused of exacerbating the overdose crisis. A third of that money was spent on the sweat lodge.

Health care companies are more than $1.5 billion to hundreds of tribes over 15 years. This windfall is similar to settlements that many of the same companies are paying to state governments, which total about $50 billion.

To some people, the lower payout for tribes corresponds to their smaller population. But some tribal citizens point out that the overdose crisis has had a disproportionate effect on their communities. Native Americans had the highest overdose death rates of any racial group each year from 2020 to 2022. And federal officials say those statistics were likely undercounted by about 34% because Native Americans’ race is often misclassified on death certificates.

Still, many tribal leaders are grateful for the settlements and the unique way the money can be spent: Unlike the state payments, money sent to tribes can be used for — anything from sweat lodges and smudging ceremonies to basketmaking and programs that teach tribal languages.

“To have these dollars to do that, it’s really been a gift,” said Espling of the Mi'kmaq tribe. “This is going to absolutely be fundamental to our patients’ well-being” because connecting with their culture is “where they’ll really find the deepest healing.”

Public health experts say the underlying cause of addiction in many tribal communities is intergenerational trauma, resulting from centuries of brutal treatment, including broken treaties, land theft, and a government-funded boarding school system that sought to erase the tribes’ languages and cultures. Along with a long-running lack of investment in the Indian Health Service, these factors have led to lower life expectancy and higher rates of addiction, suicide, and chronic diseases.

Using settlement money to connect tribal citizens with their traditions and reinvigorate pride in their culture can be a powerful healing tool, said , a researcher with the Johns Hopkins Center for Indigenous Health and a member of the Haida Nation. She for how tribes can consider spending settlement money.

Medley said that having respect for those traditional elements outlined explicitly in the settlements is “really groundbreaking.”

‘A Drop in the Bucket’

Of the 574 federally recognized tribes, more than 300 have received payments so far, totaling more than $371 million, according to , one of three court-appointed directors overseeing the tribal settlements.

Although that sounds like a large sum, it pales in comparison with what the addiction crisis has cost tribes. There are also hundreds of tribes that are excluded from the payments because they aren’t federally recognized.

“These abatement funds are like a drop in the bucket compared to what they’ve spent, compared to what they anticipate spending,” said , a lawyer who represented several tribes in the opioid litigation and a citizen of the Passamaquoddy Tribe. “Abatement is a cheap term when we’re talking about a crisis that is still engulfing and devastating communities.”

Even leaders of the Navajo Nation — the largest federally recognized tribe in the United States, which has received $63 million so far — said the settlements can’t match the magnitude of the crisis.

“It’ll do a little dent, but it will only go so far,” said Kim Russell, executive director of the Navajo Department of Health.

The Navajo Nation is trying to stretch the money by using it to improve its overall health system. Officials plan to use the payouts to hire more coding and billing employees for tribe-operated hospitals and clinics. Those workers would help ensure reimbursements keep flowing to the health systems and would help sustain and expand services, including addiction treatment and prevention, Russell said.

Navajo leaders also want to hire more clinicians specializing in substance use treatment, as well as primary care doctors, nurses, and epidemiologists.

“Building buildings is not what we want” from the opioid settlement funds, Russell said. “We’re nation-building.”

High Stakes for Small Tribes

Smaller nations like the Poarch Band of Creek Indians in southern Alabama are also strategizing to make settlement money go further.

For the tribe of roughly 2,900 members, that has meant investing $500,000 — most of what it has received so far — into a statistical modeling platform that its creators say will simulate the opioid crisis, predict which programs will save the most lives, and help local officials decide the most effective use of future settlement cash.

Some recovery advocates have questioned the model’s value, but the tribe’s vice chairman, , said it would provide the data and evidence needed to choose among efforts competing for resources, such as recovery housing or peer support specialists. The tribe wants to do both, but realistically, it will have to prioritize.

“If we can have this model and we put the necessary funds to it and have the support, it'll work for us,” McGhee said. “I just feel it in my gut.”

The stakes are high. In smaller communities, each death affects the whole tribe, McGhee said. The loss of one leader marks decades of lost knowledge. The passing of a speaker means further erosion of the Native language.

For Keesha Frye, who oversees the Poarch Band of Creek Indians’ tribal court and the sober living facility, using settlement money effectively is personal. “It means a lot to me to get this community well because this is where I live and this is where my family lives,” she said.

Erik Lamoreau in Maine also brings personal ties to this work. More than a decade ago, he sold drugs on Mi’kmaq lands to support his own addiction.

“I did harm in this community and it was really important for me to come back and try to right some of those wrongs,” Lamoreau said.

Today, he works for the tribe as a peer recovery coordinator, a new role created with the opioid settlement funds. He uses his experience to connect with others and help them with recovery — whether that means giving someone a ride to court, working on their résumé, exercising together at the gym, or hosting a cribbage club, where people play the card game and socialize without alcohol or drugs.

Beginning this month, Lamoreau’s work will also involve connecting clients who seek cultural elements of recovery to the new sweat lodge service — an effort he finds promising.

“The more in tune you are with your culture — no matter what culture that is — it connects you to something bigger,” Lamoreau said. “And that’s really what we look at when we’re in recovery, when we talk about spiritual connection. It’s something bigger than you.”

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The question has never been exactly how Ann Picha-Lillard died on Nov. 19, 2022: She succumbed to respiratory failure after an infection put too much strain on her weakened lungs. She was 65.

For Tim Lillard, the question has been why.

Lillard had been in the hospital with his wife every day for a month. Nurses in the intensive care unit had told him they were short-staffed, and were constantly rushing from one patient to the next.

Lillard tried to pitch in where he could: brushing Ann’s shoulder-length blonde hair or flagging down help when her tracheostomy tube gurgled — a sign of possible respiratory distress.

So the day he walked into the ICU and saw staff members huddled in Ann’s room, he knew it was serious. He called the couple’s adult children: “It’s Mom,” he told them. “Come now.”

All he could do then was sit on Ann’s bed and hold her hand, watching as staff members performed chest compressions, desperately trying to save her life.

A minute ticked by. Then another. Lillard’s not sure how long the CPR continued — long enough for the couple’s son to arrive and take a seat on the other side of Ann’s bed, holding her other hand.

Finally, the intensive care doctor called it and the team stopped CPR. Time of death: 12:37 p.m.

Lillard didn’t know what to do in a world without Ann. They had been married almost 25 years. “We were best friends,” he said.

Just days before her death, nurses had told Lillard that Ann could be discharged to a rehabilitation center as soon as the end of the week. Then, suddenly, she was gone. Lillard didn’t understand what had happened.

Lillard said he now believes that overwhelmed, understaffed nurses hadn’t been able to respond in time as Ann’s condition deteriorated. And he has made it his mission to fight for change, joining some nursing unions in a push for mandatory ratios that would limit the number of patients in a nurse’s care. “I without a doubt believe 100% Ann would still be here today if they had staffing levels, mandatory staffing levels, especially in ICU,” Lillard said.

Last year, Oregon became the second state after California to pass hospital-wide nurse ratios that limit the number of patients in a nurse’s care. Michigan, Maine, and Pennsylvania are now weighing similar legislation.

But supporters of mandatory ratios are going up against a powerful hospital industry to kill those efforts. And hospitals and health systems say any staffing ratio regulations, however well-intentioned, would only put patients in greater danger.

Putting Patients at Risk

By next year, the United States could have as many as 450,000 fewer nurses than it needs, according to . The hospital industry , an aging workforce, a large patient population, and an insufficient pipeline of new nurses entering the field.

But nursing unions say that’s not the full story. There are now in the country, more than ever before.

The problem, the unions say, is a hospital industry that’s been intentionally understaffing their units for years in order to cut costs and bolster profits. The unions say there isn’t a shortage of nurses but a shortage of nurses willing to work in those conditions.

The nurse staffing crisis is now affecting patient care. The number of Michigan nurses who say they know of a patient who has has nearly doubled in recent years, according to a Michigan Nurses Association survey last year.

Just months before Ann Picha-Lillard’s death, nurses and doctors at the health system where she died had asked the Michigan attorney general to investigate staffing cuts they believed were , including patient deaths, according to The Detroit News.

But Lillard didn’t know any of that when he drove his wife to the hospital in October 2022. She had been feeling short of breath for a few weeks after she and Lillard had mild covid infections. They were both vaccinated, but Ann was immunocompromised. She suffered from rheumatoid arthritis, a condition that had also caused scarring in her lungs.

To be safe, doctors at wanted to keep Ann for observation. After a few days in the facility, she developed pneumonia. Doctors told the couple that Ann needed to be intubated. Ann was terrified but Lillard begged her to listen to the doctors. Tearfully, she agreed.

With Ann on a ventilator in the ICU, it seemed clear to Lillard that nurses were understaffed and overwhelmed. One nurse told him they had been especially short-staffed lately, Lillard said.

“The alarms would go off for the medications, they’d come into the room, shut off the alarm when they get low, run to the medication room, come back, set them down, go to the next room, shut off alarms,” Lillard recalled. “And that was going on all the time.”

Lillard felt bad for the nurses, he said. “But obviously, also for my wife. That’s why I tried doing as much as I could when I was there. I would comb her hair, clean her, just keep an eye on things. But I had no idea what was really going on.”

Finally, Ann’s health seemed to be stabilizing. A nurse told Lillard they’d be able to discharge Ann, possibly by the end of that week.

