At this decades-old psychiatric hospital on the edge of the Tennessee River, an intense storm could submerge the building in 11 feet of water, cutting off all roads around the facility, according to a sophisticated computer simulation of flood risk.

Aurora, a young woman who was committed to Peninsula as a teenager, said the hospital sits so close to the river that it felt like a moat keeping her and dozens of other patients inside. Ñî¹óåú´«Ã½Ò•îl Health News agreed not to publish her full name because she shared private medical history.

“My first feeling is doom,” Aurora said as she watched the simulation of the river rising around the hospital. “These are probably some of the most vulnerable people.”

Covenant Health, which runs Peninsula Hospital, said in a statement it has a “proactive and thorough approach to emergency planning” but declined to provide details or answer questions.

Peninsula is one of about 170 American hospitals, totaling nearly 30,000 patient beds from coast to coast, that face the greatest risk of significant or dangerous flooding, according to a months-long Ñî¹óåú´«Ã½Ò•îl Health News investigation based on data provided by Fathom, a company considered a leader in flood simulation. At many of these hospitals, flooding from heavy storms has the potential to jeopardize patient care, block access to emergency rooms, and force evacuations. Sometimes there is no other hospital nearby.

Much of this risk to hospitals is not captured by flood maps issued by the Federal Emergency Management Agency, which have served as the nation’s de facto tool for flood estimation for half a century, despite being incomplete and sometimes decades out of date. As FEMA’s maps have become divorced from the reality of a changing climate, private companies like Fathom have filled the gap with simulations of future floods. But many of their predictions are behind a paywall, leaving the public mostly reliant on free, significantly limited government maps.

“This is highly concerning,” said Caleb Dresser, who studies climate change and is both an emergency room doctor and a Harvard University assistant professor. “If you don’t have the information to know you’re at risk, then how can you triage that problem?”

The deadliest hospital flooding in modern American history occurred 20 years ago during Hurricane Katrina, when the bodies of 45 people were recovered from New Orleans’ Memorial Medical Center, including some patients whom investigators . More flooding deaths were narrowly avoided one year ago when helicopters rescued dozens of people as Hurricane Helene engulfed Unicoi County Hospital in Erwin, Tennessee.

Rebecca Harrison, a paramedic, called her children from the Unicoi roof to say goodbye.

“I was scared to death, thinking, ‘This is it,’” Harrison told CBS News, which interviewed Unicoi survivors as part of Ñî¹óåú´«Ã½Ò•îl Health News’ investigation. “Alarms were going off. People were screaming. It was chaos.”

The investigation — among the first to analyze nationwide hospital flood risk in an era of warming climate and worsening storms — comes as the administration of President Donald Trump has slashed and and also dismantled FEMA programs designed to protect hospitals and other important buildings from floods.

When asked to comment, FEMA said flooding is a common, costly, and “under appreciated” disaster but made no statement specific to hospitals. Spokesperson Daniel Llargués defended the administration’s changes to FEMA by reissuing an August statement that dismissed criticism as coming from “bureaucrats who presided over decades of inefficiency.”

Alice Hill, an Obama administration climate risk expert, said the Trump administration’s dismissal of climate change and worsening floods would waste billions of dollars and endanger lives.

In 2015, Hill led the creation of the Federal Flood Risk Management Standard, which required that hospitals and other essential structures be elevated or incorporate extra flood protections to qualify for federal funding.

¹ó·¡²Ñ´¡ÌýÌýthe standard in March.

“People will die as a result of some of the choices being made today,” Hill said. “We will be less prepared than we are now. And we already were, in my estimation, poorly prepared.”

‘Flood Risk Is Everywhere’

The Ñî¹óåú´«Ã½Ò•îl Health News investigation identified more than 170 hospitals facing a flood risk by comparing the locations of more than 7,000 facilities to , a United Kingdom company that simulates flooding in spaces as small as 10 meters using laser-precision elevation measurements from the .

Hospitals were determined to have a significant risk if Fathom’s 100-year flood data predicted that a foot or more of water could reach a considerable portion of their buildings, excluding parking garages, or cut off road access to the hospital. A 100-year flood is an intense weather event that has roughly a 1% chance of occurring in any given year but can happen more often.

The investigation found heightened flood risks at large trauma centers, small rural hospitals, children’s hospitals, and long-term care facilities that serve older and disabled patients. At least 21 are critical access hospitals, with the next-closest hospital 25 miles away, on average.

Flooding threatens dozens of hospitals in coastal areas, including in Florida, Louisiana, Texas, and New York. Farther inland, flooding of rivers or creeks could envelop other hospitals, particularly in Appalachia and the Midwest. Even in the sun-soaked cities and arid expanses of the American West, storms have the potential to surround some hospitals with several feet of pooling water, according to Fathom’s data.

These findings are likely an undercount of hospitals at risk because the investigation overlooked pockets of potential flooding at some hospitals. It excluded facilities like stand-alone ERs, outpatient clinics, and nursing homes.

“The reality is that flood risk is everywhere. It is the most pervasive of perils,” said Oliver Wing, the chief scientific officer at Fathom, who reviewed the findings. “Just because you’ve never experienced an extreme doesn’t mean you never will.”

Dresser, the ER doctor, said even a small amount of flooding can shut down an unprepared hospital, often by interrupting its power supply, which is needed for life-sustaining equipment like ventilators and heart monitors. He said the most vulnerable hospitals would likely be in rural areas.

“A lot of rural hospitals are now closing their pediatric units, closing their psychiatry units,” Dresser said. “In a financially stressed situation, it can be hard to prioritize long-term threats, even if they are, for some institutions, potentially existential.”

Urban hospitals can face dangerous flooding, too. Fathom’s data predicts 5 to 15 feet of water around neighboring hospitals — Kadlec Regional Medical Center and Lourdes Behavioral Health — that straddle a tiny creek in Richland, Washington.

By Fathom’s estimate, a 100-year flood could cause the nearby Columbia River to spill over a levee that protects Richland, then loosely follow the creek to the hospitals. Some of the deepest flooding is estimated around Lourdes, which was built on land the U.S. Army Corps of Engineers set aside in 1961 as a “ponding and drainage easement.”

At the time, this land was supposed to be capable of storing enough water to fill at least 40 Olympic-size swimming pools, according to obtained through the Freedom of Information Act. A mental health facility has occupied this spot since the 1970s.

Both Kadlec and Lourdes said in statements that they have disaster plans but did not answer questions about flooding. Tina Baumgardner, a Lourdes spokesperson, said government flood maps show the hospital is not in a 100-year flood plain.

This is not uncommon. Of the more than 170 hospitals with significant flood risk identified by Ñî¹óåú´«Ã½Ò•îl Health News, one-third are located in areas that FEMA has not designated as flood hazard zones.

Sometimes the difference is stark. For example, at Ochsner Choctaw General in Alabama — the only hospital for 30 miles in any direction — FEMA maps suggest a 100-year flood would overflow a nearby creek but spare the hospital. Fathom’s data predicts the same event would flood most of the hospital with 1 to 2 feet of water, including the ER and the helicopter pad.

Ochsner Health did not answer questions about flooding preparations at Choctaw General.

FEMA flood maps were launched in the ’60s as part of the National Flood Insurance Program to determine where insurance is required and building codes should include flood-proofing. According to a FEMA statement, the maps show only a “snapshot in time” and are not intended to predict where flooding will or won’t happen.

FEMA spokesperson Geoff Harbaugh said the agency intends to modernize its maps through the Future of Flood Risk Data initiative, which will enable the agency to “better project flood risk” and give Americans “the information they need to protect their lives and property.”

The program was launched by the first Trump administration in 2019 but has since received sparse public updates. Harbaugh declined to provide a detailed update or timeline for the program.

Chad Berginnis, executive director of the Association of State Floodplain Managers, said it is unknown whether FEMA is still trying to upgrade its maps under Trump, as the agency has cut off communications with outside flooding experts.

“There has been not a single bit of loosening of what I’m calling the FEMA cone of silence,” Berginnis said. “I’ve never seen anything like it.”

Floods are expected to worsen as a warming climate fuels stronger storms, drenching areas that are already flood-prone and bringing a new level of flooding to areas once considered lower risk.

The National Oceanic and Atmospheric Administration has said that 2024 was the warmest year on record — more than 2 degrees Fahrenheit higher than the 20th-century average. Scientists across the globe that each degree of global warming correlates to a 4% increase in the intensity of extreme rainfall.

“Warmer air can hold more moisture, so this leads us to experience heavier downpours,” said Kelly Van Baalen, a sea level rise expert at the nonprofit . “A 100-year flood today could be a 10-year flood tomorrow.”

Intensifying storms raise concerns about Peninsula Hospital, which has operated for decades mere feet from the Tennessee River but has no known history of flooding.

Peninsula spokesperson Josh Cox said the river is overseen by the Tennessee Valley Authority, which uses dams to manage water levels and generate electricity. Estimates provided by the TVA suggest the dams could keep Peninsula dry even in a 500-year flood.

Fathom, however, said its flood simulation accounts for the dams and stressed that a large enough storm could drop more rain than even the TVA could control. These predictions are echoed by another flood modeling firm, , which also says an intense storm could cause more than 10 feet of flooding in the area around Peninsula.

“It’s a hospital right on the banks of a major American river,” said Wing, the Fathom scientist. “It just isn’t conceivable that such a location is risk-free.”

Jack Goodwin, 75, a retired TVA employee who has lived next to Peninsula for three decades, said he was confident the dams could protect the area. But after reviewing Fathom’s predictions, Goodwin began to research flood insurance.

“Water can rise quickly and suddenly, and the destruction is tremendous,” he said. “Just because we’ve never seen it here doesn’t mean we won’t see it.”

‘All the Elements of a Real Disaster’

One year ago, as Hurricane Helene carved a deadly path across Southern Appalachia, Angel Mitchell was visiting her ailing mother at Unicoi County Hospital in the tiny town of Erwin, Tennessee.

Swollen by Helene, the nearby Nolichucky River spilled over its banks and around the hospital, which was built in a flood plain. Staff tried to bar the doors, Mitchell said, but the water got in, trapping her and others inside. The lights went out. People fled to the roof, where the roar of rushing water nearly drowned out the approach of rescue helicopters, Mitchell said.

Ultimately, 70 people from the hospital, including Mitchell and her mother, were airlifted to safety on Sept. 27, 2024. The hospital remains closed, and the company that owns it, Ballad Health, has said its .

“Why allow something — especially a hospital — to be built in an area like that?” Mitchell told CBS News. “People have to rely on these areas to get medical help, and they’re dangerous.”

Beyond Unicoi, Ñî¹óåú´«Ã½Ò•îl Health News identified 39 inland hospitals — including 16 in Appalachia — that Fathom predicts could flood when nearby rivers, creeks, or drainage canals overspill their banks, even in storms far less intense than Helene.

