After months of threats, federal prosecutors in Philadelphia launched a legal challenge on Wednesday against the nonprofit Safehouse, which is hoping to open what could be the nation’s first site where people with opioid addiction can use drugs under medical supervision.

The civil lawsuit, which is jointly being pursued by Pennsylvania-based prosecutors and the Department of Justice in Washington, is the first time the federal government has intervened in the hotly debated issue of supervised injection sites. The lawsuit could become an important legal test case as about a dozen cities across the country consider similar proposals.

The suit comes just as Safehouse officials ramp up fundraising efforts and continue to scout a location for what they say is a medical facility that can save lives.

If federal officials succeed in court, the momentum behind Safehouse may be lost.

“This is in-your-face illegal activity using some of the most deadly, dangerous drugs that are on the streets. We have a responsibility to step in,” says William McSwain, the U.S. attorney for the Eastern District of Pennsylvania. “It’s saying, ‘Safehouse, we think this is illegal. Stop what you’re doing.’ “

According to the suit, a supervised injection site would violate a section added to the Controlled Substances Act in the 1980s during the height of the crack epidemic. That section of law was written to close crack houses, but legal experts say it has been used more expansively in the past.

McSwain’s comments affirm remarks made last year by Rod Rosenstein, deputy U.S. attorney general, who said in an interview with WHYY that swift and aggressive action would follow the opening of a supervised injection site. Such facilities operate in Canada and Europe, but none exist in the United States. That has not stopped other cities like New York, Denver and Seattle from publicly debating similar proposals.

In Philadelphia, the one-count civil lawsuit is far from the most assertive posture federal prosecutors could have taken, McSwain says.

The suit is asking U.S. District Court Judge Gerald McHugh to rule on the legality of Safehouse’s plans, rather than waiting for Safehouse to open and then cracking down with arrests and a prosecution.

“We’re not bringing a criminal case right now. We’re not arresting anybody. We’re not asking to forfeit property. We’re not looking to be heavy-handed,” McSwain says. “This can serve everyone’s interest, in order to find out what the court thinks of this. But this, in our view, is illegal.”

Ronda Goldfein, vice president and attorney for Safehouse, says federal drug laws were not written to obstruct a medical facility focused on saving lives and moving people who are addicted to opioids into treatment.

She is confident the court will rule in Safehouse’s favor.

“We have a disagreement on the analysis and intention of the law,” Goldfein says. “We don’t think it was intended to prevent activities such as this, and perhaps it will take a court’s ruling to move the issue forward.”

The provision of the law in question is widely known as the crack house statute. It makes it illegal to maintain a space for the purpose of making, storing, distributing or using an illegal drug. Safehouse would not make or provide opioids to users. But it would allow people to bring in their own drugs, to use while being monitored by medical staff.

A study by Alex Kreit, a drug policy specialist and law professor at Thomas Jefferson School of Law in San Diego, found that the law has been successfully used by prosecutors in situations that include a drug seller operating out of a car dealership; rave parties where ecstasy was prevalent; and a concert promoter who threw “jam band” music festivals where illegal drugs flowed freely.

Kreit says that while the language of the Controlled Substances Act is broad enough to encompass an injection site, he can also imagine a defense based on local conviction about the need for such a medical service gaining traction in the face of the opioid crisis. But he says winning with that pitch would be an “uphill battle” in federal court.

“It is completely untested in terms of how federal law will apply to safe injection sites,” Kreit says. “People will be watching this very closely — particularly in other cities that have expressed their intention of starting a safe injection site.”

Safehouse is a privately run nonprofit that has the support of top city officials but will not be receiving any taxpayer funding. Planners say they aspire to open a facility in 2019, though, at least publicly, they have not committed to a more specific timeline.

Philadelphia health officials estimate that opioid-related drug overdoses kill about three people a day in the city. The more than 1,100 people who died from an overdose last year is triple the murder rate.

The overdose mortality rate hit a five-year low last year, and city officials attribute the decline to the distribution of naloxone, known by the brand name Narcan. Transit workers, police and paramedics now all are equipped with the overdose-reversing drug.

Studies have shown that in Canada and Europe, supervised injection sites have curbed the transmission of HIV and other infectious diseases. And the programs have been credited with averting lethal overdoses and extending a link to treatment services.

McSwain, though, remains a skeptic.

“That doesn’t mean that you’re not going to overdose when you’re not at the site. And it doesn’t mean that there couldn’t be other negative effects of having a site, where more people are, for example, getting hooked on drugs or trying drugs, because they think it’s safe, or they think it’s legitimate or they think it’s legal,” McSwain says. “We don’t attract people to go down this path of drug dependency that destroys their lives.”

McSwain says there is no evidence that such a model would definitively work in Philadelphia. He worries an injection site would normalize or even entice people to use unpredictable synthetic opioids like fentanyl — a drug that can be 50 times as powerful as heroin.

In November, McSwain wrote Safehouse officials a letter imploring the nonprofit to comply with federal law, writing that the federal statute “makes no exception for entities, such as Safehouse, who claim a benevolent purpose.”

In response, Safehouse officials told McSwain they “respectfully disagree” that the injection site would violate federal law, since the statutes were never intended to be used to attack a medical injection site.

“We hope that the U.S. Attorney’s office will exercise prosecutorial discretion in assessing our proposed overdose prevention services,” Goldfein wrote.

Three months later, federal officials took Safehouse to court.

“These folks have good intentions and they’re trying their best to combat the opioid epidemic,” McSwain says, “but this step of opening an injection site crosses the line. If Safehouse or others want to open this type of site, they need to steer their efforts to get the law changed.”

This story comes from Keystone Crossroads, a statewide public media initiative reporting on cities across Pennsylvania.

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Antidepressants may dampen the effects of some common opioids, resulting in less effective pain management according to research findings published Wednesday. The researchers suggest physicians should consider alternative pain management strategies for patients on antidepressants.

Opioids come in two broad varieties: those that act directly and others that have to be chemically processed by the body before they can begin to relieve pain. Direct-acting opioids, like morphine or oxycodone, can get right to work.

