Category: From California Healthline.org

MIAMI — When leaders of Florida’s most populous county met in September to pick a site for what could become the nation’s largest trash incinerator, so many people went to the government center to protest that overflow seating spilled into the building’s atrium.

“MIRAMAR SAYS NO TO INCINERATOR! NOT IN OUR BACKYARD,” read green T-shirts donned by some attendees who wanted to stop the new industrial waste facility — capable of burning up to 4,000 tons of garbage a day — from being built near their homes.

Residents feared the site would not only sink their property values and threaten the environment, but also potentially harm people’s health.

Even more, the locations appeared to have been selected in a way that worried civil rights and environmental advocacy groups. All four sites considered that day were in, or near, some of the region’s most diverse communities, and the state is arguing in federal court that race should not be a consideration in permitting industries that pollute the environment.

“Historically, communities of color have suffered the impacts of toxic plants near our cities, affecting our health and well-being,” Elisha Moultrie, a 30-year Miramar resident and committee leader with the Miami-Dade NAACP, told the county commissioners.

It’s “environmental injustice and racial injustice,” she said.

Miami-Dade leaders see a different challenge: the need to effectively manage trash. The county produces nearly double the national average per person of garbage, in part due to one of the region’s major industries: tourism.

Yet, throughout 2024, Miami-Dade’s elected officials delayed a decision on where to build the planned $1.5 billion incinerator, as the county mayor and commissioners wrestled with politics. County leaders are scheduled to vote on a new site in February.

“There is no perfect place,” Miami-Dade Mayor Daniella Levine Cava said in a recent memo to county leaders.

The conundrum unfolding in South Florida is indicative of what some see as a broader trend in the national fight for environmental justice, which calls for a clean and healthy environment for all, including low-wealth and minority communities. Too often land inhabited by Black and Hispanic people is unfairly overburdened with air pollution and other emissions from trash incinerators, chemical plants, and oil refineries that harm their health, said Mike Ewall, director of Energy Justice Network, a nonprofit that advocates for clean energy and maps municipal solid waste incinerators.

“All the places that they would consider putting something no one wants are in communities of color,” he said.

More than 60 municipal solid waste incinerators operate nationwide, according to data from Energy Justice. Even though more than 60% of incinerators are in majority-white communities, those in communities of color have more people living nearby, burn more trash, and emit more pollutants, Ewall said.

And in Florida, six of the nine existing incinerators are in places where the percentages of people of color are higher than the statewide average of 46%, according to data from the Environmental Protection Agency’s EJScreen, an online tool for measuring environmental and socioeconomic information for specific areas.

Before Miami-Dade County’s old trash incinerator burned down in February 2023, the county sent nearly half of its waste to the facility. Now, the county is burying much of its trash in a local landfill or trucking it to a central Florida facility — an unsustainable solution.

Joe Kilsheimer, executive director of the Florida Waste-to-Energy Coalition, a nonprofit that advocates for owners and operators of trash incinerators, acknowledges that choosing a location is hard. Companies decide based on industry-accepted parameters, he said, and local governments must identify strategies to manage waste in ways that are both safe and efficient.

“We have an industrial-scale economy that produces waste on an industrial scale,” Kilsheimer said, “and we have to manage it on an industrial scale.”

‘Those People Don’t Matter’

Florida burns more trash than any other state, and at least three counties besides Miami-Dade are considering plans to build new facilities. Managing the politics of where to place the incinerator has especially been a challenge for Miami-Dade’s elected officials.

In late November, commissioners in South Florida considered rebuilding the incinerator where it had been for nearly 40 years — in Doral, a predominantly Hispanic community that also is home to Trump National Doral, a golf resort owned by the president-elect less than 3 miles from the old site. But facing new opposition from the Trump family, the county mayor requested delaying a vote that had been scheduled for Dec. 3.

President Joe Biden created a national council to address inequities about where toxic facilities are built and issued executive orders mandating that the Environmental Protection Agency and Department of Justice address these issues.

Asked if Trump would carry on Biden’s executive orders, Karoline Leavitt, the incoming White House press secretary, said in an email that Trump “advanced conservation and environmental stewardship” while reducing carbon emissions in his first term.

“In his second term, President Trump will once again deliver clean air and water for American families while Making America Wealthy Again,” Leavitt said.

However, during his presidency, Trump proposed drastic reductions to the EPA’s budget and staff, and rolled back rules on clean air and water, including the reversal of regulations on air pollution and emissions from power plants, cars, and trucks.

That’s a big concern for minority neighborhoods, especially in states such as Florida, said Dominique Burkhardt, an attorney with the nonprofit legal aid group Earthjustice, which filed a complaint against Florida’s Department of Environmental Protection in March 2022.

The complaint, on behalf of Florida Rising, a nonprofit voting rights group, alleges that Florida’s environmental regulator violated the Civil Rights Act of 1964 by failing to translate into Spanish documents and public notices related to the permitting of incinerators in Miami and Tampa, and by refusing to consider the impact of the facilities on nearby minority communities.

“They’re not in any way taking into account who’s actually impacted by air pollution,” Burkhardt said of the state agency. The EPA is now investigating the complaintinvestigating the complaint.

Conservative lawmakers and state regulators have been hostile to laws and regulations that center on the rights of people of color, Burkhardt said. Florida Gov. Ron DeSantis, a Republican, has signed into law bills limiting race education in public schools and banning public colleges and universities from spending money on diversity, equity, and inclusion programs.

“They want to be race-neutral,” Burkhardt said. But that ignores “the very real history in our country of racism and entrenched systemic discrimination.”

Historical racism like segregation and redlining, combined with poor access to health care and exposure to pollution, has a lasting impact on health, said Keisha Ray, a bioethicist with the University of Texas Health Science Center at Houston.