For example, in the Cumberland Mountains of southwestern Virginia, a 100-year flood is projected to cause Slate Creek to engulf Buchanan General Hospital in more than 5 feet of water.

Near the Great Lakes in Erie, Pennsylvania, LECOM Medical Center and Behavioral Health Pavilion could become flooded by a small drainage creek that is less than 50 feet from the front door of the ER.

Neither Buchanan nor LECOM responded to questions about flooding or preparations.

And in West Virginia’s capital of Charleston, where about 50,000 people live at the junction of two rivers in a wide and flat valley, a single storm could potentially flood five of the city’s six hospitals at once, along with schools, churches, fire departments, and other facilities.

“I hate to say it,” said Behrang Bidadian, a flood plain manager at the , “but it has all the elements of a real disaster.”

At the largest hospital in Charleston, CAMC Memorial Hospital, Fathom predicts that the Kanawha River could bring as much as 5 feet of flooding to the ER. Across town, the Elk River could surround CAMC Women and Children’s Hospital, cutting off all exits.

And in the center of the city, where the overflowing rivers are predicted to merge, Thomas Orthopedic Hospital could be besieged by more than 10 feet of water on three sides.

WVU Medicine, which owns Thomas Orthopedic Hospital, did not respond to requests for comment.

CAMC spokesperson Dale Witte said the hospital system is aware of its flood risk and has prepared by elevating electrical infrastructure and acquiring flood-proofing equipment, like a deployable floodwall. CAMC also regularly revises and drills its disaster plans, Witte said, although he added that hospitals there have never been tested by a real flood.

Shanen Wright, 48, a lifelong Charleston resident who lives near CAMC Memorial, said many in the city have little worry about flooding in the face of more immediate problems, like the opioid epidemic and the decline of manufacturing and mining.

Tugboats and coal barges sail past his neighborhood as if they were cars on his street.

“It’s not to say it’s not a possibility,” he said. “I’m sure the people in Asheville and the people in Texas, where the floods took so many lives, they probably didn’t see it coming either.”

‘The Water Is Coming’

Despite wide scientific consensus that climate change fuels more dangerous weather, the Trump administration has that concerns about global warming are overblown. In a speech to the United Nations in September, Trump called climate change “the greatest con job ever perpetrated on the world.”

The Trump administration has made deep staff and funding cuts to FEMA, NOAA, and the National Weather Service. At FEMA, the cuts prompted 191 current and former employees to in August warning that the agency is being dismantled from within.

Daniel Swain, a University of California climate scientist, said the administration’s rejection of climate change has left the nation less prepared for extreme weather, now and in the future.

“It’s akin to enforcing malpractice scientifically,” Swain said. “Imagine making a medical decision where you are not allowed to look at 20% of the patient’s vital signs or test results.”

Under Trump, FEMA has also taken actions critics say will leave the nation more vulnerable to flooding, specifically:

• FEMA disbanded the Technical Mapping Advisory Council, which had to modernize its flood maps to estimate future risk and account for the impacts of climate change.
• FEMA canceled its program, which provided grants to help communities and vital buildings, including hospitals, protect themselves from floods and other natural disasters.
• And after stopping enforcement early this year, FEMA the Federal Flood Risk Management Standard, which was designed to harden buildings against future floods and save tax dollars in the long run.

Berginnis, of the Association of State Floodplain Managers, said the administration’s unwillingness to prepare for climate change and worsening storms would result in a dangerous and costly cycle of flooding, rebuilding, and flooding again.

“The president is saying we are closed for business when it comes to hazard mitigation,” Berginnis said. “It bugs me to no end that we have to have reminders — like people dying — to show us why it’s important to make these investments.”

FEMA did not answer specific questions about these decisions. In the statement to Ñî¹óåú´«Ã½Ò•îl Health News, spokesperson Llargués touted the administration’s response to flooding in Texas and New Mexico and said FEMA had provided billions of dollars to help people and communities recover and rebuild. He did not mention any FEMA funding for protecting against future floods.

Few hospitals understand this threat more than the former Coney Island Hospital in New York City, which has suffered catastrophic flooding before and has prepared for it to come again.

Superstorm Sandy in 2012 forced the hospital to evacuate hundreds of patients. When the water receded, fish and a sea turtle were found in the building.

Eleven years later, the facility reopened as Ruth Bader Ginsburg Hospital, transformed by a FEMA-funded $923 million reconstruction project that added a 4-foot floodwall and elevated patient care areas and utility infrastructure above the first floor.

It is now likely one of the most flood-proofed hospitals in the nation.

But, so far, no storm has tested the facility.

Svetlana Lipyanskaya, CEO of NYC Health+Hospitals/South Brooklyn Health, which includes the rebuilt hospital, said the question of flooding is “not an if but a when.”

“I hope it doesn’t happen in my lifetime,” she said, “but frankly, I’d be surprised. The water is coming.”

Methodology

After Hurricane Helene made landfall a year ago, a raging river flooded a rural hospital in eastern Tennessee. Patients and employees were rescued from the rooftop. Floods have hit hospitals from New York to Nebraska to Texas in recent years. We wanted to determine how many other U.S. hospitals face similar peril. Ultimately, we found more than 170 hospitals at risk.

For this analysis, we used data from , a United Kingdom-based company that specializes in flood-risk modeling across the globe. To assess the United States’ vulnerability, Fathom uses sophisticated computer simulations and detailed terrain data covering the country. It accounts for environmental factors such as climate change, soil conditions, and many rivers and creeks not mapped by other sources. Fathom’s modeling has been and , the World Bank, the Nature Conservancy, and government agencies in Florida, Texas, and elsewhere. The Iowa Flood Center has .

Through a data use agreement, Fathom shared its U.S. mapping data that predicts areas with at least a 1% chance of flooding in any given year. Fathom’s data estimates the effects of of flooding: coastal, fluvial (from overflowing rivers, lakes, or streams), and pluvial (rainfall that the ground can’t absorb). The data also accounts for dams, reservoirs, and other structures that defend against floods.

To identify at-risk hospitals, we used a publicly available Department of Homeland Security database containing the GPS coordinates of more than 7,000 short-term acute, critical access, rehab, and psychiatric hospitals — basically any hospital with inpatient services. (DHS under the Trump administration has discontinued public access to the database, so data for hospitals and other infrastructure is no longer widely available.)

Using GPS coordinates as the centerpoint, we created a circle with a 150-yard radius around each hospital, which in most cases captured the building plus nearby grounds and access roads. We then mapped Fathom’s flood-risk data to see where it overlapped with these circles. We started by looking for hospitals where at least 20% of the circle’s area had a predicted flood depth of at least 1 foot. That gave us an initial list of more than 320 hospitals across the U.S.

From there, we visually inspected those hospitals using mapping software and Google Maps, both satellite and street view. We trimmed our list to only the hospitals where a considerable portion of the building or all access roads were predicted to have at least a foot of flooding.

If two hospitals were mapped to the same building — for instance, a small rehab facility within a large hospital — we counted only one hospital. We also excluded hospitals recently converted to nursing homes or for other uses.

We ended up with a list of 171 hospitals across the U.S. That is most likely an undercount. Some hospitals could still face significant impact from flooding that is not deep enough or widespread enough to fit our methodology. Our analysis also does not account for how flooding farther from a hospital could affect employees or patients. And it does not assess what steps hospitals may have already taken to prepare for severe weather events.

We also ran a spatial analysis comparing Fathom’s data with flood hazard maps from the Federal Emergency Management Agency, which in many cases are incomplete or haven’t been updated in years. We found that about a third of hospitals identified as flood risks by Fathom’s data did not overlap at all with FEMA’s 100- or 500-year hazard areas.

Fathom provided guidance and feedback as we developed our analysis.

CBS News correspondent David Schechter, photojournalist Chance Horner, and producer Aparna Zalani contributed to this report.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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“I’m comfortable here, but I’m having health issues,” said the 68-year-old, who retired from her job as a school cook several years ago after having a stroke. “Things are failing me.”

Her trailer sits halfway up a ridge miles from town and the local health clinic. Her phone and internet are “wacky sometimes,” she said. Adkins — who is fiercely independent and calls herself a “Mountain Momma” — worries she won’t be able to call for help if service goes out, which happens often.

To Frontier Communications, the telecommunications company that owns the line to her home, Adkins says: “Please come and hook me right.”

But she might be waiting years for better service, frustrated by her internet provider and left behind by troubled federal grant programs.

A quarter of West Virginia counties — including Lincoln, where the Mud River bends its way through hollows and past cattle farms — face two barriers to health care: They lack high-speed internet and have a shortage of primary care providers and behavioral health specialists, according to a Ñî¹óåú´«Ã½Ò•îl Health News analysis.

Years of Republican and Democratic administrations have tried to fix the nation’s broadband woes, through flawed attempts. Bad mapping, weak standards, and flimsy oversight have left Adkins and nearly 3 million other rural Americans in dead zones — with eroded health care services and where telehealth doesn’t reach.

Blair Levin, a former executive director of the Federal Communications Commission’s National Broadband Plan, called one rural program rollout during the first Trump administration “a disaster.”

It was launched before it was ready, he said, using unreliable federal maps and a reverse-auction process to select internet carriers. Locations went to the lowest bidder, but the agency failed to ensure winners had the knowledge and resources to build networks, said Levin, who is now an equity analyst with New Street Research.

The fund initially announced awards of $9.2 billion to build infrastructure in 49 states. By 2025, $3.3 billion of those awards were in default and, as a result, the program won’t connect 1.9 million homes and businesses, .

A $42 billion Biden-era initiative still may not help Adkins and many others shortchanged by earlier federal broadband grants. The new wave of funding, the Broadband Equity, Access, and Deployment Program, or BEAD, has an anti-waste provision and won’t provide service in places where previous grants were awarded — even if companies haven’t delivered on their commitments.

The use of federal money to get people connected is “really essential” for rural areas, said Ross DeVol, CEO and chairman of the board of Heartland Forward, a nonpartisan think tank based in Bentonville, Arkansas, that specializes in state and local economic development.

“Internet service providers look at the economics of trying to go into some of these communities and there just isn’t enough purchasing power in their minds,” DeVol said, adding that broadband expansion is analogous to rural electrification. Without high-speed internet, “you’re simply at a distinct disadvantage,” he added. “I’ll call it economic discrimination.”

‘I Got Books Full’

Adkins keeps spiral-bound notebooks and calendars filled with handwritten records of phone and internet outages.

In January, while bean soup warmed on the stove, she opened a notebook: “I got books full. Hang on.”

Her finger traced the page as she recounted outages that occurred about once a month last year. Adkins said she lost connectivity twice in November, again in October, and in July, May, and March. Each time she went for days without service.

Adkins pays Frontier Communications $102.13 a month for a “bundle” that includes a connection for her house phone and wireless internet access on her cellphone. Frontier did not respond to requests for comment on Adkins’ and other customers’ service.