The other kind are called “prodrugs” and include hydrocodone, the opioid ingredient in Vicodin. Prodrugs need to be metabolized in the liver before they’re able to bind with pain receptors in the brain.

The problem, according to Tina Hernandez-Boussard, the Stanford computational biologist who co-led the study published Wednesday in the journal PLOS ONE, is that selective serotonin reuptake inhibitors, or SSRIs, like Prozac or Zoloft, inhibit the activity of an enzyme in the liver, called CYP-2D6, that metabolizes prodrug opioids.

If the enzyme can’t do its job, then the opioid can’t either — or at least not as well.

Prodrug opioids and SSRIs are two of the most commonly prescribed medications in the US, meaning this interaction could potentially affect millions, according to Hernandez-Boussard.

“There was theoretical evidence that suggested SSRIs might block prodrug opioids, but we didn’t know if it actually affected patient outcomes,” says Hernandez-Boussard.

To find out, Hernandez-Boussard and her team mined the electronic medical records of 4,300 surgical patients who had previously been diagnosed with depression. About half of those patients were taking an SSRI antidepressant. The researchers used a machine learning approach to tease apart the effects of SSRI use, opioid type, and pre- and postoperative pain, as measured on a 0-10 scale.

The researchers found that patients on an SSRI who were prescribed a prodrug opioid, such as Vicodin, had significantly more pain after surgery than all other groups when they left the hospital. This effect persisted up to two months after surgery. “On average, SSRI and prodrug opioid patients had 1 point worse pain on the 0 to 10 scale,” says Hernandez Boussard.

One specific result of their analysis underlined the dampening effect of SSRIs for Hernandez-Boussard. As a rule, patients with higher pre-operative pain tend to have higher post-operative pain.

The researchers found that patients on SSRI medication with higher pre-operative pain tended to get prescribed non-prodrug opioids, which are often considered stronger. Despite having more pain before surgery, these SSRI/non-prodrug patients fared better than the lower preoperative pain SSRI/prodrug patients.

“This is an important study,” says Jenny Wilkerson, a professor of pharmacodynamics at the University of Florida who wasn’t involved in the study. She says that genetic variations in the CYP-2D6 enzyme can interfere with opioid metabolism in other ways, and that this study advances our understanding of how SSRIs alter the effectiveness of opioids. She adds that she’d like to more studies in different populations to better understand the impact of this interaction on patients.

Hernandez-Boussard says these results could lead to better pain management and reduce opioid prescriptions. “If the opioids aren’t being activated and you’re not getting appropriate pain management, you’re going to take more opioids and you’re going to take them for a longer period of time,” she says. Apart from patients simply being in more pain than they need to be, this interaction “could lead to misuse or abuse down the road.”

“This combination of SSRIs and prodrug opioids is likely pretty common,” says Hernandez-Boussard. Consequently, she says the potential interaction should be recognized and discussed at the point of care.

“Every opioid has a side effect, not one opioid that is better than another,” says Hernandez-Boussard. “Possibly for patients taking SSRI, morphine or oxycodone, direct-acting drugs which don’t need to be broken down by the liver might be a better choice.”

Wilkerson echoes the importance of a discussion between physicians and patients about SSRI use and pain management options, a conversation that can be complicated by mental illness. “Patients shouldn’t feel stigmatized for being depressed or in pain,” she says, “patients have to advocate for their best personal care.”

Patients who are depressed and taking SSRIs are already a vulnerable population, known to experience more pain, and to have more trouble managing it. Hernandez-Boussard hopes that this study will help doctors tailor pain treatment towards the millions of Americans taking antidepressants.

“We need to think about how we can tailor treatment towards more vulnerable groups,” she says. “More work needs to be done, but this is a good first step.”

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In Texas, a growing number of patients are turning to a little-known state mediation program to deal with unexpected hospital bills.

The bills in question often arrive in patients’ mailboxes with shocking balances that run into the tens or even hundreds of thousands of dollars.

When patients, through no fault of their own, are treated outside their insurers’ network of hospitals, the result can be a surprise bill. Other times, insurers won’t agree to pay what the hospital charges, and the patient is on the hook for the balance.

The Texas Department of Insurance’s mediation program can intervene when Texans complain about an unexpected bill — often after an emergency in which a patient rushed for treatment at an out-of-network hospital.

Historically, the state program had many restrictions that left few consumers eligible for help. But the Texas Legislature expanded it in 2017.

Since then, more patients have been filing complaints. In 2014, the department was asked to mediate 686 medical bills. During the 2018 fiscal year, however, it received 4,445 bills, more than double the 2,063 bills received in 2017.

Even after the changes, the mediation program could be a lot more robust and is likely addressing only a fraction of these problematic bills, consumer advocates say.

The road to a surprise medical bill

Brad Buckingham says he had to deal with a surprise medical bill after a bicycle accident in 2016.

Buckingham sent his bill to Kaiser Health News and NPR’s Bill of the Month portal last year.

The Austin, Texas, dentist says he was on a ride with friends in December 2016 when he crossed some train tracks at an angle to avoid a pileup. His wheel slipped out from under him, and he landed hard on his left hip.

“All I could do was scream,” he says. “I couldn’t even make words.”

His friends called an ambulance, and Buckingham was taken to the nearest hospital: St. David’s South Austin Medical Center.

“I specifically remember I gave them my health insurance information in the ambulance,” he says. “And they put me in the ER, and from the ER they took my insurance information again.”

Buckingham had insurance through Baylor Scott & White Health, which he bought through the Affordable Care Act marketplace. St. David’s was out of his plan’s network, but no one told him that — at first.

Buckingham had broken his hip, and doctors took him into surgery the same day.

“They held me in the hospital for three days just for recovery and never told me I was out of network until the time of my discharge,” he says.

A few weeks later, Buckingham got a bill that said he owed $71,543.

The total bill eventually came to $75,346. Baylor Scott & White, which left the ACA marketplace the following year, paid only $3,812.

Buckingham says he thought it was a mistake. He called the hospital and the insurer to sort it out. But after weeks of inquiring about it, there was no resolution.

