Dr. Sara McLin thought she made the right choice by going to an in-network emergency room near her Florida home after her 4-year-old burned his hand on a stove last Memorial Day weekend.

Her family is insured through her husband’s employer, HCA Healthcare, a Nashville-based health system that operates more hospitals than any other system in the nation. So McLin knew that a nearby stand-alone emergency room, HCA Florida Lutz Emergency, would be in their plan’s provider network.

But McLin said a doctor there told her she couldn’t treat her son, Keeling, because he had second- and third-degree burns that needed a higher level of care. The doctor referred them to the burn center at HCA Florida Blake Hospital, about a 90-minute drive away.

McLin, who is a dentist, said the doctor told her the stand-alone ER would not charge for the visit because they did not provide treatment.

“I don’t remember exactly how she phrased it. But something along the lines of, ‘Well, we won’t even call this a visit, because we can’t do anything,’” McLin said.

At Blake Hospital, she said, a doctor diagnosed Keeling with a second-degree burn, drained the blisters, bandaged his hand, and sent them home with instructions on how to care for the wound.

“I didn’t think anything more of it,” McLin said.

Then the bills came.

The Patient: Keeling McLin, now 5, is covered by UnitedHealthcare through his father’s employer.

Medical Service: At the stand-alone emergency room, a physician assessed Keeling and sent him to another facility for treatment. “Keeling needs a burn center,” the doctor wrote in the record of his visit.

Service Provider: Envision Physician Services, which employed the emergency room physician at HCA Florida Lutz Emergency in Lutz, Florida, near Tampa, and HCA Florida Trinity Hospital, the main, for-profit hospital to which the stand-alone emergency room belonged.

Total Bill: For the emergency room visit, Envision Physician Services billed $829 to insurance and about $72 to the family. HCA Florida Trinity Hospital billed Keeling about $129, noting it had applied an “uninsured discount.” An itemization showed the original charge had been nearly $1,509 before adjustments and discounts.

What Gives: The stand-alone emergency room and ER doctor, who saw Keeling but referred him to another hospital, billed for his visit. But McLin soon learned she was unable to dispute some of the charges — because her young child’s name was on one of the bills, not hers.

Keeling McLin, now 5, burned his hand on a stove last Memorial Day weekend. An emergency room doctor referred him to a burn center for treatment, and his family ended up getting billed for the ER visit, anyway. His mother initially could not dispute some of the charges because the bills were addressed not to her, but to Keeling.(Zack Wittman for KHN)

Months after the ER visit, McLin received a bill addressed to the “parents of Keeling McLin” from Envision Physician Services, the provider staffing service that employed the ER doctor at Lutz. McLin recalled the doctor’s promise that they would not be billed. “I should have made them write something down to that effect,” she said.

She said she called her insurer, UnitedHealthcare, and a representative told her not to pay the bill.

She received an insurance statement that identified the bill from Envision’s doctor — an out-of-network provider working in an in-network emergency room — as a “surprise bill” for which the provider may charge only copays or other cost-sharing costs under federal law. McLin said she had not heard anything since then about the bill.

After being contacted by KHN, Aliese Polk, an Envision spokesperson, said in an email that Envision would waive the debt, apologizing to Keeling’s family “for the misunderstanding.”

She described the ER doctor’s evaluation, determination, and referral as a medical service. She said the bill was for cost sharing for the visit — not the difference between what the doctor charged and what insurance paid, as the law prohibits.

“We recognize the patient’s family may have understood at the time of treatment that there would be no charge for the visit, including the medical service provided by our physician,” Polk said. “Unfortunately, this courtesy adjustment was not captured when the claim was processed.”

Maria Gordon Shydlo, a UnitedHealthcare spokesperson, said the insurer believed the matter had been resolved and did not follow up on requests for an interview, even after McLin waived federal health privacy protections, which would allow the insurer to speak to the reporter about the case.

McLin also received a bill from HCA Florida Trinity Hospital for its stand-alone ER at Lutz and decided to dispute the charges.

But after calling the hospital to appeal, McLin said, the billing department would not discuss the debt with her because the statement was in her young son’s name.

“They had him as the guarantor,” McLin said. Unlike Envision, which billed Keeling’s parents and their insurance, McLin said the hospital listed the child as “unemployed, uninsured.”

The child’s ER record also included his date of birth and doctor’s notes referencing his age. McLin said she wrote to HCA in November asking to appeal the bill and that a billing representative told her over the phone that it would put the debt on hold and review the dispute.

“I never heard anything back and assumed we were good,” McLin said.

Then, in January, she received a letter from Medicredit, a collection agency and an HCA subsidiary, stating that Keeling owed $129 and that he had until mid-February to contest the debt. KHN was unable to make contact with Medicredit representatives, and HCA Healthcare did not respond to requests for comment from its subsidiary.

Once again, Sara McLin’s name was not on the debt collector’s letter, and she said Medicredit representatives refused to discuss the debt with her because it was in her son’s name. She said she called HCA, too. “They said, ‘We can’t help you. We don’t have the case anymore,’” she said.

Erin Fuse Brown, a law professor and director of the Center for Law, Health & Society at Georgia State University, said McLin did everything right and that it is unusual for a parent to be barred from discussing a debt related to their minor child.

“The fact that the hospital wouldn’t even talk to her strikes me as the part that is absurd. It’s absurd as a business matter. It’s absurd as a privacy matter,” Fuse Brown said, adding that federal health privacy laws allow a parent or legal guardian to access their dependent’s medical information.

Fuse Brown said the hospital should have been able to correct the error quickly with more information, such as a birth certificate or other document establishing that McLin was Keeling’s parent. At the very least, she said, it could have given McLin notice before sending the bill to collections.