Adkins, a widow, spends most of her time at home and said she would do video calls with her doctors if she could. She said she still has numbness on one side of her body after the stroke. She also has high blood pressure and arthritis and uses over-the-counter pain patches when needed, such as after she carries 30-pound dog food bags into the house.

She does not own a four-wheel-drive truck and, for three weeks in January, the snow and ice were so severe she couldn’t leave. “I’m stranded up here,” she said, adding that neighbors check in: “‘Do you have electric? Have you got water? Are you OK?’”

The neighbors have all seen Adkins’ line. The pale-yellow cord was tied off with green plastic ties around a pole outside her trailer. As it ran down the hill, it was knotted around tree trunks and branches, frayed in places, and, finally, collapsed on the ground under gravel, snow, and ice at the bottom of the hill.

Adkins said a deer stepping on the line has interrupted her phone service.

David and Billi Belcher’s double-wide modular home sits near the top of the ridge past Adkins’ home. Inside, an old hunting dog sleeps on the floor. Belcher pointed out a window toward where he said Frontier’s cable has remained unrepaired for years: “It’s laying on the ground in the woods,” he said.

Frontier is West Virginia’s legacy carrier, controlling most of the state’s old landlines since in 2010. Twelve years later, the company won nearly $248 million to install high-speed internet to West Virginia through the Rural Digital Opportunity Fund, an initiative launched during President Donald Trump’s first term.

“Big Daddy,” as local transit driver Bruce Perry called Trump, is popular with the people of Lincoln County. About 80% of the county’s voters picked the Republican in the last election.

The Trump administration awarded Frontier money to build high-speed internet to Upper Mud River Road residents, like Adkins, . Frontier has until , to build.

But the Belchers needed better internet access for work and could afford to pay $700 for a Starlink satellite internet kit and insurance, they said. Their monthly Starlink bill is $120 — a price many cannot manage, especially since Congress sunset an earlier program that helped offset the cost of high-speed plans for consumers.

Meanwhile, the latest broadband program to connect rural Americans is ensnared in Trump administration policy shifts.

The National Telecommunications and Information Administration, which administers the program, in April for states to finalize their plans during a “comprehensive review” of the program.

West Viriginia Gov. Patrick Morrisey, a Republican, would take an extension. The move, though, doesn’t make a lot of sense, said Evan Feinman, who left the agency in March after directing the broadband program for the past three years.

Calling the work already done in West Virginia an “incredible triumph,” Feinman said the state had completed the planning, mapping, and the initial selection of companies. The plan that was in place would have brought high-speed fiber lines to homes ahead of schedule and under budget, he said.

“They could be building today, and it’s just deeply disappointing that they’re not,” Feinman said.

When Feinman resigned in March, he stating that the new administration wants to take fiber away from homes and businesses and substitute it with satellite connections. The move, he said, would be more expensive for consumers and hurt rural and small-town America.

Morrisey, whose office declined to respond to requests for comment, said in his announcement that he wants to ensure West Virginia spends the money in a manner “consistent with program changes being proposed by the Trump Administration” and “evaluate a broader range of technology options.”

Commissioners from Grant County supporting fiber-optic cables rather than satellite-based connections like those provided by Elon Musk’s Starlink. Nationwide, 115 lawmakers from 28 states to federal leaders stating that changes could “delay broadband deployment by a year or more.”

For Adkins and others, the wait has been long enough.

While legislators in Washington and across the country bickered over the broadband program, Adkins went without phone and internet. By late March, she said, her 42-year-old son was increasingly worried, noting “you’re getting up in age.” He told her: “Mom, move out, get off of that hill.”

Worst-Case Scenario

A few miles from Upper Mud River Road, past the McDonald’s and across the road from the local library, Brian Vance sat in his downtown Hamlin, West Virginia, office. He said his company has been trying to “build up there for a while.”

Vance is a general manager for Armstrong Telephone and Cable, a regional telecommunications provider that competes with Frontier. He grew up in the community, and parents of a high school friend live off Upper Mud River. But he said “it’s very difficult” to build fiber along the rocky terrain to homes where “you are hoping that people will hook up, and if they don’t, well, you’ve lost a lot of money.”

A found that stringing fiber-optic lines along telephone poles would cost more than $5,000 per connection in some areas — work that would need big federal subsidies to be feasible.

Yet Vance said Armstrong cannot apply for the latest BEAD funding to help finance connections. And while he likes that the federal government is “being responsible” by not handing out two federal grants for the same area, Vance said, “we want to see people deliver on the grants they have.”

If Frontier hadn’t already gotten federal funds from the earlier Trump program, “we definitely would have applied to that area,” Vance said.

The 2022 assessment noted the community’s economy would not be sustainable without “ubiquitous broadband.”

High-speed internet brings more jobs and less poverty, said Claudia Persico, an associate professor at American University. Persico, who is also a research associate with the National Bureau of Economic Research, that found increased broadband internet leads to a reduction in the number of suicides as well as improvements in self-reported mental and physical health.

More than 30% of Lincoln County’s population reports cases of depression, according to data from the Centers for Disease Control and Prevention. The rate of opioid prescriptions dispensed in Lincoln County is down about 60% from 2014 to 2024 — but still higher than the state average, according to the West Virginia Board of Pharmacy.

Twenty percent of the county’s population lives below the poverty line, and residents are also more likely than the national average to experience heart disease, diabetes, and obesity.

Lincoln Primary Care Center offers telehealth services such as electronic medical records on a patient portal and a pharmacy app, said Jill Adkins, chief quality and risk officer at Southern West Virginia Health System, which operates the clinic.

But because of limited access, only about 7% of patients use telehealth, she said.

Della Vance was a patient at the clinic but said she has never used a patient portal. If she could, Vance said, she would check records on the baby she is expecting.

“You can’t really get on if you don’t have good service and no internet,” she said. “It makes me angry, honestly.”

Vance and her husband, Isaiah, live off a gravel road that veers from Upper Mud River. There is a tall pole with black wires dangling across the road from their small home. Pointing to the cables, Isaiah Vance said he couldn’t get phone service anymore.

Verizon announced plans last year to buy Frontier . The deal, which must be approved by federal and state regulators, is expected to be completed in early 2026, according to an .

In its federal , Frontier stated that it had taken on too much debt after emerging from bankruptcy and that debt would make it difficult to finish the work of installing fiber to customers in 25 states.

In West Virginia, Frontier’s Allison Ellis , seeking approval for the merger from state regulators, that Verizon will honor the rural program commitments. The previous month, in February, Frontier with the state public service commission to keep the number of customers using copper lines and the faster fiber-optic lines confidential.

Kelly Workman, West Virginia’s broadband director, said during a November interview that her office has asked federal regulators for “greater visibility” into Frontier’s rural program construction, particularly because those locations cannot win the Biden-era infrastructure money when it's available.

“The worst-case scenario would be for any of these locations to be left behind,” Workman said.

‘Money Cow’

Frontier’s progress installing fiber-optic lines and its unreliable service have frustrated West Virginians for years. In to the FCC, U.S. Sen. Shelley Moore Capito (R-W.Va.) cited “the failure of Frontier to deliver on promises to federal partners” and its “mismanagement” of federal dollars, which forced the state to pay back $4.7 million because of improper use and missed deadlines.

Michael Holstine, a longtime member of the West Virginia Broadband Enhancement Council, said the company has “just used West Virginia as a money cow.” Holstine has been fighting for the construction of fiber-optic lines in Pocahontas County for years. “I really just hope I get it before I die.”

Across the state, people like Holstine and Adkins are eager for updated networks, according to interviews as well as letters released under a public records request.

Chrissy Murray, vice president of Frontier’s external communications, acknowledged that the company was “building back our community efforts” in West Virginia after a bankruptcy filing and reorganization. She said there has been a “notable decline” in consumer complaints, though she did not provide specific numbers.

Murray said Frontier built fiber-optic cables to 20% of its designated rural funds locations as of the end of 2024. It has also invested in other infrastructure projects across the state, she said in a January email, adding that the company to West Virginia University’s rural Jackson’s Mill campus.

According to , Frontier has connected 6,100 — or fewer than 10% — of the more than 79,000 locations it was awarded in the Rural Digital Opportunity Fund program.

The FCC oversees the rural fund. The agency did not respond to a request for comment. Frontier expects to receive $37 million annually from the agency through 2032, .

In April, a from West Virginia residents filed as “support” for Frontier’s merger with Verizon appeared in the state regulatory docket:

“My support for this case depends on whether Verizon plans to upgrade or replace the existing Frontier infrastructure,” wrote one customer in Summers County, in the far southern corner of the state, adding, “West Virginians in my neck of the woods have been held hostage by Frontier for a generation now because no other providers exist.”

A customer from Hardy County, in the state’s northeastern corner, wrote: “This is [a] move by frontier to to [sic] escape its responsibility to continue services.”

‘D±ð±ð±è-¸é´Ç´Ç³Ù±ð»å’

Adkins moved to Upper Mud River with her husband, Bobby, decades ago.

For years, Bobby and Ada Carol Adkins ran a “carry-out” on Upper Mud River Road. The old building is still at the rock quarry just down the hill and around the curve from where her trailer sits.

It was the type of store where locals kept a tab — which Bobby treated too much like a “charity,” Adkins said. They sold cigarettes, beer, bread, bags of chips, and some food items like potatoes and rice. “Whatever the community would want,” she said.

Then, Bobby Adkins’ “health started deteriorating and money got tighter,” Adkins said. He died at 62 years old.

Now, Adkins said, “I’m having kidney problems. I got arthritis, they’re treating me for high blood pressure.”

Her doctor has begun sending notes over the internet to refill her blood pressure medicine and, Adkins said, “I love that!”

But Adkins’ internet was out again in early April, and she can’t afford Starlink like her neighbors. Even as Adkins said she is “deep-rooted,” her son’s request is on her mind.

“I’m having health problems,” Adkins said. “He makes a lot of sense.”

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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He was prescribed painkillers as a teenager for a series of sports injuries. He said the doctor never warned him they could be addictive. Julian didn’t learn that fact until years later, when he was cut off and began suffering withdrawal symptoms. At that point, he started siphoning pills from family members and buying them from others in his southern Maine community.

After his brother , Julian used opioids to cope with more than physical pain.

He stole to support his addiction, cycled in and out of jail and treatment, and overdosed 10 times, he said. His mother once gave him CPR on their bathroom floor.

Life was “hell on Earth,” said Julian, now 43 and in long-term recovery.

Like tens of thousands of others who have suffered similarly, Julian filed claims for compensation from pharmaceutical companies accused of fueling the opioid crisis.

Earlier this year, he received his first payout: $324.58.

That’s enough to fill his car with gas about eight times or pay about a tenth of the rent for an apartment he shares with his fiancee and two children.

Meanwhile, Maine’s Cumberland County, where Julian lives, has received more than $700,000 in opioid settlement money and expects nearly $1.6 million more in the coming years, according to a newly updated database from Ñî¹óåú´«Ã½Ò•îl Health News. Jurisdictions throughout his state have received more than $68 million to date, and governments nationwide have raked in upward of $10 billion, the database shows.