Both the hospital and insurer insisted payment was his responsibility.

“I’m sitting there thinking to myself that there is no way – there is no way — this is right,” he says.

Baylor Scott & White says it couldn’t discuss Buckingham’s bill “due to confidentiality requirements.”

After Buckingham gave St. David’s permission to discuss his case with the media, the hospital released a statement saying his bill was actually the amount he owed from his deductible and coinsurance — not a balance bill.

The hospital also said the bill was so large because of his “high deductible plan.”

Those plans “may be attractive to some people because they cost less, though they place more financial responsibility on the patient,” the statement from St. David’s said.

Buckingham says his policy had a deductible of $5,000 for in-network care and $10,000 for out-of-network care. He says he still doesn’t know how his bill got to be so high.

Buckingham didn’t know about the state’s mediation program. But even if he had known, he wasn’t eligible for the program at the time. His bike accident and the billing dispute with the hospital happened months before the Texas Legislature decided to expand the pool of eligible patients. So he hired his own lawyer to help him negotiate with the hospital.

Buckingham says he now owes a couple of thousand dollars to St. David’s, but he remains frustrated by the experience.

“You know, whenever I tell my story to anybody, they kind of agree — like, ‘Oh my gosh, this is ridiculous,’ ” he says. “But then when you talk to the people that have any control over it, it’s the exact opposite. It’s: ‘You owe it; we don’t.’ “

‘A total roll of the dice’

A surprise bill can happen to anyone who makes an urgent trip to the nearest emergency room.

“It’s a total roll of the dice,” says Stacey Pogue, a senior policy analyst with the Center for Public Policy Priorities in Austin. She has been looking into balance billing for years. “The medical emergency that’s going to send you to the hospital where you could get a surprise bill — is that emergency room going to be in or out of network?”

Pogue says the Texas Department of Insurance’s mediation process forces an insurance company and the hospital or medical provider to negotiate a fair price for services. She says 90 percent of the time those negotiations happen over the phone.

There are two big reasons the number of bills sent for mediation more than doubled from 2017 to 2018, Pogue says.

“One is just increased awareness,” she says. “There is constant media attention now to surprise medical bills because the stories are so shocking, right? We see them covered more, so people are more aware that when they get one, they could do something about it.”

The second reason is that in 2017, the Texas Legislature opened the mediation program up to more people, including teachers.

Can’t wish it away

Stacey Shapiro, a first-grade teacher in Austin, also received a surprise bill from St. David’s South Austin Medical Center after she landed in the emergency room last March.

The marathon runner said she woke up one Saturday for an early run and wasn’t feeling well.

“All of a sudden the whole room started spinning. … I started sweating, sweating like buckets,” she says. “It was terrible, and then all I remember is that my ears started popping, my vision got blurred and then the next thing I knew, I had passed out.”

Shapiro’s boyfriend heard her hit the bathroom floor. He found her passed out, with her eyes open and hardly breathing. He took her to St. David’s because it was the closest hospital.

Shapiro says she was taken care of in a few hours. Hospital staff gave her fluids and anti-nausea medication. Doctors found she had a dramatic change in her blood pressure that was likely due to a spell of hypoglycemia, or low blood sugar.

Two months later, a bill for $6,720 came in the mail.

Like many teachers in Austin, Shapiro gets her health insurance from Aetna.

In a statement, the insurer said Austin school district employees are supposed to use the Seton Accountable Care network, comprising several Catholic hospitals in the area. St. David’s parent company, the for-profit hospital chain HCA, doesn’t participate in that network.

“Unfortunately, HCA is not currently accepting payments through Aetna’s [contracted payment] program, which provides set payment fees for non-participating providers. This has resulted in Ms. Shapiro being balance billed for her emergency room visit,” Aetna wrote in a statement.

Shapiro says she had heard of other Austin Independent School District employees dealing with high hospital bills. In fact, Shapiro reached out to KUT after hearing the story of Drew Calver, an Austin high school teacher who was balance billed for nearly $109,000 by St. David’s after a heart attack. Calver’s story was part of Kaiser Health News and NPR’s Bill of the Month series last year.

Shapiro says that in her case, Aetna told her not to pay what the hospital was charging her. She says she was told to pay only her deductible ($1,275), which she did right away. But St. David’s kept sending her bills for the remaining balance, which was more than $5,000.

“I guess I just thought that it was going to go away,” Shapiro says.

But it didn’t. For a public school teacher, $5,000 would have been a huge blow to her budget, she says.

Shapiro applied for financial assistance, but St. David’s told her she didn’t qualify. She says she felt like she was out of options — until a friend told her about the state’s mediation program.

After she contacted the program, a state mediator set up a scheduled call with Aetna and St. David’s. But before it took place, a KUT reporter asked St. David’s for a comment on the situation. Shortly afterward, Shapiro says, St. David’s told her she no longer owed anything.

St. David’s later told KUT that Shapiro had “already satisfied her financial obligation.” It also denied that she was balance billed to begin with.

Shapiro says the whole experience has been exhausting. “It’s just very frustrating because this has been very time-consuming,” she says.

More work to do

The Center for Public Policy Priorities’ Pogue has been arguing that the state needs to find more ways to get involved.

She says the current mediation process is pretty good, but not enough people know it’s an option.

“Because first, the instructions for how to do it are on your medical bill and your explanation of benefits — the most indecipherable documents you are going to get,” she says.

And even if people understand they have a right to mediation, they might get scared off by the concept and think they need a lawyer, Pogue adds.

But when people use the program, it tends to work by saving patients money.

In fiscal year 2018, the initial complaints amounted to $9.7 million worth of medical bills, according to the state insurance agency. After mediation, the final charges had been negotiated down to $1.3 million.

Pogue says mediation is helpful, but it still puts a big burden on the patient, who may be confused. “Why didn’t this happen in the first place?” Pogue says. “How come I had to, while recovering from an emergency, decipher medical bills, fill out paperwork with the state department of insurance, jump through all these hoops, when all that needed to happen was a phone call?”