Studies have found that neighborhoods with more low-income and minority residents tend to have higher exposure to cancer-causing pollutants. Communities with large numbers of industrial facilities also have stark racial disparities in health outcomes.

Incinerators emit pollutants such as carbon monoxide, nitrogen oxides, and fine particulate matter, which have been associated with heart disease, respiratory problems, and cancer. People living near them often don’t have the political power to push the industries out, Ray said.

Ignoring the disparate impact sends a clear message to residents who live there, she said.

“What you’re saying is, ‘Those people don’t matter.’”

Covered in Ash

Florida is one of 23 states that have petitioned the courts to nullify key protections under the Civil Rights Act. The protections prohibit racial discrimination by organizations receiving federal funding and prevent polluting industries from overburdening communities of color.

Those rules ask the states “to engage in racial engineering,” argued Florida Attorney General Ashley Moody in an April 2024 letter to the EPA, co-signed by attorneys general for 22 other states. A federal court in Louisiana, which sued the EPA in May 2023, has since stopped the agency from enforcing the rules against companies doing business in that state.

Miami-Dade’s incinerator, built west of the airport in 1982, was receiving nearly half the county’s garbage when it burned down in February 2023. Though the facility had pollution control devices, those measures did not always protect nearby residents from the odor, smoke, and ash that the incinerator emitted, said Cheryl Holder, an internal medicine physician who moved into the neighborhood in 1989.

Holder said every morning her car would be covered in ash. Residents persuaded the county, which owned the facility, to install “scrubbers” that trapped the ash in the smokestack. But the odor persisted, she said, describing it as “a strange chemical — faint bleach/vinegar mixed with garbage dump smell” — that often occurred in the late evening and early morning.

Holder still started a family in the community, but by 2000 they moved, out of concern that pollution from the incinerator was affecting their health.

“My son ended up with asthma … and nobody in my family has asthma,” said Holder, who in 2018 helped found Florida Clinicians for Climate Action, a group focused on the health harms of climate change. Though she cannot prove that incinerator pollution caused her son’s illness — the freeways, airport, and landfill nearby also emit toxic substances — she remains convinced it was at least a contributing factor.

Many South Florida residents are concerned about the health effects of burning trash, despite assurances from Miami-Dade Mayor Cava and the county’s environmental consultants that modern incinerators are safe.

Cava’s office did not respond to KFF Health News’ inquiries about the incinerator. She has said in public meetings and a September memo to county commissioners that the health and ecological danger from the new incinerator would be minimal. She cited an environmental consultant’s assessment that the health risk is “below the risk posed by simply walking down the street and breathing air that includes car exhaust.”

But some environmental health experts say it’s not only a facility’s day-to-day operations that are cause for concern. Unplanned events, such as the fire that destroyed Miami-Dade’s incinerator, can cause environmental catastrophes.

“It might not be part of their regular operations,” said Amy Stuart, a professor of environmental and occupational health at the University of South Florida’s College of Public Health. “But it happens every once in a while. And it hasn’t been that well regulated.”

No Easy Solutions

In addition to Miami-Dade’s planned incinerator, three other facilities have been proposed elsewhere in the state, according to Energy Justice Network and news reports.

State lawmakers adopted a law in 2022 that awards grants for expansions of existing trash incinerators and financial help for waste management companies losing revenue on the sale of the electricity their facilities generate.

A bill filed in the Florida Legislature by Democrats this year would have required an assessment of a facility’s impact on minority communities before the state provided financial incentives. The legislation died in committee.

As local governments in Florida and elsewhere turn to incineration to manage waste, the industry has argued that burning trash is better than burying it in a landfill.

Kilsheimer, whose group represents the incinerator industry, said Miami-Dade has no room to build another landfill, though the toxic ash left behind from burning trash must be disposed of in a landfill somewhere.

“This is the best solution we have for the conditions that we have to operate in,” he said.

But University of South Florida’s Stuart said that burning trash isn’t the only option and that the government should not ignore historical and environmental racism. The antidote cannot be to put more incinerators and other polluting facilities in majority-white neighborhoods, she said.

The focus of public money instead should be on reducing waste altogether to eliminate the need for incinerators and landfills, Stuart said, by reducing communities’ consumption and increasing recycling, repurposing, and composting of refuse.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

LAS VEGAS — Maurice Clark huddled in his tent along dusty railroad tracks as two homeless-outreach workers began asking him questions to determine whether he would qualify for free or subsidized housing.

Did he use drugs? Had he ever been in jail? How many times had he been to an emergency room? Had he been attacked on the streets? Tried to harm himself? Engaged in sex for money?

Clark didn’t feel comfortable being honest with the two surveyors he’d never met before, who were flanked by police officers as they recorded his responses from a questionnaire on a tablet.

“I’ve done some crazy things to survive, but I’m, like, I’m going to say no because there’s these officers right there,” he said, recalling the encounter on a fall afternoon outside his tent.

“I’m a Black man in America, so asking this stuff hits a little bit different.”

National homelessness experts and local leaders say such personal questions exacerbate racial disparities in the ranks of the nation’s unhoused, particularly as more people experiencing homelessness compete for scarce taxpayer-subsidized housing amid a deepening affordability crisis.

Vulnerability questionnaires were created to determine how likely a person is to get sick and die while homeless, and the system has been adopted widely around the country over the past decade to help prioritize who gets housing. The more a homeless person is perceived to be vulnerable, the more points they score on the questionnaire and the higher they move in the housing queue. The surveys are being singled out for worsening racial disparities by systematically placing homeless white people at the front of the line, ahead of their Black peers — partly because the scoring awards more points for using health care, and relies on trust in the system, both of which favor white people.

Black people make up 13.7% of the overall U.S. population yet account for 32.2% of the nation’s homeless population. White people, including some people of Hispanic descent, make up 75% of the country and represent 55% of America’s homeless.

