More than $4.3 billion in opioid settlement money has landed in the hands of city, county and state officials to date — with billions more on the way. But instead of using the cash to add desperately needed treatment, recovery and prevention services, some places are using it to replace existing funding.

Local officials say they’re trying to stretch tight budgets, especially in rural areas. But critics say it’s a lost opportunity to bolster responses to an ongoing addiction crisis and save lives.

“To think that replacing what you’re already spending with settlement funds is going to make things better — it’s not,” said Robert Kent, former general counsel for the Office of National Drug Control Policy. “Certainly, the spirit of the settlements wasn’t to keep doing what you’re doing. It was to do more.”

The debate is playing out in Scott County, Ind. The rural community made headlines in 2015 after intravenous drug use led to a massive HIV outbreak and then-Gov. Mike Pence (R) legalized syringe service programs. (The county has since shuttered its syringe program.) 

In 2022, the county received more than $570,000 in opioid settlement funds. It spent about 45 percent of that on salaries for its health director and emergency medical services staff, according to reports it filed with the state. The money usually budgeted for those salaries was freed to buy an ambulance and create a rainy-day fund for the health department.

In public meetings, Scott County leaders said they hoped to reimburse the departments for resources they dedicated to the HIV outbreak years ago. 

Their conversations echo the struggles of other rural counties, which have tight budgets in part because for years they poured money into combating the opioid crisis. Now they want to recoup some of those expenses.

But many families affected by addiction, recovery advocates, and legal and public health experts say that misses the point, that the settlements were aimed at helping the nation make progress against the overdose epidemic.

Thirteen states and Washington, D.C., have restricted substituting opioid settlement funds for existing government spending, according to state guides created by OpioidSettlementTracker.com and the public health organization Vital Strategies. A national set of principles created by Johns Hopkins University also advises against the practice, known as supplantation.

But it’s happening anyway. 

County commissioners in Blair County, Pa., used about $320,000 of settlement funds for a drug court that has been operating with other sources of money for more than two decades, according to a report the county filed with a state council overseeing settlement funds.

In New York, some lawmakers and treatment advocates say the governor’s proposed budget substitutes millions of opioid settlement dollars for a portion of the state addiction agency’s normal funding.

Given the complexities of state and local budgets, it’s often difficult to spot supplantation. But one place to start is identifying how much opioid settlement money your community has received so far. Use our searchable database to find out. Then ask elected officials how they’re spending those dollars. In many places, dedicated citizens are the only watchdogs for this money.

If you discover anything interesting, shoot me a note.

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This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact NewsWeb@kff.org.

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Ousted Hillsborough County State Attorney Andrew Warren announced Tuesday morning that he will run for re-election to his former job, where he will likely face off against sitting State Attorney Susan Lopez, appointed by Gov. Ron DeSantis in August 2022 to replace him.

DeSantis suspended Warren, a Democrat, for alleged “neglect of duty” and “incompetence” after he signed a pledge not to prosecute alleged crimes arising from abortion or transgender care.

Warren challenged his suspension in federal court. U.S. District Judge Robert Hinkle ruled that DeSantis had violated the First Amendment in removing Warren because of political differences and anticipated “political benefit” to the governor — but said he lacked power to reinstate him. However, a federal appeals court ruled in January that Hinkle should reconsider that decision.

“In 2020, you reelected me to serve as your state attorney, because you believed in my vision, and it worked,” Warren says in a video his campaign released Tuesday morning announcing that he will run again.

“Crime went down 30%. We kept dangerous criminals off the street and together with law enforcement and community partners we made Hillsborough the safest large county in Florida. But on Aug. 4, 2022, Ron DeSantis threw out your vote. He illegally forced me from office under armed guard.”

DeSantis’ removal of Warren was stunning at the time, but it was followed nearly a year later with a suspension of another progressively minded Florida state attorney in Democrat Monique Worrell from Florida’s Ninth Judicial Circuit, representing Orange and Osceola Counties.  Worrell has also filed a reinstatement lawsuit with the Florida Supreme Court, claiming her suspension was unconstitutional. She has also announced that she is running for reelection.

