When Mike Stabile first moved to Los Angeles in 2011, he was struck by a freeway billboard that showed a line of cocaine and an overturned shot glass. The caption read: “You know why. Free HIV test.”

“I literally pulled over the car and was like what’s going on?” Stabile remembers. “I was having a panic attack.”

He describes another billboard showing two men in bed, looking nervous, and posing this question: “Trust Him?”

“As a gay man, you really have to fight against this idea that you’re constantly in danger,” says Stabile, who came of age during the height of the AIDS epidemic in the ’80s. “Fear and stigma actually works against people getting tested.”

Stabile is a documentary filmmaker, activist and a spokesperson for the Free Speech Coalition, the trade association for the adult entertainment industry, which is opposing Proposition 60.

He says he sees the same heavy-handed, moralistic attitude behind Proposition 60, the California ballot initiative that would require adult film performers to use condoms on porn sets. If the performers don’t comply, and state regulators fail to enforce the mandate in a timely manner, any Californian can sue the film producer.

“Its success depends on stigma around sex, stigma around porn,” says Stabile.

The man behind Proposition 60 — and all those billboards — is Michael Weinstein, president of the AIDS Healthcare Foundation and a longtime maverick in gay activist circles.

The nonprofit runs pharmacies and provides HIV care in 13 states and 37 countries, and it gave away 38.5 million condoms last year. It’s putting $4.5 million from its pharmacy sales into backing the Proposition 60 condom mandate. (It has also put $14.7 million behind Proposition 61, Weinstein’s initiative aimed at lowering prescription drug prices in California.)

Weinstein says he’s steadfastly promoting condoms when other groups seem to have forgotten them.

“It’s unfashionable,” he says. “I was on a panel discussion and one of the guys said, ‘You’re acting like our mother telling us to wear galoshes.’ And my reaction was ‘Yeah, somebody needs to do that!’ I mean, I’m not trying to win a popularity contest, obviously.”

For Weinstein, Proposition 60 is primarily about protecting adult film workers against sexually transmitted diseases — at a time when infection rates are at a 20-year high across California. But it’s also another large-scale condom campaign.

“A lot of people get their sex education through these films, and I think it’s sending a bad message,” Weinstein says. “I don’t want young people to be educated that the only kind of sex that’s hot is unsafe sex.”

Weinstein has long taken controversial positions, but he’s often landed on the right side of history. In the 1980s, he fought lawmakers in California who wanted to quarantine AIDS patients. When nurses were afraid to touch patients, leaving them languishing in the hallways of county hospitals, he helped set up one of the first AIDS hospices, where people could die with dignity and compassion. And when AIDS drug cocktails became available, Weinstein risked bankruptcy to provide the life-extending drugs to uninsured patients.

“We decided we had a moral obligation to give them, and we paid for them and those people lived,” he says.

One of Weinstein’s more recent and most unpopular stances is on pre-exposure prophylaxis, or PreP, the daily pill that can prevent people from contracting HIV. Many activists consider it a powerful tool for prevention.

Weinstein doesn’t see PreP that way. “It’s often taken in conjunction with crystal meth and other party drugs,” he says. “It’s really a get-out-of-jail-free card.”

He says it gives people a free pass to not use condoms and be reckless, driving a rise in other STDs, which recent studies bear out.

But other public health groups say PreP will reduce HIV transmission and save lives, which the studies also support. “It’s not helpful to have one of the largest HIV organizations in the world trivializing it or downplaying its importance,” says Courtney Mulhern-Pearson, director of state and local affairs at the San Francisco AIDS Foundation.

Her group, along with AIDS Project LA, is opposed to Proposition 60, in part, because it ignores PreP. Mulhern-Pearson says Weinstein’s singular focus on condoms is outdated and unrealistic.

“Condom fatigue is real,” she says. “And I think that all of us are probably not realistic and not forthcoming about our condom use.”

History and opposition

Weinstein has been fighting to mandate condoms in adult films for years. While federal and state worker safety laws technically already require producers to protect performers against STDs with condoms, the law is largely ignored and poorly enforced. Weinstein has pushed California’s Division of Occupational Safety and Health, known as Cal/OSHA, to refine and clarify its regulations, without success. He’s backed local measures in Los Angeles County to require condoms, which passed, but enforcement has, again, been minimal.

At every turn, the adult film industry has fought the condom mandates. Some say it would force them to make products that won’t sell, or that it would drive the business underground or out of state.

In mid-October, more than a hundred adult film performers rallied outside Weinstein’s office in Los Angeles to protest Proposition 60. They chanted slogans like “Our Bodies, Our Choice!” and carried signs that read “Where is Weinstein?”