The ideal solution to surprise medical bills would remove consumers from this confusing web altogether, she says.

Pogue points out that states like New York, California and Florida have systems that make things easier for consumers. She thinks Texas should do that too.

In 2015, New York became the first state to pass a law aimed at protecting patients from surprise medical bills from out-of-network hospitals. The Emergency Medical Services and Surprise Bills Law holds consumers harmless if they are treated by an out-of-network doctor at a participating hospital, among other things.

In 2016, Florida lawmakers passed legislation protecting consumers from receiving surprise medical bills “from doctors and hospitals that don’t have a contract with the patient’s insurance plan,” the Miami Herald reported.

And in 2017, California passed a law shielding patients from balance billing. The law kicks in if someone visits an in-network provider, including a hospital, imaging center or lab, according to the San Francisco Chronicle. Under the law, patients “will be responsible only for [their] in-network share of the cost, even if [they are] seen by an out-of-network provider,” the Chronicle reported.

In the meantime, Pogue says, more Texans should take advantage of what’s already in place in the state.

The number of people who seek mediation is “tiny compared to the number of people who get surprise bills,” she says, “so there is a ton of work to be done.”

This story is part of NPR’s reporting partnership with KUT and Kaiser Health News. You can follow Ashley Lopez on Twitter: @AshLopezRadio.

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Surrounded by patients who told horror stories of being stuck with hefty bills, President Trump recently waded into a widespread health care problem for which almost all people — even those with insurance — are at risk: surprise medical billing.

Trump’s declaration that taming unexpected bills would be a top priority for his administration echoed through the halls of Congress, where a handful of Republican and Democratic lawmakers had already been studying the problem.

The sudden presidential interest has lawmakers on both sides of the aisle expressing optimism about attacking a problem that has affected 57 percent of American adults, according to a University of Chicago survey conducted in August 2018.

Sen. Lamar Alexander, the Tennessee Republican who chairs the influential Health, Education, Labor and Pensions Committee, recently told reporters that he expects to see surprise-billing legislation “in the next several months.”

Alexander is encouraged by the movement, said a committee spokesman — giving a particular nod to the efforts of Sen. Bill Cassidy, R-La. “The chairman looks forward to reviewing their work and hopes it leads to a bipartisan consensus on how to address the issue,” the spokesman added.

“Indications in Congress have always been that this would be something they could do on a bipartisan basis,” said Paul Ginsburg, a health economist at the Brookings Institution.

Attention to surprise billing, which involves charging patients for care that is more expensive than expected or not covered by their insurance, has grown following an ongoing Kaiser Health News-NPR Bill of the Month project.

Still, the details of a possible solution remain up in the air.

The Trump administration hasn’t laid out precisely how it would take on surprise bills. But key lawmakers, including Alexander and Cassidy, have met with administration officials to discuss the problem of how to reduce health care costs. Trump administration officials have made it clear that they are looking at surprise billing within this context.

With an eye toward drafting legislation, these two senators and several others have been consulting with billing experts, as well as state and local officials, about the biggest challenges and most promising approaches being used around the country.

And though Senate Majority Leader Mitch McConnell, R-Ky., has yet to address the issue, House Speaker Nancy Pelosi, D-Calif., said it would be a priority.

“Ending surprise billing is an important part of Democrats’ ongoing effort to lower out-of-pocket health costs, and we’ll be working on it in the coming Congress,” said Henry Connelly, a Pelosi spokesman.

Previously introduced bills would impose new notification requirements, as well as limitations on what doctors and hospitals might charge patients. They would regulate bills for either emergency care at an out-of-network facility or nonemergency care when the facility is in network but the doctor isn’t.

• A draft bill pushed by Cassidy, a gastroenterologist and the leader of a small, bipartisan group of senators studying the issue, would cap what patients pay and prohibit balance billing — when a patient is expected to make up the difference between what the provider charged and what the insurer paid. Instead of arbitration, the state would set the amount a health plan must pay. In the absence of a local policy, health plans would default to a federal formula outlined in the bill. (This is similar to laws passed in California and Connecticut.)
• A bill from Sen. Maggie Hassan, D-N.H., would tackle the issue by preventing a hospital, physician group or other medical provider from charging patients more for an emergency procedure than they would have expected to pay for in-network care. It would then establish an arbitration process to determine what the patient’s health plan should pay. (This is similar to laws passed in New York and New Jersey.)
• A bill from Texas Democrat Lloyd Doggett, chairman of the House Ways and Means Committee’s Health Subcommittee, introduced during the last Congress with Sen. Sherrod Brown, D-Ohio, would require hospitals to notify patients whether the hospitals — and the doctors and other providers that patients would see there — are in network. Hospitals would also have to tell patients how much they could expect to pay out of pocket. Without at least 24 hours’ notice and the patient’s consent — or if the patient was receiving same-day, emergency treatment — the hospital would be able to charge the patient no more than an in-network provider would.

To draw attention to the issue, Hassan intends to bring to this week’s State of the Union address a guest who was billed more than $1,600 for a trip to an in-network emergency room. The patient learned after the fact that the doctor she briefly saw there was out of network.

“There does seem to be across-the-board understanding that what’s happening to patients right now isn’t right or fair,” Hassan said.

Other members of Congress, including Sen. Amy Klobuchar, D-Minn., and Sen. Tammy Baldwin, D-Wis., are expected to bring guests with painful, personal stories regarding the high cost of prescription drugs.

For its part, the administration says its commitment to addressing surprise medical bills is firm.

“President Trump has identified surprise medical bills as a serious concern of the administration. Protecting patients from these outrageous and unexpected bills and charges is a top priority for Secretary [Alex] Azar,” said Caitlin Oakley, a Department of Health and Human Services spokeswoman.

Hassan said she hasn’t heard from the White House. But as Congress shifts its focus away from the partial government shutdown, she predicted, surprise billing could emerge as a legislative priority. She said that she and Cassidy have coordinated on the issue.

Both Hassan’s and Cassidy’s bills “would go a long way toward protecting patients,” suggested Zack Cooper, a Yale University health economist who researches surprise billing. Hassan’s legislation, he said, has the additional benefit of likely bringing down health care costs.