That discrepancy between individuals’ and governments’ compensations highlights a sense of injustice felt by people directly affected by the crisis who say their suffering is the reason that governments secured these settlements.

Opioid settlements with companies like Purdue Pharma, Walmart, and Johnson & Johnson have led to headline-grabbing multibillion-dollar payouts, but most of the windfall is flowing to state and local governments, not directly to victims of the crisis.

Only a handful of companies — those that filed for bankruptcy, including Purdue Pharma, Mallinckrodt, Endo, and Rite Aid — have set aside payouts for individuals. To qualify, people must have filed claims within a certain window and provided documents proving they were prescribed painkillers from that company. Even then, many victims will receive just a few thousand dollars, lawyers and advocates estimate. Most of these companies have not started paying yet, so victims might have to wait months or years more before seeing the cash.

In contrast, state and local governments have already received settlement money. To understand the size of those payouts, Ñî¹óåú´«Ã½Ò•îl Health News in January downloaded data from , the court-appointed firm administering many national opioid settlements, and used it to update a searchable database that allows users to determine how much their city, county, or state has received or expects to receive each year.

Governments are receiving that money because attorneys general argued that their states’ public safety, health, and social service systems were harmed by the opioid crisis. Jurisdictions are supposed to spend settlement money on addiction treatment, recovery, and prevention programs. But many affected individuals and families say governments have failed to adhere to that mission.

“At the very minimum, they could spend these dollars right to prevent the future loss of life,” said , a national recovery advocate and previous co-chair of a committee in the Purdue Pharma bankruptcy case, where he represented victims. “That is the opposite of what we’ve seen to date.”

In Pennsylvania, a group of bereaved family members raised similar concerns to Democratic Gov. Josh Shapiro, who finalized opioid settlements when he was attorney general.

“Instead of directing funds toward evidence-based solutions, you and your administration have allowed counties to divert these resources into law enforcement, ineffective programs, and initiatives that already have other funding streams available — disrespecting both our families and the lives lost,” they dated Feb. 14. “Meanwhile, bereaved families — many of whom have lost everything — have no financial relief.”

‘Governments Were Way More Powerful’

To be sure, many governments have spent millions of settlement dollars on treatment programs, recovery supports, distribution of overdose reversal medications, and other efforts. Some officials in charge of the money say those services, which reach many residents, can have a greater impact than individual payouts.

Will Simons, a spokesperson for the Pennsylvania governor, said in a statement that the Shapiro administration has invested nearly $90 million of settlement funds into treatment, recovery, harm reduction, and prevention initiatives, including for youths, a , and aimed at retaining workers in the addiction treatment and recovery field.

Many of the awarded organizations “support families who have lost loved ones to this crisis, providing counseling and other family supports,” Simons said.

A few jurisdictions have created fairly modest funds directed at individuals, such as to aid families who have lost loved ones to addiction, and for grandparents having to raise children because of parental substance use.

But nationwide, there’s little that resembles the widespread cash payments that many advocates, like Hampton, originally envisioned.

In the mid-2010s, Hampton said, he and other advocates considered filing class action lawsuits against pharmaceutical companies but realized they didn’t have the resources.

A few years later, when state attorneys general began pursuing cases against those companies, victims were thrilled, thinking they would finally get compensation alongside their governments. Hampton and other advocates held rallies, shared their stories publicly, and galvanized support for the states’ lawsuits.

In 2019, when Hampton became co-chair of the Official Committee of Unsecured Creditors in Purdue Pharma’s bankruptcy and arrived at the negotiating table with state attorneys general and other entities, he thought “everybody was there to take on the big bad pharmaceutical company and to put victims’ interests first,” he said. But as the negotiation proceeded among various creditors vying for the company’s assets, he said, “governments were way more powerful than victims and believed that they were more harmed than victims in terms of cost.”

Details of the Purdue settlement are still being finalized, and payments are unlikely to start until next year, but state and local governments will receive the lion’s share, while more than 100,000 victims will split a fraction of the bankruptcy payout.

Mallinckrodt, a manufacturer of generic opioids, is the only company that had begun paying victims as of early 2025, said , a partner at the Nebraska-based law firm High & Younes, which is representing personal injury claimants in several opioid bankruptcies.

After paying roughly 25% in administrative fees to the national trust overseeing the bankruptcy and an additional 40% in attorney fees, some of his clients have received between $400 and $700, Younes said.

He expects payouts from two other companies — Endo and Rite Aid — “will be even lower.”

But many victims won’t receive anything. Some didn’t know they could file claims until it was too late. Others struggled to obtain medical records from shuttered doctors’ offices or pharmacies that didn’t retain older documents.

Out of nearly 20,000 people who contacted Younes’ firm to participate in the various opioid bankruptcies, he said, only about 3,500 were able to file.

‘Do Something for These Families’

John McNerney was told his Purdue Pharma claim didn’t qualify, because he hadn’t been prescribed enough OxyContin to meet the threshold. He submitted claims for Mallinckrodt and Endo instead.

McNerney, 60, who lives in Boca Raton, Florida, said he suffered a spinal injury decades ago from a fall during a plumbing repair. For years afterward, he was prescribed various painkillers. Once his doctors cut him off, he began using pills a friend bought off the street. McNerney spent about $30,000 on rehabs before he entered long-term recovery.

Now when he sees governments spending settlement money on police cars or “instead of putting 100% of it into rehab,” he said, “it really bothers the heck out of me.”

“I haven’t received a nickel,” he said.

In Ohio, a group of affected families were similarly frustrated that money wasn’t reaching them or the places where they thought it was needed most.

The families to submit grant applications to the , which controls most of the . They asked for several million dollars to put toward family support groups, training for family members who take in children whose parents have substance use disorders, and emergency cash aid for families to buy cribs or school supplies and cover funeral costs.

Jackie Lewis, a member of the group, said that when her 34-year-old son, Shaun, died of an overdose, she had to pay his funeral costs by credit card. She has filed a claim in the opioid bankruptcies but hasn’t received any money yet.

“Too many families didn’t have a credit card to do that with,” Lewis said. “There are families I’ve talked to that couldn’t do flowers. Some had to do a cremation instead of a traditional funeral.”

Her group did not receive funding in the from the OneOhio Recovery Foundation.

Connie Luck, a spokesperson for the foundation, said the legal documents that established the foundation do not allow direct payments to individuals affected by the crisis. The foundation has awarded over $45 million to 245 projects throughout the state, including dozens that provide family support services like child care and rental assistance.

“We deeply empathize with those who have lost loved ones to the opioid epidemic — their pain is real, and it fuels the Foundation’s mission to end this crisis and prevent it from happening again,” Luck said in a statement.

In Maine, Julian has made peace with his $325 payout, deciding to consider it a surprise bonus rather than compensation for his years of suffering.

But he hopes governments will use their more substantial sums to provide real help — food and rental assistance for people in recovery and more treatment beds so no one has to wait six months to enter rehab as he once did.

“They’re getting millions of dollars,” said Julian, who has lost numerous close friends to overdose. “They could do something for these families that have suffered great losses.”

Ñî¹óåú´«Ã½Ò•îl Health News data editor Holly K. Hacker contributed to this article.

Methodology

For more than two years, Ñî¹óåú´«Ã½Ò•îl Health News how state and local governments use — and misuse — billions of dollars in opioid settlement funds. This database marks our third update of data showing how much money state and local governments have received through national settlements with companies that made or distributed prescription painkillers.

, the court-appointed firm administering many national opioid settlements, tracks how much money it has delivered to various state and local governments, as well as how much is allocated to those jurisdictions for future years. It initially kept this information private.

In 2023, Ñî¹óåú´«Ã½Ò•îl Health News negotiated to obtain that information and made it public for the first time. Five months later, BrownGreer began posting updated versions of the information .

Last year, Ñî¹óåú´«Ã½Ò•îl Health News downloaded BrownGreer’s data on payouts from pharmaceutical distributors AmerisourceBergen (now called Cencora), Cardinal Health, and McKesson, as well as opioid manufacturer Janssen (now known as Johnson & Johnson Innovative Medicine), and used the state-by-state spreadsheets with separate entries for each settling company to create a searchable database.

This year, Ñî¹óåú´«Ã½Ò•îl Health News has updated that database with new data from BrownGreer, including payouts from opioid manufacturers Allergan and Teva, as well as CVS, Walgreens, and Walmart pharmacies.

Ñî¹óåú´«Ã½Ò•îl Health News downloaded data from BrownGreer’s website between Jan. 20 and 24, 2025, concerning payouts from all companies. Users can use the database to determine the total dollar amount their city, county, or state has received or expects to receive each year.

Although this is the most comprehensive data available at a national scale, it provides just a snapshot of all opioid settlement payouts. Other settlements, including with OxyContin manufacturer Purdue Pharma, are . This data does not reflect additional settlements that some state and local governments have entered into beyond the national deals, such as the agreement between Illinois, Indiana, Kentucky, Michigan, and Ohio and regional supermarket chain Meijer. As such, this database undercounts the amount of opioid settlement money most places have received and will receive.

Payment details for some states are not available, because those states were not , had unique settlement terms, or opted not to have their payments distributed via BrownGreer. A few examples:

• West Virginia declined to join several national settlements and instead reached individual settlements with many of these companies.• Texas and Nevada were paid in full by Janssen outside the national settlement, so their payout data reflects payments only from other companies with which they entered national settlements.• Florida, Louisiana, and Pennsylvania, among others, opted to receive a lump-sum payment via BrownGreer then distribute the money to localities themselves.

BrownGreer shows that several states received some of their anticipated 2027 payment from the distributors (AmerisourceBergen — now called Cencora — Cardinal Health, and McKesson) early in 2024. However, for three states — Colorado, Michigan, and Washington — BrownGreer does not provide data on how much of this prepayment went to each locality. As such, locality payments in these states may be undercounted for 2024 and overcounted for 2027.

For Oregon, BrownGreer shows 2024 payments from Walmart as fully paid in its statewide data but lists some August 2024 payments for localities as “projected.” Since the data was downloaded well past that August 2024 date, we have included those “projected” amounts in the 2024 paid total for Oregon localities. No other states had this discrepancy.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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If you regularly experience connection issues,Ìý.

Next to the router sat medications, vitamin D pills, and Williams’ blood glucose monitor kit.

“I haven’t used that thing in a month or so,” said Williams, 72, waving toward the kit. Diagnosed with diabetes more than six years ago, she has developed nerve pain from neuropathy in both legs.

Williams is one of nearly 3 million Americans who live in mostly rural counties that lack both health care and reliable high-speed internet, according to an analysis by Ñî¹óåú´«Ã½Ò•îl Health News, which showed that these people tend to live sicker and die younger than others in America.