“You get the feeling that it’s this large, automated process, that there’s no human to get through to, that there’s no human to talk to and override the mistake,” Fuse Brown said. “Maybe it’s routine, but she couldn’t even talk to someone to correct a correctable billing error, and then the system just steamrolls over the patient.”

The Resolution: When the collection agency’s deadline passed without resolution, McLin said she felt frustrated. “Nobody can explain to me who has to approve talking to me,” she said. “I don’t know who that person is or what the process is.”

After KHN contacted the health system, HCA Healthcare canceled the family’s debt. HCA representatives declined to be interviewed on the record despite also receiving a privacy waiver from McLin.

“We have attempted to contact Mrs. McLin to apologize to her for the inconvenience this has caused her and to let her know that there is a zero balance on the account,” Debra McKell, marketing director for HCA West Florida Division, said in an email on March 3. “We also will be sharing with her that we are reviewing our processes to ensure this does not happen again.”

McLin later received a letter from HCA stating that the account had been cleared. She also said she received a call from a customer service representative informing her that the debt had not been reported to any credit agencies.

She said she was pleased, but that patients should not have to struggle to correct a billing error before it is sent to a collection agency and potentially ruins their credit.

“It’s the principle of the thing that’s annoying me at this point,” she said.

The Takeaway: Though the notion of a debt collector pursuing a 4-year-old boy may seem farcical, it happens. When seeking medical care for a minor, it is important for the parent or guardian to ensure their name is listed as the responsible party.

Consumers who find themselves fighting a medical billing error need to “think like a lawyer,” Fuse Brown said, including documenting every interaction with the debt collector, getting any promises in writing, and recording phone calls. (State laws vary about how many parties on a call must give permission to record a conversation.)

Patients do not have to give up once a bill goes to collections, Fuse Brown said. “Once you hear from a debt collector, it’s not like the game is over and you lose,” she said. “Consumers do have rights.”

François de Brantes, a home health company executive and expert on how money flows through the health care system, said that hospital billing errors are not uncommon but that he had never heard of a situation like the one McLin experienced. He called it “puzzling” that HCA would issue a formal claim in a dependent child’s name.

De Brantes said those in a similar situation should also ensure that the collection agency removes any record of a debt against a minor to protect the child’s financial future.

“This stuff happens, where you have children who are improperly billed for stuff that they shouldn’t be billed, and they end up in collection,” he said. “Then the kid finds themselves with a collection record and they can’t get loans in the future, potentially student loans.”

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Daniel Chang:
dchang@kff.org,
@dchangmiami

Aneri Pattani

State and local governments will, over the next nearly two decades, receive billions of dollars from companies accused of sparking the opioid epidemic. KHN recently published an investigation showing these jurisdictions have promised little to no public reporting on how that money is spent.

The investigation is based on a detailed analysis of hundreds of written plans, statutes, executive orders, and public statements, first conducted by Christine Minhee of OpioidSettlementTracker.com and bolstered by KHN’s reporting. The information has been compiled into an interactive map and a detailed spreadsheet that we hope can help others investigate opioid settlement stories in their communities.

KHN’s story provides the national perspective. You can run our story in full or use it as context if you pursue a local angle. Please always credit KHN for the reporting and Minhee for the data.

Tips to get started:

1. Find out what information your state or local governments are required to report about their use of settlement funds.

Start with the interactive map. It shows how your state compares with others on public reporting. Click on a state to see details, including:

The percentage of funds an average person would be able to track. The percentage of funds that will be reported to some oversight body but not necessarily shared with the public.

To see the language that underpins these numbers — including the specific laws and legal documents that require reporting on the money — check out this table at OpioidSettlementTracker.com.

2. Access those reports.

Once you know what your state is required to report, go find it. If reports are displayed online, links are shown via the interactive map. If reports are kept by an agency, that agency is identified in the table. Reach out and ask for the reports, citing the legal requirements listed in the table if necessary.

If you cannot find a report — despite it being mandated in legal language — that may be a story itself.

3. Dig into the spending decisions.

Once you have reports on how the funds were used, dig into specifics. The national settlements came with a list of recommended strategies. Check if your community’s use aligns with them.

Ask how these spending decisions were made. Were community members involved in identifying priorities? Was there a fair and open process to apply for grants?

The settlement dollars will be paid out over nearly two decades. Do these reports reflect one-off spending decisions or ongoing allocations over that time? Is there a plan to evaluate the impact of the money after a few years and reshape future priorities?

4. If your state or local government has no public reporting requirement, that might be its own story.

The KHN investigation found nearly half of all states have not enacted any specific reporting requirements. If yours is one of them, ask why. Some have called settlement funds “blood money” for those who died of overdoses and feel they have a right to know how the payouts are used.

You can use the interactive map to compare the level of transparency in your state to that of similar or neighboring states. Pay attention to not only the public reporting but also the reporting required to an oversight body; ask why that information is not made public as well.

Talk to people in recovery, family members who have lost loved ones to overdoses, treatment providers, advocates, and others in the field about what consequences the lack of transparency is having in your community.

5. Check for any reports suggesting your state or local government spent money in ways unrelated to the opioid crisis.

Even states that have no reporting requirements of their own are subject to a bare minimum national standard: reporting how much money they use on expenses unrelated to the opioid epidemic. (This can be at most 15% of the state’s settlement cash.)

Reports from state and local governments can be found here. Governments are required to submit reports only if they determine they’ve used funds for non-opioid purposes, so you may not see a report from your community. Those that do file reports list only a dollar amount, so you’ll need to contact the person who signed off for details about how that money was used. New reports are filed approximately every six months.