Reversal

Although Warren has fought to win his job back through the courts, in January of this year he seemingly dropped plans of running again for the seat, saying he didn’t trust DeSantis not to suspend him again if he were successful.

But two days after he made that announcement, a three-judge panel of the U.S. Court of Appeals for the Eleventh Circuit ordered Judge Hinkle to reconsider his decision that he could not reinstate Warren.

“We conclude that the district court erred in two ways: first, in concluding that the First Amendment did not protect Warren’s support of a sentence in the advocacy statement about prosecuting abortion cases, and second, in concluding that the First Amendment did not preclude DeSantis from suspending Warren to gain political benefit from bringing down a reform prosecutor,” wrote Judge Jill Pryor, one of the judges on the panel.

Warren, a native of Gainesville, had been a federal prosecutor working in Washington, D.C., before he came to Tampa to run against 16-year Republican incumbent Mark Ober in Hillsborough County in 2016. He defeated Ober by less than one percentage point. He then came back and defeated Republican challenger Mike Perotti by more than six points in 2020.

But that was when Hillsborough had many more Democratic Party registered voters than it now has. As the Phoenix reported last week, Republicans are now within a percentage point of parity with the Democrats in terms of voter registration in county.

Lopez has raised more than $470,000 in her combined campaign accounts, while Warren has yet to do any fundraising (he did set up a campaign account last fall but had not been raising any money).

The Lopez campaign came out swinging after hearing about Warren’s entry back into the race.

“Andrew Warren is an ultra-liberal ideologue who cares more about pleasing the far-left activists and donors that have powered his political career than he does about victims of crimes in Hillsborough County,” said Ryan Smith, a senior strategist with the Lopez campaign. “State Attorney Suzy Lopez is a career prosecutor with a proven track-record of getting violent criminals off our streets and delivering justice for victims and their families. Sheriff Chad Chronister and law enforcement across Tampa Bay endorsed her because they know that Hillsborough is Safer with Suzy.”

‘A fighter’

As of now, there is one other candidate in the race: Democrat Elizabeth Martinez Strauss.

Florida Democratic Party Chair Nikki Fried hailed Warren’s decision to run in a press release.

“Andrew Warren is a fighter, and Hillsborough’s only duly elected State Attorney. We welcome his decision to run for re-election and stay in the fight to return as Hillsborough State Attorney. That decision is now rightfully in the hands of voters, not Ron DeSantis,” she said.

“For years, Andrew has challenged Ron DeSantis’s illegal and unconstitutional suspension and joins former State Attorney Monique Worrell, who was also unjustly removed by Ron DeSantis in seeking re-election. State Attorney Worrell was targeted and removed by Ron DeSantis in 2023 in a politically motivated stunt to score points on the debate stage during his failed presidential campaign,” Fried said.

Update: This story has been changed to add comment from the Suzy Lopez campaign.

Abortion opponents have maneuvered in courthouses for years to end access to reproductive health care. In Arizona last week, a win for the anti-abortion camp caused political blowback for Republican candidates in the state and beyond.

The reaction echoed the response to an Alabama Supreme Court decision over in vitro fertilization just two months before.

The election-year ruling by the Arizona Supreme Court allowing enforcement of a law from 1864 banning nearly all abortions startled Republican politicians, some of whom quickly turned to social media to denounce it.

The court decision was yet another development forcing many Republicans legislators and candidates to thread the needle: Maintain support among anti-abortion voters while not damaging their electoral prospects this fall. This shifting power dynamic between state judges and state lawmakers has turned into a high-stakes political gamble, at times causing daunting problems, on a range of reproductive health issues, for Republican candidates up and down the ballot.

“When the U.S. Supreme Court said give it back to the states, OK, well now the microscope is on the states,” said Jennifer Piatt, co-director of the Center for Public Health Law and Policy at Arizona State University’s Sandra Day O’Connor College of Law. “We saw this in Alabama with the IVF decision,” she said, “and now we’re seeing it in Arizona.”

Multiple Republicans have criticized the Arizona high court’s decision on the 1864 law, which allows abortion only to save a pregnant woman’s life. “This decision cannot stand. I categorically reject rolling back the clock to a time when slavery was still legal and where we could lock up women and doctors because of an abortion,” state Rep. Matt Gress said in a video April 9. All four Arizona Supreme Court justices who said the long-dormant Arizona abortion ban could be enforced were appointed by former Gov. Doug Ducey, a Republican who in 2016 expanded the number of state Supreme Court justices from five to seven and cemented the bench’s conservative majority.