By Nov. 17, Ann was no longer sedated and she cried when she saw Lillard and her daughter. Still unable to speak, she tried to mouth words to her husband “but we couldn’t understand what she was saying,” Lillard said.

The next day, Lillard went home feeling hopeful, counting down the days until Ann could leave the hospital.

Less than 24 hours later, Ann died.

Lillard couldn’t wrap his head around how things went downhill so fast. Ann’s underlying lung condition, the infection, and her weakened state could have proved fatal in the best of circumstances. But Lillard wanted to understand how Ann had gone from nearly discharged to dying, seemingly overnight.

He turned his dining room table into a makeshift office and started with what he knew. The day Ann died, he remembered her medical team telling him that her heart rate had spiked and she had developed another infection the night before. Lillard said he interviewed two DMC Huron Valley-Sinai nurse administrators, and had his own doctor look through Ann’s charts and test results from the hospital. “Everybody kept telling me: sepsis, sepsis, sepsis,” he said.

Sepsis is when an infection triggers an extreme reaction in the body that can cause rapid organ failure. It’s one of the in U.S. hospitals. Some experts say are preventable, while others say is far lower.

when sepsis is fast, which requires careful attention to small changes in vital signs. One study found that for every additional patient a nurse had to care for, the mortality rate from sepsis .

Lillard became convinced that had there been more nurses working in the ICU, someone could have caught what was happening to Ann.

“They just didn’t have the time,” he said.

DMC Huron Valley-Sinai’s director of communications and media relations, Brian Taylor, declined a request for comment about the 2022 staffing complaint to the Michigan attorney general.

Following the Money

When Lillard asked the hospital for copies of Ann’s medical records, DMC Huron Valley-Sinai told him he’d have to request them from its .

Like so many hospitals in recent years, the Lillards’ local health system had been absorbed by a series of other corporations. In 2011, the Detroit Medical Center health system was , which was backed by the private equity company Blackstone Group.

Two years after that, in 2013, Vanguard itself was , a for-profit company based in Dallas that, , operates 480 ambulatory surgery centers and surgical hospitals, 52 hospitals, and approximately 160 additional outpatient centers.

As health care executives face increasing pressure from investors, nursing unions say hospitals have been intentionally to and . Also, insurance reimbursements incentivize keeping nurse staffing levels low. “Hospitals are not directly reimbursed for nursing services in the same way that a physician bills for their services,” said , an associate professor of nursing in the at the University of Pennsylvania. “And because hospitals don’t perceive nursing as a service line, but rather a cost center, they think about nursing as: How can we reduce this to the lowest denominator possible?” she said.

Lasater is a proponent of mandatory nurse ratios. “The nursing shortage is not a pipeline problem, but a leaky bucket problem,” she said. “And the solutions to this crisis need to address the root cause of the issue, which is why nurses are saying they’re leaving employment. And it’s rooted in unsafe staffing. It’s not safe for the patients, but it’s also not safe for nurses.”

A Battle Between Hospitals and Unions

In November, almost one year after Ann’s death, Lillard told a room of lawmakers at the Michigan State Capitol that he believes the could save lives. The health policy committee in the Michigan House was holding a hearing on the proposed act, which would limit the amount of mandatory overtime a nurse can be forced to work, and require hospitals to make their staffing levels available to the public.

Most significantly, the bills would require hospitals to have mandatory, minimum nurse-to-patient ratios. For example: one nurse for every patient in the ICU; one for every three patients in the emergency room; a nurse for triage; and one nurse for every four postpartum birthing patients and well-baby care.

Efforts to pass mandatory ratio laws failed in last year after facing opposition from the hospital industry. In Minnesota, the Minnesota Nurses Association accused the Mayo Clinic of using “”: Mayo had told lawmakers it would in investment from the state if mandatory ratio legislation passed. Soon afterward, lawmakers from the legislation.

While Lillard waited for his turn to speak to Michigan lawmakers about the Safe Patient Care Act in November, members of the , which says it represents some , told lawmakers that its units were dangerously understaffed. They said critical care nurses were sometimes caring for up to 11 patients at a time.

“Last year I coded someone in an ICU for 10 minutes, all alone, because there was no one to help me,” said the nurses association president and registered nurse , reading from another nurse’s letter.

“I have been left as the only specially trained nurse to take care of eight babies on the unit: eight fragile newborns,” said , a registered nurse from the Grand Blanc area of Michigan.

said she has left full-time emergency room nursing, a job she believes is her calling. After her friend died in the hospital where she worked, she was left wondering whether understaffing may have contributed to his death.

“If the Safe Patient Care Act passed, and we have ratios, I’m one of those nurses who would return to the bedside full time,” Parker told lawmakers. “And so many of my co-workers who have left would join me.”

But not all nurses agree that mandatory ratios are a good idea. 

While the supports enforceable ratios as an “essential approach,” that organization’s does not, saying there may not be enough nurses in the state to satisfy the requirements of the Safe Patient Care Act.

For some lawmakers, the risk of collateral damage seems too high. State Rep. said he worries that mandating ratios could backfire.

“We’re going to severely hamper health care in the state of Michigan. I’m talking closed wards because you can’t meet the ratio in a bill. The inability for a hospital to treat an emergent patient. So it feels kind of to me like a gamble we’re taking,” said Filler, a Republican.

Michigan hospitals are already struggling to fill some , according to the . That association says that complying with the Safe Patient Care Act would require hiring .

Every major health system in the state opposing mandatory ratios, saying it would force them to close as many as .

Lillard watched the debate play out in the hearing. “That’s a scare tactic, in my opinion, where the hospitals say we’re going to have to start closing stuff down,” he said.

He doesn’t think legislation on mandatory ratios — which are still awaiting a vote in the Michigan House’s health policy committee — are a “magic bullet” for such a complex, national problem. But he believes they could help.

“The only way these hospitals and the administrations are gonna make any changes, and even start moving towards making it better, is if they’re forced to,” Lillard said.

Seated in the center of the hearing room in Lansing, next to a framed photo of Ann, Lillard’s hands shook as he recounted those final minutes in the ICU.

“Please take action so that no other person or other family endures this loss,” he said. “You can make a difference in saving lives.”

Grief is one thing, Lillard said, but it’s another thing to be haunted by doubts, to worry that your loved one’s care was compromised before they ever walked through the hospital doors. What he wants most, he said, is to prevent any other family from having to wonder, “What if?”

This article is from a partnership that includes ,, and Ä¢¹½Ó°Ôº Health News.

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Another woman in California, desperate for relief, used a screwdriver to lengthen her jawbone daily, turning screws that protruded from her neck.

A third in New York had bone from her rib and fat from her belly grafted into her jaw joint, and twice a prosthetic eyeball was surgically inserted into the joint as a placeholder in the months it took to make metal hinges to implant into her jaw.

“I feel like Mr. Potato Head,” said Jenny Feldman, 50, of New York City, whose medical records show she’s had at least 24 TMJ-related surgeries since she was a teenager. “They’re moving ribs into my face, and eyeballs, and I feel like a toy … put together [by] somebody just tinkering around.”

These are some of the horrors of temporomandibular joint disorders, known as TMJ or TMD, which afflict up to 33 million Americans, according to the National Institutes of Health. Dentists have attempted to heal TMJ patients for close to a century, and yet the disorders remain misunderstood, under-researched, and ineffectively treated, according to an investigation by Ä¢¹½Ó°Ôº Health News and CBS News.

Dental care for TMJ can do patients more harm than good, and a few fall into a spiral of futile surgeries that may culminate in their jaw joints being replaced with metal hinges, according to medical and dental experts, patients, and their advocates speaking in interviews and video testimony submitted to the FDA.

TMJ disorders cause pain and stiffness in the jaw and face that can range from discomfort to disabling, with severe symptoms far more common in women. Dentists have commonly treated the disorder with splints and orthodontics. And yet these treatments are based on “strongly held beliefs” and “inadequate research” — not compelling scientific evidence nor consistent results — according to the National Academies of Sciences, Engineering, and Medicine, which reviewed decades of research on the topic. The NIH echoes this message, warning that there is “” that splints reduce pain and recommends “staying away” from any treatment that permanently changes the teeth, bite, or jaw.

“I would say that the treatments overall have not been effective, and I can understand why,” said Rena D’Souza, director of the NIH’s National Institute of Dental and Craniofacial Research. “We don’t understand the disease.”

For this investigation, journalists with Ä¢¹½Ó°Ôº Health News and CBS News interviewed 10 TMJ patients with severe symptoms who said they felt trapped by an escalating series of treatments that began with splints or dental work and grew into multiple surgeries with diminishing returns and dwindling hope.

In every interview, the patients said the TMJ pain worsened throughout their treatment and they regretted some, if not all, of the care they received.

“The grand irony to me is that I went to the doctor for headaches and neck pain, and I’ve had 13 surgeries on my face and jaw, and I still have even worse neck pain,” said Tricia Kalinowski, 63, of Old Orchard Beach, Maine. “And I live with headaches and jaw pain every day.”

TMJ has become an umbrella term for about 30 disorders that afflict roughly 5% to 10% of Americans. Minor symptoms may not require treatment at all, and many cases resolve by themselves over time. Severe symptoms include chronic pain and may limit the ability to eat, sleep, or talk.

In a by the national academies, including input from more than 110 patients, experts found that most health care professionals, including dentists, have received “” on TMJ disorders and patients are “often harmed” by “overly aggressive” care and the lack of proven treatments.

Almost 100 years this has been in dentistry, and look at what we have… A whole ton of people pretending they know everything, and we don’t know anything.