6. Get help for further reporting.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).

More than $50 billion in settlement funds is being delivered to thousands of state and local governments from companies accused of flooding their communities with opioid painkillers that have left millions addicted or dead.

That’s an enormous amount of money — double NASA’s budget and five times the revenue of an NBA season.

But how that massive windfall is being deployed and how future dollars will be spent seem to be shrouded in mystery. Reporting requirements are scant, and documents filed so far are often so vague as to be useless.

Most of the settlements stipulate that states must spend at least 85% of the money they will receive over the next 15 years on addiction treatment and prevention. But defining those concepts depends on stakeholders’ views — and state politics. To some, it might mean opening more treatment sites. To others, buying police cruisers.

Those affected by the opioid epidemic and those working to fight it have an array of ideas: To Marianne Sinisi, who lost her 26-year-old son, Shawn, to overdose in western Pennsylvania, the settlement funds are “blood money” that she hopes can spare other parents similar grief. To Steve Alsum, who works with people who use drugs in Grand Rapids, Michigan, it’s a chance to finally reach all those in need. And to David Garbark, who is in recovery from opioid addiction, it’s a way to give others in his eastern North Carolina community a second chance, too.

Spending the money effectively and equitably is a tall order, given the persistence and complexity of addiction, which affects individuals and communities, and is the topic of heated debates in scientific research, social services, politics, criminal justice, and even at kitchen tables.

What’s more, many states are not being transparent about where the funds are going and who will benefit. An investigation by KHN and Christine Minhee, founder of OpioidSettlementTracker.com, concluded only 12 states have committed to detailed public reporting of all their spending.

The analysis involved scouring hundreds of legal documents, laws, and public statements to determine how each state is divvying up its settlement money among state agencies, city and county governments, and councils that oversee dedicated trusts. The next step was to determine the level and detail of public reporting required. The finding: Few states promise to report in ways that are accessible to the average person, and many are silent on the issue of transparency altogether.

More than $3 billion has gone out to state and local governments so far. KHN will be following how that cash — and the billions set to arrive in coming years — is used.

Per most of the settlements, governments are required to report only on the 15% of the money that can be used for things unrelated to the epidemic, like offsetting budget shortfalls or fixing old roads. As of March 28, only three states and counties had filed such reports. Although they listed dollar amounts, none said precisely how the money was spent.

State and local governments can enact more rigorous reporting protocols — for example, requiring a publicly available list of every place that receives money and for what purpose — but few have so far.

Left in the Dark

More than 250,000 Americans have died of overdoses from prescription opioids, which were aggressively promoted as painkillers and distributed by a host of health care companies, including Johnson & Johnson, AmerisourceBergen, McKesson, and Walmart. The settlements are meant to compensate and remediate the effects of that corporate behavior.

But many people whose lives have been upended are again feeling traumatized.

Sinisi said she and other parents who’ve lost kids to addiction have been left in the dark or, worse, treated like nuisances by officials in charge of the money.

“They want to look at you as this angry parent who lost a child,” she said, “rather than a concerned citizen who wants to see a difference made for other mothers, fathers, and their children.”

In Michigan, even the state’s Opioid Advisory Commission, which is tasked with evaluating the use of settlement money, has struggled to track the cash.

For six months after the state legislature allotted $39 million of settlement funds to the health department last summer, little information was made public about how that money would be spent. No news releases. No way for organizations to apply for funds.

“We can’t really identify the impact of those dollars if we don’t know how they’re being used,” said Dr. Cara Poland, the commission’s chair and an addiction-medicine doctor.

A family photo of Josh and Shawn Sinisi (right) as children, taken by their mother, Marianne, in 1994. (Nancy Andrews for KHN) Sinisi has been asking elected officials to allow her and other families to be part of decisions on how to spend opioid settlement dollars. Without public input, Sinisi fears, the funds will be wasted or cause harm.(Nancy Andrews for KHN)

With scant oversight nationwide, many people fear dollars may flow to efforts that research has proven mostly useless but jibe with the local political bent, like arresting people who use drugs, expanding jails, and favoring abstinence-only recovery over medications. They may go to the loudest bidder, with companies promising to find the next groundbreaking treatment and rehab facilities — some with shoddy track records — eyeing the cash.

Not to mention concerns that money will flow to activities that have little to nothing to do with opioid treatment: building new stadiums or public schools. Back in the ’90s, these day-to-day budget priorities consumed most of what states won from cigarette companies in the national tobacco settlement, leaving little for anti-smoking programs.

The opioid settlement funds will be different, say state attorneys general who fought for them. In addition to requiring at least 85% of the money be used on opioid-related expenses, most agreements include a list of suggested interventions like increasing addiction treatment for the uninsured and expanding recovery housing.

“We wanted to give states flexibility on what approaches they wanted to adopt,” while ensuring money didn’t go to “provide corporate tax relief” as the tobacco dollars did, said North Carolina Attorney General Josh Stein, who led negotiations for the national settlements.

But enforcement of the 85% standard is, oddly, left to the companies that paid out the money. They are unlikely to be vigilant, legal experts say. The money is committed already and, for many of these multibillion-dollar companies, the settlements are chump change. For example, Johnson & Johnson is set to pay $5 billion over nine years, but the company reported sales of nearly $95 billion in the past year alone.

An Emerging Picture

As the checks start to trickle in, a handful of states are committed to transparency while others seem to be falling short. Missouri has promised to report all its spending in online reports so that anyone can see who receives money, how much, and for what programs. New Hampshire already has posted reports online, and Colorado has created a public dashboard to track how funds are used.

Other states, like Nevada, have taken a middle-of-the-road approach, requiring that recipients report to the legislature or another oversight body, but not ensuring the reports will go public. Some states require audits but don’t promise to list specific expenses. And others allow the public to request records but won’t provide them automatically.