“There are a lot of issues that can’t be fixed or at least can’t be fixed easily. This is an issue that causes immense pain and is quite visceral and can be fixed,” Cooper said.

And federal legislation is likely necessary, experts say. Some states have passed laws meant to curb surprise billing and protect patients from the costs — but those laws don’t apply to self-insured large employers, which fall under federal jurisdiction and affect more than 60 percent of people who get insurance through work.

The presidential bully pulpit could be hugely influential — in particular, Ginsburg suggested, by “leaning on Congress” to bring legislation to Trump’s desk.

And new legislation probably is the most effective vehicle. It’s unclear what kind of executive action HHS could take without Congress.

“Some creative lawyers could come up with creative interpretations [of existing laws] and lead to smart policy,” said Barak Richman, a Duke University law school professor who focuses on health policy.

But reinterpreting federal law would almost certainly invite legal challenges, he added.

Already, competing industry groups are lobbying to put their stamp on any federal policy. The emergency physicians trade group has backed an approach like Hassan’s, while the insurance lobby is calling for a Cassidy-style bill.

When asked about the industry’s response, Hassan said she has gotten “a variety of feedback — as you would expect.”

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that isn’t affiliated with Kaiser Permanente.

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Ashoor Rasho has spent more than half his life alone in a prison cell in Illinois — 22 to 24 hours a day. The cell was so narrow he could reach his arms out and touch both walls at once.

“It was pretty broke down — the whole system, the way they treated us,” says the 43-year-old Rasho, who has been diagnosed with several mental health conditions, including severe depression, schizophrenia and borderline personality disorder.

Rasho says little things would trigger him, and he’d react violently. Although he’d been sentenced to prison initially for robbery and burglary, his sentence was extended over and over for assaults on prison staff.

“Even if they would label us schizophrenic or bipolar, we would still be considered behavioral problems,” Rasho says. “So the only best thing for them to do was keep us isolated. Or they heavily medicate you.”

He spent most of his 26-year prison sentence in restrictive housing, or solitary confinement, where he had hallucinations, engaged in self-mutilation and tried to kill himself.

In 2007, Rasho and 12,000 other inmates with mental illness sued the Illinois Department of Corrections, alleging that the agency punishes inmates with mental illness instead of properly treating them.

A settlement was reached in 2016, when the state agreed to revamp mental health care and provide better treatment.

But a federal judge has ruled that care remains “grossly insufficient” and “extremely poor.” The agency has not hired enough mental health staff to provide care to everyone who needs it, and inmates with mental illness suffer as they continue to wait for long-overdue treatment.

Punishment, not treatment

Dr. Stuart Grassian is a psychiatrist who spent 25 years at Harvard studying how the conditions in solitary confinement cause harm — especially for people who are mentally ill.

“You’re looking at the population of a state psychiatric hospital,” says Grassian, who has met hundreds of inmates like Rasho who have served long sentences in extreme isolation.

“They’re not the worst of the worst,” Grassian says. “They’re the sickest of the sick; the wretched of the Earth. Maybe they weren’t even that bad before they got in, and they just get worse and worse. It’s a tragedy — absolutely immoral — to see that happen to people.”

Inadequate treatment of mentally ill prisoners is a problem across the U.S. When psychiatric institutions began closing down in the 1950s, they weren’t replaced with mental health services in the community. So, many people with mental illness have scrapes with the law, and end up in prisons that are ill-equipped to treat them.

According to federal data on state and federal prisons from 2011 to 2012, nearly 40 percent of inmates reported having been told by a mental health professional that they had a mental health disorder.

Yet among those who met the threshold for having serious psychological distress at the time of the survey, only about half were receiving treatment — medication, counseling, or both — for their illness. And they were more likely to be written up or charged with verbal or physical assault against correctional staff or other inmates than prisoners without an indicator of a mental health problem.

Correctional facilities in the U.S. are considered the largest provider of mental health services. Yet many prison systems are facing fiscal crises and struggle to provide constitutionally adequate treatment, even after lawsuits lead to court mandates for access to mental health care.

The problem is particularly bad in Illinois, which has long ranked near last in terms of the amount of money it spends on health care for inmates, according to the Pew Charitable Trusts.

And when prison inmates don’t receive the mental health care they need, they’re more likely to cycle in and out of the criminal justice system.

Alan Mills, one of the attorneys representing inmates in the 2007 class-action lawsuit, has made numerous visits to Illinois prison facilities in recent years.

“When you walk through these galleries, you get overwhelmed by the pain and suffering that you see in front of you,” says Mills, director of the Uptown People’s Law Center in Chicago.

An obvious problem

Even state officials acknowledge the prison system has not done well for inmates with mental illness.

“Corrections in Illinois was a little slow to recognize we are the mental health system for Illinois,” says John Baldwin, who directs the state’s corrections department. “Whether we want to be or not, we are; and we have to start acting like it.”

Baldwin says since he took over in 2015, the department has hired more mental health staff and provided training to all employees on how to engage with people who are mentally ill.

Most inmates now spend at least eight hours a week out of their cell and see a therapist once a month.

And about 765 of the inmates who are most ill have been transferred to new residential treatment facilities — where they are finally receiving appropriate care, Baldwin says.

But Mills points out: That’s a small fraction of the 12,000 who are mentally ill.

“And for the vast majority of those, not a lot has changed,” Mills says. “They simply aren’t getting the kind of treatment they need in order to improve their situation at all.”

A sign of progress

The Joliet Treatment Center in the southwest suburbs of Chicago doesn’t look like a typical prison facility.

Half a dozen single-story buildings — called dorms — surround a big grassy area. Walking paths connect the dorms.

“I always refer to it as the quad,” Warden Andrea Tack says, as she takes me on a tour. “It reminds me of some of the college campuses that have [a] big center lawn area and then all the classrooms surround it.”

But, unlike a college campus, this facility is surrounded by two layers of barbed wire fencing.