“It’s racist in a systemic way,” said Marc Dones, a California-based policy director at the University of California-San Francisco and a lead researcher for one of the nation’s largest studies analyzing the Black homeless population. “If you’re a white person, the more likely you are to rank higher than if you’re a Black person, so you’re more likely to get selected for housing.”

Vulnerability surveys took off after President Barack Obama in 2009 signed into law sweeping rules requiring the country’s local homelessness agencies, known as Continuums of Care and currently numbering 381, to adopt a method to assess the vulnerability of homeless people to receive federal housing and homelessness funding. Cities and counties predominantly adopted a survey called VI-SPDAT, which is still used by an estimated two-thirds of homeless agencies, even as it has been found to favor white people and rank Black people lower.

Some experts argue it’s time to toss the vulnerability assessment altogether and look not only at health and social needs but also systemic racism, poverty, involvement in the criminal justice system, barriers to housing, and other economic drivers that influence, and in some cases cause, homelessness. Several U.S. communities are revamping their vulnerability assessment systems to reduce racial disparities and help more Black people get housing.

In Los Angeles, officials are launching an effort to use artificial intelligence to better assess whether someone should be prioritized for placement, in part by looking at overpolicing of Black people and discrimination in health care. In Las Vegas, officials are revamping their vulnerability assessment to give higher scores for systemic problems including incarceration. In Austin, Texas, officials are testing a system to account for people displaced by gentrification.

“We need to own the racism that is embedded in our systems,” said Quiana Fisher, vice president of homelessness response systems for the lead agency in Travis County, Texas, which includes Austin. “It’s not just about the tool — it’s about funding, and it’s about program outcomes. Even if it’s unintentional, we have created a homeless response system that is rooted in racism.”

The assessment tool was first tested in Boston, where members of the homeless population were more likely to be white, male, and have a severe mental illness or substance use disorder. Black people, meanwhile, are more likely to be homeless because of economic reasons, such as poverty or joblessness, and are less likely to have a record of medical care due to higher uninsurance and less use of health care.

“This whole system was piloted on this older white population in Boston, so it does a poor job of capturing the needs of Black folks, who don’t tend to be as sick as white folks — they’re more broke,” Dones said. “The initial thought was to prioritize these people because they’re going to die sooner. It was trying to tackle mortality, but it wound up in racism.”

As a result, white people are more likely to gain housing because they tend to score more points on vulnerability assessments that rank sickness higher, including histories of chronic disease, addiction, mental illness, and emergency room visits and hospitalizations, according to national surveys. Black people, meanwhile, are less likely to have health insurance or medical diagnoses and to reveal their ailments, and are more mistrustful due to biases in the health care system. “Black folks are less likely to seek care, even with coverage, due to medical racism,” Dones said.

Local leaders say part of the problem is becoming homeless in the first place and economic disadvantages that drive more Black people into homelessness, including placement in foster care and higher rates of eviction and joblessness. But once homeless, helping Black people get into stable housing becomes more elusive.

In Los Angeles County, home to more homeless people than any other county in the country, 31% of homeless people are Black, though the overall Black population accounts for 9%. In Austin, Black people account for nearly 32% of the homeless population, compared with 7.6% overall. And in Clark County, which includes Las Vegas, Black people represent 42% of the homeless population but just 12% of the overall population.

“We’ve failed to capture the complex vulnerabilities of our marginalized groups. We’re asking all these questions, but we created a waiting list to nowhere,” said Brenda Barnes, who leads the Southern Nevada Homelessness Continuum of Care.

Streets of Las Vegas

Grasping his toothbrush after cleaning up in his tent on a recent morning, Clark, 45, recalled taking his housing questionnaire this year. He ticked off responses to outreach workers that should rank him high in the queue — he lacked stable housing, has been homeless for nearly four years, and has no job or reliable income.

He’d frequented emergency rooms and had been to jail, pleading guilty to a felony theft crime he said he didn’t commit, and several times for possession of drugs and paraphernalia, he told them. He used methamphetamine, mostly to be alert at night when it became dangerous. Was he ever assaulted? Yes, especially in adulthood since becoming homeless in 2020.

In reality, he hustled sometimes for a dime, and he worried he’d be targeted for taking recyclables or engaging in prostitution. “I’ve done it to get a room for a night. It’s like a last resort,” he said.

And Clark wasn’t forthcoming with outreach workers about the details of his drug use or involvement with law enforcement, that he’d sold his body for sex, that he’d experienced abuse. He couldn’t recall all the details of his medical history either. Continually fleeing law enforcement sweeps with his tent, hauling it along busy train tracks, he’s high at times, and often in a state of chaos and fear that can scramble his memory or make him fearful of arrest. He didn’t share with them his occasional thoughts of suicide or his health concerns, including possibly having diabetes.

“They asked me about drugs, I was like, um, I don’t know,” Clark said. “Like I’m supposed to tell them I got addicted to meth or sold my body for a meal and hotel room? I had no idea where this information was going or what it was being used for.” After he took the survey, no housing came.

Even those who do answer honestly find themselves competing for a limited supply of affordable housing. John Harris was sleeping under a bridge on a recent October afternoon. He said he has taken the questionnaire twice. It led nowhere.

“They asked me, have I been incarcerated? And I said yes. I’ve been to prison too many times. And I have mental health struggles,” said Harris, 59, who has been in and out of sober living shelters but still uses methamphetamine. He has been a repeat visitor to emergency rooms, and on an October afternoon recorded a high blood pressure reading that put him at risk for a heart attack — factors that should score points for vulnerability.

“I called and asked what happened with my housing. They said I didn’t score high enough,” he said. After getting his blood pressure checked by a street medicine nurse, he shrugged, saying he may just wind up back in the emergency room, as he retreated under the bridge.