Compared with those in other regions, patients across the rural South, Appalachia, and remote West are most often unable to make a video call to their doctor or log into their patient portals. Both are essential ways to participate in the U.S. medical system. And Williams is among those who can do neither.

This year, more than $42 billion allocated in the 2021 Infrastructure Investment and Jobs Act is expected to begin flowing to states as part of a national “” initiative launched by the Biden administration. But the program faces uncertainty after Commerce Department Secretary Howard Lutnick a “rigorous review” asserting that the previous administration’s approach was full of “woke mandates.”

High rates of chronic illness and historical inequities are hallmarks of many of the more than 200 U.S. counties with poor services that Ñî¹óåú´«Ã½Ò•îl Health News identified. Dozens of doctors, academics, and advocates interviewed for this article unanimously agreed that limited internet service hinders medical care and access.

Without fast, reliable broadband, “all we’re going to do is widen health care disparities within telemedicine,” said Rashmi Mullur, an endocrinologist and chief of telehealth at VA Greater Los Angeles. Patients with diabetes who also use telemedicine are more likely to get care and control their blood sugar, .

Diabetes requires constant management. Left untreated, uncontrolled blood sugar can cause blindness, kidney failure, nerve damage, and eventually death.

Williams, who sees a nurse practitioner at the county hospital in the next town, said she is not interested in using remote patient monitoring or video calls.

“I know how my sugar affects me,” Williams said. “I get a headache if it’s too high.” She gets weaker when it’s down, she said, and always carries snacks like crackers or peppermints.

Williams said she could even drink a soda pop — orange, grape — when her sugar is low but would not drink one when she felt it was high because she would get “kind of goozie-woozy.”

‘This Is America’

Connectivity dead zones persist in American life despite at least $115 billion lawmakers have thrown toward fixing the inequities. Federal broadband efforts are fragmented and overlapping, with more than 133 funding programs administered by 15 agencies, according to a .

“This is America. It’s not supposed to be this way,” said Karthik Ganesh, chief executive of Tampa, Florida-based OnMed, a telehealth company that in September installed a walk-in booth at the Boligee Community Center about 10 minutes from Williams’ home. Residents can call up free life-size video consultations with an OnMed health care provider and use equipment to check their weight and blood pressure.

OnMed, which partnered with local universities and the Alabama Cooperative Extension System, relies on SpaceX’s Starlink to provide a high-speed connection in lieu of other options.

A short drive from the community center, beyond Boligee’s Main Street with its deserted buildings and an empty railroad depot and down a long gravel drive, is the 22-acre property where Williams lives.

Last fall, Williams washed a dish in her kitchen, with its unforgiving linoleum-topped concrete floors. A few months earlier, she said, a man at the community center signed her up for “diabetic shoes” to help with her sore feet. They never arrived.

As Williams spoke, steam rose from a pot of boiling potatoes on the stove. Another pan sizzled with hamburger steak. And on a back burner simmered a mix of Velveeta cheese, diced tomatoes, and peppers.

She spent years on her feet as head cook at a diner in Cleveland, Ohio. The oldest of nine, Williams returned to her family home in Greene County more than 20 years ago to care for her mother and a sister, who both died from cancer in the back bedroom where she now sleeps.

Williams looked out a window and recalled when the landscape was covered in cotton that she once helped pick. Now three houses stand in a carefully tended clearing surrounded by tall trees. One belongs to a brother and the other to a sister who drives with her daily to the community center for exercise, prayers, and friendship with other seniors.

All the surviving siblings, Williams said, have diabetes. “I don’t know how we became diabetic,” she said. Neither of their parents had been diagnosed with the illness.

In Greene County, an estimated quarter of adults have diabetes — twice the national average. The county, which has about 7,600 residents, also has among the nation’s highest rates for several chronic diseases such as high blood pressure, stroke, and obesity, Centers for Disease Control and Prevention data shows.

The county’s population is predominately Black. The federal CDC reports that Black Americans are to be diagnosed with diabetes and are 40% more likely than their white counterparts to die from the condition. And in the South, rural Black residents are more likely , according to the Joint Center for Political and Economic Studies, a Washington-based think tank.

To identify counties most lacking in reliable broadband and health care providers, Ñî¹óåú´«Ã½Ò•îl Health News used data from the Federal Communications Commission and George Washington University’s Mullan Institute for Health Workforce Equity. Reporters also analyzed U.S. Census Bureau, CDC, and other data to understand the health status and demographics of those counties.

The analysis confirms that internet and care gaps are “hitting areas of extreme poverty and high social vulnerability,” said Clese Erikson, deputy director of the health workforce research center at the Mullan Institute.

Digital Haves vs. Have-Nots

Just over half of homes in Greene County have access to reliable high-speed internet — among the lowest rates in the nation. Greene County also has some of the country’s poorest residents, with a median household income of about $31,500. Average life expectancy is less than 72 years, below the national average.

By contrast, the Ñî¹óåú´«Ã½Ò•îl Health News analysis found that counties with the highest rates of internet access and health care providers correlated with higher life expectancy, less chronic disease, and key lifestyle factors such as higher incomes and education levels.

One of those is Howard County, Maryland, between Baltimore and Washington, D.C., where nearly all homes can connect to fast, reliable internet. The median household income is about $147,000 and average life expectancy is more than 82 years — a decade longer than in Greene County. A much smaller share of residents live with chronic conditions such as diabetes.

One is 78-year-old Sam Wilderson, a retired electrical engineer who has managed his Type 2 diabetes for more than a decade. He has fiber-optic internet at his home, which is a few miles from a cafe he dines at every week after Bible study. On a recent day, the cafe had a guest Wi-Fi download speed of 104 megabits per second and a 148 Mbps upload speed. The speeds are fast enough for remote workers to reliably take video calls.

Americans are demanding more speed than ever before. Most households have multiple devices — televisions, computers, gaming systems, doorbells — in addition to phones that can take up bandwidth. The more devices connected, the higher minimum speeds are needed to keep everything running smoothly.

To meet increasing needs, federal regulators updated the , establishing standard speeds of 100/20 Mbps. Those speeds are typically enough for several users to stream, browse, download, and play games at the same time.

Christopher Ali, professor of telecommunications at Penn State, recommends minimum standard speeds of 100/100 Mbps. While download speeds enable consumption, such as streaming or shopping, fast upload speeds are necessary to participate in video calls, say, for work or telehealth.

At the cafe in Howard County, on a chilly morning last fall, Wilderson ordered a glass of white wine and his usual: three-seeded bread with spinach, goat cheese, smoked salmon, and over-easy eggs. After eating, Wilderson held up his wrist: “This watch allows me to track my diabetes without pricking my finger.”

Wilderson said he works with his doctors, feels young, and expects to live well into his 90s, just as his father and grandfather did.

Telehealth is crucial for people in areas with few or no medical providers, said Ry Marcattilio, an associate director of research at the Institute for Local Self-Reliance. The national research and advocacy group works with communities on broadband access and reviewed Ñî¹óåú´«Ã½Ò•îl Health News’ findings.

High-speed internet makes it easier to use video visits for medical checkups, which most patients with diabetes need every three months.

Being connected “can make a huge difference in diabetes outcomes,” said Nestoras Mathioudakis, an endocrinologist and the co-medical director of Johns Hopkins Medicine Diabetes & Education Program, who treats patients in Howard County.

Paying More for Less

At Williams’ home in Alabama, pictures of her siblings and their kids cover the walls of the hallway and living room. A large, wood-framed image of Jesus at the Last Supper with his disciples hangs over her kitchen table.

Williams sat down as her pots simmered and sizzled. She wasn’t feeling quite right. “I had a glass of orange juice and a bag of potato chips, and I knew that wasn’t enough for breakfast, but I was cooking,” Williams said.

Every night Williams takes a pill to control her diabetes. In the morning, if she feels as if her sugar is dropping, she knows she needs to eat. So, that morning, she left the room to grab a peppermint, walking by the flickering wireless router.

The router’s download and upload speeds were 0.03/0.05 Mbps, nearly unusable by modern standards. Williams’ connection on her house phone can sound scratchy, and when she connects her cellphone to the router, it does not always work. Most days it’s just good enough for her to read a daily devotional website and check Facebook, though the stories don’t always load.

Rural residents like Williams on average in late 2020 for slow internet connections than those in urban areas, according to Brian Whitacre, an agricultural economics professor at Oklahoma State University.

“You’re more likely to have competition in an urban area,” Whitacre said.

In rural Alabama, cellphone and internet options are limited. Williams pays $51.28 a month to her wireless provider, Ring Planet, which did not respond to calls and emails.

In Howard County, Maryland, national fiber-optic broadband provider Verizon Communications faces competition from Comcast, a hybrid fiber-optic and cable provider. Verizon advertises a home internet plan promising speeds of 300/300 Mbps starting at $35 a month for its existing mobile customers. The company also offers a discounted price as low as $20 a month for customers who participate in certain federal assistance programs.

“Internet service providers look at the economics of going into some of these communities and there just isn’t enough purchasing power in their minds to warrant the investment,” said Ross DeVol, chief executive of Heartland Forward, a nonpartisan think tank based in Bentonville, Arkansas, that specializes in state and local economic development.

Conexon, a fiber-optic cable construction company, estimates it costs $25,000 per mile to build above-ground fiber lines on poles and $60,000 to $70,000 per mile to build underground.

Former President Joe Biden’s 2021 infrastructure law earmarked $65 billion with a goal of Money was designated to establish digital equity programs and to help low-income customers pay their internet bills. The law also set aside tens of billions through the Broadband Equity, Access, and Deployment Program, known as BEAD, to connect homes and businesses.

That effort prioritizes fiber-optic connections, but federal regulators recently outlined , including low Earth orbit satellites like SpaceX’s Starlink service.

Funding the use of satellites in federal broadband programs has been controversial inside federal agencies. It has also been a sore point for Elon Musk, who is chief executive of SpaceX, which runs Starlink, and is a lead adviser to President Donald Trump.

After preliminary approval, a federal commission ruled that Starlink’s satellite system was “” of offering reliable high speeds. Musk tweeted last year that the commission had “” money awarded under the agency’s Trump-era Rural Digital Opportunity Fund.

In February, Trump nominated Arielle Roth to lead the federal agency overseeing the infrastructure act’s BEAD program. Roth is telecommunications policy director for the Senate Committee on Commerce, Science, and Transportation. Last year, ’s emphasis on fiber and said it was beleaguered by a “woke social agenda” with too many regulations.

Commerce Secretary Lutnick he will get rid of “burdensome regulations” and revamp the program to “take a tech-neutral approach.” Republicans echoed his positions during a U.S. House subcommittee hearing the same day.

When asked about potentially weakening the program’s required low-cost internet option, former National Telecommunications and Information Administration official Sarah Morris said such a change would build internet connections that people can’t afford. Essentially, she said, they would be “building bridges to nowhere, building networks to no one.”