Terrie Cowley, TMJ patient

The , which represents about 160,000 dentists nationwide and establishes guidelines for the profession, declined an interview request. In a written statement, ADA President Linda Edgar said that TMJ disorders are “often managed rather than cured” and that it sees “great potential” in new efforts to research more treatment options.

Terrie Cowley, a longtime TMJ patient who leads the TMJ Association, an advocacy group that has spoken with tens of thousands of patients, said she was so disillusioned with dental care for TMJ that she advises many patients to avoid treatment entirely, potentially for years.

“Almost 100 years this has been in dentistry, and look at what we have,” Cowley said. “A whole ton of people pretending they know everything, and we don’t know anything.”

‘Not Taken Seriously’

Scientific studies have found that TMJ disorders arise , particularly those in their 20s and 30s, leading to theories that the cause may be linked to reproductive hormones. But a true understanding of TMJ disorders remains elusive.

Kyriacos Athanasiou, a biomedical engineering professor at the University of California-Irvine, said it was because TMJ disorders are more prevalent among women that they were historically dismissed as neither serious nor complex, slowing research into the cause and treatment.

The resulting dearth of knowledge, which is glaring when compared with other joints, has been “a huge disservice” to patients, Athanasiou said. In a 2021 study he co-authored, researchers found that the knee, despite being a much simpler joint, was the subject of about six times as many research papers and grants in a single year than the jaw joint.

D’Souza agreed that TMJ disorders were “not taken seriously” for decades, along with other conditions that predominantly affect women.

“That has been a bias that is really long-standing,” she said. “And it’s certainly affected the progress of research.”

Patients have felt the effect too. In interviews, female patients said they felt patronized or trivialized by male health care providers at some point in their TMJ treatment, if not throughout. Some said they felt blamed for their own pain because they were viewed as too stressed and clenching their jaw too much.

“We desperately need research to find the reasons why more women get TMJ disease,” wrote Lisa Schmidt, a TMJ Association board member, in . “And surgeons need to stop blaming this condition on women.”

Every time you have a surgery, your pain gets worse… If I could go back in time and go talk to younger Lisa, I would say ‘Run!’

Lisa Schmidt, TMJ patient

Schmidt, 52, of Poway, California, said she was diagnosed with TMJ disorder in 2000 due to headaches, and an orthodontist immediately recommended her for a splint, braces, and surgery.

After wearing the splint for only three days, Schmidt said, she was in “excruciating pain” and could no longer open her mouth far enough to eat solid food. Schmidt said she spent the next 17 years stuck on a “surgery carousel” with no escape, and eventually was in so much pain she abandoned her career as an aerospace scientist who worked alongside NASA astronauts.

Schmidt said her low point came in 2016. In an attempt to restore bone that had been cut away in prior surgeries, a surgeon implanted long screws into Schmidt’s jaw that protruded downward out of her neck. Schmidt said she was instructed to tighten those screws with a screwdriver daily for about 20 days, lengthening the corners of her jaw to restore the bone that had been lost. It didn’t work, Schmidt said, and she was left in more pain than ever.

“Every time you have a surgery, your pain gets worse,” Schmidt said. “If I could go back in time and go talk to younger Lisa, I would say ‘Run!’”

Lack of Sufficient Evidence

Many of the shortcomings of TMJ care were laid bare in the published by the national academies in March 2020 that received limited public attention amid the coronavirus pandemic. The report’s 18 authors include medical and dental experts from Harvard, Duke, Clemson, Michigan State, and Johns Hopkins universities.

Sean Mackey, a Stanford professor who co-led the team, said it found that patients were often steered toward costly treatments and “pathways of futility” instead of being taught to manage their pain through strategies and therapies with “good evidence.”

“We learned it’s a quagmire,” Mackey said. “There is a perverse incentive in our society that pays more for things we do to people than [for] talking and listening to people. … Some of those procedures, some of those surgeries, clearly are not helping people.”

Among its many findings, the national academies said it has been widely assumed in the field of dentistry that TMJ disorders are caused by a misaligned bite, so treatments have focused on patients’ teeth and bite for more than 50 years. But there is a “” that a misaligned bite is a cause of TMJ disorders, and the belief traces back to “inadequate research” in the 1960s that has been repeated in “poorly-designed studies” ever since, the report states.

Therefore, TMJ treatment that makes permanent changes to the bite — like installing braces or crowns or grinding teeth down — has “no supporting evidence,” according to the national academies report. The that these TMJ treatments “don’t work and may make the problem worse.”

Dental splints, the most common TMJ treatment, also known as night guards or mouth guards, are removable dental appliances that are molded to fit over the teeth and can cost hundreds or even thousands of dollars out-of-pocket, according to the TMJ Association. Like most medical devices, splints generally go through the FDA’s 510(k) clearance process, which does not require each splint to be proven effective before it can be sold, according to the agency.

The national academies’ report states that splints produce “mixed results” for TMJ patients, and even when splints succeed at reducing jaw pain it is not understood why they work. Hundreds of splint designs exist, the report states, and some dentists reject research that challenges the use of splints unless it focuses on the specific design they prefer.

“Because of the hundreds of variations in [splint] design, it is unlikely that any study could ever be conducted that will be considered sufficient to a particular dentist with a pre-existing belief about the effectiveness of one appliance,” the report states.

Other treatments fare no better. The FDA has not labeled any drugs specifically for TMJ disorders, and to be a long-term solution, according to the TMJ Association. Botox injections may ease pain but have during animal testing. The NIH warns that minor surgeries that flush the jaw with liquid bring only temporary pain relief and that more complex surgeries should be reserved for severe cases because they have yet to be proved safe or effective in the long term.

To improve care, the national academies called for better education about TMJ disorders across medicine and dentistry and more research funding from the NIH, which has a “ripple effect” on research and training across the nation.

Since the 2020 report, the NIH has launched a and increased annual research funding from about $15 million to about $34 million, D’Souza said. TMJ care was added to must teach to be accredited in 2022. The national academies launched an last year.

But TMJ funding still pales in comparison to other ailments. The NIH spends billions each year to research deadly diseases, like cancer and heart disease, that also afflict large numbers of Americans. It spends millions more on research of non-life-threatening conditions like arthritis, back pain, eczema, and headaches.

Mackey noted that much of the NIH’s spending is allocated by Congress.

“If Congress comes in and says, ‘We want to devote X amount of money to [TMJ],’ all of the sudden you will see an increase in money,” Mackey said. “So that’s my message to people out there: Raise your voices. Write your legislator.”

Total Jaw Replacements

Plagued by TMJ symptoms, and after failed treatments, some patients turn to a last resort: replacing their jaw joint with synthetic implants. Surgeons might replace the cartilage disk at the core of the joint or use “total joint replacement surgery” to fasten a metal hinge to the bones of the skull.

But the implants have a harrowing history: Several disk implants were recalled or discontinued in the ’90s due to dangerous failures. The FDA now classifies TMJ implants among its because the products on the market today can cause “adverse health consequences” if the devices fail, according to the agency’s website.

Two companies, Zimmer Biomet and Stryker, make the only total jaw replacement implants currently sold in the U.S.

Zimmer Biomet, which has made its implant for more than two decades, described it in email statements as “a safe and efficacious solution” for patients who need their jaw joint replaced, either due to TMJ disorders, failed surgeries, injuries, or other ailments. An FDA-mandated study completed in 2017 found about 14% of patients who get the Zimmer Biomet implant require additional surgery or removal within 10 years, said agency spokesperson Carly Pflaum.

Stryker, which in 2021 bought a company that made a total jaw replacement implant and now makes the implant itself, declined to comment. Although the NIH has advised TMJ patients to avoid surgery since at least 2022, Stryker launched a “” for the implant last year and is recruiting surgeons to be added to a “surgeon locator” feature on the site, according to posts on Facebook and .

A study of the Stryker implant’s success rate was mandated by the FDA and completed in 2020, but the agency has yet to make the results public.

D’Souza, the NIH official, said that based on her professional experience, she estimates that most total jaw replacement surgeries are ultimately ineffective.

“The success rate is low,” D’Souza said. “It is not very encouraging.”

Multiple patients provided Ä¢¹½Ó°Ôº Health News and CBS News with medical records showing their total jaw replacement implants had to be removed due to malfunction, infection, or previously unknown metal allergies. Several patients said that since their implants were removed months or years ago, they have lived with no hinge in their jaw at all.

Kalinowski, the TMJ patient in Maine, has had portions of her jaw joint replaced six times, including receiving four implants. Her medical records show that the cartilage disk on her right side was replaced in 1986 with an implant that was later recalled and again in 1987 with another that was later discontinued. Her left and right disks were replaced in 1992 with a muscle flap and rib graft, respectively, and her entire right joint was replaced with yet another implant that was later discontinued in 1998. Both joints were replaced again in 2015, her records show.

Since then, Kalinowski said, her artificial jaw has functioned properly, although she remains in pain and cannot move her jaw from side to side. Her mouth hangs open when her face is at rest, and she drinks protein shakes for lunch because it’s easier than struggling with solid food.

But the “worst part,” Kalinowski said, is that her surgeries caused nerve damage on her lower face, and so she has not felt her husband’s kisses since the ’90s.

“If there was one moment in my life I could take back and do over again, it would be that first surgery. Because it set me on a trajectory,” Kalinowski said. “And it never goes away.”

CBS News producer Nicole Keller contributed to this article.