Yet in a post the day of the ruling on the social platform X, Ducey said the decision “is not the outcome I would have preferred.”

The irony is that the decision came after years of efforts by Arizona Republicans “to lock in a conservative majority on the court at the same time that the state’s politics were shifting more towards the middle,” said Douglas Keith, senior counsel at the left-leaning Brennan Center for Justice.

All the while, anti-abortion groups have been pressuring Republicans to clearly define where they stand.

“Whether running for office at the state or federal level, Arizona Republicans cannot adopt the losing ostrich strategy of burying their heads in the sand on the issue of abortion and allowing Democrats to define them,” Kelsey Pritchard, a spokesperson for Susan B. Anthony Pro-Life America, said in an emailed statement. “To win, Republicans must be clear on the pro-life protections they support, express compassion for women and unborn children, and contrast their position with the Democrat agenda.”

Two months before the Arizona decision, the Alabama Supreme Court said frozen embryos from in vitro fertilization can be considered children under state law. The decision prompted clinics across the state to halt fertility treatments and caused a nationwide uproar over reproductive health rights. With Republicans feeling the heat, Alabama lawmakers scrambled to pass a law to shield IVF providers from prosecution and civil lawsuits “for the damage to or death of an embryo” during treatment.

But when it comes to courts, Arizona lawmakers are doubling down: state Supreme Court justices are appointed by the governor but generally face voters every six years in retention elections. That could soon change. A constitutional amendment referred by the Arizona Legislature that could appear on the November ballot would eliminate those regular elections — triggering them only under limited circumstances — and allow the justices to serve as long as they exhibit “good behavior.” Effectively it would grant justices lifetime appointments until age 70, when they must retire.

Even with the backlash against the Arizona court’s abortion decision, Keith said, “I suspect there aren’t Republicans in the state right now who are lamenting all these changes to entrench a conservative majority on the Supreme Court.”

Meanwhile, abortion rights groups are trying to get a voter-led state constitutional amendment on the ballot that would protect abortion access until fetal viability and allow abortions afterward to protect the life or health of the pregnant person.

State court decisions are causing headaches even at the very top of the Republican ticket. In an announcement in which he declined to endorse a national abortion ban, presumptive Republican presidential nominee Donald Trump on April 8 said he was “proudly the person responsible” for ending Roe v. Wade, which recognized a federal constitutional right to abortion before being overturned by the U.S. Supreme Court in 2022, and said the issue should be left to states. “The states will determine by vote or legislation, or perhaps both, and whatever they decide must be the law of the land,” he said. But just two days later he sought to distance himself from the Arizona decision. Trump also praised the Alabama Legislature for enacting the law aiming to preserve access to fertility treatments. “The Republican Party should always be on the side of the miracle of life,” he said.

Recent court decisions on reproductive health issues in Alabama, Arizona, and Florida will hardly be the last. The Iowa Supreme Court, which underwent a conservative overhaul in recent years, on April 11 heard arguments on the state’s near-total abortion ban. Republican Gov. Kim Reynolds signed it into law in 2023 but it has been blocked in court.

In Florida, there was disappointment all around after dueling state Supreme Court decisions this month that simultaneously paved the way for a near-total abortion ban and also allowed a ballot measure that would enshrine abortion rights in the state constitution to proceed.

The Florida high court’s decisions were “simply unacceptable when five of the current seven sitting justices on the court were appointed by Republican Governor Ron DeSantis,” Andrew Shirvell, executive director of the anti-abortion group Florida Voice for the Unborn, said in a statement. “Clearly, grassroots pro-life advocates have been misled by elements within the ‘pro-life, pro-family establishment’ because Florida’s highest court has now revealed itself to be a paper tiger when it comes to standing-up to the murderous abortion industry.”

Tension between state judicial systems and conservative legislators seems destined to continue given judges’ growing power over reproductive health access, Piatt said, with people on both sides of the political aisle asking: “Is this a court that is potentially going to give me politically what I’m looking for?”