“No matter what society says today, things ain’t never going to change,” he said.

‘I Don’t Know What the Solution Is’

How communities assign points to homeless people and rank them for housing is the biggest problem.

The most common questionnaire deployed by communities around the country, the VI-SPDAT, assigns points meant to gauge the vulnerability of a person living on the streets. Experts say this model was never tested as a housing assessment tool, nor meant to determine whether someone gets into housing.

“This is not a reliable instrument, and Black men consistently score the lowest for vulnerability, so they are deprioritized for housing — to get housing, you really need to score high,” said Courtney Cronley, a University of Tennessee researcher who analyzed the vulnerability assessment. Her findings were published in 2020 in the Journal of Social Distress and Homelessness.

Cronley pointed to a range of questions that exacerbate racial bias and have little to do with qualifying for housing:

How many times have you received health care in an emergency room? Have you been attacked or beaten up? Have you threatened to harm yourself or anyone else in the last year?

Does anyone force you or trick you to do things that you do not want to do? Do you exchange sex for money? Run drugs?

Experts who study the vulnerability questionnaire also point out that the racial or ethnic background of surveyors often doesn’t reflect that of the people being questioned, which can lead to inaccurate results if a respondent doesn’t feel safe or understand the survey’s purpose.

Some cities and counties are creating surveys that local homeless agencies hope will narrow racial disparities.

Clark County deployed a new vulnerability assessment in June after a 2023 secret-shopper project found the system was not connecting homeless people with housing or services, especially people of color.

“We failed in every category,” Barnes said. Formerly homeless people fanned out on the streets and in the tunnels to test whether the housing questionnaire resulted in providing housing for the most vulnerable. “All we were doing is counting people.”

Clark County’s new weighted questionnaire now considers how likely a person is to exit homelessness on their own — instead of how likely they are to die on the streets or in the tunnels.

The new system assigns homeless people points in four categories to get higher in the queue for housing: whether someone is pregnant or a parent; whether they have a substance use disorder, chronic health condition, or mental health diagnosis; whether they’re 55 or older; and whether they have committed a felony or violent crime.

“Because you’re not going to get approved for a job or housing if they run a background check and there’s a criminal record,” she said, “so we want to address that in our housing system.”

Still, Barnes isn’t sure Clark County will get it right this time. As of mid-November, more homeless Black people were waiting for housing than white people. According to local data obtained through public records requests, nearly 1,500 Black people are in the county’s housing queue, compared with roughly 1,000 white people.

“I don’t know what the solution is,” Barnes said. “To be honest, the numbers may spike again.”

Los Angeles County, where an estimated 75,000 people experience homelessness, is creating a weighted tool to assign more points for factors that disproportionately affect people of color.

If someone has been incarcerated or detained by law enforcement, instead of getting one point, a homeless person would score five, moving them up on the housing list, said Eric Rice, a social scientist and professor at the University of Southern California.

“We are assigning more points to structural inequities,” said Rice, who is helping develop the new questionnaire.

Los Angeles County also plans to assign more points for drug use and for having HIV, which affects Black men more than any other group. New HIV diagnoses for Black adults were eight times those of white people, according to research by KFF, a health information nonprofit that includes KFF Health News, the publisher of California Healthline.

Homelessness coordinators have also revamped their vulnerability assessment in Travis County, Texas, where a Black resident is six times as likely to fall into homelessness as a white person.

The county’s homelessness agency, according to Fisher, looked at historically Black neighborhoods in Austin that had been gentrified and scored homeless people higher if they’d lived in those areas but were now homeless.

“If you lived in a place that was previously redlined or now gentrified, you got a point for that,” Fisher said. The survey also gave points for involvement in the criminal justice system, because Black people are more likely to get arrested or jailed, she said.

Some experts say the idea of using a tool to rank people should disappear altogether.

Instead, communities should have flexibility to tailor their housing resources based on the local needs and demographic makeup of their homeless populations, said Mary Frances Kenion, vice president of training and technical assistance at the National Alliance to End Homelessness.

She said communities can cultivate trust between homeless people and outreach workers through a one-on-one approach that can be more responsive to individual needs and local housing conditions, which can better determine whether someone should be moved to the top of the housing list.

Kenion also encouraged federal, state, and local governments to reimagine their approach to prioritizing people for housing based not on vulnerability but economic factors like income, history of eviction, or having a felony record. She argued communities should devote more resources to stem the flow of Black people into homelessness.

“If we don’t manage to stop that,” she said, “this is just going to keep getting exponentially worse.”

LAS VEGAS — Case manager Bryon Johnson flashed a light into a dark tunnel beneath the glitz of the Las Vegas Strip on a recent fall afternoon. He stepped into an opening in a concrete ditch littered with trash and discarded clothing to search an underground world for his homeless clients.

Beneath the Caesars Palace hotel and casino, Johnson found one of them stretched out on a plywood bed. Jay Flanders, 49, had sores across his back, up his arms, and into his fingers. The homeless man acknowledged occasional meth use and mental health concerns. He couldn’t recall exactly how long he’d lived underground, but it had been several years.

“Why don’t you come inside,” asked Johnson, trying to persuade Flanders to leave the tunnels. “Come get treatment.”

It’s Johnson’s job to coax homeless people out of drainage tunnels that stretch beneath Las Vegas, a perilous grid where people hide from law enforcement and shelter from extreme weather but risk being swept away by floodwaters. Drugs and alcohol are prevalent. Johnson tells clients they have a better shot at recovery above ground, where they can get medical care to treat chronic illnesses, such as diabetes, depression, and heart disease, and start drug and alcohol treatment programs.

Street medicine providers and homeless outreach workers who travel into the tunnels said they have noticed an uptick in the number of people living underground as housing costs have skyrocketed and local officials have adopted a zero-tolerance approach to homelessness. Caseworkers are also confronting a level of drug addiction that’s making it harder to get people, many suffering from mental illness and health conditions, to come aboveground for care.