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“I listened to the insurance agent and, basically, he really promoted Medicare Advantage,” Timmins said. The agent described less expensive and broader coverage offered by the plans, which are funded largely by the government but administered by private insurance companies.

For Timmins, who is now 76, it made economic sense then to sign up. And his decision was great, for a while.

Then, three years ago, he noticed a lesion on his right earlobe.

“I have a family history of melanoma. And so, I was kind of tuned in to that and thinking about that,” Timmins said of the growth, which doctors later diagnosed as malignant melanoma. “It started to grow and started to become rather painful.”

Timmins, though, discovered that his enrollment in a Premera Blue Cross Medicare Advantage plan would mean a limited network of doctors and the potential need for preapproval, or prior authorization, from the insurer before getting care. The experience, he said, made getting care more difficult, and now he wants to switch back to traditional, government-administered Medicare.

But he can’t. And he’s not alone.

“I have very little control over my actual medical care,” he said, adding that he now advises friends not to sign up for the private plans. “I think that people are not understanding what Medicare Advantage is all about.”

Enrollment in Medicare Advantage plans has grown substantially in the past few decades, enticing more than half of all eligible people, primarily those 65 or older, with low premium costs and perks like dental and vision insurance. And as the private plans’ share of the Medicare patient pie has ballooned to 30.8 million people, so too have concerns about the insurers’ aggressive sales tactics and misleading coverage claims.

Enrollees, like Timmins, who sign on when they are healthy can find themselves trapped as they grow older and sicker.

“It’s one of those things that people might like them on the front end because of their low to zero premiums and if they are getting a couple of these extra benefits — the vision, dental, that kind of thing,” said Christine Huberty, a lead benefit specialist supervising attorney for the Greater Wisconsin Agency on Aging Resources.

“But it’s when they actually need to use it for these bigger issues,” Huberty said, “that’s when people realize, ‘Oh no, this isn’t going to help me at all.’”

Medicare pays private insurers a fixed amount per Medicare Advantage enrollee and in many cases also pays out bonuses, which the insurers can use to provide supplemental benefits. Huberty said those extra benefits work as an incentive to “get people to join the plan” but that the plans then “restrict the access to so many services and coverage for the bigger stuff.”

David Meyers, assistant professor of health services, policy, and practice at the Brown University School of Public Health, analyzed a decade of Medicare Advantage enrollment and found that — rural and urban — left their contract by the end of five years. Most of those enrollees switched to another Medicare Advantage plan rather than traditional Medicare.

In the study, Meyers and his co-authors muse that switching plans could be a positive sign of a free marketplace but that it could also signal “unmeasured discontent” with Medicare Advantage.

“The problem is that once you get into Medicare Advantage, if you have a couple of chronic conditions and you want to leave Medicare Advantage, even if Medicare Advantage isn’t meeting your needs, you might not have any ability to switch back to traditional Medicare,” Meyers said.

Traditional Medicare can be too expensive for beneficiaries switching back from Medicare Advantage, he said. In traditional Medicare, enrollees pay a monthly premium and, after reaching a deductible, in most cases are expected to pay 20% of the cost of each nonhospital service or item they use. And there is no limit on how much an enrollee may have to pay as part of that 20% coinsurance if they end up using a lot of care, Meyers said.

To limit what they spend out-of-pocket, traditional Medicare enrollees typically sign up for supplemental insurance, such as employer coverage or a private Medigap policy. If they are low-income, Medicaid may provide that supplemental coverage.

But, Meyers said, there’s a catch: While beneficiaries who enrolled first in traditional Medicare are guaranteed to qualify for a Medigap policy without pricing based on their medical history, Medigap insurers can deny coverage to beneficiaries transferring from Medicare Advantage plans or base their prices on medical underwriting.

Only four states — Connecticut, Maine, Massachusetts, and New York — prohibit insurers from denying a Medigap policy if the enrollee has preexisting conditions such as diabetes or heart disease.

Paul Ginsburg is a former commissioner on the Medicare Payment Advisory Commission, also known as MedPAC. It’s a legislative branch agency that advises Congress on the Medicare program. He said the inability of enrollees to easily switch between Medicare Advantage and traditional Medicare during open enrollment periods is “a real concern in our system; it shouldn’t be that way.”

The federal government offers specific enrollment periods every year for switching plans. During Medicare’s open enrollment period, from Oct. 15 to Dec. 7, enrollees can switch out of their private plans to traditional, government-administered Medicare.

Medicare Advantage enrollees can also switch plans or transfer to traditional Medicare during another open enrollment period, from .

“There are a lot of people that say, ‘Hey, I’d love to come back, but I can’t get Medigap anymore, or I’ll have to just pay a lot more,’” said Ginsburg, who is now a professor of health policy at the University of Southern California.

Timmins is one of those people. The retired veterinarian lives in a rural community on Whidbey Island just north of Seattle. It’s a rugged, idyllic landscape and a popular place for second homes, hiking, and the arts. But it’s also a bit remote.

While it’s typically harder to find doctors in rural areas, Timmins said he believes his Premera Blue Cross plan made it more challenging to get care for a variety of reasons, including the difficulty of finding and getting in to see specialists.

Nearly half of Medicare Advantage plan directories contained inaccurate information on what providers were available, according to the . Beginning in 2024, new or expanding Medicare Advantage plans with federal network expectations or their applications could be denied.

Amanda Lansford, a Premera Blue Cross spokesperson, declined to comment on Timmins’ case. She said the plan meets federal network adequacy requirements as well as travel time and distance standards “to ensure members are not experiencing undue burdens when seeking care.”

Traditional Medicare allows beneficiaries to go to in the U.S., and in most cases enrollees do not need approval to get services.

Timmins, who recently finished immunotherapy, said he doesn’t think he would be approved for a Medigap policy, “because of my health issue.” And if he were to get into one, Timmins said, it would likely be too expensive.

For now, Timmins said, he is staying with his Medicare Advantage plan.

“I’m getting older. More stuff is going to happen.”

There is also a chance, Timmins said, that his cancer could resurface: “I’m very aware of my mortality.”

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Once estados y Washington, DC, ofrecen cobertura completa de salud a más de un millón de inmigrantes de bajos ingresos, independientemente de su estatus migratorio, según datos estatales recopilados por Ä¢¹½Ó°Ôº Health News. La mayoría son indocumentados, según funcionarios estatales.

La inscripción en estos programas podría llegar a duplicarse para 2025, ya que al menos siete estados están iniciando o ampliando la cobertura. En enero, Utah, controlado por los republicanos, comenzará a cubrir a los niños independientemente de su estatus migratorio. Nueva York y California ampliarán la elegibilidad para cubrir a más adultos.

“Estos son niños, y tenemos corazón”, dijo el republicano Jim Dunnigan, representante estatal de Utah, que al principio se oponía al plan de cubrir a niños indocumentados, pero cedió después de compromisos, incluyendo un límite en la inscripción.

Según estimaciones del Pew Research Center, hay más de 10 millones de personas viviendo en el país sin papeles.

Defensores de inmigrantes y académicos señalan dos factores que aumentaron el interés de líderes estatales en proporcionar atención médica a esta población: la pandemia destacó la importancia de la cobertura de salud para controlar la propagación de enfermedades infecciosas, y algunos estados se centran en personas sin estatus legal para reducir aún más la tasa récord de personas sin seguro en el país.

Según legisladores, los estados también han ampliado la cobertura en respuesta a las súplicas de los hospitales para reducir la carga financiera del tratamiento de pacientes sin seguro.

Todos los estados pagan a los hospitales por brindar servicios de emergencia a algunos residentes sin papeles, un programa conocido como Medicaid de Emergencia. Alrededor de una docena de estados han extendido la cobertura solo para cuidado prenatal para este grupo. La cobertura completa proporcionada por el estado es mucho menos común, pero está aumentando.

Según una encuesta de Ä¢¹½Ó°Ôº-Los Angeles Times, se estima que la mitad de las personas que viven en el país sin un estatus legal , más de cinco veces la tasa de personas sin cobertura entre los ciudadanos estadounidenses.

Los inmigrantes sin papeles no son elegibles para los programas federales de salud, pero los estados pueden usar su propio dinero para proporcionar cobertura a través de Medicaid, el programa de seguro estatal-federal para personas con bajos ingresos.

California fue el primer estado en comenzar a cubrir a inmigrantes sin considerar su estatus legal, comenzando con niños en 2016.

“Esto es un verdadero reflejo del conflicto que tenemos en el país y de cómo los estados se dan cuenta de que no podemos ignorar a las comunidades de inmigrantes simplemente por su estatus migratorio”, dijo Adriana Cadena, directora del grupo de defensa Protecting Immigrant Families.

Muchas de las millones de personas sin residencia permanente han estado en los Estados Unidos durante décadas y no tienen un camino hacia la ciudadanía, agregó.

Estas ampliaciones estatales de la cobertura se producen en medio de una creciente hostilidad hacia los migrantes entre los republicanos.

La Patrulla Fronteriza detuvo a casi 1.5 millones de personas en el año fiscal 2023 después de cruzar la frontera con México, una cifra récord. Los candidatos presidenciales republicanos han retratado la frontera como una crisis bajo Biden, y a los peligros de la inmigración ilegal, entre ellos el supuesto aumento de la criminalidad, como la principal preocupación nacional.

Simon Hankinson, investigador especializado en temas de inmigración en la conservadora Heritage Foundation, dijo que los estados lamentarán expandir la cobertura a inmigrantes indocumentados por al costo. Puso como ejemplo a Illinois, que recientemente puso una pausa en la inscripción en su programa debido a preocupaciones financieras.