Then there are states hit hard by the opioid epidemic like Michigan and Ohio, where problems with transparency are already emerging. Each state is expecting to receive at least $1 billion.

When Poland, of Michigan’s Opioid Advisory Commission, realized she was getting little information on how the state’s funds were being spent, her commission decided to use its first annual report — published this month — to demand better. “Timely and transparent reporting” to the public is “an ethical responsibility,” it said, calling on lawmakers to enact greater oversight for settlement cash recipients and create a public dashboard to track spending.

KHN interviewed nearly a dozen people and filed a public records request to uncover how the state health department is spending the initial settlement funds allocation of $39 million.

A budget document obtained by KHN shows that as of Jan. 9, the Michigan Department of Health and Human Services had contracted $3.9 million in settlement funds to 35 grantees. Most are local health departments or syringe service programs that the state health department has previously funded.

An additional $27 million is set aside for particular interventions, such as growing the addiction treatment workforce, expanding recovery housing, and mitigating the harms of opioid use with medications like naloxone.

And, after KHN’s inquiries, the department released a statement that listed similar priorities.

Jonathan Stoltman is the director of the Michigan-based Opioid Policy Institute, which researches digital privacy in addiction treatment and discrimination against people who use drugs. “Anything that is backdoor scares me,” Stoltman says about the process of applying for settlement funds. (Ellen Manegold)

Those initiatives make sense to Jonathan Stoltman, director of the Michigan-based Opioid Policy Institute, which researches stigma and digital privacy in addiction treatment. But he would have liked to have known about them in advance and to have had a clear process laid out for groups to apply for the funds. Otherwise, organizations that are well positioned to use the money to help those most in need may miss a once-in-a-lifetime chance to scale up their work and save lives.

Last summer, when Stoltman inquired about applying for the funds, the health department told him to submit a “high level proposal” to “share around,” according to emails reviewed by KHN.

“Anything that is backdoor scares me,” said Stoltman. “I got lucky that I found who to talk to, even if it didn’t go anywhere.”

Steve Alsum, executive director of the Grand Rapids Red Project, which was awarded about $266,000 to improve the health of people who use drugs, said he expected the state to have an application process with scoring criteria to explain why certain groups were chosen. But, he said, “it hasn’t been clear who is making the decision and how it’s made.”

Jared Welehodsky, who leads the department’s efforts related to the settlement, said it is in the process of releasing several competitive grant applications for the bulk of the money. That didn’t happen sooner because most payments didn’t arrive until the end of 2022 and “we didn’t want to comment on how the money was going out when we didn’t have money to go out,” he said.

Talk of Keeping the Public Out

In Newark, Ohio, Linda Mossholder, 75, has been inquiring about the settlement dollars at City Council meetings since last summer. As a volunteer with Newark Homeless Outreach, which serves weekly free lunches, she encounters many people who use drugs and wants to see the money help them.

The proud owner of a T-shirt that reads, “Your first mistake is thinking I’m just an old lady,” Mossholder has followed up with emails, voicemails, and public records requests. But she hasn’t gotten a clear answer about how the city plans to use the nearly $50,000 it’s already received.

In January, Mossholder said, the city’s director of public service finally told her the plan was to allocate settlement cash to first responders for naloxone. But when KHN filed public records requests to confirm, City Auditor Ryan Bubb wrote, “No funds have been allocated or spent.”

Meanwhile, in northeastern Ohio, a regional board that will control millions of settlement dollars spent a February meeting discussing whether the public should be allowed to access meeting recordings at all.

“I wouldn’t open it up to the public, honestly,” said Judy Moran, a board member who represents Eastlake, according to a recording of the meeting obtained by KHN. Other board members asked if their gatherings were subject to the state’s open-meeting laws.

Moran later told KHN, “Of course the public has a right to know how these funds are disbursed,” but she said she worried recordings would allow people to take words “out of context.”

In Ohio at least, that may not be a choice for much longer.

A lawsuit brought by Harm Reduction Ohio to open the meetings of a separate board — the OneOhio Recovery Foundation, which oversees the lion’s share of the state’s expected $1 billion — is working its way through the courts. A local judge this month rejected the foundation’s request to dismiss the lawsuit, writing that “the public deserves transparency.”

In Ohio, the lion’s share of settlement funds will be controlled by the OneOhio Recovery Foundation. Dennis Cauchon, president of the nonprofit Harm Reduction Ohio, sued the foundation board for violating the state’s open-meeting and public records laws. (Maddie McGarvey for KHN)

But OneOhio spokesperson Connie Luck said the foundation is a “private, nonprofit organization, and not a government agency.” It has so far allowed public attendance at meetings, but has said it is not required to do so.

The final ruling in this lawsuit, which is the first of its kind on opioid settlement funds, will set a precedent for the public’s right to information nationally.

In some parts of the country, the prospect of dollars to treat a long-underfunded epidemic brings hope, said Tricia Christensen, who works at a nonprofit tracking settlement funds across Appalachia. When people know what’s happening, it not only deters misuse but can reveal surprising successes, she said.

Crystal Glass is in recovery from opioid and meth use and now works as a peer recovery specialist in southwestern Virginia, supporting others with substance use disorders. “These funds are the cavalry coming in,” she says of the opioid settlements. “You’re finally getting relief after suffering alone for so long.”(Kayla Davidson)

That knowledge is empowering.

“These funds are the cavalry coming in. You’re finally getting relief after suffering alone for so long,” said Crystal Glass, of southwestern Virginia, who is in recovery from opioid and meth use and now works as a peer recovery specialist.

She hopes officials will involve people affected by addiction in their decisions.