They say they prefer to rely on the industry’s bi-monthly testing protocol over condoms. Performer Ela Darling says condoms don’t work on porn sets; they’re uncomfortable and cause friction rashes.

“The sex you have on camera isn’t like the sex you have at home,” she says. “It’s like Olympic-level, athletic sex.”

She’s frustrated that Weinstein is ignoring performers’ concerns.

“He will not hear us, he will not speak to us, but he’s happy speaking for us,” she says. “And that’s the problem.”

Weinstein defends his refusal to meet with the adult film industry.

“I’m not going to put myself in a position of debating people where all they do is call me names,” he says.

Weinstein’s critics have called him bombastic, a bully. They compare him with Donald Trump. They post tweets that refer to him as the “Condom Nazi.”

“In case they haven’t noticed, I’m Jewish and I’m gay, OK?” he says. “It makes my skin curl.”

Weinstein says he’s never liked the limelight. He’s had to develop a thick skin to stay in this business, to stand up for what he believes is the moral thing to do, for what he believes is his responsibility toward young generations.

Yet it’s clear that the criticism bothers him.

“He’s been hurt,” says Sharon Raphael, an old friend and fellow activist. “I know that it hurts him.”

Still, she adds, everyone knows he’s a force to be reckoned with.

“When most people would be down and out, strike three, he’d get up again,” she says. “He never gives up. Ever.”

This story is part of a reporting partnership with NPR, KQED and Kaiser Health News.

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When it comes to health care, the choice between Hillary Clinton and Donald Trump comes down to whether to keep, or trash, the Affordable Care Act.

Trump says he wants to repeal and replace the health care law that is responsible for insuring about 20 million people, while Clinton has vowed to retain it and even expand its reach.

Here are the candidates’ plans:

HILLARY CLINTON

• Keep and build on Obamacare
• Offer a tax credit of up to $5,000 to offset out-of-pocket costs over 5 percent of income
• Create a “public option” for health insurance
• Increase funding for community health centers
• Establish federal oversight of drug price increases
• Allow people to “buy in” to Medicare starting at age 55

Clinton’s plan maintains the basic structure of Obamacare, with its expansion of Medicaid to more people with higher incomes and the ability to buy insurance through government-run exchanges. But she acknowledges problems with the program in its current form and offers changes to cut consumer costs, rein in drug prices, and ensure more uninsured people get covered.

The so-called public option would allow consumers to buy health insurance directly from the federal government. It’s proposed in most cases to ensure there are choices for buyers in places where only one insurance company offers policies through the Obamacare exchanges.

An analysis of Clinton’s plan by the Commonwealth Fund, a private foundation that supports independent health care research, concludes it would boost the number of people with health insurance by about 400,000. But the impact on the federal deficit is unclear: The report says it could range from a small decline to an increase of as much as $90 billion.

The Commonwealth analysis doesn’t account for Clinton’s proposal to allow people to “buy in” to Medicare at 55 rather than waiting until 65. That could reduce premiums for younger people who buy insurance through the ACA exchanges but would increase the cost of Medicare, says Joe Antos, a scholar at the American Enterprise Institute.

“She says ‘buy in’ because that disguises the fact that there has to be more taxpayer money in the subsidy to work,” Antos says.

If the House remains under Republican control, there’s little to no chance the public option or Medicare buy-in will become law.

DONALD TRUMP

• Repeal and replace Obamacare
• Promote tax-free health savings accounts
• Make insurance premiums tax-deductible
• Allow insurers to sell policies across state lines
• Turn Medicaid into a state block grant program
• Allow consumers to import drugs from other developed countries

Trump, like most Republicans, says he wants to repeal Obamacare, but he hasn’t offered many details about what will happen to the 20 million people who will lose their insurance if that happens. In a speech this week, his running mate, Mike Pence, said Obamacare subsidies would be phased out so consumers could have a smoother transition to new insurance.

To buy that insurance, Trump wants to expand the use of health savings accounts, which allow people to save money tax-free to pay for health care costs. He also says allowing insurance companies to sell policies across state lines will cut costs, a notion economists question.

The Commonwealth Fund analysis says Trump’s proposal would increase the number of people without insurance by as many as 25 million.

As with Clinton’s plan, the estimates of this plan’s impact on the budget is a big range, from no impact to an increase of as much as $41 billion. That’s because much of his plan involves tax breaks to encourage people to buy insurance, while taking away the requirement to buy that’s embedded in the Affordable Care Act.

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For many Missouri health advocates, an increase in the state’s tobacco tax is long overdue. But onlookers might be surprised to hear that tobacco companies are spending a fortune this election year to get one or another increase in that tax passed, while health groups are urging a no vote.