“It’s meth. It’s fentanyl. It’s opioids. We’re seeing it more and more,” said Rob Banghart, vice president of community integration for the nonprofit homeless outreach organization Shine a Light, who lived in the tunnels for 2½ of the five years he was homeless, often using drugs.

Now sober for more than six years, Banghart recalled the tunnels providing a respite. “In that state of mind, I said to myself, ‘It’s got a roof; it’s out of the sun.’ It’s a little twisted, but it was a community.”

Outreach workers say more people are retreating underground. Though dark and damp, the tunnels provide cover from the harsh desert sun, warmth when temperatures drop, and privacy from society’s judgment above ground.

Constructed in the 1990s and measuring some 600 miles, the tunnels provide flood control for the city and outlying communities. Homeless outreach workers said 1,200 to 1,500 people live in them. Many have constructed elaborate shelters, often out of plywood and scraps of metal or brick below the casinos that define the Strip.

Tunnel living is not limited to Nevada. Across California’s Central Valley and its southern deserts, people unable to afford housing are retreating into caves and earthen tunnels, often dug into flood control berms, riverbanks, or along drainage canals, where people can escape the heat and law enforcement. In San Antonio, homeless people have constructed tunnel encampments, and in New York, homeless people have long retreated into subterranean existence in tunnels and defunct train corridors.

In Las Vegas, some tunnel dwellers said they hide to avoid constant encampment sweeps, which have increased nationally since the U.S. Supreme Court this year ruled that local authorities have a right to enforce sleeping or camping bans in public spaces, even when no shelter or housing is available.

Others said they go down to escape the unbearable weather. Triple digits are common in the summer; this year, Las Vegas climbed as high as 120 degrees. And the tunnels provide protection when temperatures drop into the 30s in the winter. It even snows there.

Street medicine providers are also trying to persuade homeless people to leave the tunnels to receive care. In addition to more drug and alcohol use, they have seen new problems with wounds and skin disorders associated with the street drug known as “tranq,” slang for the animal tranquilizer xylazine, which is often mixed with fentanyl or meth.

Tranq causes deep skin infections that, left untreated, can lead to bone infections and require amputation.

Flanders, the homeless man in the tunnels, had several of these skin sores, which he referred to as spider bites — a euphemism for the deep skin wounds caused by tranq. He estimated he has been to the emergency room at least 10 times this year, several times requiring hospitalization.

“One time I was there for six days; I almost lost a finger,” Flanders said, holding up the index finger that had been warped from a deep infection, as he started to tear up. Despite the risks, Flanders said, he still felt safer living in the tunnels than aboveground.

Las Vegas’ population boom has contributed to rising housing costs. The market rent for southern Nevada rose 20% from 2022 to 2023, according to a Clark County homelessness report — higher than the national average.

As more people get displaced, more retreat underground. And often, outreach workers say, it’s not just locals who can’t afford the rising cost of living who wind up homeless, but also out-of-towners. Some come to make it in the city’s booming entertainment industry, while others become homeless after losing it all at the casinos.

“People come here on vacation to gamble or try and make it, and they lose everything,” said Johnson, who works for Shine a Light, one of two organizations in Las Vegas that provide substantial outreach, housing referrals, and drug treatment services for homeless people in the tunnels.

“The housing market is insane; rents keep going up. A lot of people wind up down here,” said Johnson, who lived in the tunnels until he got sober with help from Shine a Light. “People just get stuck.”

Still, Nevada’s scorching heat and rains and monsoons pose a major threat to those living in the tunnels, though it’s unclear exactly how deadly life in them can be.

But Louis Lacey, homeless response director for the nonprofit Help of Southern Nevada, said homeless people living belowground put their lives at risk, often in the monsoon season when the tunnels flood. His organization coordinates with the city of Las Vegas and Clark County to get as many people as possible into shelters before the start of the rainy season, which typically runs from June to September.

“We go into the tunnels to make sure people who want to get out are out, but not everyone leaves, often because they don’t want to leave their belongings,” he said. “People die every year.”

KFF Health News senior fellow and editor-at-large for public health Céline Gounder discussed the incoming Trump administration — notably, the possibility of Robert F. Kennedy Jr. as Health and Human Services secretary— on the “On With Kara Swisher” podcast on Dec. 19. She also discussed the health stories that shaped 2024 on CBS on Dec. 19.

KFF Health News senior correspondent Renuka Rayasam discussed the struggle to close the health gap, especially for rural, low-income African Americans, on KERA’s “Think” on Dec. 16.

KFF Health News senior correspondent Aneri Pattani discussed state and local efforts to combat the opioid epidemic on C-SPAN on Dec. 15.

KFF Health News Peggy Girshman fellow Jackie Fortiér discussed the nationwide IV fluid shortage on PBS NewsHour on Dec. 14.

KFF Health News contributor Andy Miller discussed the killing of UnitedHealthcare’s CEO and growing frustration over difficult insurance claims on The Atlanta Journal-Constitution’s “Politically Georgia” podcast on Dec. 13.

KFF Health News chief Washington correspondent Julie Rovner discussed health insurance on CBS News on Dec. 13.

KFF Health News Northern California correspondent Vanessa G. Sánchez discussed a recent immigrant detention center lawsuit on City Limits’ podcast, “El Diario Sin Límites” on Dec. 9.

A western New York health insurance provider for seniors and the CEO of its medical analytics arm have agreed to pay a total of up to $100 million to settle Justice Department allegations of fraudulent billing for health conditions that were exaggerated or didn’t exist.

Independent Health Association of Buffalo, which operates two Medicare Advantage plans, will pay up to $98 million. Betsy Gaffney, CEO of medical records review company DxID, will pay $2 million, according to the settlement agreement. Neither admitted wrongdoing.