As she put it: Transparency “is letting everyone — I mean everyone — know they can be part of this.”

People sometimes leave painted rocks and other remembrances at the Circle of Hope statue in Tuckahoe Park in Altoona, Pennsylvania.(Nancy Andrews for KHN)

KHN’s Colleen DeGuzman and Megan Kalata contributed to this report.

Aneri Pattani:
apattani@kff.org,
@aneripattani

Arielle Zionts

Some adults who take prescription medication for attention-deficit/hyperactivity disorder are required to have their urine tested for drugs several times a year. Others never are tested.

Such screenings are designed to check if ADHD patients are safely taking their pills, such as Adderall, and not selling them, taking too many, or using other drugs.

Several doctors told KHN there are varying opinions and no national standards on the role of urine testing to monitor adults who take ADHD medication. So patients face dramatically different requirements, depending on their clinics’ and health insurers’ policies.

“There really isn’t much literature to guide you on how to do this,” said Dr. Margaret Chaplin, a Connecticut psychiatrist who treats patients with ADHD, mental illnesses, or substance use disorders.

Chaplin first noticed the lack of testing standards about eight years ago, when she and colleagues proposed ways to prevent stimulant misuse in adult ADHD patients.

Her team recommended urine tests only if patients exhibit “red-flag behavior,” such as appearing intoxicated, repeatedly reporting lost prescriptions, or frequently switching doctors. Some doctors and clinics make testing decisions on a patient-by-patient basis taking into account those red flags or patient history. Others apply universal policies, which may be aimed at preventing discrimination. Some insurance companies and state Medicaid systems also have testing requirements.

ADHD stimulants, opioid pain medications, and some other drugs are classified as controlled substances, which are tightly regulated because they can be addictive or misused.

ADHD patients subjected to frequent drug screens say the tests can be time-consuming and expensive. Some feel stigmatized.

A.C. Shilton felt relieved when she was diagnosed with ADHD in her mid-30s. The farmer and freelance journalist from rural Tennessee said the diagnosis explained why she felt so disorganized and forgetful, and as if her brain were a motor running all day. Shilton said her medication slows that motor down.

The 38-year-old Jamestown resident said her first doctor ordered urine tests once a year. That doctor eventually closed his practice, and Shilton said her next physician made her take a test at nearly every visit.

“You go in to get the standard of care, which is this medicine, and you’re kind of treated like you’re a bad person again; there’s some shame associated with that,” Shilton said.

She was also upset after learning office staffers were incorrect when they told her that urine testing was required by law — something that other ADHD patients posting on social media forums said had happened to them too.

Shilton said few doctors treat adult ADHD patients in her rural community. She now drives more than an hour to a different clinic, which doesn’t require her to take as many drug tests.

Travis Gordon, 47, of Charlotte, North Carolina, has gone to the same ADHD clinic for more than 10 years. Gordon said he wasn’t drug-tested in the first few years. Then, for several years, he had to give a urine sample every three months. During much of the covid-19 pandemic, he wasn’t tested. Now, he’s screened every six months.

“We shouldn’t have to feel like street criminals to get drugs that are needed for our daily success,” Gordon said.

Gordon said it would make sense for doctors to order tests more frequently as they get to know new patients. But he said he doesn’t understand why such testing should continue for people like him, established patients who properly take their medication.

Traci Camper, 50, of northeastern Tennessee, said she has “never even tried a cigarette,” much less used illicit drugs, but her doctor has required urine tests every three months for more than 10 years. Camper said the process can be inconvenient but she’s ultimately OK with the tests, especially since she lives in an area with high rates of drug abuse.

The clinics that Shilton, Gordon, and Camper went to did not respond to KHN’s requests for interviews about their testing policies.

Adults are diagnosed with ADHD if they have multiple, frequent symptoms so severe they interfere with work, relationships, or other aspects of life. Treatments include therapy and medication, most often stimulants.

ADHD patients have been affected by the response to the opioid crisis, which has led to more scrutiny for all controlled medications. Some have reported trouble filling their prescriptions as drug distribution companies limit sales to certain pharmacies. Some patients, especially rural ones, could face obstacles if the federal government reverts to pre-pandemic rules that require at least one in-person appointment to receive controlled drugs via telehealth.

Chaplin said doctors who treat ADHD may feel the need to be extra vigilant with drug testing because of this increased scrutiny, or due to the risk of misuse.

An estimated 3.7 million Americans 12 or older misused prescription stimulants in 2021, and 1.5 million had a prescription stimulant use disorder, according to the National Survey on Drug Use and Health. Americans are more likely to misuse or be addicted to prescription opioids, sedatives, and tranquilizers, the agency said.

Adults with ADHD are more likely to have a substance use disorder than those without the condition, according to the Substance Abuse and Mental Health Services Administration.

Although there aren’t formal standards, several health care organizations and professionals have made recommendations to prevent and detect adult ADHD stimulant misuse. Suggestions include requiring patients to sign prescription-agreement contracts and regularly checking databases that show all controlled medications each patient is buying.

Chaplin said there’s little research into how effective any method is at preventing medication misuse.

A recent survey found that 42% of family physicians and 21% of college health professionals who treat adult ADHD require their patients to submit random urine drug screens.

Gordon, Camper, and some ADHD patients on social media forums said their drug screens have come at predictable intervals, instead of random ones.

Dr. Sidarth Wakhlu, a psychiatrist who specializes in treating substance use disorders at the University of Texas Southwestern Medical Center in Dallas, said some of his patients also have ADHD. He suggests drug-testing most ADHD patients once or twice a year. For “someone who has no addiction history, has no red flags, every three months is an overkill,” he said.

The cost of drug testing is as variable as the frequency.