At 17 cents for a pack of cigarettes, Missouri’s tax is the lowest in the country — a fraction of what you’d pay in many states. New York’s tax is the highest at $4.35 a pack, for example, and Florida ranks around the middle of the states at $1.34 a pack. Missouri’s cigarette tax also hasn’t changed since 1993.

Health groups like the American Lung Association say Missouri’s low cigarette prices contribute to one of the highest smoking rates of any state in the country: Twenty-two percent of adults in Missouri smoke, according to data compiled by the Centers for Disease Control and Prevention.

On Nov. 8, Missouri voters will decide whether to approve not one, but two tobacco tax increases. This time, however, health groups are actually urging voters to leave the tax alone, while tobacco companies are lobbying the electorate to vote yes.

The current tobacco tax debate got its start as way to expand early childhood education. In Missouri, just 19 percent of 4-year-olds attend a preschool or a Head Start program.

To Linda Rallo, an early childhood education advocate in St. Louis, a small increase in the tax seemed like an easy way to fund the schooling expansion. But then she took the idea to lawmakers in Jefferson City.

After years of failed attempts to increase the tax in the legislature, lawmakers and others in the capital seemed to consider another attempt to do so almost laughable.

“We had big, right-leaning people mocking us,” Rallo says. “It was rough.”

So Rallo and supporters decided instead to try to create a tax through a ballot measure. Their polling showed voters might approve an additional 60 cents a pack — and that’s the tax increase they’re proposing.

They estimated that their plan, which became Constitutional Amendment 3 on this month’s Missouri ballot, would generate around $300 million a year to fund mostly early education, with some funds going to smoking cessation and to health facilities that provide health care for children.

Rallo says her group reached out to get the help of health organizations like the American Lung Association. But there was a problem with her amendment, some public health researchers told her. Public health data suggest the size of the tax in Rallo’s amendment is too small to make a difference in smoking rates.

“Raising prices of tobacco products, we know, is the most effective way to prevent people from starting to smoke, to help people not get addicted to tobacco products and — for those who are smoking — to help them quit,” explains Dr. Doug Luke, director of the Center for Public Health Systems Science at Washington University, in Saint Louis. But the size of the tax, research shows, has to be big enough to make people think twice before buying that pack of cigarettes.

Washington University has come out against Amendment 3, as has the American Lung Association, which argues that the amendment’s schedule of gradual increases in tax over four years would also keep it from having a big influence on smoking rates.

Rallo says it was this sort of disagreement over the size of the tax that caused her talks with health groups to break down.

“It was basically, ‘It’s my way or the highway.’ So we took the highway,” Rallo says. “And when you’re going down the highway, you might pick up an interesting companion.”

That “interesting companion” is tobacco giant R.J. Reynolds. Since December of 2015, the company has donated more than $12 million to committees supporting Amendment 3.

In a written statement, R.J. Reynolds said this is the first time the company has supported a cigarette tax increase.

But that’s not the end of the campaign’s complications. Amendment 3 also pits the big tobacco giant against smaller manufactures, known collectively as “Little Tobacco.”

As the result of a national settlement in the late ’90s, big tobacco companies right now must pay the state a special fee that that their smaller competitors don’t face.

Rallo says the fee allows these smaller companies to undercut firms like R.J. Reynolds, in their price per pack.

“You have such a low price on cigarettes — such a discounted price — that it’s very easy for low income people to buy cigarettes,” Rallo says.

Amendment 3 creates an additional tax increase for the little tobacco companies that don’t pay the fee. Rallo says that extra tax is meant to stop the small companies from being able to sell cigarettes at bargain prices.

But little tobacco has fired back. They’ve thrown their weight behind a different ballot measure — Proposition A, which would add a smaller tax (23 cents a pack) on all brands. That way, the smaller producers would still be less expensive than Big Tobacco’s cigarettes.

Two of the smaller manufacturers, Xcaliber International and Cheyenne International, have donated nearly $5 million in support of the smaller tax.

Meanwhile, many education advocates aren’t crazy about how the tax money raised by Rallo’s proposed amendment would be spent. Rather than earmarking it for public schools, the money raised by Amendment 3 would be available as grants that could alternatively go to religious or private education groups.

Rallo says these other institutions provide a lot of pre-K programs in Missouri and are better prepared than public schools to expand in many parts of the state. Proposition A’s money would fund infrastructure projects.

The numerous debates and controversies that have arisen from Amendment 3 have led to some alliances never seen before, and to shifts in many of these groups’ default positions on tobacco and taxes.