A few years ago, Illinois spent $17 million to convert what used to be a youth detention center at Joliet into a mental health treatment facility for inmates with serious mental illness.

The dining hall is at the center of the quad; the gym is just to the east, and a building to the south houses a library, medical clinic and classrooms where inmates take GED courses and receive job training.

Tack says the inmates here spend about 30 hours a week out of their cell in various activities, according to their individual treatment plans.

She says she’s seen inmates who’ve been transferred to the Joliet facility make huge strides over the past year.

People who were attempting to hang themselves and acting out aggressively, “now, they’re out and about in the community — going to classes, going to meals, interacting with others,” Tack says. “Some are serving as mentors for other residents.”

Mills says he, too, has seen this transformation in some inmates.

“And it’s a difficult transition,” he says, “because you’ve been treated in a place where you’re continually traumatized, and then you get to a place where actually people care about you.”

It takes time, Mills says, for many to learn that they can trust and receive help, instead of acting out aggressively the way they’ve been conditioned to do for so many years.

‘Culture of abuse’

The atmosphere at the Joliet center stands in stark contrast to the experience at some of the state’s other prisons, such as Pontiac Correctional Center, located about 60 miles south of Joliet.

There, inmates with mental illness are often kept isolated and are lucky to get even one hour of mental health treatment a month, says Dr. Pablo Stewart, a psychiatrist. He was appointed by the federal court to oversee the settlement in the lawsuit.

In his most recent report, Stewart singled out the prison at Pontiac for having a “culture of abuse and retaliation” against mentally ill inmates.

“Almost everyone at the mental health unit at Pontiac should be at Joliet,” Stewart says.

If they were getting that same level of mental health care, Stewart says, they wouldn’t have as many behavior issues.

The Pontiac prison has a high concentration of inmates with behavior problems; the most challenging inmates are transferred there from prison facilities across the state.

And the facility lacks the necessary mental health staff to provide treatment to everyone who needs it.

As a result, Stewart says, many mentally ill inmates are isolated from the rest of the prison population, with little or no meaningful social interaction. The conditions cause them to deteriorate, he says, making them more prone to acting out.

Mentally ill prisoners isolated this way “end up throwing feces or urine at staff; end up exposing themselves [or] masturbating in front of female staff,” Stewart says.

Inmates with untreated mental illness also often get into fights with other inmates and prison staff.

Stewart says the workers themselves are traumatized from their job, and that can make them prone to retaliate. Based on interviews with both inmates and staff, Stewart says he’s absolutely convinced that some staff members abuse inmates at Pontiac.

Asked about those abuse allegations, a spokesperson for the corrections department, Lindsey Hess, writes in an email that the agency takes allegations of excessive force seriously and investigates them.

In an interview prior to the latest court monitor’s report, Baldwin said he would “be surprised” if inmates with mental illness were being abused today.

“We take swift action to refer [any reports of abuse] we get to the state police or the state’s attorney,” he said. “We will not tolerate that.”

As for prison staff who may be traumatized by their job, Hess says the agency has implemented several initiatives in recent years to improve the mental, physical and emotional well-being of employees.

These include peer support groups for staff, access to professional counselors and a recurring class — called “From Corrections Fatigue to Fulfillment” — that teaches staff members about the psychological dynamics of working in the field of corrections.

Stewart says Joliet is one Illinois facility that is finally providing inmates with adequate mental health treatment. That should be the norm everywhere, he says. But it’s not.

“That’s the standard of care that’s required,” Stewart says.

A lingering problem

When I interviewed Rasho last May, he’d been out of prison for more than a year. But his many years spent in solitary confinement still haunt him.

“I don’t sleep right,” he told me. “Any little thing triggers something in me.”

Last fall, Rasho was arrested again, so he’s now back in the prison system.

Mills says the situation in Illinois shows that lawsuits don’t always solve the problems — at least not right away.

“A court order is great, but it’s a piece of paper,” he says. “It’s not actually treatment.”

The orders from U.S. District Judge Michael Mihm continue.

Days before Christmas, he ordered Illinois’ prison agency to correct widespread deficiencies. He gave the agency until March to hire enough mental health staff to provide adequate care to all inmates who need it.

This story was produced by Side Effects Public Media, a news collaborative covering public health. Christine Herman is a recipient of the 2018-2019 Rosalynn Carter Fellowships for Mental Health Journalism. Follow her on Twitter: @CTHerman.

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The first nine months of 2013 started off as a banner year for the Sackler family, owners of the pharmaceutical company that produces OxyContin, the addictive opioid pain medication. Purdue Pharma paid the family $400 million from its profits during that time, claims a lawsuit filed by the Massachusetts attorney general.

However, when profits dropped in the fourth quarter, the family allegedly supported the company’s intense push to increase sales representatives’ visits to doctors and other prescribers.

Purdue had hired a consulting firm to help reps target “high-prescribing” doctors, including several in Massachusetts. One physician in a town south of Boston wrote an additional 167 prescriptions for OxyContin after sales representatives increased their visits, according to the latest version of the lawsuit filed Thursday in Suffolk County Superior Court in Boston.

The lawsuit claims Purdue paid members of the Sackler family more than $4 billion between 2008 and 2016. Eight members of the family who served on the board or as executives as well as several directors and officers with Purdue are named in the lawsuit. This is the first lawsuit among hundreds of others that were previously filed across the country to charge the Sacklers with profiting from the harm and death of people taking the company’s opioids.

WBUR along with several other media outlets sued Purdue Pharma to force the release of previously redacted information that was filed in the Massachusetts Superior Court case. When a judge ordered the records to be released with few, if any, redactions this week, Purdue filed two appeals and lost.

Read the documents here or below:

The complaint filed by Massachusetts Attorney General Maura Healey says that former Purdue Pharma CEO Richard Sackler allegedly suggested the family sell the company or, if they weren’t able to find a buyer, to milk the drugmaker’s profits and “distribute more free cash flow” to themselves.

That was in 2008, one year after Purdue pleaded guilty to a felony and agreed to stop misrepresenting the addictive potential of its highly profitable painkiller, OxyContin.