For example, Dr. Michael Fingerhood at Johns Hopkins University uses urine tests that cost as little as $60 before insurance. Fingerhood makes testing decisions case by case for patients who take controlled substances to treat ADHD, pain, or opioid addiction.

Gordon used to pay $110 for each of his tests when he had insurance his doctor did not accept. Shilton’s insurance was billed $545 for a test. Shilton said she complained to a nurse who said, in the future, she could use a less expensive test.

Shilton said she replied, “Well, why aren’t we doing that to begin with? Why are we doing this extremely fancy drug testing?”

Wakhlu said the more expensive urine tests can identify specific types and quantities of drugs. Such tests are usually used to confirm the results of initial, less pricey tests, according to the Centers for Disease Control and Prevention.

Wakhlu said that when test results show a patient might be misusing stimulants, doctors should initiate a non-accusatory conversation to discuss the results and, if needed, offer help. He also said it’s important to emphasize safety, such as how taking too much ADHD medication or combining it with other stimulants, such as methamphetamine, can be dangerous.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Uno de cada 4 adolescentes en Colorado informó que podía acceder a una pistola cargada en 24 horas, según los resultados de una encuesta publicada el lunes 27 de marzo. Casi la mitad de esos adolescentes dijeron que les tomaría menos de 10 minutos conseguir un arma.

“Eso es tener mucho acceso y en poco tiempo”, dijo Virginia McCarthy, estudiante de doctorado en la Escuela de Salud Pública de Colorado y autora principal de la carta editorial que describe los hallazgos de la investigación publicados en la revista médica JAMA Pediatrics.

Los resultados de la encuesta se publicaron en un momento difícil para los habitantes de Colorado, que hace poco enfrentaron otro tiroteo en una escuela.

El 22 de marzo, un estudiante de 17 años disparó e hirió a dos administradores escolares en la secundaria East High School en Denver. La policía encontró su cuerpo en las montañas al oeste de Denver, en el condado de Park, y confirmó que había muerto de una herida de bala autoinfligida. Otro estudiante de East High School murió de un disparo en febrero mientras estaba sentado en su auto afuera de la escuela.

El tiempo que toma acceder a un arma es importante, dijo McCarthy, especialmente en casos de intento de suicidio, decisiones que para los adolescentes suelen ser impulsivas. En una investigación de personas que intentaron suicidarse, casi la mitad dijo que el tiempo entre pensar en hacerlo y actuar fue menos de 10 minutos.

Al tomar medidas que limiten el acceso a las armas de fuego, como guardar las pistolas bajo llave y descargadas, se extiende el tiempo en que la persona puede actuar por impulso y aumenta la probabilidad de que se arrepienta o de que alguien intervenga.

“La esperanza es comprender el concepto de acceso para alargar ese lapso y mantener a los niños lo más seguros posible”, agregó McCarthy.

Los datos de la investigación provienen del estudio Healthy Kids Colorado, una encuesta realizada cada dos años con una muestra aleatoria de 41,000 estudiantes de escuela media y secundaria. La encuesta de 2021 le hizo la siguiente pregunta a los jóvenes: “¿Cuánto tiempo te llevaría estar listo para disparar un arma cargada sin el permiso de tus padres?”.

En Colorado, los estudiantes indígenas americanos reportaron el mayor acceso a armas cargadas, de un 39%, incluyendo un 18% que dijeron poder obtener un arma en 10 minutos (comparado con el 12% de todos los jóvenes que participaron en la encuesta). Los jóvenes indígenas americanos y nativos de Alaska también tienen las tasas más altas de suicidio.

Casi el 40% de los estudiantes en zonas rurales reportaron tener acceso a armas de fuego, en comparación con el 29% de residentes de ciudades.

Colorado está pasando por una etapa tensa con respecto a la violencia armada entre los jóvenes. A principios de este mes, cientos de estudiantes dejaron sus aulas y caminaron casi 2 millas hasta el Capitolio estatal para abogar por leyes de control de armas y escuelas más seguras. Enfrentaron a los legisladores nuevamente la semana pasada, luego del tiroteo en la escuela secundaria del día 22.

La Legislatura estatal está considerando varios proyectos de ley para prevenir la violencia armada.

Estos incluyen aumentar la edad mínima para comprar o poseer un arma a 21 años; establecer un período de espera de tres días para poder comprar un arma de fuego; limitar las protecciones legales para los fabricantes y vendedores de armas y ampliar el grupo de personas que pueden solicitar órdenes de protección por riesgo extremo para confiscar las armas de personas que están en riesgo de lastimar a otras o de suicidarse.

Según los Centros para el Control y la Prevención de Enfermedades (CDC), en 2020 las armas de fuego fueron la principal causa de muerte entre las personas de 19 años o menores, al superar el número de muertes por accidentes automovilísticos. Y las muertes de niños por armas de fuego aumentaron durante la pandemia, con un promedio de siete niños por día muriendo a causa de un arma, en 2021.

En los últimos 25 años, Colorado ha sufrido una serie de tiroteos en escuelas, incluyendo en Columbine High School en 1999, Platte Canyon High School en 2006, Arapahoe High School en 2013 y STEM School Highlands Ranch en 2019.

Aunque los tiroteos en las escuelas reciben más atención, la mayoría de las muertes de adolescentes por armas de fuego son suicidios.

“El problema del suicidio en los adolescentes es mayor que nunca”, dijo el doctor Paul Nestadt, investigador del Johns Hopkins Center for Gun Violence Solutions. “Esto tiene que ver en parte con el hecho de que cada vez hay más armas accesibles para los jóvenes”.