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SACRAMENTO, Calif. — Nearly a half-million health workers who stand to benefit from California’s nation-leading $25 minimum wage law could be in for a rude awakening if hospitals and other health care providers follow through on potential cuts to hours and benefits.

A medical industry challenge to a new minimum wage ordinance in one Southern California city suggests layoffs and reductions in hours and benefits, including cuts to premium pay and vacation time, could be one result of a state law set to begin phasing in in June. However, some experts are skeptical of that possibility.

The California Hospital Association brought a partly successful legal challenge to Inglewood’s $25 minimum wage ordinance, which barred employers from taking those sorts of steps to offset their higher costs.

“Layoffs, reductions in premium pay rates, reductions in non-wage benefits, reductions in hours, and increased charges are consequences of an employer having less money to spend—which will necessarily be the case given the significant increase in spending on wages due to the minimum wage,” the association said in its lawsuit. Additional examples include reducing health coverage and charging for parking or work-related equipment.

Inglewood voters approved the ordinance in November 2022, nearly a year before California legislators enacted a $25 minimum wage for health workers. Those statewide higher wages are to be phased in starting in June under California’s first-in-the-nation law, but Gov. Gavin Newsom has since said they are too expensive as the state faces a deficit estimated between $38 billion and $73 billion. It’s unclear if lawmakers will agree to a delay or take other steps to reduce the cost.

U.S. District Judge Dale S. Fischer agreed with the hospital industry in a March 11 tentative ruling when he shot down the portion of Inglewood’s ordinance banning layoffs and clawbacks by employers, while allowing the rest of the ordinance to remain in effect. He gave the sides time to object to his preliminary decision, though none did.

The California Hospital Association represents more than 400 hospitals and was a key backer of the state’s carefully crafted compromise law, which notably contains none of the employee safeguards included in the Inglewood ordinance.

Spokesperson Jan Emerson-Shea said the association doesn’t know how providers will react once the state law takes effect. “We don’t have any insights,” she said.

“The challenge for any health care organization is figuring out how to pay for the higher wages,” said Joanne Spetz, director of the Philip R. Lee Institute for Health Policy Studies at the University of California-San Francisco. “Since labor costs are the largest part of any health care organization’s costs, it’s hard to figure out how to reduce spending without looking at labor costs.”

Providers can try to increase revenues by bargaining for higher reimbursements from commercial insurers, she said. Public hospitals, nursing homes, and community clinics get most of their money through Medi-Cal, the state’s Medicaid program.

Providers could reduce the services they offer, pare back charity care, and cut or delay capital investments, Spetz said. In the long term, she expects some combination of spending cuts and revenue increases.

Both the state law and local ordinance cover far more than doctors and nurses, with a definition of health worker that includes janitors, housekeepers, groundskeepers, security guards, food service workers, laundry workers, and clerical staff.

The most recent estimate by the Health Care Program at the University of California-Berkeley Labor Center is that as many as 426,000 health workers would make an average of $6,400 extra in the law’s first year, a 19% average pay bump mainly benefiting lower-income workers of color and women. State finance officials project that well over 500,000 workers will benefit.

Researchers didn’t include layoffs and other potential staffing and benefit reductions when they projected the state law’s costs and benefits, said Laurel Lucia, the program’s director. But she pointed to initial projections by hospitals, doctors, and business and taxpayer groups that the wage hike would cost $8 billion annually, thereby imperiling services and resulting in higher premiums and higher costs for state and local governments.

“It seems like a contradiction to say this law’s going to cost billions of dollars while at the same time saying it’s going to reduce workers’ total compensation,” said Lucia, who projects a far lower price tag.

She added that state finance officials had anticipated that Medi-Cal reimbursements would reflect the increased labor costs, while Medicare would eventually at least partially compensate for the higher labor costs.

Michael Reich, chair of the Center on Wage and Employment Dynamics at UC Berkeley’s Institute for Research on Labor and Employment, and affiliated economist Justin Wiltshire recently argued that California’s new $20 minimum wage law for fast-food workers won’t result in mass layoffs and price increases, as some have predicted.

Health care is much different than fast food, Reich acknowledged, but he argued for much the same positive result.