The complaint says the Sacklers voted to pay themselves $250 million at a board meeting in June 2008. Another payment in September totaled $199 million.

The company continued to receive complaints about OxyContin similar to those that led to the 2007 guilty plea, according to unredacted documents filed in the case.

While the company settled lawsuits in 2009 totaling $2.7 million brought by family members of those who had been harmed by OxyContin throughout the country, the company amped up its marketing of the drug to physicians by spending $121.6 million on sales reps for the coming year. The Sacklers paid themselves $335 million that year.

The lawsuit claims Sackler family members directed efforts to boost sales. An attorney for the family and other board directors is challenging the authority to make that claim in Massachusetts. A motion on jurisdiction in the case hasn’t been heard. That attorney hasn’t responded to a request for comment on the most recent allegations.

Purdue Pharma, in a statement, said the complaint filed by Healey is “part of a continuing effort to single out Purdue, blame it for the entire opioid crisis, and try the case in the court of public opinion rather than the justice system.”

Purdue went on to charge Healey with attempting to “vilify” Purdue in a complaint “riddled with demonstrably inaccurate allegations.” Purdue said it has more than 65 initiatives aimed at reducing the misuse of prescription opioids. The company says Healey fails to acknowledge that most opioid overdose deaths currently are the result of fentanyl.

Purdue fought the release of many sections of the 274-page complaint. Attorneys for the company said at a hearing on Jan. 25 that they had agreed to release much more information in Massachusetts than has been cleared by a judge overseeing hundreds of cases consolidated in Ohio. Purdue filed both state and federal appeals this week to block release of the compensation figures and other information about Purdue’s plan to expand into drugs to treat opioid addiction.

The attorney general’s complaint says that in a ploy to distance themselves from the emerging statistics and studies that showed OxyContin’s addictive characteristics, the Sacklers approved public marketing plans that labeled people hurt by opioids as “junkies” and “criminals.”

Richard Sackler allegedly wrote that Purdue should “hammer” them in every way possible.

While Purdue Pharma publicly denied its opioids were addictive, internally company officials were acknowledging it and devising a plan to profit off them even more, the complaint states.

Kathe Sackler, a board member, pitched Project Tango, a secret plan to grow Purdue beyond providing painkillers by also providing a drug, Suboxone, to treat those addicted.

“Addictive opioids and opioid addiction are ‘naturally linked,’ ” she allegedly wrote in September 2014.

According to the lawsuit, Purdue staff wrote: “It is an attractive market. Large unmet need for vulnerable, underserved and stigmatized patient population suffering from substance abuse, dependence and addiction.”

They predicted that 40-60 percent of the patients buying Suboxone for the first time would relapse and have to take it again, which meant more revenue.

Purdue never went through with it, but Healey contends this and other internal documents show the family’s greed and disregard for the welfare of patients.

A version of this story first ran on WBUR’s CommonHealth. You can follow @mbebinger on Twitter.

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“Medicare-for-all,” once widely considered a fringe proposal for providing health care in the U.S., is getting more popular. Several Democratic presidential hopefuls are getting behind the idea.

Sen. Kamala Harris, D-Calif., endorsed the approach Monday in a CNN town hall-style event, saying her aim would be to eliminate all private insurance.

“Who of us has not had that situation, where you’ve got to wait for approval and the doctor says, well, ‘I don’t know if your insurance company is going to cover this,’ ” Harris said. “Let’s eliminate all of that. Let’s move on.”

Harris was a co-sponsor of a 2017 bill written by Sen. Bernie Sanders, I-Vt., that would have created a national, single-payer health system, eliminating the private insurance system.

Sens. Elizabeth Warren, D-Mass., and Kirsten Gillibrand, D-N.Y., both presidential hopefuls, also co-sponsored the Sanders bill.

Everyone would get a Medicare card and doctors would have to sign annual agreements to participate.

The major questions the candidates face is how the government would pay for it.

Total spending on health care in the U.S. was about $3.5 trillion in 2017 and is forecast to rise to $5.7 trillion in 2026, according to the Department of Health and Human Services.

The federal government already pays for a lot of that through Medicare, Medicaid, military health care and the Department of Veterans Affairs. Much of the rest is through employer health insurance plans and individual health insurance and payments by patients.

Sanders laid out several options to pay for his proposal, including increasing taxes on employers who would no longer be paying insurance premiums; increasing individual income taxes; and boosting taxes on the wealthy.

Harris didn’t say, in the town hall-style meeting, how she would pay for the program. And her Senate office didn’t respond to an email asking whether she has a funding proposal.

Warren has proposed a 2 percent tax on the wealth of an individual that’s above $50 million and 3 percent on wealth of more than $1 billion.

The mechanism for paying for “Medicare-for-all” can make the politics muddy.

A recent poll by the Kaiser Family Foundation suggests that 56 percent of people in the U.S. like the idea overall.

But when people heard more details, those numbers changed.

When the question included the idea that “Medicare-for-all” would guarantee health insurance as a right, its support rose to 71 percent. But when it said people would have to pay more taxes, the popularity plummeted to 37 percent.

That dynamic has created an opening for potential centrist candidates to stake out a middle road.

Howard Schultz, the former CEO of Starbucks, who has said he is considering a presidential run, told CBS reporters that Harris’ proposal to eliminate the health insurance industry is “not American.” He also called proposed tax increases on the wealthy “punitive.”

Mike Bloomberg, the former mayor of New York and founder of Bloomberg LP, who is also considering a run, said in New Hampshire Tuesday that he, too, opposed the idea.

“To replace the entire private system where companies provide health care for their employees would bankrupt us for a very long time,” he told workers at a factory he was visiting.

Bloomberg has said he supports opening Medicare to people who don’t have coverage through their employers.

The health insurance industry is already gearing up to oppose any “Medicare-for-all” proposals, according to The Intercept, an investigative news website.

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David Lerman, a lawyer in Berkeley, Calif., changed health plans this year, only to learn that his new insurer has no contract with the main medical provider in his community.