Si bien la posesión de armas presenta un mayor riesgo de suicidio para todos los grupos etarios, los adolescentes son particularmente vulnerables, dado que las habilidades para controlar los impulsos no suelen estar completamente desarrolladas en sus cerebros.

“Un adolescente puede ser inteligente y saber cómo manejar correctamente un arma de fuego, pero ese mismo adolescente en un momento de desesperación puede actuar impulsivamente sin pensar en las consecuencias”, dijo la doctora Shayla Sullivant, psiquiatra de niños y adolescentes en el hospital infantil Children’s Mercy Kansas City. “Las áreas del cerebro que se ocupan de tomar decisiones no están completamente maduras hasta la adultez”.

Otras investigaciones han demostrado que los padres y sus hijos tienen distintas ideas sobre el acceso a las armas de fuego en el hogar. Un estudio de 2021 indicó que el 70% de los padres que tienen armas en sus casas piensan que sus hijos no pueden agarrarlas, pero el 41% de los niños de esas mismas familias dijeron que podrían conseguir esas armas en dos horas.

“Hacer que las armas sean inaccesibles no significa solo bloquearlas. Significa asegurarse de que el niño no sepa dónde están las llaves o no pueda adivinar la combinación”, dijo Catherine Barber, investigadora principal del Harvard Injury Control Research Center de la Escuela de Salud Pública TH Chan de la Universidad de Harvard. “Los padres se olvidan con qué facilidad sus hijos pueden adivinar la combinación o verlos ingresar los números, o ver dónde se guardan las llaves”.

Si un adolescente tiene sus propias armas para la caza o el deporte, estas también deben mantenerse bajo el control de los padres cuando no se están usando, dijo.

El próximo paso de los investigadores de Colorado será indagar más a fondo para entender en dónde los adolescentes están consiguiendo armas, para poder adaptar las estrategias de prevención a distintos grupos de jóvenes.

“Al darle un poco más de contexto a estos datos, podremos comprender mejor qué tipos de educación y prevención se pueden implementar”, dijo McCarthy.

Markian Hawryluk:
MarkianH@kff.org,
@MarkianHawryluk

This story originally appeared at khn.org.

For some counties and cities that share a public health agency with other local governments, differences over mask mandates, business restrictions, and other COVID preventive measures have strained those partnerships. At least two have been pushed past the breaking point.

A county in Colorado and a small city in Southern California are splitting from their longtime public health agencies to set up their own local departments. Both Douglas County, Colorado, and West Covina, California, plan to contract some of their health services to private entities.

In Douglas County, which is just south of Denver and has one of the nation’s highest median household incomes, many residents had opposed mask mandate guidance from the Tri-County Health Department, a partnership among Adams, Arapahoe, and Douglas counties. Tri-County issued a mask order for the counties’ school districts in September 2021 and, within days, conservative Douglas County announced its commissioners had voted unanimously to form its own health department.

Douglas County, which in 1966 joined what was then called the Tri-County District Health Department, is phasing out of the partnership, with plans to exit entirely by the end of this year. It has already taken over many of its own COVID relief efforts from Tri-County.

It is contracting things like COVID case investigation, contact tracing, and isolation and quarantine guidance to a private consultant, Jogan Health Solutions, founded in early 2021. The contract is reportedly worth $1.5 million.

“We believe the greatest challenges are behind us … those associated with being one of three counties with differing and competing public health demands, on a limited budget,” Douglas County spokesperson Wendy Manitta Holmes said in a statement.

Daniel Dietrich, Jogan Health’s president, declined a request for an interview. “All of the data that Jogan Health is collecting is being relayed directly to Douglas County so that public policy aligns with real-time data to keep the residents of Douglas County safe,” Jogan Health spokesperson Sam Shaheen said in a prepared statement.

Lapses in food efforts possible

A similar situation is playing out east of Los Angeles, in West Covina, California. Its City Council has voted to terminate its relationship with the Los Angeles County Department of Public Health over disagreements about COVID shutdowns.

West Covina officials have criticized the county health department’s COVID restrictions as a one-size-fits-all approach that may work for the second-largest city in the U.S., but not their suburb of about 109,500 people. West Covina plans to join Long Beach, Pasadena, and Berkeley as one of a small number of California cities with its own health agency. A date for the separation has not been set.

As in Douglas County, West Covina plans to contract some services to a private consultant, Transtech Engineers, that works mainly on city engineering projects and federal contracts, according to its website. Transtech officials did not respond to requests for comment.

West Covina Councilman Tony Wu and area family physician Dr. Basil Vassantachart are leading efforts to form the city’s own department. They hope L.A. County’s oversight of about 10 million people — “bigger than some states,” as Vassantachart noted — can be broken up into regional departments.

Amitabh Chandra, who directs health policy research at the Harvard Kennedy School of Government, said the private sector won’t necessarily have better answers to a public health problem. “It might be the case that they’re good at delivering on some parts of what needs to be done, but other parts still have to be done in-house,” Chandra said.

Jeffrey Levi, a professor of health policy and management at the George Washington University, suggests there are too many local health departments in the U.S. and there should be more regionalization, rather than splitting into smaller departments.

“It’s very hard to effectively spend money and build the foundational capabilities that are associated with a meaningful public health department,” Levi said. “Doing this just because of anger at something like a mask ordinance is really unfortunate.”

Levi noted that public health departments are responsible for everything from restaurant and septic system inspections to administering the Special Supplemental Nutrition Program for Women, Infants, and Children, or WIC, a federal food assistance program. If a department is not adequately resourced or prepared, residents could see lapses in food or water safety efforts in their community, Levi said.

“L.A. County Public Health Department is one of the most sophisticated, and one of the most robust health departments in the country,” Levi said. “You are losing access to just a wide, wide range of both expertise and services that will never be replicable at the local level. Never.”