“Necesitamos compartir recursos con personas que contribuyen a la sociedad y no permitir que las personas obtengan beneficios para las que no han contribuido, ya que no veo cómo las matemáticas funcionarían a largo plazo”, dijo Hankinson. “De lo contrario, estarías creando un incentivo para que las personas vengan y obtengan cosas gratis”.

La mayoría de los adultos sin papeles trabajan, representan aproximadamente , según el Pew Research Center. California es el estado con más indocumentados con seguro médico estatal, que actualmente cubre a unos 655,000 inmigrantes sin tener en cuenta su estatus migratorio. En enero, ampliará la cobertura a personas de 26 a 49 años, en este grupo, beneficiando a unos 700,000 californianos adicionales.

Connecticut, Maine, Massachusetts, Nueva York, Rhode Island, Vermont, Washington, DC, y el estado de Washington también ofrecen cobertura completa a algunas personas que viven en el país sin documentos. Nueva York y el estado de Washington ampliarán la elegibilidad el próximo año.

Oregon, Colorado y Nueva Jersey comenzaron a cubrir a más de 100,000 personas en total en los últimos años, independientemente de su estatus legal. Minnesota seguirá en 2025, cubriendo a unas 40,000.

Aunque algunos estados están expandiendo la cobertura de salud, están imponiendo límites en la inscripción para controlar el gasto.

El costo del programa de Utah tiene un tope de $4.5 millones al año, limitando la inscripción a alrededor de 2,000 niños. Las primas variarán según los ingresos, pero no costarán más de $300 al año, con servicios preventivos cubiertos por completo.

“La pandemia destacó la necesidad de tener cobertura para todos”, dijo Ciriac Alvarez Valle, analista de políticas senior de Voices for Utah Children, un grupo de defensa. “Tendrá un gran impacto en la vida de estos niños”.

Sin cobertura, muchos niños usan las salas de emergencia para atención primaria y las familias no pueden pagar medicamentos, especialistas o internaciones, dijo. “No estoy segura de si esto abrirá la puerta para que los adultos tengan cobertura, pero es un buen paso adelante”, agregó Alvarez Valle.

Colorado también limita la inscripción para la cobertura subsidiada en su programa, estableciendo un límite de 10,000 personas en 2023, y 11,000 en 2024. Los espacios disponibles para 2024 se llenaron en dos días desde el inicio de la inscripción en noviembre.

Adriana Miranda pudo obtener cobertura los dos años.

“Te sientes mucho más tranquila sabiendo que no le debes tanto a los hospitales”, dijo Miranda, de 46 años, que está inscrita en un plan privado a través de OmniSalud, un programa estatal similar al mercado de seguros del Obamacare en el que los residentes de bajos ingresos de Colorado sin residencia legal pueden buscar planes con primas con descuento.

Miranda dejó México en 1999 para seguir a sus dos hermanos a Estados Unidos. Ahora trabaja en Lamar Unidos, una organización sin fines de lucro que trabaja por los derechos de los inmigrantes.

Antes de tener seguro médico, luchaba para pagar por la atención de su diabetes y acumuló miles de dólares en deudas después de una cirugía de pie, contó. Bajo el programa estatal, no paga una prima mensual debido a sus bajos ingresos, con un copago de $40 para visitas a especialistas.

“Estaba realmente feliz, ¿verdad? Porque pude obtenerlo. Pero sé que muchas personas que también tienen muchas necesidades no lo obtuvieron”, dijo. OmniSalud cubre solo a una pequeña fracción de las más de 200,000 personas que viven en Colorado sin papeles, dijo Adam Fox, subdirector de la Iniciativa de Salud del Consumidor de Colorado.

Pero a partir de 2025, todos los niños en familias de bajos ingresos podrán estar cubiertos por el Medicaid estatal o el Programa de Seguro de Salud Infantil (CHIP), independientemente de su estatus migratorio.

“Hay un reconocimiento creciente de que las personas, más allá de su estatus migratorio, son parte de la comunidad y deben tener acceso a atención médica de manera regular y confiable”, dijo Fox. “Si no lo hacen, agrega costos y trauma a los sistemas de salud y a las comunidades”.

Zach Dyer, productor de audio senior de Ä¢¹½Ó°Ôº Health News, colaboró con este informe.

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Eleven states and Washington, D.C., together provide full health insurance coverage to more than 1 million low-income immigrants regardless of their legal status, according to state data compiled by Ä¢¹½Ó°Ôº Health News. Most aren’t authorized to live in the U.S., state officials say.

Enrollment in these programs could nearly double by 2025 as at least seven states initiate or expand coverage. In January, Republican-controlled Utah will start covering children regardless of immigration status, while New York and California will widen eligibility to cover more adults.

“These are kids, and we have a heart,” said Utah state Rep. Jim Dunnigan, a Republican who initially opposed his state’s plan to cover children lacking legal status but relented after compromises including a cap on enrollment.

There are more than 10 million people living in the U.S. without authorization, according to estimates by the Pew Research Center. Immigrant advocates and academic experts point to two factors behind state leaders’ rising interest in providing health care to this population: The pandemic highlighted the importance of insurance coverage to control the spread of infectious diseases; and some states are focusing on people without legal status to further drive down the country’s record-low uninsured rate.

States have also expanded coverage in response to pleas from hospitals, lawmakers say, to reduce the financial burden of treating uninsured patients.

All states pay hospitals to provide emergency services to some unauthorized residents in emergency rooms, a program known as Emergency Medicaid. About a dozen states have extended coverage for only prenatal care for such people. Full state-provided health insurance coverage is much less common, but increasing.

An estimated living in the U.S. without authorization are uninsured, according to a Ä¢¹½Ó°Ôº-Los Angeles Times survey. That’s more than five times the uninsured rate for U.S. citizens. Immigrants lacking authorization are ineligible for federal health programs. But states can use their own money to provide coverage through Medicaid, the state-federal insurance program for low-income people.

California was the first state to begin covering immigrants regardless of their legal status, starting with children in 2016.

“This is a real reflection of the conflict we have in the country and how states are realizing we cannot ignore immigrant communities simply because of their immigration status,” said Adriana Cadena, director of the advocacy group Protecting Immigrant Families. Many of the millions of people without permanent legal residency have been in the United States for decades and have no path to citizenship, she said.

These state extensions of health coverage come against a backdrop of rising hostility toward migrants among Republicans. The U.S. Border Patrol apprehended nearly 1.5 million people in fiscal year 2023 after they crossed the southern border, a record. GOP presidential candidates have portrayed the border as in crisis under Biden, and dangers of illegal immigration, like increasing crime, as the nation’s top domestic concern.

Simon Hankinson, a senior research fellow specializing in immigration issues with the conservative Heritage Foundation, said states would regret expanding coverage to immigrants lacking permanent legal residency because of the cost. Illinois, he noted, recently paused enrollment in its program over financial concerns.

“We need to share resources with people who contribute to society and not have people take benefits for those who have not contributed, as I don’t see how the math would work in the long run,” Hankinson said. “Otherwise, you create an incentive for people to come and get free stuff.”

Most adults lacking authorization work, of the U.S. labor force, according to the Pew Research Center. The state with the most unauthorized residents with state-provided health insurance is California, which currently covers about 655,000 immigrants without regard for their legal status. In January, it will expand coverage to people ages 26-49 regardless of their immigration status, benefiting an estimated 700,000 additional Californians.

Connecticut, Maine, Massachusetts, New York, Rhode Island, Vermont, Washington, D.C., and Washington state also provide full coverage to some people living in the U.S. without authorization. New York and Washington state are expanding eligibility next year.

Oregon, Colorado, and New Jersey in recent years began covering more than 100,000 people in total regardless of legal status. Minnesota will follow in 2025, covering an estimated 40,000 people.

While states are expanding coverage to people living in the U.S. potentially without authorization, some are imposing enrollment limits to control spending.

The cost of Utah’s program is capped at $4.5 million a year, limiting enrollment to about 2,000 children. Premiums will vary based on income but cost no more than $300 a year, with preventive services covered in full.

“The pandemic highlighted the need to have coverage for everybody,” said Ciriac Alvarez Valle, senior policy analyst for Voices for Utah Children, an advocacy group. “It will make a huge impact on the lives of these kids.”

Without coverage, many children use emergency rooms for primary care and have little ability to afford drugs, specialists, or hospital care, she said. “I am not sure if this will open the door to adults having coverage, but it is a good step forward,” Alvarez Valle said.

Colorado also limits enrollment for subsidized coverage in its program, capping it at 10,000 people in 2023 and 11,000 in 2024. The 2024 discounted slots were booked up within two days of enrollment beginning in November.

Adriana Miranda was able to secure coverage both years.

“You feel so much more at ease knowing that you’re not going to owe so much to the hospitals,” said Miranda, 46, who is enrolled in a private plan through OmniSalud, a program similar to the state’s Obamacare marketplace in which low-income Coloradans without legal residency can shop for plans with discounted premiums.

Miranda left Mexico in 1999 to follow her two brothers to the United States. She now works at Lamar Unidos, a nonprofit immigrant rights group.

Before she had health insurance, she struggled to pay for care for her diabetes and racked up thousands of dollars of debt following foot surgery, she said. Under the state program, she doesn’t pay a monthly premium due to her low income, with a $40 copay for specialist visits.