'That Hurt’

Over a lunch of tortilla chips with the savory sauce that had been simmering on the stove, Williams said she hadn’t been getting regular checkups before her diabetes diagnosis.

“To tell you the truth, if I can get up and move and nothing is bothering me, I don’t go to the doctor,” Williams said. “I’m just being honest.”

Years ago, Williams recalled, “my head was hurting me so bad I had to just lay down. I couldn’t stand up, walk, or nothing. I’d get so dizzy.”

Williams thought it was her blood pressure, but the doctor checked for diabetes. “How did they know? I don’t know,” Williams said.

As lunch ended, she pulled out her glucose monitor. Williams connected the needle and wiped her finger with an alcohol pad. Then she pricked her finger.

“Oh,” Williams said, sucking air through her teeth. “That hurt.”

She placed the sample in the machine, and it quickly displayed a reading of 145 — a number, Williams said, that meant she needed to stop eating.

Here’s how Ñî¹óåú´«Ã½Ò•îl Health News did its analysis for the “Dead Zone” series, which pinpointed counties that lag behind the rest of the United States in access to broadband service and health care providers.

To identify “dead zones,” Ñî¹óåú´«Ã½Ò•îl Health News consulted two main data sources.

• The Federal Communications Commission was used to identify broadband deserts as of June 2024. We used the FCC’s minimum speed standard of 100 Mbps download and 20 Mbps upload, and followed its definition of reliable broadband: service accessible via wired (fiber optics, cable, DSL) or licensed fixed wireless technology. It’s the standard for grants awarded through the federal Broadband Equity, Access, and Deployment Program, . The FCC data shows whether such service is available, and not necessarily whether households subscribe to it.
• Data from George Washington University’s Fitzhugh Mullan Institute for Health Workforce Equity was used to determine counties with health provider shortages. GWU’s (family and internal medicine doctors, pediatricians, obstetricians and gynecologists, physician assistants, and nurse practitioners) reflects providers who serve at least one person enrolled in Medicaid. We used the most recent years available: 2020 for 44 states, and 2019 data for Texas. Five states — Delaware, Florida, Maine, Minnesota, and New Hampshire — were excluded from analysis because they lacked reliable data for either year.

GWU’s reflects psychiatrists, psychologists, counselors, therapists, and addiction medicine specialists, regardless of whether their patients receive Medicaid. We used data from 2021, the most recent year available.

We classified counties as “dead zones” if they met these criteria:

• Fewer than 70% of homes had access to fast, reliable broadband.
• They ranked in the bottom third of Medicaid primary care providers, defined as the number of Medicaid enrollees per provider.
• They ranked in the bottom third of behavioral health providers, defined as the number of residents per provider.

A total of 210 counties met those criteria. At the other extreme, we defined 203 counties as “most served” if they had the most residences with broadband access (at least 96.7%) and ranked in the top third of Medicaid primary care and behavioral health provider ratios.

We also compared the health outcomes and demographics of dead zone counties relative to others using several data sources:

• , for data on household income, education levels, and other demographics.
• , part of the University of Wisconsin Population Health Institute, for data on life expectancy and the percentage of residents living in rural areas.
• , for data on diabetes, high blood pressure, and other chronic health conditions.

This project was produced in partnership withÌý. InvestigateTV is Gray Television’s national investigative team and provides innovative, original journalism from a dedicated investigative team and partners, as well as weekday and weekend shows. Gray is the nation’s second-largest television broadcaster, with television stations serving 113 markets.Ìý

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).

Ñî¹óåú´«Ã½Ò•îl Health News, partnering with researchers at the and , a national nonprofit focused on addiction, undertook a yearlong investigation to find out.

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

Among the findings:

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

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

Despite the in overall overdose deaths in the U.S., still died in the 12 months ending July 2024 and rates in many .

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

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

Ñî¹óåú´«Ã½Ò•îl Health News and its partners reviewed hundreds of settlement spending reports, extracting expenditures line by line, and developed a methodology to sort the expenditures into categories like treatment or prevention. States were given an opportunity to review the data and comment on their spending.

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

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

Treatment a Clear Winner

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

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

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

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

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

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

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

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

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

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

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

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

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

consider methadone and buprenorphine a crutch. But study after study show that the medications help people and reduce the . that treatment without these medications can be more harmful than no treatment at all.

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

Babies, Forgotten Victims of the Epidemic

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

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

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

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

It almost happened to her.

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

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

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

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

But the nursery’s future is uncertain.

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

She’s hoping opioid settlement money can help.

In 2022, Jacob’s Hope from Arizona’s opioid settlements. But this year, the legislature captured the state’s share of remaining funds and, in , gave it to the Department of Corrections.

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

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

Heart Disease Screening, Robot Ambulances, and More

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

Settlement dollars nationwide have bought body scanners, , , , and for police and sheriffs.

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

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

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

A second area of contention is youth prevention.

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

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

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

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

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

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

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

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

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

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

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

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

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

Ñî¹óåú´«Ã½Ò•îl Health News’ Henry Larweh and Megan Kalata, Johns Hopkins Bloomberg School of Public Health’s Sara Whaley and Vivian Flanagan, and Shatterproof’s Kristen Pendergrass and Sahvanah Prescott contributed to this article.

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

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

Shatterproof is partnering with some states on projects funded by opioid settlements. Ñî¹óåú´«Ã½Ò•îl Health News, the Johns Hopkins Bloomberg School of Public Health, and the Shatterproof team who worked on this report are not involved in those efforts.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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Indeed, it was a plotline on the . But for some it has been a tragedy.

People have died after drinking tea brewed from unwashed poppy seeds.

And after eating lemon poppy seed bread or an everything bagel, mothers reportedly have been separated from newborns because the women failed drug tests.

Poppy seeds come from the plant that and from which narcotics such as morphine and codeine are derived. During harvesting and processing, the seeds can become coated with the opium fluid.

Members of the House and Senate have “to prohibit the distribution and sale of contaminated poppy seeds in order to prevent harm, addiction, and further deaths from morphine-contaminated poppy seeds.” The bill was one of several on the agenda for a .

The day before the hearing, and reported on a woman who ate a salad with poppy seed dressing before giving birth, tested positive at the hospital for opiates, was reported to child welfare, and saw her baby taken into protective custody. Almost two weeks passed before she was allowed to bring her baby home, the story said.

“It’s not an urban legend: Eating poppy seeds can cause diners to test positive for codeine on a urinalysis,” the Defense Department in 2023.

The U.S. Anti-Doping Agency long ago issued a to athletes.

The Center for Science in the Public Interest, a watchdog group, in 2021 to limit the opiate content of poppy seeds. In May, after more than three years with no response, it to force action.

“So far the FDA has been negligent in protecting consumers,” said Steve Hacala, whose son died after consuming poppy seed tea and who has joined forces with CSPI.

The lawsuit was put on hold in July, after the FDA said it would respond to the group’s petition by the end of February 2025.

The FDA did not answer questions for this article. The agency generally does not comment on litigation, spokesperson Courtney Rhodes said.

A co-authored by CSPI personnel found more than 100 reports to poison control centers between 2000 and 2018 resulting from intentional abuse or misuse of poppy seeds, said CSPI scientist Eva Greenthal, one of the study’s authors.

Only rarely would baked goods or other food items containing washed poppy seeds trigger positive drug tests, doctors who have studied the issue said.

It’s “exquisitely doubtful” that the “relatively trivial” amount of morphine in an everything bagel or the like would cause anyone harm, said Irving Haber, a doctor who has , specializes in pain medicine, and signed the CSPI petition to the FDA.

On the other hand, tea made from large quantities of unwashed poppy seeds could lead to addiction and overdose, doctors said. The risks are heightened if the person drinking the brew is also consuming other opioids, such as prescription pain relievers.

Benjamin Lai, a physician who chairs a program on opioids at the Mayo Clinic in Rochester, Minnesota, said he has been treating a patient who developed long-term opioid addiction from consuming poppy seed tea. The patient, a man in his 30s, found it at a health food store and was under the impression it would help him relax and recover from gym workouts. After a few months, he tried to stop and experienced withdrawal symptoms, Lai said.

Another patient, an older woman, developed withdrawal symptoms under similar circumstances but responded well to treatment, Lai said.

Some websites tout poppy seed tea as offering health benefits. And some sellers “may use specific language such as ‘raw,’ ‘unprocessed,’ or ‘unwashed’ to signal that their products contain higher concentrations of opiates than properly processed seeds,” the CSPI lawsuit said.

Steve Hacala’s son, Stephen Hacala, a music teacher, had been experiencing anxiety and insomnia, for which poppy seed tea is promoted as a natural remedy, the lawsuit said. In 2016, at age 24, he ordered a bag of poppy seeds online, rinsed them with water, and consumed the rinse. He died of morphine poisoning.

The only source of morphine found in Stephen’s home, where he died, was commercially available poppy seeds, a medical examiner at the Arkansas State Crime Lab said in a letter to the father. The medical examiner wrote that poppy seeds “very likely” caused Stephen’s death.

Steve Hacala estimated that the quantity of poppy seeds found in a 1-liter plastic water bottle in his son’s home could have delivered more than 10 times a lethal dose.

Steve Hacala and his wife, Betty, have funded CSPI’s efforts to call attention to the issue. (The publisher of Ñî¹óåú´«Ã½Ò•îl Health News, David Rousseau, is on the .)

The lawsuit also cited mothers who, like those in the investigation by The Marshall Project and Reveal, ran afoul of rules meant to protect newborns. For example, though Jamie Silakowski had not used opioids while pregnant, she was initially prevented from leaving the hospital with her baby, the suit said.

Silakowski recalled that, before going to the hospital, she had eaten lemon poppy seed bread at Tim Hortons, a fast-food chain, CSPI said in its petition. “No one in the hospital believed Ms. Silakowski or appeared to be aware that the test results could occur from poppy seeds.”

People from child protective services made unannounced visits to her home, interviewed her other children, and questioned teachers at their school, she said in an interview.

While on maternity leave, she had to undergo drug testing, Silakowski said. “Peeing in front of someone like I’m a criminal — it was just mortifying.”

Even family members were questioning her, and there was nothing she could do to dispel doubts, she said. “Relationships were torn apart,” she said.

The parent company of Tim Hortons, Restaurant Brands International, which also owns Burger King and Popeyes, did not respond to questions from Ñî¹óåú´«Ã½Ò•îl Health News.

In July, The Washington Post reported that Trader Joe’s Everything but the Bagel seasoning was in South Korea because it contains poppy seeds. Trader Joe’s did not respond to inquiries for this article. The seasoning is listed for sale on the company’s website.

The U.S. says unwashed poppy seeds can kill when used alone or in combination with other drugs. While poppy seeds are exempt from drug control under the Controlled Substances Act, opium contaminants on the seeds are not, the agency says. The Justice Department has brought criminal prosecutions over the sale of unwashed poppy seeds.

Meanwhile, the legislation to control poppy seed contamination has not gained much traction.