“The public will be hurt in ways that are not instantly measurable,” he added.

Building from scratch

The most recent major private-sector takeover of public health was a flop. A private nonprofit, the Institute for Population Health, took over Detroit’s public health functions in 2012 as the city was approaching bankruptcy.

The experiment failed, leaving a private entity unable to properly oversee public funding and public health concerns placed on the back burner amid the city’s economic woes. Residents also didn’t have a say in where the money went, and the staff on the city’s side was stripped down and couldn’t properly monitor the nonprofit’s use of the funds. By 2015, most services transferred back to the city as Detroit emerged from bankruptcy in 2014.

“That private institute thought it was going to issue governmental orders until it was informed it had no power,” said Denise Chrysler, who directs the Network for Public Health Law’s Mid-States Region at the University of Michigan School of Public Health.

In Colorado, Tri-County’s deputy director, Jennifer Ludwig, expressed concerns about Douglas County creating non-COVID programs essential to the functioning of a public health department.

“We have programs and services that many single-county health departments are not able to do just because of the resources that we can tap into,” Ludwig said. “Building that from scratch is a huge feat and will take many, many, many years.”

There are also practical benefits. A larger health department, according to Ludwig, is more competitive in securing grant funding, can attract and retain high-quality expertise like a data team, and can buy supplies in bulk.

But West Covina’s Wu accepts that the city will not be able to build its department overnight. “You have to start small,” he said.

Douglas County and West Covina face another key snag: hiring amid a national public health worker shortage. Douglas County officials say they are conducting a national search for an executive director who will determine the new health department’s staffing needs.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

This commentary originally appeared in the Nevada Current.

In 2020 the price of oil crashed, even falling to less than zero one day. Traders actually had to pay buyers to get them to take oil contracts off their hands.

Oil companies would prefer not to sell oil unless they can make money off it. Oil companies are just funny that way. So U.S. producers curtailed production. A lot.

U.S. oil production is still about 12% less than it was pre-pandemic, and isn’t projected to get back to pre-pandemic levels until next year. Demand for petroleum products, by contrast, has rebounded to pre-pandemic levels.

Investor pressure did much to stall a rebound in production, and continues to do so. Investors prefer that the oil companies spend their money on dividends and stock buybacks instead of new field development.

In the meantime, OPEC+ is in no rush to bail out the world.

Russia is the world’s third largest oil producer, behind the U.S. and Saudi Arabia. Joe Biden hasn’t sanctioned Russian oil because people are paying enough for gas already. But Russian oil is effectively off the market anyway because traders don’t want to touch it. “Global financial institutions are doing the heavy lifting and blanket banning anything with Russia written on the documentation,” according to an energy analyst with the futures trading firm OANDA. Oil production and sales evidently aren’t as accurately reported as in the U.S., but a British firm that watches the industry estimates that nearly 70% of Russian crude has no buyers.

Combine Russia’s role as a key oil producer with the anxiety over its invasion of Ukraine, and you get traders worrying that oil supply will be further limited, which in turn increases demand and the price. Bullish traders keep buying, betting the price will go higher still.

Which makes the price go higher now.

Why Colorado drillers are unlikely to pump more oil amid Russia-Ukraine crisis

And all of that’s on top of prices that had already been rising prior to Putin’s war, for reasons noted above.

When Republicans aren’t blaming Biden instead of Vladimir Putin for Putin’s war of aggression, they’re blaming Biden “for not reopening America’s energy sector,” as candidate for U.S. Senate Adam Laxalt put it the other day. 

Laxalt seems to spend most of his time coming up with new and painfully overwrought ways to warn of the existential threat posed by any and all non-Trumpism, so it’s hard to know how much bandwidth he has left to review energy market conditions.

But the Republican claim that Biden has “crippled” (another Laxaltism) U.S. energy production is routinely premised on two Biden administration actions: canceling the Keystone XL Pipeline and pausing new oil and gas leasing on public lands.

As I’ve noted before:

Even if Biden hadn’t canceled the Keystone XL and it had proceeded as planned, it would not be delivering any oil to the U.S until 2023 at the earliest. There are a lot of reasons for high gas prices. Biden’s decision on that pipeline isn’t one of them and has exactly nothing to do with the price of gas today. The pause on leasing only applies to new leasing and does nothing to prohibit or even limit drilling on millions of acres of public land that, according to the Bureau of Land Management, is currently available for development. Biden isn’t responsible for oil company resistance to drill. Investors are.

The main congressional Republican initiative right now to alleviate pain at the pump is to “push for expanded domestic energy production” by reversing those two actions. But neither action is hindering domestic energy production now (and by the way oil flowing through the Keystone XL would not be domestic but Canadian). If anything expands domestic energy production anytime soon, it will be oil selling at (checks Sunday morning price) $115.70 per barrel, not vapid boilerplate Republican talking points.

Many and maybe most voters, perhaps only slightly better informed than Laxalt, don’t care about any of the things discussed above. As far as Joe & Jill Voter are concerned, gas prices are high, so it must be the party in power’s fault, and that’s that.

Republicans know – and love – this. Just as they have no credible policy fixes for today’s high prices at the pump, neither do they have any policy for fighting inflation in general. The only solid position the GOP has on rising prices is to hope they stay high enough long enough to assure Democrats lose in November.

The U.S. is the world’s largest oil producer, accounting for 20% of global oil production. And the U.S. consumes about 20% of global oil production, also more than any other nation.

The U.S. has about 4% of the world’s population.

The U.S. doesn’t have an oil production problem. It has an oil consumption problem. 

A version of this column was originally published in the Daily Current newsletter, which you can subscribe to, for free, here.