“I was really happy, right? Because I was able to get it. But I know a lot of people who also have a lot of need couldn’t get it,” she said.

OmniSalud covers only a small fraction of the more than 200,000 people living in Colorado without authorization, said Adam Fox, deputy director of the Colorado Consumer Health Initiative. But starting in 2025, all low-income children will be able to be covered by the state’s Medicaid or the related Children’s Health Insurance Program regardless of immigration status.

“There is a growing acknowledgement that people regardless of their immigration status are part of the community and should have access to health care in a regular, reliable manner,” Fox said. “If they don’t, it adds costs and trauma to the health systems and communities.”

Ä¢¹½Ó°Ôº Health News senior audio producer Zach Dyer contributed to this report.

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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That money has gone from an emerging funding stream for which people had lofty but uncertain aspirations to a coveted pot of billions of dollars being invested in real time to address addiction.

Altogether, the companies are expected to pay more than $50 billion to state and local governments over nearly two decades.

Meanwhile, more than 100,000 Americans have annually in recent years, underscoring the urgent nature of the crisis.

Ä¢¹½Ó°Ôº Health News has been all year and covering the windfall’s mixed impact in communities across the country. Here are five things we’ve noticed in 2023 and plan to keep an eye on next year:

1. The total amount of settlement money state and local governments expect to receive is a moving target.

Before the start of the year, national settlements were in place with at least five companies, and several other deals were in the final stages, said , founder of OpioidSettlementTracker.com.

Today, most states in settlements with opioid manufacturers Johnson & Johnson, Teva Pharmaceutical Industries, and Allergan; pharmaceutical distributors AmerisourceBergen, Cardinal Health, and McKesson; and retail pharmacies Walmart, Walgreens, and CVS. Many are also the national supermarket chain Kroger.

Several of these deals in the second half of this year, leading to bumps in states’ .

But there have been dents and slowdowns too.

Mallinckrodt Pharmaceuticals, a manufacturer of generic opioids, originally agreed to pay $1.7 billion as a result of its 2020 bankruptcy filing to state and local governments, as well as people directly affected by the crisis. But the company in August, from that figure.

Purdue Pharma, perhaps the best known of all the companies for its creation and marketing of OxyContin, had agreed to pay $6 billion as part of its bankruptcy proceedings. But the Biden administration this summer, and the case now lies in the hands of the Supreme Court. At its core is the question of whether it’s legal for the Sackler family to gain immunity from future civil cases about the opioid crisis under the company’s bankruptcy deal when they have not filed for bankruptcy as individuals.

The Supreme Court in December and is expected to rule on the case next spring or summer. Until then, no Purdue money will flow.

2. Most states still aren’t being transparent about how the money is used.

In March, Ä¢¹½Ó°Ôº Health News and Minhee published a comprehensive investigation showing that only 12 states had promised to publicly report how they were using all their settlement dollars.

Since then, that number has to 16.

But 15 states still have not committed to publicly reporting anything at all, and others have promised to publicize only a portion of their spending.

Many people aren’t happy about the secrecy.

In Ohio, a local advocacy group, the OneOhio Recovery Foundation, which controls most of the state’s settlement dollars, for violating public records and open-meeting laws. Although a judge , it became a moot point in July, when the state passed a budget that from such requirements.

In Michigan, the Department of Health and Human Services came under fire for not publicly reporting how it was spending upward of $40 million in settlement funds. In October — just hours before a legislative subcommittee hearing in which about the money — the department , displaying a to which it had awarded funds.

At the national level, a dozen Democratic lawmakers have raised concerns about a lack of transparency and oversight via a to the Office of National Drug Control Policy, which is leading the federal government’s response to the opioid crisis.

“We urge the Biden administration to closely track opioid settlement fund spending, to ensure that populations in need of additional support receive it,” the lawmakers wrote.

The Office of National Drug Control Policy responded this month that it did not have the statutory authority from Congress to do so.

“Currently, no mechanism exists that would allow ONDCP to require states to disclose their spending,” the office wrote in a . “ONDCP cannot effectively monitor how states use these funds.”

3. Nationwide, money is being spent in several common areas.

Although there is no national data on how settlement dollars are spent, piecemeal tracking by journalists and advocates has surfaced some favorites.

One of the biggest is investing in treatment. Many jurisdictions are building residential rehab facilities or expanding existing ones. They’re covering the cost of care for uninsured people and trying to increase the number of clinicians prescribing medications for opioid use disorder, which have been shown to .

Another common expense is naloxone, a medication that reverses opioid overdoses. Wisconsin is spending on this effort. Kentucky has . And many local governments are .

Some other choices have sparked controversies.

Several governments used settlement dollars to purchase police patrol cars, technology to help officers hack into phones, and body scanners for jails. Supporters say these tools are critical to crack down on drug trafficking, but research suggests law enforcement efforts don’t prevent overdoses.

People are also divided over school-based programs to prevent kids from developing addictions. While they agree on the goal, some people favor programs that teach kids about the dangers of drugs — like D.A.R.E. in the ’80s — while others prefer programs focused on improving mental health, resiliency, and communication skills.

Perhaps the most contentious use, though, is shoring up county budgets and paying back old bills. Even if it’s legal, many people directly affected by the epidemic say this misses the goal of the settlement money, which is to address today’s ongoing crisis.

4. The settlements required companies to change problematic business practices, but that has had unintended consequences.

As part of their settlements, manufacturers like Allergan and Johnson & Johnson agreed not to sell opioids for 10 years and curb marketing and promotion activities. Pharmaceutical distributors were required to step up efforts to identify suspicious orders from pharmacies, under the oversight of an independent third-party monitor. Retail pharmacy chains must conduct audits and site visits to their pharmacies, as well as share data with state agencies about problematic prescribers.

The goal of these stipulations is to prevent further misuse of prescription opioids. But some people see unintended consequences.

Distributors have placed stricter limits not only on pharmacy orders of opioids, but on many drugs considered potentially addictive, known as “controlled substances.” As a result, orders for these medications are being canceled more often and some pharmacies are hesitant to fill prescriptions for new patients. That has left people for chronic pain, anxiety, attention-deficit/hyperactivity disorder — and, ironically, even medication that treats opioid addiction.

, a researcher in North Carolina who studies substance use and health policy, said buprenorphine, which is considered a gold-standard treatment for opioid use disorder, was already difficult to obtain at many community pharmacies and in rural areas. But the settlements appear to be making it worse.

Instead of increasing access to treatment — which is critical to stemming the number of overdoses — “I really worry the settlements may be having the opposite effect,” Ostrach said.

5. Many places haven’t decided what to do with the money yet.

Several states, including Montana and Hawaii, have yet to spend any of the settlement funds controlled by their state agencies. In Maine and West Virginia, councils overseeing the lion’s share of funds are still in the process of identifying priorities and developing processes to award grants.

Across the nation, some county officials say they need more guidance on appropriate uses of the money. Others are surveying residents on what they want before making decisions.

The slow pace has frustrated some advocates, who say there should be greater urgency at a time when the drug supply is becoming . But others say the money will continue arriving through 2038, so setting up thoughtful processes now could pay off for years to come.

It’s a trade-off between putting out current fires and preventing future ones, said , project director of the addiction and public policy initiative at Georgetown University’s O’Neill Institute. She’s hopeful officials will strike the right balance.

“Is there a vision in each state about where we’re going to be when the settlement monies are done?” she said. “My hope is that 18 years from now we’re not still where we are today.”

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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The money is part of the approximately $50 billion that states and local governments will over nearly two decades. The payments come from that made, distributed, or sold prescription opioid painkillers that were sued for their role in fueling the overdose epidemic.

Many places have begun deciding where that money will go and making payments to schools, public health departments, and local governments. South Carolina, for example, more than $7 million to 21 grantees. Wisconsin two years’ worth of spending plans that total nearly $40 million.

Montana, West Virginia, and Hawaii are among the states moving slower.

Montana began receiving its first settlement payments in January, and, by fall, payments totaled roughly $13 million. As of early December, the — a private nonprofit created to oversee 70% of the state’s share — had met once to agree to its rules of operation, and its money remained locked behind an inactive grant portal. The remainder, divided among the state and local governments, either hadn’t been spent or wasn’t publicly recorded.

Those charged with distributing the money say they’re building a framework to spend it in ways that last. Meanwhile, some addiction treatment providers are eager to use the funds to plug gaps in services.

The tension in Montana reflects a nationwide push-pull. Those handling settlement dollars say governments should take their time planning how to use the enormous windfall. Others argue for urgency as the drug supply has become . Americans died of overdoses in 2022, surpassing the previous year’s record-setting death toll.

Nearly 200 Montanans died of a drug overdose in 2021, the latest year . That number, likely an undercount, is roughly 40 more deaths than the year before. Emergency medical responders have continued to record an increasing number of this year.

In Billings, the Rimrock Foundation, one of the state’s largest behavioral health providers, has seen its number of clients with opioid use dependency more than triple since 2021. Like other treatment facilities, Rimrock has a waitlist, and addiction treatment providers worry about the limited community resources that exist for patients once they are discharged. “The result of not addressing this is a lot of deaths,” said Jennifer Verhasselt, Rimrock Foundation’s chief clinical officer.

Debbie Knutson, Rimrock’s medical unit and nursing supervisor, said there is widespread confusion about how and when the state’s settlement dollars can be used.

“It’s very concerning if we have money available that we could use to help people that is just kind of sitting, waiting for somebody to decide where it should go,” Knutson said.