The Senate bill, introduced by Sen. Tom Cotton (R-Ark.), has .

The House bill, introduced by Rep. Steve Womack (R-Ark.), . Though it was on the agenda, it didn’t come up at the recent hearing.

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Translating “cardiac arrest” into Spanish is also tricky because “arresto” means getting detained by the police. Likewise, “intoxicado” means you have food poisoning, not that you’re drunk.

The examples of how translation could go awry in any language are endless: Words take on new meanings, idioms come and go, and communities adopt slang and dialects for everyday life.

Human translators work hard to keep up with the changes, but California plans to soon entrust that responsibility to technology.

State health policy officials want to harness emerging artificial intelligence technology to translate a broad swath of documents and websites related to “health and social services information, programs, benefits and services,” . Sami Gallegos, a spokesperson for California’s Health and Human Services Agency, declined to elaborate on which documents and languages would be involved, saying that information is “confidential.”

The agency is seeking bids from IT firms for the ambitious initiative, though its timing and cost is not yet clear. Human editors supervising the project will oversee and edit the translations, Gallegos said.

Agency officials said they hope to save money and make critical health care forms, applications, websites, and other information available to more people in what they call the nation’s most linguistically diverse state.

The project will start by translating written material. Agency said the technology, if successful, may be applied more broadly.

“How can we potentially not just transform all of our documents, but our websites, our ability to interact, even some of our call center inputs, around AI?” Ghaly asked during an in Sacramento.

But some translators and scholars fear the technology lacks the nuance of human interaction and isn’t ready for the challenge. Turning this sensitive work over to machines could create errors in wording and understanding, they say — ultimately making information less accurate and less accessible to patients.

“AI cannot replace human compassion, empathy, and transparency, meaningful gestures and tones,” said , a Fresno-based medical and legal interpreter for 30 years who specializes in Khmer, the main language of Cambodia.

is the science of designing computers that emulate human thinking by reasoning, problem-solving, and understanding language. A type of artificial intelligence known as , or GenAI, in which computers are trained using massive amounts of data to “learn” the meaning of things and respond to prompts, is driving a wave of investment, led by such companies as Open AI and Google.

AI is quickly being integrated into health care, including programs that diagnose diabetic retinopathy, analyze mammograms, and connect patients with nurses remotely. Promotors of the technology often make the grandiose claim that soon everyone will have their own “.”

AI also has been a game changer in translation. , and are not only faster than older technologies such as Google Translate, but they can process huge volumes of content and draw upon a vast database of words to nearly mimic human translation.

Whereas a professional human translator might need three hours to translate a 1,600-word document, AI can do it in a minute.

, an assistant professor of biomedical informatics at Harvard Medical School and the deputy editor of , said the use of AI technology represents a natural progression in medical translation, given that patients already use Google Translate and AI platforms to translate for themselves and their loved ones.

“Patients are not waiting,” he said.

He said GenAI could be particularly useful in this context.

These translations “can deliver real value to patients by simplifying complex medical information and making it more accessible,” he said.

In its bidding documents, the state says the goal of the project is to increase “speed, efficiency, and consistency of translations, and generate improvements in language access” in a state where 1 in 3 people speak a language other than English, and more than 200 languages are spoken.

In May 2023, the state Health and Human Services Agency adopted a “” that requires its departments to translate all “vital” documents into at least the top five languages spoken by Californians with limited English proficiency. At the time, those languages were Spanish, Chinese, Tagalog, Vietnamese, and Korean.

Examples of vital documents include application forms for state programs, notices about eligibility for benefits, and public website content.

Currently, human translators produce these translations. With AI, more documents could be translated into more languages.

A by the California Health Care Foundation late last year found that 30% of Spanish speakers have difficulty explaining their health issues and concerns to a doctor, compared with 16% of English speakers.

Health equity advocates say AI will help close that gap.

“This technology is a very powerful tool in the area of language access,” said , president and CEO of the foundation. “In good hands, it has many opportunities to expand the translation capability to address inequities.”

But Hernández cautioned that AI translations must have human oversight to truly capture meaning.

“The human interface is very important to make sure you get the accuracy and the cultural nuances reflected,” she said.

Lim recalled an instance in which a patient’s daughter translated preoperative instructions to her mother the night before surgery. Instead of translating theÌýinstructions as “you cannot eat” after a certain hour, she told her mom, “You should not eat.”

The mother ate breakfast, and the surgery had to be rescheduled.

“Even a few words that change meaning could have a drastic impact on the way people consume the information,” said , a doctoral candidate in digital journalism, human-computer interaction, and emerging media at Boston University.

Paik, who grew up speaking Korean, also pointed out that AI models are often trained . The data that drives the translations filters languages through an English perspective, “which could result in misinterpretations of the other language,” she said. Amid this fast-changing landscape, “we need more diverse voices involved, more people thinking about the ethical concepts, how we best forecast the impact of this technology.”

Manrai pointed to other flaws in this nascent technology that must be addressed. For instance, AI sometimes invents sentences or phrases that are not in the original text, potentially creating false information — a phenomenon AI or “confabulation.”

Ching Wong, executive director of the Vietnamese Community Health Promotion Project at the University of California-San Francisco, has been translating health content from English into Vietnamese and Chinese for 30 years.

He provided examples of nuances in language that might confuse AI translation programs. Breast cancer, for instance, is called “chest cancer” in Chinese, he said.

And “you” has different meanings in Vietnamese, depending on a person’s ranking in the family and community. If a doctor uses “you” incorrectly with a patient, it could be offensive, Wong said.

But Ghaly emphasized that the opportunities outweigh the drawbacks. He said the state should “cultivate innovation” to help vulnerable populations gain greater access to care and resources.

And he was clear: “We will not replace humans.”

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At issue is not just whether people are using enough sunscreen, but what ingredients are in it.

The Food and Drug Administration’s ability to approve the chemical filters in sunscreens that are sold in countries such as Japan, South Korea, and France is hamstrung by a 1938 U.S. law that has required sunscreens to be tested on animals and classified as drugs, rather than as cosmetics as they are in much of the world. So Americans are not likely to get those better sunscreens — which that can cause skin cancer and lead to wrinkles — in time for this summer, or even the next.

Sunscreen makers say that requirement is unfair because companies including and , which make the newer sunscreen chemicals, submitted on sunscreen chemicals to the some 20 years ago.

Steven Goldberg, a retired vice president of BASF, said companies are wary of the FDA process because of the cost and their fear that additional animal testing could ignite a in the European Union, which of cosmetics, including sunscreen. The companies are asking Congress to change the testing requirements before they take steps to enter the U.S. marketplace.

In a rare example of bipartisanship last summer, Sen. Mike Lee (R-Utah) (D-N.Y.) for urging the FDA to speed up approvals of new, more effective sunscreen ingredients. Now a bipartisan bill is pending in the House that would to allow non-animal testing.

“It goes back to sunscreens being classified as over-the-counter drugs,” said Carl D’Ruiz, a senior manager at DSM-Firmenich, a Switzerland-based maker of sunscreen chemicals. “It’s really about giving the U.S. consumer something that the rest of the world has. People aren’t dying from using sunscreen. They’re dying from melanoma.”

Every hour, at least two people in the United States. Skin cancer is the in America, and 6.1 million adults are treated each year for basal cell and squamous cell carcinomas, according to the . The nation’s second-most-common cancer, breast cancer, is diagnosed about , though it is far more deadly.

Though skin cancer treatment success rates are excellent, 1 in 5 Americans will develop skin cancer by age 70. The disease costs the health care system , according to CDC researchers. One study found that the annual cost of treating skin cancer in the United States from 2002 to 2011, while the average annual cost for all other cancers increased by just 25%. And unlike many other cancers, most forms of skin cancer can largely be prevented — by using sunscreens and taking other precautions.

But a heavy dose of misinformation has permeated the sunscreen debate, and some people question the safety of sunscreens sold in the United States, which they deride as “chemical” sunscreens. These sunscreen opponents prefer “physical” or “mineral” sunscreens, such as zinc oxide, even though all sunscreen ingredients are chemicals.

“It’s an artificial categorization,” said E. Dennis Bashaw, a retired FDA official who ran the agency’s clinical pharmacology division that studies sunscreens.

Still, such concerns were partly after it published a study that said some sunscreen ingredients had been found in trace amounts in human bloodstreams. When the , and then again , that older sunscreen ingredients needed to be studied more to see if they were safe, sunscreen opponents saw an opening, said , president of Alpha Research & Development, which imports chemicals used in cosmetics.

“That’s why we have extreme groups and people who aren’t well informed thinking that something penetrating the skin is the end of the world,” Shaath said. “Anything you put on your skin or eat is absorbed.”

Adamson, the Austin dermatologist, said some sunscreen ingredients have been used for 30 years without any population-level evidence that they have harmed anyone. “The issue for me isn’t the safety of the sunscreens we have,” he said. “It’s that some of the chemical sunscreens aren’t as broad spectrum as they could be, meaning they do not block UVA as well. This could be alleviated by the FDA allowing new ingredients.”

falls between X-rays and visible light on the electromagnetic spectrum. Most of the UV rays that people come in contact with are UVA rays that can penetrate the middle layer of the skin and that cause up to 90% of skin aging, along with a smaller amount of UVB rays that are .

The sun protection factor, or SPF, rating on American sunscreen bottles denotes only a sunscreen’s ability to block UVB rays. Although American sunscreens labeled “broad spectrum” should, in theory, block UVA light, to meet the European Union’s higher UVA-blocking standards.

“It looks like a number of these newer chemicals have a better safety profile in addition to better UVA protection,” said , deputy director of Environmental Working Group, a nonprofit that researches the ingredients in consumer products. “We have asked the FDA to consider allowing market access.”

The FDA defends its review process and its call for tests of the sunscreens sold in American stores as a way to ensure the safety of products that many people use daily, rather than just a few times a year at the beach.

“Many Americans today rely on sunscreens as a key part of their skin cancer prevention strategy, which makes satisfactory evidence of both safety and effectiveness of these products critical for public health,” Cherie Duvall-Jones, an FDA spokesperson, wrote in an email.

D’Ruiz’s company, DSM-Firmenich, is the only one currently seeking to have a new over-the-counter sunscreen ingredient approved in the United States. The company has spent the past 20 years trying to gain , a process D’Ruiz said has cost $18 million and has advanced fitfully, despite attempts by Congress in 2014 and 2020 to speed along applications for new UV filters.

Bemotrizinol is the bedrock ingredient in nearly all European and Asian sunscreens, including those by the South Korean brand and , a Japanese brand.

D’Ruiz said bemotrizinol could secure FDA approval by the end of 2025. If it does, he said, bemotrizinol would be the most vetted and safest sunscreen ingredient on the market, outperforming even the safety profiles of zinc oxide and titanium dioxide.

As Congress and the FDA debate, many Americans have taken to importing their own sunscreens from Asia or Europe, despite the .