“This becomes very confusing to the public,” says Luke. “They see multiple bills on the ballot. They hear that public health groups are arguing about this. And even the tobacco industry is fighting itself, which is very unusual.”

Groups like Tobacco Free Missouri, the Health Care Foundation of Greater Kansas City and Campaign for Tobacco-Free Kids have joined fiscal conservatives in opposing Amendment 3. These anti-smoking groups worry that creating such a small tax now might eliminate the chance of future tax that would be big enough to significantly change smokers’ behavior.

“There is a sense here of, ‘At some point we need to get something passed,’ ” says Luke. “But that’s not how you do sound policy.”

This story is part of a reporting partnership with NPR, KCUR and Kaiser Health News.

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The number of preterm births in the United States rose in 2015 for the first time in eight years, according to data presented Tuesday by the March of Dimes. Babies born too early face a risk of health complications that can last a lifetime.

The organization also reported that racial minorities continue to experience early labor at higher rates.

Preterm births increased from 9.57 to 9.63 percent of births in 2015, an additional 2,000 babies born prematurely in the U.S., the report found.

Seven states — Arkansas, Connecticut, Idaho, Nebraska, New Mexico, Utah and Wisconsin — had higher preterm birth percentages than in 2014. Four states — Vermont, Oregon, New Hampshire and Washington — earned the highest marks from the organization for having a preterm birth rate at 8.1 percent or below.

Overall, the national uptick earned the U.S. a C rating on an A to F scale. The March of Dimes researchers used data compiled by the National Center for Health Statistics and assigned grades using a formula that compared the state’s current prenatal birth rate to the national average in 2014 and the organization’s goal of 8.1 percent.

Despite its wealth and medical prowess in saving the lives of premature newborns, the U.S. lags behind the majority of industrialized countries and some less developed ones in preventing their early arrival. According to the latest data available from the World Health Organization, the U.S in 2010 ranked in the middle of the pack, falling behind Somalia, Afghanistan and Thailand.

Lowering the rate of preterm births to 8.1 percent would place the U.S. among countries with the lowest rates of preterm births. The March of Dimes says the U.S. should reach this goal by 2020, but the lack of progress signals to Edward McCabe, the chief medical officer of the organization, that new responses are needed. “We feel that this is a recognition that we need to work harder as a nation, that we need to focus,” he says.

Preterm birth is defined as a child born before 37 weeks of pregnancy. It’s the leading cause of neurological disorders such as cerebral palsy, according to the Centers for Disease Control and Prevention, and also can cause blindness, hearing problems and developmental delays. It’s the single largest cause of infant death.

Preterm births cost society more than $26 billion a year, according to a 2005 report from the National Academy of Medicine.

Disparities continue across geographic, ethnic and racial lines, McCabe said. Asians and Pacific Islanders fared best, with a preterm birth rate of 8.5 percent, a full percent lower than the national average. Preterm birth rates in Hispanics and whites hovered at about 9 percent.

African-American women were most likely to give birth prematurely, with 13 percent of births affected, according to the report. States with large African-American populations and a lack of access to health care, such as Louisiana, Mississippi and Alabama, had the highest percentages of preterm births.

“We want every baby, no matter where they’re born, no matter their birth ethnicity, to be born with the best start in life,” McCabe says.

Vermont officials agree. The state boasts a 7.3 percent birth rate, the lowest rate in the U.S. It runs the Vermont Regional Perinatal Program, which allows smaller medical facilities to transfer high-risk pregnant women to larger tertiary hospitals. It also supports nurse home visits to help new mothers.

Breena Holmes, maternal and child health director at the Vermont Department of Health, says though she is proud of the state’s low rate, she still worries that there are too many preterm babies born there. “I’m still aware that every time a baby comes early, there was a system problem that we could have worked on,” she says.

The racial and ethnic divides reveal an overemphasis on medical intervention and a lack of knowledge among women, says Claire Brindis, director of the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco. Planning for pregnancy does not start with prenatal care, she says, but with understanding risk factors and a woman’s wishes regarding family planning.

The causes of preterm birth aren’t clear, but risk factors include high blood pressure, diabetes, smoking and having had a previous premature birth.

While not every preterm birth can be prevented, McCabe acknowledges, a woman should be able to have the best pregnancy possible.

“Every woman is trying to do the best that she can,” he says. “We need to show her what can be done.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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Donald Trump is continuing his homestretch campaign strategy of trying to stay on message. As the Clinton campaign also tries to focus on issues and policy in the heat of another FBI investigation, Trump rolled out his health care plan for the country. Noticeably, Hillary Clinton was largely absent from his speech Tuesday in Valley Forge, Pa.