Anthem Blue Cross of California, one of the state’s largest health insurers, is battling with Sutter Health over how much it should pay to care for tens of thousands of people it insures in Northern California. Sutter operates 24 hospitals in the region and lists about 5,000 doctors in its network.

“It’s not the peace of mind I thought I was buying to have the entire Sutter network — which is the biggest game in Northern California — be out of network,” says Lerman, whose family is insured through his wife’s job as a California State University professor.

Lerman and his family, who are enrolled in an Anthem Blue Cross PPO, can continue to visit Sutter facilities until midyear, even if a new contract does not materialize before then. Fortunately, he says, nobody in his family suffers from a chronic illness. But not knowing which providers ultimately will be in his health plan’s network is aggravating, he says.

Contract disputes between insurers and medical providers have been a regular feature of the national health industry for a long time. But the stakes have risen as big players on both sides have expanded to gain market share and leverage in network negotiations.

Most negotiations are completed before the old contract expires, and consumers usually don’t hear about these behind-the-scenes disagreements. But when insurers and providers fail to reach an agreement on time, it can force patients to pay higher prices for care that is no longer covered by their health plans. At the least, it can cause considerable anxiety.

“It is a game of chicken, and at the end of the day somebody blinks and they come to an agreement,” says Wendell Potter, a former senior executive at health insurance giant Cigna, who became a critic of the industry and a strong proponent of sweeping health care reform.

“The big losers in this are patients,” Potter says, “because there’s a period of uncertainty and angst — and a real possibility that the physicians and hospitals you want to go to are no longer in network.”

Amy Thoma Tan, a Sutter spokeswoman, said in an emailed statement, “We are in active negotiations with Anthem Blue Cross and recognize that a timely agreement — one that protects access and choice — is in the best interest of our patients, employers, hospitals and clinicians.”

A statement by Eric Lail, an Anthem Blue Cross spokesman, also lacked details: “As we negotiate with providers, we try to strike a balance between protecting affordability and providing a broad network of providers to create choices, which can take time.”

Sutter, under fire for high prices, has been accused of using its regional market share for financial advantage. As large hospital systems merge with competitors and snap up medical practices, “it’s much more difficult for insurers to say, ‘OK, we’re letting you go,’ ” says Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.

Corlette says both sides should have a greater incentive these days to come to an agreement.

“When you have a big behemoth health care system and a big behemoth payer with tens of thousands of enrolled lives, the incentives to work something out privately become much stronger,” she says. “The [public relations] risks are so high for both parties.”

Other states have seen their share of feuding between health systems and insurers.

In Western Pennsylvania, nearly 50,000 people with Medicare managed care plans from Highmark Health will lose in-network access to University of Pittsburgh Medical Center hospitals and doctors starting July 1 because of a slow-moving divorce between the two regional health giants.

One of those patients is Judy Hays, a 75-year-old retired office manager from the Pittsburgh suburb of Crescent Township, who relies on UPMC’s physicians and hospitals to treat her rare form of leukemia. Now she plans to change her doctors midtreatment because she wants to keep her insurance, which she says has paid for her expensive medications.

“It’s very tough. These people have been taking care of me for the last nine years. I can’t have any interruption in my care,” Hays says. “I’m very angry about it.”

In Georgia, WellStar Health System, with 11 hospitals and numerous medical offices, plans to stop accepting Anthem’s individual policyholders as in-network patients on Feb. 4, amid a contract dispute between the two companies.

In 2017, an impasse between Anthem and the Hartford HealthCare system in Connecticut forced hundreds of thousands of patients to go out of network before the two parties finally inked a deal. The patients’ bills were retroactively treated as in network, so patients did not suffer financially.

However, “there were stories of people who had to cancel surgeries and switch providers,” says Ted Doolittle, Connecticut’s state health care advocate. “There was all this anxiety and disruption.”

Under pressure from their constituents, Connecticut lawmakers last year passed legislation enabling consumers to continue getting care at in-network prices for 60 days during contract disputes. The new law is “an improvement,” says Doolittle, who had urged legislators to pass such legislation.

In the current California dispute, Anthem Blue Cross members with PPOs can still use Sutter doctors and hospitals at in-network rates for the next six months, says Thoma Tan, the Sutter spokeswoman. People with HMOs face more uncertainty.

Lail, the Anthem Blue Cross spokesman, says the insurer’s customers “can continue to see their Sutter care providers for the time being as these negotiations continue.” But, as required by state law, Anthem Blue Cross has notified patients with Medicare and Medi-Cal HMO plans that they may be reassigned to non-Sutter providers, Lail says.

There are exceptions that will allow pregnant women, very young children and some other patients to continue receiving care from Sutter at in-network rates, regardless of the type of insurance they have with Anthem Blue Cross, Thoma Tan says.

Sutter has quarreled with other insurers, including with Blue Shield of California in a dispute that affected about 270,000 consumers before the two sides reached a deal that took effect in February 2015.

Sutter’s market dominance in California and its high prices for inpatient care have long drawn criticism. One patient reported that Sutter charged $1,555 for a 10-minute emergency room visit to treat a cut finger, including $55 for a gel bandage and $487 for a tetanus shot.

Last year, the state’s attorney general, Xavier Becerra, sued the giant health system, alleging it had illegally overcharged patients and driven out competition in California. Sutter has contended that Becerra overstepped his authority and that limiting Sutter’s ability to negotiate with insurers will harm consumers.

Anthem Blue Cross, which insures hundreds of thousands of Californians and whose parent company, Anthem, generated profits of $3.8 billion in 2017, has also drawn the ire of state regulators. The Department of Managed Health Care fined the insurer $5 million in 2017 for failing to respond in a timely way to consumer complaints. The state previously had fined Anthem Blue Cross $6 million between 2002 and 2017 for consumer-grievance-system violations.

In Berkeley, Lerman just wants Anthem and Sutter to resolve their differences so his family will have access to the most comprehensive coverage options.

“As a consumer, is there no place where you can go and not worry that you’ll not be covered?” he frets. “If I’m sick, do I go to the local hospital — or to the airport and fly to Europe?”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN is not affiliated with Kaiser Permanente.

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