“A higher minimum wage will make it easier and cheaper for hospitals to recruit and retain these workers. The cost savings, and the productivity benefits of more experienced workers, could offset much of the labor cost increase,” Reich said.

The hospital association filed its lawsuit against Inglewood’s ordinance in July, while it was still opposing early versions of the statewide minimum wage legislation. Among many other provisions, the statewide law put on hold an initiative to cap hospital executives’ salaries in Los Angeles.

The hospital association’s legal challenge referenced in part layoffs and reduced working hours imposed by Centinela Hospital Medical Center after Inglewood’s ordinance took effect.

But Centinela said the reduction was entirely unrelated to the ordinance and that all staff were offered alternate positions, which many accepted.

“Centinela Hospital also has since added many more jobs in new clinical positions above minimum wage scale,” the hospital said in a statement.

Service Employees International Union-United Healthcare Workers West, the prime backer of both the local ordinance and the statewide law, sued the hospital in April 2023 alleging that it cut workers’ hours to offset the higher minimum wage. The case is still pending.

The union did not respond to repeated requests for comment.

In a court filing, however, the union and city of Inglewood said similar employer restrictions in previous minimum wage laws have survived.

The ordinance “merely sets the backdrop for collective bargaining negotiations,” and does not bar employers from locking out employees or hiring replacement workers during a strike. Employers can still lay off workers or reduce their hours, they said, so long as they don’t do so to fund the higher minimum wage.

But Fischer agreed with the hospital association that layoffs and reductions in employees’ total compensation packages are “obvious responses by an employer to rising compensation costs.”

Restricting employers’ options would violate federal labor relations rules, he said.

“The minimum wage an employer has to pay its employees will invariably affect the total amount of compensation it is able or willing to pay,” he wrote “This will then invariably affect the number of employees it can retain and the number of hours those employees will be scheduled to work.”

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

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Editor’s note: This is the fourth installment of an occasional States Newsroom series called When and Where: Abortion Access in America, profiling individuals who have needed abortion care in the U.S. before and after Dobbs. The first installment can be found here, the second installment is here, and the third is here.

Kelly Shannon was grieving a pregnancy she would need to terminate because of multiple fetal anomalies when she got the call that Alabama doctors wouldn’t approve an abortion procedure despite exceptions in the law. That meant she would have to leave the state.

Shannon, 36, was about 16 weeks along in January 2023 when genetic testing – and confirmation from an amniocentesis – showed her fetus likely had Trisomy 21, better known as Down syndrome. It didn’t take long for the doctor to determine the fetus likely wouldn’t survive to term. There was fluid buildup in the head and body, evidence of a heart defect, and a tumor on the abdomen that was roughly one-third the size of its entire body.

“There was so much decision-making and processing, and you’re still feeling the baby kick the whole time,” Shannon said. “And every time she would kick, I was just sitting there like, ‘I’m so sorry. I wish I got to be your mom, but I don’t get to be your mom.’”

Three years before the U.S. Supreme Court issued the Dobbs decision in June 2022 and returned the ability to regulate abortion to the states, Alabama had already passed an abortion ban. Gov. Kay Ivey said at the time she signed the bill that even though it was likely unenforceable since abortion was still legal nationally, it was a signal to the courts to overturn Roe v. Wade. A group of physicians challenged the Alabama law in court and received a preliminary injunction that had barred its enforcement for years. But when Dobbs took effect, the injunction was lifted. Doctors are now subject to felony charges with punishment of up to life in prison.

Alabama is one of few states with an abortion ban at any stage of pregnancy that also contains an exception for lethal fetal anomalies. In the law, it’s defined as a condition from which the fetus would die after birth or shortly thereafter, or be stillborn. There are also exceptions for performing an abortion to save a pregnant patient’s life or preserve their health. However, according to the latest WeCount report of abortions performed since Dobbs, Alabama has recorded zero abortion procedures. Activists have argued that exceptions in abortion bans are meaningless because there is too much fear and uncertainty about what circumstances will qualify for an exception.

Down syndrome is the most common chromosomal abnormality, and more often occurs when the pregnant person is over the age of 35. According to the Centers for Disease Control and Prevention, infants with Down syndrome and a heart defect are five times more likely to die in their first year of life than those without.