“When we win on November 8th,” he said, “and elect a Republican Congress, we will be able to immediately repeal and replace Obamacare. Have to do it. I will ask Congress to convene a special session so we can repeal and replace. And it will be such an honor for me, for you, and for everybody in this country because Obamacare has to be replaced. And we will do it and we will do it very, very quickly. It is a catastrophe.”

Trump criticized rising premiums under the Affordable Care Act and took an opportunity to appeal to young voters, where his campaign’s support has reached historic lows.

“This is particularly unfair to millennials and younger Americans generally who will be totally crushed by these massive health care costs before they even get started on their journey through life,” he said.

The event was billed as an address on health care but segued into a more standard stump speech. Trump calmly and quickly mentioned his campaign’s plans for health savings accounts, Medicaid dollars and family options before moving on to the topics of trade and manufacturing. He also turned to education, pledging to “totally eliminate Common Core and bring it local,” then praised the concept of vocational training and promised to “start it up big league.”

But despite his measured tone in Pennsylvania, Trump hasn’t been able to completely resist mentioning the FBI controversy. He spent the morning before his speech tweeting about “Crooked Hillary” and the email case.

And on Monday, Trump used a rally in Michigan to call out Hillary Clinton’s top aide, Huma Abedin, and Abedin’s estranged husband.

“Thank you, Huma. Good job, Huma. Thank you, Anthony Weiner,” he taunted.

Trump turned the investigation into a campaign pitch. He warned the crowds that, if elected, Clinton would be too distracted by what he called “a constitutional crisis” to be an effective president.

“How can Hillary manage this country if she cannot even manage her emails?” he asked his cheering supporters.

But Trump himself, who is no stranger to court cases, lawsuits and scandals, has a few legal hurdles in front of him post-election day.

The fraud case against Trump University is moving forward later this month. Former students allege they were tricked into paying tens of thousands of dollars for real estate courses that ultimately had no teachers, classes or degrees.

And the Trump Foundation is still under investigation in New York for “impropriety,” with Trump reportedly spending money from the foundation on himself and using funds to settle his lawsuits.

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There are rating systems for hospitals, nursing homes and doctors. So why is it so hard to compare providers of child care?

Part of the reason is that there are no nationally agreed-upon standards for what determines the quality of child care. The standards that do exist are formulated in each state, and they vary widely.

For example, some states require that child care workers have a teaching certificate. Others require certain college courses. Some have strict ratios of how many caregivers are required per child.

But all of these criteria are important in assessing the quality of a child care facility, says Susan Hibbard, director of Build Initiative, which works with states developing early childhood programs.

What’s needed, she says, is a tool that makes it easier for parents to evaluate and compare the child care options in their communities.

“So you know that if you see 3 stars out of 3 stars, your child is going to have teachers who are nurturing, have experience, understand child development and know how to work with children and help them thrive,” she says.

About 20 states are “on their way,” Hibbard says, having received federal funding in 2011 to build a system to define, measure and improve quality. Some states are working to create online tools based on standards suggested by the federal Department of Health and Human Services. These standards are the basis for a rating system HHS calls the Quality Rating and Improvement System.

A recent poll by NPR found that among parents whose child gets care from someone other than a relative, 71 percent cite quality as one of the top two or three reasons for choosing one child care provider or program over another. Our polling partners are the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health.

The quality factors most frequently volunteered by parents included trustworthy providers (20 percent), activities for learning (13 percent), educated/well-trained providers (12 percent) and activities for building friendships (7 percent). Parents cited more than a dozen other quality factors as important to them.

A more comprehensive rating system might have helped Kinsee Morlan avoid problems with a child care provider, even though she did do her best to find out basic information.

When Morlan got pregnant with her first child, Harper, she and her husband started looking for day care. They explored lots of options, including large day-care centers near their San Diego home. But the large centers, with lines of cribs and lines of rocking chairs just weren’t for them. “I just couldn’t wrap my brain around that,” Morlan says.

Eventually they decided on a small home setting, which seemed perfect. It had a little preschool room in the back of the house which was “like this magical little room with glass windows everywhere, really bright and in a garden,” Morlan says, adding it was just the kind of place it seems kids “would love to be.”

Morlan made sure the day care center was licensed by the state of California, and she even checked to make sure there were no serious infractions on file.

Harper was less than a year old when she enrolled him.

Everything seemed to be going well until one day the caretaker mentioned Harper had been kicking and screaming while in a car seat.

Morlan and her husband didn’t think much about it until they got home that night, changed his diaper and saw deep red abrasions on his leg.

“As a first time mom, I freaked out,” Morlan says. She took Harper to urgent care, where doctors “gave us a grave look” and said it looked like Harper was in some sort of car seat or child holding device for “way too long.”