“Today’s result sends a clear message to the Medicare Advantage community that the United States will take appropriate action against those who knowingly submit inflated claims for reimbursement,” Michael Granston, a DOJ deputy assistant attorney general, said in announcing the settlement on Dec. 20.

Frank Sava, a spokesperson for Independent Health, said in a statement: “The assertions by the DOJ are allegations only, and there has been no determination of liability. This settlement is not an admission of any wrongdoing; it instead allows us to avoid the further disruption, expense, and uncertainty of litigation in a matter that has lingered for over a decade.”

Under the settlement, Independent Health will make “guaranteed payments” of $34.5 million in installments from 2024 through 2028. Whether it pays the maximum amount in the settlement will depend on the health plan’s financial performance.

Michael Ronickher, an attorney for whistleblower Teresa Ross, called the settlement “historic,” saying it was the largest payment yet by a health plan based solely on a whistleblower’s fraud allegations. It also was one of the first to accuse a data mining firm of helping a health plan overcharge.

The settlement is the latest in a whirl of whistleblower actions alleging billing fraud by a Medicare Advantage insurer. Medicare Advantage plans are private health plans that cover more than 33 million members, making up over half of all people eligible for Medicare. They are expected to grow further under the incoming Trump administration.

But as Medicare Advantage has gained popularity, regulators at the federal Centers for Medicare & Medicaid Services have struggled to prevent health plans from exaggerating how sick patients are to boost their revenues.

Whistleblowers such as Ross, a former medical coding professional, have helped the government claw back hundreds of millions of dollars in overpayments tied to alleged coding abuses. Ross will receive at least $8.2 million, according to the Justice Department.

Ross said that CMS “created a bounty” for health plans that added medical diagnosis codes as they reviewed patients’ charts — and whether those codes were accurate or not “didn’t seem to bother some people.”

“Billions of dollars are being paid out by CMS for diagnoses that don’t exist,” Ross told KFF Health News in an interview.

Data Mining

DOJ’s civil complaint, filed in September 2021, was unusual in targeting a data analytics venture — and its top executive — for allegedly ginning up bogus payments.

DxID specialized in mining electronic medical records to capture new diagnoses for patients — pocketing up to 20% of the money it generated for the health plan, according to the suit, which said Independent Health used the firm from 2010 through 2017. DxID shut down in 2021.

Gaffney pitched its services to Medicare Advantage plans as “too attractive to pass up,” according to the Justice Department complaint.

“There is no upfront fee, we don’t get paid until you get paid and we work on a percentage of the actual proven recoveries,” Gaffney said, according to the complaint. Timothy Hoover, an attorney for Gaffney, said in a statement that the settlement “is not an admission of any liability by Ms. Gaffney. The settlement simply resolves a dispute and provides closure to the parties.”

‘A Ton of Money’

CMS uses a complex formula that pays health plans higher rates for sicker patients and less for people in good health. Health plans must retain medical records that document all diagnoses they highlight for reimbursement.

Independent Health violated those rules by billing Medicare for a range of medical conditions that either were exaggerated or not supported by patient medical files, such as billing for treating chronic depression that had been resolved, according to the complaint. In one case, an 87-year-old man was coded as having “major depressive disorder” even though his medical records indicated the problem was “transient,” according to the complaint.

DxID also cited chronic kidney disease or renal failure “in the absence of any documentation suggesting that a patient suffered from those conditions,” according to the complaint. Past conditions, such as heart attacks, that required no current treatment, also were coded, according to the DOJ.

The suit alleges that Gaffney said renal failure diagnoses were “worth a ton of money to IH [Independent Health] and the majority of people (over) 70 have it at some level.”

Ross filed the whistleblower case in 2012 against Group Health Cooperative in Seattle, one of the nation’s oldest managed-care groups.

Ross, a former medical coding manager there, alleged that DxID submitted more than $30 million in disease claims — many of which were not valid — on behalf of Group Health for 2010 and 2011. For instance, Ross alleged that the plan billed for “major depression” in a patient described by his doctor as having an “amazingly sunny disposition.”

Group Health, now known as the Kaiser Foundation Health Plan of Washington, denied wrongdoing. But it settled the civil case in November 2020 by agreeing to pay $6.3 million. The DOJ filed a second complaint in 2021, against Independent Health, which also used DxID’s services.

Ross said she lost her job after her suit became public in 2019 and was unable to secure another one in the medical coding field.

“It was rough at times, but we got through it,” she said. Ross, 60, said she is now “happily retired.”

False Claims

Whistleblowers sue under the False Claims Act, a federal law dating to the Civil War that allows private citizens to expose fraud against the government and share in any recovery.

At least two dozen such suits, some dating to 2009, have targeted Medicare Advantage plans for overstating the severity of medical conditions, a practice known in the industry as “upcoding.” Previous settlements from such suits have totaled more than $600 million.

The whistleblowers have played a key role in holding health insurers accountable.

While dozens of CMS audits have concluded that health plans overcharged the government, the agency has done little to recoup money for the U.S. Treasury.

In a surprise action in late January 2023, CMS announced that it would settle for a fraction of the estimated tens of millions of dollars in overpayments uncovered through its audits dating to 2011 and not impose major financial penalties on health plans until a round of audits for 2018 payments, which have yet to be done. Exactly how much plans will end up paying back is unclear.

“I think CMS should be doing more,” said Max Voldman, an attorney who represents Ross.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

Over 6½ years ago, KFF Health News and NPR kicked off “Bill of the Month,” a crowdsourced investigation highlighting the impact of medical bills on patients.

The goal was to understand how the U.S. health care system generates outsize bills and to empower patients with strategies to avoid them. We asked readers and listeners to submit their bills — and they kept coming. “Bill of the Month” has received nearly 10,000 submissions, each a picture of a health system’s dysfunction and the financial burden it places on the patients.