“The sunscreen issue has gotten people to see that you can be unsafe if you’re too slow,” said , a professor of economics at George Mason University. “The FDA is just incredibly slow. They’ve been looking at this now literally for 40 years. Congress has ordered them to do it, and they still haven’t done it.”

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Through their phones, young people and some caregivers can meet BrightLife Kids and Soluna coaches, some who specialize in peer support or substance use disorders, for roughly 30-minute virtual counseling sessions that are best suited to those with more mild needs, typically those without a clinical diagnosis. The apps also feature self-directed activities, such as white noise sessions, guided breathing, and videos of ocean waves to help users relax.

“We believe they’re going to have not just great impact, but wide impact across California, especially in places where maybe it’s not so easy to find an in-person behavioral health visit or the kind of coaching and supports that parents and young people need,” said Gov. Gavin Newsom’s health secretary, Mark Ghaly, during the Jan. 16 announcement.

The apps represent one of the Democratic governor’s major forays into health technology and come with four-year contracts valued at $498 million. California is believed to be the first state to offer a mental health app with free coaching to all young residents, according to the Department of Health Care Services, which operates the program.

However, the rollout has been slow. Only about 15,000 of the state’s 12.6 million children and young adults have signed up for the apps, school counselors say they’ve never heard of them, and one of the companies isn’t making its app available on Android phones until summer.

Advocates for youth question the wisdom of investing taxpayer dollars in two private companies. Social workers are concerned the companies’ coaches won’t properly identify youths who need referrals for clinical care. And the spending is drawing lawmaker scrutiny amid a state deficit pegged at as much as .

An App for That

Newsom’s administration says the apps fill a need for young Californians and their families to access professional telehealth for free, in multiple languages, and outside of standard 9-to-5 hours. It’s part of Newsom’s sweeping $4.7 billion for kids’ mental health, which was introduced in 2022 to increase access to mental health and substance use support services. In addition to launching virtual tools such as the teletherapy apps, the initiative is working to expand workforce capacity, especially in underserved areas.

“The reality is that we are rarely 6 feet away from our devices,” said Sohil Sud, director of Newsom’s Children and Youth Behavioral Health Initiative. “The question is how we can leverage technology as a resource for all California youth and families, not in place of, but in addition to, other behavioral health services that are being developed and expanded.”

The virtual platforms come amid rising depression and suicide rates among youth and a . Nearly half of California youths from the ages of 12 to 17 report having recently struggled with mental health issues, with nearly a third experiencing serious psychological distress, according to a by the UCLA Center for Health Policy Research. These rates are even higher for multiracial youths and those from low-income families.

But those supporting youth mental health at the local level question whether the apps will move the needle on climbing depression and suicide rates.

“It’s fair to applaud the state of California for aggressively seeking new tools,” said Alex Briscoe of California Children’s Trust, a statewide initiative that, along with more than 100 local partners, works to improve the social and emotional health of children. “We just don’t see it as fundamental. And we don’t believe the youth mental health crisis will be solved by technology projects built by a professional class who don’t share the lived experience of marginalized communities.”

The apps, BrightLife Kids and Soluna, are operated by two companies: Brightline, a 5-year-old venture capital-backed startup; and Kooth, a London-based publicly traded company that has experience in the U.K. and has also signed on some schools in Kentucky and Pennsylvania and a . In the first five months of Kooth’s Pennsylvania pilot, 6% of students who had access to the app signed up.

Brightline and Kooth represent a growing number of health tech in this space. They beat out dozens of other bidders including international consulting companies and other youth telehealth platforms that had already snapped up contracts in California.

Although the service is intended to be free with no insurance requirement, Brightline’s app, BrightLife Kids, is folded into and only accessible through the company’s main app, which asks for insurance information and directs users to paid licensed counseling options alongside the free coaching. After Ñî¹óåú´«Ã½Ò•îl Health News questioned why the free coaching was advertised below paid options, Brightline reordered the page so that, even if a child has high-acuity needs, free coaching shows up first.

The apps take an expansive view of behavioral health, making the tools available to all California youth under age 26 as well as caregivers of babies, toddlers, and children 12 and under. When Ñî¹óåú´«Ã½Ò•îl Health News asked to speak with an app user, Brightline connected a reporter with a mother whose 3-year-old daughter was learning to sleep on her own.

‘It’s Like Crickets’

Despite being months into the launch and having millions in marketing funds, the companies don’t have a definitive rollout timeline. Brightline said it hopes to have deployed teams across the state to present the tools in person by midyear. Kooth said developing a strategy to hit every school would be “the main focus for this calendar year.”

“It’s a big state — 58 counties,” Bob McCullough of Kooth said. “It’ll take us a while to get to all of them.”

So far BrightLife Kids is available only on Apple phones. Brightline said it’s aiming to launch the Android version over the summer.

“Nobody’s really done anything like this at this magnitude, I think, in the U.S. before,” said Naomi Allen, a co-founder and the CEO of Brightline. “We’re very much in the early innings. We’re already learning a lot.”

The contracts, obtained by Ñî¹óåú´«Ã½Ò•îl Health News through a records request, show the companies operating the two apps could earn as much as $498 million through the contract term, which ends in June 2027, months after Newsom is set to leave office. And the state is spending hundreds of millions more on Newsom’s virtual behavioral health strategy. The state said it aims to make the apps available long-term, depending on usage.

The state said 15,000 people signed up in the first three months. When Ñî¹óåú´«Ã½Ò•îl Health News asked how many of those users actively engaged with the app, it declined to say, noting that data would be released this summer.

Ñî¹óåú´«Ã½Ò•îl Health News reached out to nearly a dozen California mental health professionals and youths. None of them were aware of the apps.

“I’m not hearing anything,” said Loretta Whitson, executive director of the California Association of School Counselors. “It’s like crickets.”

Whitson said she doesn’t think the apps are on “anyone’s” radar in schools, and she doesn’t know of any schools that are actively advertising them. Brightline will be presenting its tool to the counselor association in May, but Whitson said the company didn’t reach out to plan the meeting; she did.

Concern Over Referrals

Whitson isn’t comfortable promoting the apps just yet. Although both companies said they have a clinical team on staff to assist, Whitson said she’s concerned that the coaches, who aren’t all licensed therapists, won’t have the training to detect when users need more help and refer them to clinical care.

This sentiment was echoed by other school-based social workers, who also noted the apps’ duplicative nature — in some counties, like Los Angeles, youths can access free virtual counseling sessions through Hazel Health, a for-profit company. Nonprofits, too, have entered this space. For example, , a peer-to-peer hotline operated by Southern California-based Didi Hirsch Mental Health Services, is free nationwide.

While the state is also funneling money to the schools as part of Newsom’s master plan, students and school-based mental health professionals voiced confusion at the large app investment when, in many school districts, few in-person counseling roles exist, and in some cases are dwindling.

Kelly Merchant, a student at College of the Desert in Palm Desert, noted that it can be hard to access in-person therapy at her school. She believes the community college, which has about 15,000 students, has only one full-time counselor and one part-time bilingual counselor. She and several students interviewed by Ñî¹óåú´«Ã½Ò•îl Health News said they appreciated having engaging content on their phone and the ability to speak to a coach, but all said they’d prefer in-person therapy.

“There are a lot of people who are seeking therapy, and people close to me that I know. But their insurances are taking forever, and they’re on the waitlist,” Merchant said. “And, like, you’re seeing all these people struggle.”

Fiscal conservatives question whether the money could be spent more effectively, like to bolster county efforts and existing youth behavioral health programs.

Republican state Sen. Roger Niello, vice chair of the Senate Budget and Fiscal Review Committee, noted that California is forecasted to face deficits for the next three years, and taxpayer watchdogs worry the apps might cost even more in the long run.

“What starts as a small financial commitment can become uncontrollable expenses down the road,” said Susan Shelley of the Howard Jarvis Taxpayers Association.

This article was produced by Ñî¹óåú´«Ã½Ò•îl Health News, which publishes , an editorially independent service of the .Ìý

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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State and local governments are receiving billions of dollars in settlements from companies that made, sold, or distributed prescription painkillers and were accused of fueling the opioid crisis. More than a dozen companies will pay the money over nearly two decades. As of late February 2024, had landed in government coffers.

Ñî¹óåú´«Ã½Ò•îl Health News has been tracking how that money is used — or misused — nationwide.

But determining how much of that windfall arrived in a specific county or city — and how much will follow in the future — can be challenging. Most localities are not required to make the information public.

, the court-appointed firm administering the settlements, tracks much of this data but kept it private until Ñî¹óåú´«Ã½Ò•îl Health News negotiated to obtain it last year. Ñî¹óåú´«Ã½Ò•îl Health News made that information public for the first time last June.

Five months later, BrownGreer began quietly posting updated versions of the information .

, a partner at BrownGreer, told Ñî¹óåú´«Ã½Ò•îl Health News that the change was made to assist state and local governments in accessing the information easily and “to promote transparency into the administration” of the settlements. She said the data is updated “regularly when new payments are issued,” which can be as frequent as twice a month.

Ñî¹óåú´«Ã½Ò•îl Health News downloaded the data on March 4 and transformed it from state-by-state spreadsheets with separate entries for each settling company to a searchable database. Users can determine the total dollar amount their city, county, or state has received or expects to receive each year.

Determining how much money has arrived is the first step in assessing whether the settlements will make a dent in the nation’s addiction crisis.

Although this is the most comprehensive data available at a national scale, it provides just a snapshot of all opioid settlement payouts.

The information currently reflects only the largest settlement to date: $26 billion to be paid by pharmaceutical distributors AmerisourceBergen (now called Cencora), Cardinal Health, and McKesson, as well as opioid manufacturer Janssen (now known as Johnson & Johnson Innovative Medicine).

Most states have also settled with drug manufacturers Teva and Allergan, as well as Walmart, Walgreens, and CVS. Petkauskas said BrownGreer began distributing payments from these five companies in 2024 and plans to update its data to reflect such payments in July.

Other settlements, including with OxyContin manufacturer Purdue, are still pending.

This data does not reflect additional settlements that some state and local governments have entered into beyond the national deals, such as the agreement between Illinois, Indiana, Kentucky, Michigan, and Ohio and regional supermarket chain Meijer.

As such, this database undercounts the amount of opioid settlement money most places have received and will receive.

Payment details for some states are not available because those states were not , had unique settlement terms, or opted not to have their payments distributed via BrownGreer. A few examples include:

• Alabama and West Virginia declined to join several national settlements and instead reached individual settlements with many of these companies.
• Texas and Nevada were paid in full by Janssen outside of the national settlement, so their payout data reflects payments only from AmerisourceBergen, Cardinal Health, and McKesson.
• Florida, Louisiana, and Pennsylvania, among others, opted to receive a lump-sum payment via BrownGreer then distribute the money to localities themselves.

Ñî¹óåú´«Ã½Ò•îl Health News’ Colleen DeGuzman contributed to this report. Jai Aslam also contributed.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).