She says she and her husband lost faith in the day care system after that and decided to care for Harper within the family. Morlan took off work one day a week. So did her husband. Morlan’s mother-in-law filled in the other three days.

The parents made this commitment: They would not send Harper to preschool until he could communicate clearly and tell them what happened at school.

Today, Harper is 3 and is enrolled in preschool. Morlan makes sure that she asks him how his day went every day.

While this case is extreme, it’s an example of the difficulty parents face when trying to figure out if a day care program is good, just OK or bad.

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Prices for Obamacare have risen for many — but so have discounts. Many may end up paying less this year.

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Young children and teenagers are increasingly likely to be poisoned by opioid painkillers that are often prescribed for other family members, a study finds.

The rate of children hospitalized for opioid poisoning increased 165 percent from 1997 to 2012, from about 1.40 per 100,000 kids to 3.71 per 100,000.

“Opioids are ubiquitous now,” says Julie Gaither, a postdoctoral fellow at Yale School of Public Health and the study’s lead author. “Enough opioids are prescribed every year to put a bottle of painkillers in every household. They’re everywhere, and kids are getting into them.”

The study, which was published Monday in JAMA Pediatrics, examined more than 13,000 hospital-discharge records from 1997 to 2012 for opioid poisonings and used census data to extrapolate rates. The discharge data was collected by the Agency for Healthcare Research and Quality.

The data stops in 2012, so it may not reflect more recent trends in opioid prescribing and public awareness. But the findings track with adult rates of abuse and addiction, which have dropped since 2012 but remain troublingly high, experts say.

The rate of toddlers hospitalized more than doubled, going from 0.86 per 100,000 to 2.62 per 100,000. It’s likely that these very young patients take the drugs because they think they are candy or a treat. Opioids can be dispensed as pills, patches or a flavored lollipop.

Teens are also at risk of overdosing on their parents’ meds. Of all children, this age group is most likely to be hospitalized for opioid poisoning, and teens are more likely to do be poisoned deliberately — likely, the researchers wrote, because teenagers are at a particularly high risk of depression and suicide. In 2012, 10.17 per 100,000 teenagers were hospitalized for opioid poisoning.

The findings, Gaither and her co-authors say, indicate a need for public health approaches that not only address overprescribing, but also try to raise awareness about the need for safe storage of these painkillers.

Doctors need to to talk to patients about ways to store drugs safely, especially if children are in the household, Gaither says.

That’s a good idea in theory, says Jonathan Chen, a physician at Stanford Medicine who has researched how guidelines for prescribing opioids affect primary care. But doctors already face a lengthy list of sensitive subjects they should discuss with patients. And they aren’t always conditioned to consider how a patient’s medications could affect other family members.

“Conceptually, yes, of course that should be part of the conversation,” Chen says. But he notes that doctors have a long list of things to discuss with patients, and “there’s a lot of things we should discuss.” Chen was not involved with the study.

Pediatricians could also play a role by asking parents at well-child and well-baby visits about whether there’s a risk of children being exposed to opioids. But that sort of screening hasn’t traditionally been drilled into doctors the same way as discussing other risks, such as safe storage of cleaning supplies, whether the family has a swimming pool and whether there are guns in the home.

Doctors also may not be conditioned to considering toddlers as particularly at risk of opioid poisoning.

“This is largely seen as an adolescent problem or an adult problem,” says Sharon Levy, who directs the adolescent substance abuse program at Boston Children’s Hospital and is an associate professor of pediatrics at Harvard Medical School. “But this paper really highlights that this really knows no age boundaries.” Levy was also not involved with the study.

It’s also unclear, Levy says, what the long-term health effects, including addiction, are for children who ingest opioids they weren’t prescribed.

And there are serious short-term risks, including death. “Opioids cause respiratory suppression,” she said. “If you are a 30-pound person and getting into the medication that was supposed to be for a 150-pound person, it’s going to be a whopping dose for you.”

The findings also suggest doctors should be more thoughtful in prescribing to children, especially teenagers. About 1 in 10 high school students reports having taken opioids for a nonmedical reason, and close to 40 percent of them say they got those drugs through their own prior prescriptions.

The American Academy of Pediatrics notes that the rate of young patients being prescribed opioids almost doubled between the 1990s and 2000s.

The Centers for Disease Control and Prevention has been pushing doctors to prescribe opioids more safely by prescribing for just a few days. That could help reduce the number of leftover pills. Large prescriptions — coupled with the fact that many people don’t know how to dispose of drugs when they no longer need them — can make it easier for children and teens to get ahold of them, Gaither says.