Each abnormality on its own would possibly have been manageable, Shannon said, but the maternal-fetal medicine specialist told her the combination meant she would likely either miscarry at some point during the pregnancy or her daughter’s life would be short and punctuated by multiple surgeries. Shannon and her husband made the difficult decision at that point to terminate.

“That made the decision easier because it was like, well now if I know I’m going to lose her regardless, I can lose her on a controlled timeline, protect my health, start the grieving process, get healthy and then still be able to have another child,” she said.

Shannon filled out paperwork and made a termination appointment pending approval from the other maternal-fetal medicine specialists at the University of Alabama at Birmingham. Her doctor felt confident that given the severity of the anomalies, the abortion would be allowed.

‘I don’t think I would’ve taken that risk on me’

A few days later, in the car on her way to meet her husband and toddler at a local dog park, the doctor called back.

“I knew why she was calling me. I knew that was the day the (second) committee was supposed to meet and she’d be calling me with their decision,” Shannon said.

Shannon scheduled the Jan. 24 termination date, made arrangements to take leave from work, and had decided on cremation. But with one phone call, all the decisions she’d made had to change.

The termination had easily been approved by the first committee, and it seemed like the higher-level committee would sign off too. But in a halting manner, the doctor explained the committee had decided since each condition by itself was survivable, it didn’t meet the criteria for termination. She told Shannon it was the hardest phone call she’d made in her professional career.

The only way the committee might approve the request was if the fetus also developed a condition called hydrops fetalis, an excessive buildup of fluid that is often fatal. Shannon said that put her in a strange place of having some kind of hope that her pregnancy was even worse than originally thought. But she wasn’t upset with the doctors themselves.

“I mostly just felt sorry for them, even at the time,” she said. “As angry as I was that I wasn’t going to get to handle my pregnancy and my termination in the way that made the most sense to me … if I had been in their shoes and thought well, is this one case worth my license and jail time and prosecution? Her life’s not in danger, her baby’s probably going to die. I don’t think I would’ve taken that risk on me.”

The manager for public relations at the University of Alabama at Birmingham said no one was available to speak with States Newsroom for this story.

She had one more ultrasound at 17 weeks, where her providers checked for hydrops, but there was no presence of it. As the pregnancy had progressed further since the last ultrasound, multiple holes between the chambers of the fetus’s heart were clearly visible, and the tumor had grown 0.7 centimeters. Despite the increased severity of those problems, without hydrops she still had to go out of state.

A scheduling error meant Shannon had to wait two more weeks before she could get an appointment at a hospital in Richmond, Virginia — an 11-hour drive. Rather than bring her husband and toddler along for the ordeal, Shannon’s parents accompanied her. It was the first night she’d ever spent away from her toddler.

She chose to be induced for the procedure. After a long day of waiting, Shannon gave birth a few minutes before midnight and got to hold her daughter.

“I kept her with me until about 2 or 3 in the morning,” she said.

The logistics of what to do with the remains became more complicated since she was now more than 700 miles away from home and wouldn’t be able to visit a burial site in Virginia the way she could have in Alabama. She opted to have her daughter buried with other babies that had died because of miscarriage, termination, or other premature causes.

Baby boy born in mid-March

In mid-March, Shannon gave birth to a healthy baby boy who was a surprise pregnancy. She had been aiming for her next pregnancy to happen over the summer, when she wasn’t teaching.

“When I found out I was pregnant, I just started crying. Instead of being excited, the trauma came back,” she said. “And I felt like, I want to be excited and happy, but I’m not there yet because I don’t know if we get to keep this one yet either.”

She said she wants her story to make a difference, in hopes that another person doesn’t have to go through the same pain.

“I get angry whenever I see people with the ‘choose life’ bumper stickers and license plates, because they’re not thinking about me. They’re not recognizing that it’s not a black and white issue, it’s nothing but shades of gray when you’re dealing with pregnancy, particularly high-risk pregnancy,” Shannon said. “I am a married, white, straight, Christian, grew-up-in-the-church woman who was attempting to grow her family within the bounds of marriage, and I just keep thinking, if anybody is going to be able to change a mind about this issue, shouldn’t it be me?”