Since 2018, we have analyzed bills totaling almost $6.3 million — including nearly $2.8 million that patients were expected to pay out-of-pocket.

Cited at statehouses and the U.S. Capitol, the series has led to changes in health policy. Two patients featured by “Bill of the Month” were invited to the White House in 2019 to discuss their surprise bills: Elizabeth Moreno’s $18,000 urine test and Drew Calver’s $109,000 heart attack. In 2020, Congress passed the federal No Surprises Act, shielding patients from most out-of-network bills in emergencies, among other protections.

Last year, the Biden administration announced plans to lower health costs that included targeting a loophole that allowed health providers to evade the surprise-billing law — a problem first identified by “Bill of the Month.”

Many patients submitted high prescription drug bills. In treatment for prostate cancer, Paul Hinds was billed nearly $74,000 for two shots of an old drug called Lupron, which can cost just a couple of hundred dollars overseas.

Now, the federal government has identified Lupron as one of the medicines that has seen its price rise faster than inflation — meaning its manufacturer owes rebates to Medicare under President Joe Biden’s 2022 Inflation Reduction Act.

The law also authorized the Biden administration to begin negotiating the price of specified drugs for Medicare patients, who now benefit from a cap on the price of insulin.

“Bill of the Month” has helped many patients and readers get their medical bills reduced or forgiven. Roughly 1 in 3 bills were resolved for patients by the time their features were published.

Bisi Bennett was charged $550,124 after her son was in a neonatal intensive care unit for nearly two months — despite having insurance. In a recent interview, nearly three years after her bill was investigated by “Bill of the Month,” she said she initially thought resolving the bill would be simple.

“Nine months later, 10 months later, I was still fighting with them,” she said. “I really did feel like it kind of robbed me a little bit of the joy of the first months of motherhood.”

Once a reporter started making calls, Bennett said, “they somehow miraculously figured out how to bill the right parties and get it sorted out.”

But relief from individual bills is one thing; patients say bigger solutions are needed for what ails our health system. “This isn’t just about my bill,” Calver said in 2018, when his nearly $109,000 bill was reduced to $332 after being investigated by “Bill of the Month.” “I don’t feel any consumer should have to go through this.”

The Takeaways

The “Bill of the Month” mantra is: If the bill is unexpected or seems off, don’t write the check. Each installment offered directions to navigate health care’s rough financial waters.

Some bills memorably illustrated the absurdity of a system that turns ordinary mishaps into extraordinary revenues. After 3-year-old Lucy Branson got a Polly Pocket doll shoe stuck up her nose, her family was charged about $2,659 for an ER doctor to fish it out with forceps — essentially a long pair of tweezers.

Here are some of the most important lessons — and some patients who offered their experiences to teach them:

• Before scheduling services, ask if a provider is in-network — then read waiting-room forms closely. Feeling sick and unable to rule out covid-19, Elyse Greenblatt booked a telemedicine appointment. But her in-network doctor’s office paired her with an out-of-network doctor — and said she’d signed a consent form. Her insurer declined to pay a penny of the $660 bill.
• Ask for an itemized bill, and question charges that don’t make sense. Eloise Reynolds paid her husband’s final hospital bill after he died from colon cancer. A year later, she received a second bill for his stay. Reynolds requested an itemized bill — and using a yardstick as a straight edge, went line by line to sort out why the hospital said she owed nearly $1,100 more. The balance was eventually deemed a “clerical error” and eliminated.
• Beware ambulances. The landmark No Surprises Act protected patients from many surprise bills in emergencies, but it does not apply to ground ambulances, which are unlikely to contract with insurance and thus might bill willy-nilly. When Peggy Dula was in a car accident, she was picked up by a fire department ambulance that was out-of-network. Though she wasn’t terribly hurt, her ride generated a $3,606 charge, and — after her insurance paid an amount it deemed “reasonable and customary” — she owed around $2,711.
• Location Matters, Part 1: Any intervention or test done in a hospital is likely to cost more than elsewhere. After her first prenatal checkup, Reesha Ahmed had her blood drawn for routine tests by a hospital lab. The bill: $9,520. Ahmed, who had a miscarriage, owed $2,390.
• Location Matters, Part 2: Doctors’ offices can be reclassified as hospital facilities if they’re purchased by a hospital system — and then add on hospital facility fees. Kyunghee Lee, a retired seamstress, went to her doctor for regular injections to treat arthritis for a copay of about $30. Then the office moved one floor up — and her bill changed: Newly designated as taking place in “a hospital-based setting,” one visit was billed at $1,394, including a facility fee listed as “operating room services.” Lee owed about $355.
• Location Matters, Part 3: Some free-standing emergency rooms may look like urgent care centers but come with ER charges. Tieqiao Zhang believed he was visiting urgent care when he sought treatment for a kidney stone at a facility called an “urgent care emergency center.” He went there twice and, both times, was given IV hydration and painkillers, then sent home. The visits yielded a bill of $19,543, including a $500 copay for each visit to what was actually a free-standing ER.
• Sometimes it can pay to pay cash. Dani Yuengling needed a breast biopsy after a concerning mammogram. The hospital’s online price calculator listed a price of about $1,400 for those without insurance. So she was shocked to see her own bill, paid using insurance, was almost $18,000, of which she owed more than $5,000 under the terms of her high-deductible plan.

The Resolution

Some bills signal that there’s more to be done to tame a health care industry in which seemingly everything can be billable. Mansi Bhatt took her toddler, Martand, to the emergency room for a burn on his hand, but after a long wait, they left before being seen by a doctor. Just checking in yielded an $859 bill, which the family had to pay since they hadn’t met their deductible.