That’s an important factor to consider, Chen says. “Leftover pills aren’t used, but do they get returned to the pharmacy, or thrown in the trash? Nope. They’re stored in the medicine cabinet.”

Smaller prescriptions will likely help, but they won’t solve everything, Chen notes. After all, there are situations where a larger opioid dosage makes sense. For instance, someone suffering long-term cancer probably needs a larger amount of heavy duty painkillers, even if he or she has children in the house.

But the risk to children must be a part of the conversation, Gaither says. “We’ve got to pay attention to children and the toll the opioid crisis is taking on them,” she says. “Kids make up about a fourth of the U.S. population, and they’re suffering from this crisis, too.”

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As a hospice chaplain, it’s Kerry Egan’s job to help dying people accept their own mortality. Sometimes that means sitting with them as they express their regrets and fears. Other times, she listens as they recount their life stories and reflect on the experiences that brought them joy.

“There’s no time to preach or teach,” Egan tells Fresh Air‘s Terry Gross. “You have to use whatever tools that person already has in their spiritual toolbox to help them come to meaning in their lives.”

Every patient is unique. Some find meaning in religion. For others, it comes from family, friends and relationships or in art and literature and music. “If you think about how different every single person who’s living … is, well, people are just as different in the dying process,” says Egan, who lives in Columbia, S.C.

In her new memoir, On Living, Egan describes her hospice work and the impact it has had on her own life. She says that despite the sadness and loss that are implicit in her work, there is also great joy.

“I’m constantly reminded of the strength of the human soul,” she says. “I’m constantly reminded of … how much love people have for each other, and the love that’s all around us that we just don’t necessarily take a moment to see.”

Interview Highlights

On what a hospice chaplain does

A chaplain should never go in and preach to someone; that’s not our role. Our role isn’t to tell you what to believe. Our role is to say, “What is it you believe and how does that help you — or not help you — in this process, this process of dying, this process of letting go of the life you’ve loved (or maybe have not loved) and coming to some peaceful place?” …

Ideally you have months to do this. You have months to sit down with someone once a week or twice a month and talk with them about their beliefs, religious and otherwise, to make meaning of their lives. But a lot of times, you just don’t have that time.

On helping people get to a calmer place

One of the big things a chaplain does is to model it, and that sounds so simple … but when you start to learn how to work as a chaplain, you hear people talk all the time about presence. You have to have pastoral presence, or sometimes I call it spiritual presence, and I remember thinking, What does that even mean? I don’t know what in God’s earth that means.

What it really means is to model a sense of — in the midst of this storm of emotion — you can stay calm. Right, it does not have to overtake you. You would be surprised how powerful that is for someone else, just to be with someone who is maintaining a sense of presence, of not being in the past, of not being in the future, of literally being present, you know? … That has a way of calming people down.

Also, as human beings we’re such social creatures, it’s easier to do this with someone. It’s easier to sort of face the hard things in your life when you’re not alone, and that’s a big part of what a chaplain does, is she stays with you. … That’s the key point of the job is you need to keep it together so that the other person can sort of fall apart and then you’re modeling for them what it looks like to come back to a place of peace where you can start to say, “OK, what does that all mean?”

On how many people in hospice feel about death

People who die in hospice hopefully have had a little more time to reflect on their lives, to talk about what they think comes next, and ideally for me, and maybe this is a little selfish, I don’t know … I would hope that my patients aren’t afraid anymore. I think people would be really surprised to know that a lot of hospice patients aren’t nearly as afraid of dying as you think they are. I think some of us who are healthy in the middle of life have a real fear and horror of death, and I think a lot of hospice patients don’t. They don’t anymore. Some of them are downright curious.

On people often having visions of their mothers before they die

Anybody who works in hospice will tell you, anybody, that it’s really common for people who are dying to see their mothers. It’s not a necessary step, everybody doesn’t experience it, but it happens a lot. … They come to them, they wave at them, sometimes they talk to them, and it’s really, really comforting to people.

Is that real? Not real? You know, I’ve come to this place where I don’t know and I’m OK with that. I’m really OK not fully understanding. I wasn’t like that before. I think there are going to be a lot of things in life, whether you’ve experienced them yet or not, that we cannot fully understand, that we can’t fully make meaning of, we can try, and that at some point, you have to be OK saying, “I don’t know that I really know what that means, but it’s part of my experience and I need to accept it.”

On needing to stay “soft” in her work, but with a “spine of steel”

I think it’s just the nature of living, that there’s a lot that’s so beautiful and so wonderful and so joyful and so fun, but there’s also so much loss and pain. Everybody dies, I mean it’s just the nature of life, and so you’re going to have to deal with those losses and that sadness.