Rusty Gackle, the Montana Opioid Abatement Trust executive director, said a lot of work has happened behind the scenes to get local governments ready to accept their initial payments and for regional leaders to form systems to request money from the trust. That included hosting a series of town hall-style meetings to share information about the process. He said many of those local regions are still finalizing their governance structures.

“I would love to progress a little bit faster,” Gackle said. “But I’d rather do it right so that we’re not having to go backwards.”

Montana officials got a late start too, he added. Some states began receiving settlement dollars last year, but Montana was toward the tail end of the line.

Montana is dividing its money three ways: 15% to the state, 15% to local governments, and the rest to the Montana Opioid Abatement Trust, with some money set aside for attorneys’ fees.

As of late November, the state hadn’t begun spending the $2.4 million it had in hand for state agencies. Officials also aren’t tracking how and when local governments spend their direct payments.

Similarly, West Virginia and hadn’t — by late November — begun spending the largest shares of their funding. In West Virginia, the makeup of the foundation board that will oversee roughly 70% of the state’s settlement dollars was announced only in August, six weeks , and the board is now sitting on .

Nationwide, state and local governments have received more than as of Nov. 9. How much of that has been used remains uncertain due to states’ lack of public reporting. But from what is known, it varies.

Colorado, whose spending plan is similar to Montana’s but received its settlement money earlier, toward school and community-based programs, recovery housing services, and expanded treatment services.

, a Johns Hopkins researcher who tracks states’ uses of opioid settlement funds, said a slower start isn’t inherently wrong. She prefers governments take time to spend the money well rather than fund outdated or untested practices. In some cases, governments are building entirely new systems to dole out the money. Several waited until the courts finalized the settlement amounts and details.

“There are definitely states that were like, ‘We are going to get money at some point. We don’t know how much or when, but let’s start setting up our system,’” Whaley said. “Other folks were like, ‘We have a lot going on already. We’ll just wait until we get it and then we’ll know what the settlement terms are.’”

Even once committees start meeting, it can take months for the money to reach front-line organizations.

Connecticut’s opioid settlement advisory committee in November, eight months after it was formed. Maine’s recovery council, which controls half the state’s settlement funds, has been November 2022, but just recently for the it has on hand and still needs to establish a grant application process.

Tennessee’s Opioid Abatement Council accepted grant applications this fall. Stephen Loyd, council chair, said the process — from picking awardees to processing payments — will take roughly six months. Within that time, he said, 2,808 Tennesseans are likely to die of drug overdoses.

As an interim step, Loyd proposed at an October meeting to award $7.5 million to an emergency six-month initiative to flood the state with naloxone, a medication that reverses opioid overdoses.

But his proposal was met with protests from council members, who pushed back on what they saw as a circumvention of the grant process they had spent months establishing. The council didn’t vote on the emergency initiative but instead created an expedited review process to consider fast-tracking future applications.

Gackle said he doesn’t think Montana is far behind others. Now that spending systems are almost in place, he said, things should move faster.

Lewis and Clark County, home to the state capital, Helena, has a yearlong plan and budget for opioid settlement funds. A cohort of 17 counties in rural eastern Montana defined its regional settlement decision-makers in November and, by early December, had yet to begin official talks about where the money should go.

Brenda Kneeland, CEO of Eastern Montana Community Mental Health Center and an advisory committee member for the Montana Opioid Abatement Trust, said eastern Montana has one inpatient treatment center for substance use disorders and zero detox facilities, so emergency rooms end up serving as a fallback resource.

Kneeland said local officials want to ensure they understand the rules to avoid trouble later and to stretch the funding.

“You don’t get an opportunity to try to correct such a wrong very often,” Kneeland said. “It’s just a huge job at a county level. I’ve never seen an undertaking like this in my career.”

The Montana Opioid Abatement Trust advisory committee will meet quarterly, meaning its next chance to review any submitted grants will be next spring.

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“Growing up, we ate whatever we caught — catfish, carp, freshwater drum,” he said. “That was the only real source of fish in our diet as a family, and we ate a lot of it.”

Today, a branch of the Rouge River runs through Eisenman’s property in a suburb north of Detroit. But in recent years, he has been wary about a group of chemicals known as PFAS, also referred to as “forever chemicals,” which don’t break down quickly in the environment and accumulate in soil, water, fish, and our bodies.

The chemicals have spewed from manufacturing plants and landfills into local ecosystems, polluting surface water and groundwater, and the wildlife living there. And hundreds of military bases have been pinpointed as sources of PFAS chemicals leaching into nearby communities.

Researchers, anglers, and environmental activists nationwide worry about the staggering amount of PFAS found in freshwater fish. At least 17 states have issued PFAS-related fish consumption advisories, Ä¢¹½Ó°Ôº Health News found, with some warning residents not to eat any fish caught in particular lakes or rivers because of dangerous levels of forever chemicals.

With no federal guidance, what is considered safe to eat varies significantly among states, most of which provide no regulation.

Eating a single serving of freshwater fish can be the equivalent of drinking water contaminated with high levels of PFAS for a month, according to a from the Environmental Working Group, a research and advocacy organization that tracks PFAS. It’s an unsettling revelation, especially for rural, Indigenous, and low-income communities that depend on subsistence fishing. Fish remain a large part of cultural dishes, as well as an otherwise healthy source of protein and omega-3s.

“PFAS in freshwater fish is at such a concentration that for anyone consuming, even infrequently, it would likely be their major source of exposure over the course of the year,” said David Andrews, a co-author of the study and researcher at EWG. “We’re talking thousands of times higher than what’s typically seen in drinking water.”

Dianne Kopec, a researcher and faculty fellow at the University of Maine who studies PFAS and mercury in wildlife, warned that eating fish with high concentrations of PFAS may be more harmful than mercury, which long ago was found to be a neurotoxin most damaging to a developing fetus. The minimal risk level — an estimate of how much a person can eat, drink, or breathe daily without “detectable risk” to health — for PFOS, a common PFAS chemical, is 50 times as low as for methylmercury, the form of mercury that accumulates in fish, according to the federal . But she emphasized, “They’re both really nasty.”

Just like mercury, PFAS bioaccumulate up the food chain, so bigger fish, like largemouth bass, generally contain more chemicals than smaller fish. Mercury is more widespread in Maine, but Kopec said PFAS levels near contamination sources are concerningly high.

‘Fishing Is a Way of Life’

The Ecology Center, an environmental group in Michigan, educates anglers about consumption advisories and related health impacts. But Erica Bloom, its toxics campaign director, noted that for many people out on the river, “fishing is a way of life.”

Eisenman participated in an Ecology Center published this year, which tested fish from Michigan’s Huron and Rouge rivers for PFAS that poured out from auto and other industry contamination. Across 15 sites, anglers caught 100 fish samples from a dozen species, and what they found scared him.

“There were no sites that registered zero,” said Eisenman, noting that some had significantly higher levels of chemicals than others. “You need to make a value judgment. I’m going to still eat fish, but I don’t know if that’s a good thing.”

Last year, the National Academies of Sciences, Engineering, and Medicine published a sweeping that associated PFAS exposure with health effects like decreased response to vaccines, cancer, and low birth weight.

There are thousands of PFAS, or perfluoroalkyl and polyfluoroalkyl substances, many of them used to make both household and industrial products stain-resistant or nonstick. They’re in fire-retardant foam used for decades by fire departments and the military, as well as in cookware, water-repellent clothing, carpets, food wrappers, and other consumer goods.

In late October, the EPA to its list of “chemicals of special concern.” This will require manufacturers to report the presence of those PFAS chemicals in their products — even in small amounts or in mixtures — starting Jan. 1.

Sparse Testing Leaves Blind Spots

About 200 miles north of Detroit, in rural Oscoda, Michigan, state officials against eating fish or deer caught or killed near the former Wurtsmith Air Force Base because of PFAS contamination.

“We have a 9-mile stretch of river system in which the state determined way back in 2012 that it wasn’t safe to even eat a single fish,” said Tony Spaniola, an advocate for communities affected by PFAS. He owns a home across a lake from the shuttered military site.

In Alaska, several lakes are designated catch and release only because of . A study by the U.S. Geological Survey and Pennsylvania Department of Environmental Protection led to a warning to avoid eating fish from the Neshaminy Creek watershed.

Nationwide, use of firefighting foam and other PFAS-loaded products by the Department of Defense alone has led to the contamination of at least 359 military bases and communities that need to be cleaned up, with an additional 248 still under investigation as of June.

But many lakes and streams haven’t been tested for PFAS contamination, and researchers worry far more sites hold fish laced with high levels of PFAS.

Federal efforts to curb PFAS exposure have focused mostly on drinking water. Earlier this year, the EPA proposed the nation’s first PFAS drinking water standards, which would limit contamination from six types of chemicals, with levels for the two most common compounds, PFOA and PFOS, set at 4 parts per trillion.

But the EWG researchers found that one serving of fish can be equivalent to a month's worth of drinking water contaminated with 48 parts per trillion of PFOS.

Store-bought fish caught in the ocean, like imported Atlantic salmon and canned chunk tuna, appear to have lower PFAS levels, according to .

A focused on the San Francisco Bay Area’s Asian and Pacific Islander community measured PFAS levels in the blood and found higher amounts of the compounds compared with national levels. The researchers also about their fish consumption and found that 56% of those who ate locally caught fish did so at least once a month.

Eating a fish’s fillet is often recommended, as it than organs or eggs, but many participants reported eating other parts of the fish, too.