Even new protections, such as those for air-ambulance bills, have problems. Amari Vaca was 3 months old and recovering from open-heart surgery when he contracted the life-threatening virus RSV, or respiratory syncytial virus. When doctors said he needed specialized care, he was transferred by air ambulance to a different hospital. The family’s insurer denied the claim, determining the flight wasn’t medically necessary, and the hospital declined to file an appeal. Vaca’s mother, Sara England, notified KFF Health News in October that their final appeal was denied. They owe $97,000.

And old bills die hard. When “Bill of the Month” reconnected with Phil Gaimon this fall, he said he had called his providers recently to check his outstanding balance — and learned it was, at last, zero.

Gaimon was competing to qualify for the Olympics when he was in a bicycle crash and wound up with bills topping $200,000. “I think I was home from the hospital in 10 days, riding my bike again in a month,” he said in an interview. “And then the bills … three years.”

While our “Bill of the Month” partnership with NPR is sunsetting, the “Bill of the Month” series will continue as KFF Health News investigates your medical bills. Keep them coming! And watch for future stories in The Washington Post’s Well+Being.

Elisabeth Rosenthal is a senior contributing editor for KFF Health News and the creator of “Bill of the Month.”

Emily Siner reported the audio story.

Henry Larweh and Molly Castle Work of KFF Health News contributed reporting for this article.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

It seems simple: Require hospitals and insurers to post their negotiated prices for most health care services and — bingo — competition follows, yielding lower costs for consumers.

But nearly four years after the first Trump administration’s regulations forced hospitals to post massive amounts of pricing information online, the effect on patients’ costs is unclear. And while President Joe Biden added requirements to make pricing information more user-friendly, Donald Trump’s imminent return to the White House has raised questions about what’s next, even though posting prices is an area of rare bipartisan agreement.

The uncertainty of what might happen next led some proponents to lobby Congress to include hospital and insurer price transparency in must-pass legislation before Trump takes office. That would turn both his and Biden’s regulations into law, making them less susceptible to being weakened or repealed by a future administration. But that effort failed.

The legislative step could also help protect against legal challenges in the wake of a Supreme Court decision that limited government agencies’ regulatory authority.

Employers are using transparency data to try to slow growth of their health care costs, and “the last thing you want to do is start over,” said James Gelfand, president and CEO of the ERISA Industry Committee, which represents large employers who finance their own health plans. His group is among the organizations pressing Congress to act.

“Congress’ failure to act is deeply disappointing, but employers and other advocates will redouble our efforts,” Gelfand said. “This will get done.”

While there are reports that many hospitals are not fully complying, federal regulators have sent thousands of warning letters to hospitals and fined just over a dozen.

The transparency rules require hospitals to list the prices they accept from all insurers for thousands of items and services, from stitches to delivery room costs to X-rays. For consumers, hospitals must also provide a list of 300 “shoppable” services, including bundled prices accepted for common services such as having a baby or getting a hip replacement. Insurers in July 2022 were similarly required to list their negotiated prices, not only for care at hospitals, but also surgery centers, imaging facilities, laboratories, and doctors’ offices.

It’s a massive and often confusing amount of data that has drawn interest from researchers and commercial outlets like Turquoise Health, which has sought to organize the information to better help ordinary consumers shopping for medical services or employers overseeing workers’ health plans.

The data shows a huge variation in prices, both in what hospitals charge and what insurers pay, for the same services. But the result of making those prices public is so far hard to quantify.

A recent study by Turquoise looked at negotiated rates in the nation’s 10 largest metro areas for a set of common health care services. It found that rates in the top quarter tier — the most expensive category — declined by 6.3% from December 2021 to June 2024, during the time the transparency rules were in place. But negotiated rates for the lowest-cost tier of services rose by 3.4%.

That may indicate hospitals and insurers — who can now see what rivals are charging and paying — have either cut prices or demanded better rates, at least for the costliest services.

Even so, Gerard Anderson, who oversees research into the data as a professor at the Bloomberg School of Public Health at Johns Hopkins University, said the changes Turquoise noted were small and are not reflective of what his team has seen in their own studies.

“So far we have not detected any impact of this data on behavior, of where insurers decide to go or what hospitals do to change prices once they realize what others are charging,” Anderson said.

Some health policy experts think it’s unlikely the incoming Trump administration would reverse its prior commitment to price transparency.

“I don’t see a world where he tanks his own regulations,” said Joe Wisniewski, an associate vice president at Turquoise Health. “There is also so much broad bipartisan support on the Hill.”

The current price-posting rules began with requirements in the Affordable Care Act, which the initial Trump administration more fully defined. The hospital industry failed in a legal challenge to block those rules, and the Trump-era requirements became effective in January 2021.

But even after the Biden administration made the data more user-friendly, it’s still not very helpful to consumers, Anderson said.

“This data is not telling them the price they will pay. It’s telling them the average price people paid last month or last quarter for a similar type of service,” he said.

More useful, Anderson and other experts say, are requirements in the price transparency rules that demand insurers offer online calculators for hundreds of nonemergency services. The detailed cost estimates must take into account how much patients have paid toward annual deductibles.

For uninsured consumers or others who don’t have access to online calculators, it remains difficult to piece together how much a service might cost from the information hospitals post online. For one thing, not every hospital has posted its negotiated rates.

The Department of Health and Human Services’ inspector general said in November an audit of 100 hospitals found that 63 complied with the price transparency rule, while the rest failed to meet one or more requirements.

The advocacy group Patient Rights Advocate, which looked at a sample of 2,000 hospitals, says that only 21% were fully compliant, although it used broader measures for compliance than the inspector general.

“By keeping their prices hidden, hospitals continue to block American consumers from their right to compare prices and protect themselves from overcharges,” said Cynthia Fisher, founder and chairman of the group, which has called for stricter rules and enforcement.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.