There’s two ways to do it, and in hospice you’re really going to deal with a lot of loss, because all of your patients die and you do come to love them and their families. You can put on this hard outer shell and not let it affect you, just be like, I don’t feel it, I don’t feel you, I don’t love you, I have no connection to you. That’s one way — unfortunately, sometimes a really common way — that people deal with the barrage of loss.

But to be effective as a chaplain, to create that peaceful place, that presence that I talked about, you have to be very open to them. You have to be willing to enter into their world, to engage with them, to walk with them in that journey of meaning-making.

If you’re not willing to be soft on the outside, you’re not going to get any work done. And if you have to be soft on the outside to be an effective chaplain, well then something’s got to hold you up, and the only thing that can hold you up is sort of an interior strength. That’s it.

On why being a hospice chaplain makes her a happier person

I’m a happier person when I’m working as a chaplain. … Death is really sad. When someone dies, it’s really sad, but there’s also enormous joy to be had and funny times and happy times and everything. It’s life, right? Dying is part of living, so everything you have in the course of a life you have in the course of dying. …

I think when people are dying they can’t necessarily do a lot physically, and so they’re in their minds a lot, they remember a lot, they remember their lives. They talk about what they did in their lives, and they find so much happiness and joy in the memory — but oftentimes they’ll say, “You know, I was so happy and I didn’t appreciate it then.”

So that’s a constant reminder for me to stop and say, “Wow, I’ve got some really good stuff going on in my life right now. I’m really happy.” I think a lot of people go around happy and they don’t even know they’re happy. It’s such a joy to be aware of it.

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Acknowledging that “there is more work to be done” to ensure that patients with mental illness and addiction don’t face discrimination in their health care, a presidential task force made a series of recommendations Friday including $9.3 million in funding to improve enforcement of the federal parity law.

The long-awaited report is the product of a task force President Obama announced in March during a speech about the opioid epidemic.

“These disorders affect society in ways that go beyond the direct cost of care,” the report authors write. “Without effective treatment, people with these health conditions may find it difficult to find or maintain a job, may be less able to pursue education and training opportunities, may require more social support services, and are more likely to have their housing stability threatened.”

Since the passage of the Mental Health Parity and Addiction Equity Act in 2008, health insurers and employers have made progress toward improving coverage for mental health and substance abuse issues. Most insurance plans, for example, no longer charge higher copays or separate deductibles for mental health care.

But there have been significant problems with the parity law, too, including lax enforcement and little guidance for the public about the law itself or how to file a complaint.

Over the past seven months, the task force received 1,161 public comments from patients, families, insurers, advocates, state regulators and others. Based on the findings, the group has taken several actions.

• The Centers for Medicare & Medicaid Services is awarding $9.3 million to states to help enforce parity protections. California, New York, Massachusetts, Oregon and Rhode Island were cited as models of promising enforcement efforts.
• A new government website will help consumers identify the right agency to assist with their parity complaints and appeals.
• A newly released consumer guide will help patients, families and providers understand their rights and look into whether they have experienced a parity violation.
• The Department of Labor will report each year on its investigations into parity violations.

In addition, the task force recommended that the government increase its capacity to audit health plans for parity compliance and allow the Department of Labor to assess civil monetary penalties for violations.

Former congressman Patrick Kennedy, one of the authors of the parity law, said the report and actions were a step in the right direction. “However, much of what was released today still places the burden of real action squarely on the shoulders of the patients living with these conditions,” he said in a written statement. “[We] are asking these individuals to take up their own cases when they experience a parity violation, which usually occurs at the height of their crisis.”

The next administration, Kennedy added, will need to be vigilant in enforcing the parity law.

America’s Health Insurance Plans, the insurance industry’s main trade group, gave its support to the task force’s finding. “Health plans are committed to parity. We will continue to work hard to implement these changes,” AHIP said in a statement. “The report also recognizes the need for clearer, more consistent guidance on parity compliance for everyone.”

The American Psychiatric Association was also on board. “Adoption of the Task Force recommendations is essential to achievement of parity for patients with mental illness,” said Dr. Saul Levin, the CEO and medical director of the association. “APA trusts that Congress and the Administration will work together to ensure that the recommendations become reality.”

But even if the recommendations of the task force are successfully implemented, Benjamin Miller, director of the health policy center at the University of Colorado School of Medicine, said true parity will only come from erasing the lines between mental and physical health care.

“Separate is not equal — mental health is core to health,” said Miller. “People do not see themselves as a disease or a select health benefit, but rather a person who has needs. Benefits and payments should follow the person, address their needs, and address the whole of their health.”

Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation. You can follow Jenny Gold on Twitter: @JennyAGold.

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