California is one of many states with no fish consumption advisories in place for PFAS. Jay Davis, senior scientist at the San Francisco Estuary Institute, said that’s in part because of “limited monitoring dollars” and a priority on legacy chemicals like PCBs as well as mercury left over in particularly high concentrations from gold and mercury mining.

Wesley Smith, a senior toxicologist with California’s Office of Environmental Health Hazard Assessment, said the state is reviewing the latest scientific literature but needs more data to develop an advisory that is “neither too restrictive nor too permissive.”

States like New Hampshire, Washington, Maine, and New Jersey have some of the most protective guidance, while other states, such as Maryland and Michigan, lag when it comes to designating fish unsafe to eat.

Advisory levels for at-risk groups — such as children and women of childbearing age — are usually lower, while “do not eat” thresholds for the general population range from 25.7 parts per billion in New Hampshire to 300 ppb in Michigan, 408 ppb in Maryland, and .

“That’s wicked outdated to have levels that high and consider that safe for folks to eat,” said Kopec, the University of Maine researcher.

Though it is no longer made in the U.S., PFOS remains the most commonly found — and tested for — PFAS chemical in fish today.

The primary maker of PFOS, 3M, announced it would begin phasing the chemical out in 2000. This year, the company said it would pay at least $10.3 billion to settle a class-action lawsuit brought by public water system operators. But in July, attorneys general from 22 states asked the court to reject the settlement, saying it was insufficient to cover the damages.

The military first documented health concerns surrounding PFAS chemicals in the 1970s yet continued to use firefighting foam made with them. Mandated by Congress, the Defense Department was required to stop buying retardant containing PFAS by Oct. 1 and phase it out altogether by 2024. A recently published study linked testicular cancer among military personnel to PFOS.

Tackling Pollution at the Source

Pat Elder, an activist and director of the environmental advocacy group , has tested water for PFAS up and down the East Coast, including in Piscataway Creek, which drains from Joint Base Andrews, the home of Air Force One.

In 2021, after testing fish from Piscataway Creek, Maryland officials released the state’s sole PFAS fish consumption advisory to date. But Elder worries Maryland has not gone far enough to protect its residents.

“People eat the fish from this creek, and it creates an acute health hazard that no one seems to be paying attention to,” Elder said.

Since then, Maryland’s Department of the Environment has conducted more fish monitoring in water bodies near potential PFAS sources, as well as at spots regularly used by subsistence anglers, said spokesperson Jay Apperson. He added that the state plans to put out more advisories based on the results, though declined to give a timeline or share the locations.

Part of the challenge of getting the word out and setting location-specific consumption advisories is that contamination levels vary significantly from lake to lake, as well as species to species, said Brandon Reid, a toxicologist and the manager of Michigan’s Eat Safe Fish program.

Michigan set its screening values for fish consumption advisories in 2014, and the state is in the process of updating them within the next year, Reid said.

But to see the chemicals dip to healthier levels, the pollution needs to stop, too. There is hope: Andrews, the EWG researcher, compared EPA fish sample data from five years apart and found about a 30% drop on average in PFAS contamination.

Bloom has watched this cycle happen in the Huron River in southeastern Michigan, where PFAS chemicals upstream seeped into the water from a chrome plating facility. While the levels of PFAS in the water have slowly gone down, the chemicals remain, she said.

“It's very, very hard to completely clean up the entire river,” Bloom said. “If we don't tackle it at the source, we're going to just keep having to spend taxpayer money to clean it up and deal with fish advisories.”

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“These families came to me knowing we could offer them a safe and healthy environment,” Hutzenbiler said. Part of ensuring that healthy environment is having a strong vaccination policy, she said, especially for those who are immunocompromised or too young to receive the full slate of childhood vaccines.

So, when officials at Montana’s health department revived a proposal that would allow people to claim religious exemptions from immunization requirements at child care facilities, Hutzenbiler was both dismayed and relieved. Dismayed, because allowing more children to claim exemptions could compromise the community immunity levels necessary to defend against highly infectious diseases like measles and pertussis. Relieved, because as she scoured the proposed regulations, she found that her facility, which is licensed to care for up to 15 children, would be in a category of smaller providers that could choose whether to enroll unvaccinated kids.

“If it came down to where I had to, I had no choice, I would stop enrolling children today,” Hutzenbiler said. “In five years, I would be closed.”

Montana, , allows religious exemptions from immunization requirements for school-age children. If the state is successful in expanding its policy to child care facilities, it would become the second this year to add a religious exemption to its immunization requirements for younger kids. Mississippi for schools and child care centers in July following a court ruling that the state’s lack of a religious exemption violated the U.S. Constitution’s free exercise clause.

Until recently, the trend had been going the other way, with four states — California, New York, Connecticut, and Maine — removing religious exemption policies over the past decade. West Virginia has never had a religious exemption.

But religious exemptions, fueled by conservative backlash to covid-19 vaccinations, have become caught up in partisan politics, said , a University of California-Davis law professor who specializes in the law, history, and politics of reproduction, health care, and conservatism.

“It tends to be breaking down much more along red state-blue state lines, where progressive states are moving in the direction of mandating vaccines in more situations and conservative states are moving more in the direction of broadening exemptions,” Ziegler said. “So, as much as religious exemptions for vaccines are not a new issue, they’ve become polarized in a new way.”

The proposal in Montana the state Department of Public Health and Human Services floated last year, which a legislative committee temporarily blocked after public health advocates and child care providers objected. Afterward, in October 2022, health department officials said they would not enforce a religious exemption ban in child care centers.

“We are committed to ensuring that these families have viable child care options in accordance with state and federal law,” department spokesperson Jon Ebelt at the time.

However, in the state’s latest proposal, 45 pages into of child care licensure rules, the health department seeks to extend that exemption to child care facilities, where a family now can claim a vaccine exemption only for medical reasons. (There is an existing religious exemption for the vaccine against .)

Ä¢¹½Ó°Ôº Health News sent the health department a list of questions about its decision to include a religious exemption in the rules proposal. Ebelt emailed a statement that did not address the exemption at all.

“The rules package cuts red tape to increase access to child care for hardworking Montana families, and ensures that related regulations align with statutory changes directed by the Legislature in 2021 and 2023,” his statement said.

The prohibits the state from infringing on a person’s right to the exercise of religion. Another based on vaccination status.

A religious exemption under Montana’s proposed rules would require a child’s parent or guardian to submit a form attesting that vaccination is contrary to their religious belief, observance, or practice. With no mechanism to check the validity of such claims, health professionals worry exemptions would spike, reducing community immunity levels.

“Exemptions lead to less people being vaccinated, which can lead to more outbreaks and more sick kids,” said Marian Kummer, a retired pediatrician who practiced in Billings for 36 years.

The risk of disease outbreaks would increase not only in those child care centers but in communities as well, said , an associate professor at the University of Montana School of Public and Community Health Sciences.

A community is from measles, for example, if 95% of the population is vaccinated against it, according to the World Health Organization. Montana’s vaccine exemption rate among kindergartners was 3.5% in the 2020-21 school year, according to , putting it within that range of protection.

The health department’s proposed changes also would eliminate a requirement that child care facilities keep out infected and unvaccinated children and staffers when someone becomes sick with a vaccine-preventable disease, said Kiely Lammers, director of the nonprofit advocacy group .

Some have questioned the legitimacy of religious exemptions. Most religions, including a majority of Christian denominations, have no theological objection to vaccination, according to a in the journal Vaccine. And the U.S. Supreme Court has ruled limits do exist on religious and parental rights: “The right to practice religion freely does not include liberty to expose the community or the child to communicable disease or the latter to ill health or death,” says the 1944 ruling in .

The American Academy of Pediatrics has called for the elimination of all nonmedical exemptions, including both religious exemptions and personal-belief exemptions, “as inappropriate for individual, public health, and ethical reasons,” according to .

In Connecticut, plaintiffs who challenged the state’s decision to remove religious exemptions said they objected to the use of fetal or animal cell lines in the research and development of vaccines. But a three-judge panel for the 2nd U.S. Circuit Court of Appeals that religious exemptions do not serve “to protect the health and safety of Connecticut students and the broader public” when it upheld Connecticut’s decision.

Yet even in California, which , efforts are underway to overturn the law. In a , several parents backed by a conservative law firm are challenging the law’s constitutionality. One plaintiff, Sarah Clark, said she believes vaccines run counter to her interpretation of the Bible “because they are a foreign substance and are harmful to the body.” Attorney General Rob Bonta’s office said Nov. 1 it hadn’t been served with the case yet but will review the complaint and respond as appropriate.

Montana’s proposed rule is scheduled for a public hearing Nov. 13. Some child care providers, like Hutzenbiler, expect it ultimately to take effect. She said she is already drafting language to submit to the state as required under the proposed rules, saying Munchkin Land Daycare will not accept unvaccinated children.

Lammers said state officials should be open to changes and give child care centers with 16 or more kids the same choice as smaller facilities not to enroll unvaccinated children.

“I’m hoping at the very least we can make it equal in all settings,” she said of the rule proposal.

Kummer, the retired pediatrician, said she hopes the proposal prompts enough opposition that the state removes the plans for the religious exemption. But she doubts that will happen, given the anti-vaccination sentiment of Montana policymakers.

“It’s going to take a tragedy in our state or somewhere else where people wake up to the fact that we need vaccinations,” Kummer said.

California news editor Judy Lin contributed to this report.

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