“Facing eviction?” the sign read. “You could be eligible for up to $3,000 in rent assistance. Apply today.”

It seemed a hopeful omen after a series of financial and health blows. In March, Pettigrew, 52, learned he has an invasive mass on his lung that restricts his breathing. His doctor told him his condition puts him at high risk of developing deadly complications from COVID-19 and advised him to stop working as a night auditor at a Motel 6, where he manned the front desk. Reluctantly, he had to leave that job and start piecing together other work.

With pay coming in less steadily, Pettigrew and his wife, Stephanie, fell behind on the rent. Eventually, they were many months late, and the couple’s landlord filed to evict them.

Then Pettigrew saw the rental assistance sign.

“There were nights I would lay in bed and my wife would be asleep, and all I could do was say, ‘God, you need to help me. We need you,'” Pettigrew said. “And here he came. He showed himself to us.”

As many asÌý faced a looming eviction risk in August, according to a report authored by 10 national housing and eviction experts. The Centers for Disease Control and Prevention cited that estimate in early September when it ordered an unprecedented, nationwideÌý through the end of 2020.

That move — a moratorium from the country’s top public health agency — spotlights a message experts have preached for years without prompting much policy action: Housing stability and health are intertwined.

The CDC is now citing stable housing as a vital tool to control the coronavirus,Ìý. Home is where people isolate themselves to avoid transmitting the virus or becoming infected. When local governments issue stay-at-home orders in the name of public health, they presume that residents have a home. For people who have the virus, home is often where they recover from COVID-19’s fever, chills and dry cough — in lieu of, or after, a hospital stay.

But the moratorium isÌý. Renters have to submit aÌýÌýto their landlord, agreeing to a series of statements under threat of perjury, including “my housing provider may require payment in full for all payments not made prior to and during the temporary halt, and failure to pay may make me subject to eviction pursuant to state and local laws.”

Ìýmeans some tenants areÌýÌýto leave their homes.

Princeton University is tracking eviction filings in 17 U.S. cities during the pandemic. As of Sept. 19, landlords in those cities have filed for more thanÌýÌýsince March 15. The tally includes about 11,900 in Houston, 10,900 in Phoenix and 4,100 in Milwaukee.

It’s an incomplete snapshot that excludes some major American cities such as Indianapolis, where local housing advocates said court cases are difficult to track, but landlords have sought to evict thousands of renters.

Children raised in unstable housing areÌýÌýhospitalization than those with stable housing. Homelessness is associated withÌý, and mothers in families that lose homes to evictionÌýÌýhigher rates of depression and other health challenges.

ÌýÌýillustrates that even theÌýthreatÌýof eviction can exact a physical and mental toll from tenants.

Nicole MacMillan, 38, lost her job managing vacation rentals in Fort Myers, Florida, in March when the pandemic shut down businesses. Later, she also lost the apartment where she had been living with her two children.

“I actually contacted a doctor, because I thought, mentally, I can’t handle this anymore,” MacMillan said. “I don’t know what I’m going to do or where I’m going to go. And maybe some medication can help me for a little bit.”

But the doctor she reached out to wasn’t accepting new patients.

With few options, MacMillan moved north to live with her grandparents in Grayslake, Illinois. Her children are staying with their fathers while she gets back on her feet. She recently started driving for Uber Eats in the Chicagoland area.

“I need a home for my kids again,” MacMillan said, fighting back tears. The pandemic “has ripped my whole life apart.”

Searching for Assistance to Stay at Home

That store window sign? It directed Pettigrew toÌý, a Milwaukee nonprofit that received $7 million in federal pandemic stimulus funds to help administer a local rental aid program. More than 3,800 applications for assistance have flooded the agency, said Deborah Heffner, its housing strategy director, while tens of thousands more applications have flowed to a separate agency administering Ìýin Milwaukee.

Persistence helped the Pettigrews break through the backlog.

“I blew their phone up,” said Stephanie Pettigrew, with a smile.

She qualifies for federal Social Security Disability Insurance, which sends her $400 to $900 in monthly assistance. That income has become increasingly vital since March when Robert left his motel job.

He has since pursued a host of odd jobs to keep food on the table — such as the window-washing he was doing when he saw the rental assistance sign — work where he can limit his exposure to the virus. He brings home $40 on a good day, he said, $10 on a bad one. Before they qualified for rent assistance, February had been the last time the Pettigrews could fully pay their $600 monthly rent bill.

Just as their finances tightened and their housing situation became less stable, the couple welcomed more family members. Heavenly, Robert’s adult daughter, arrived in May from St. Louis after the child care center where she worked shut down because of concerns over the coronavirus. She brought along her 3-year-old son.

Through its order, the CDC hopes to curtail evictions, which can add family members and friends to already stressed households. The federal order notes that “household contacts are estimated to be 6 times more likely to become infected by [a person with] COVID-19 than other close contacts.”

“That’s where that couch surfing issue comes up — people going from place to place every few nights, not trying to burden anybody in particular, but possibly at risk of spreading around the risk of coronavirus,” said Andrew Bradley of , a nonprofit focusing on community development.

The Pettigrews’ Milwaukee apartment — a kitchen, a front room, two bedrooms and one bathroom — is tight for the three generations now sharing it.

“But it’s our home,” Robert said. “We’ve got a roof over our head. I can’t complain.”

Housing Loss Hits Black and Latino Communities

A U.S. Census BureauÌýÌýconducted before the federal eviction moratorium was announced found that 5.5 million of American adults feared they were either somewhat or very likely to face eviction or foreclosure in the next two months.

State and local governments nationwide are offering a patchwork of help for those people.

In Massachusetts, the governor extended the state’s pause on evictions and foreclosures until Oct. 17. Landlords are challenging that move both in state and federal court, but both courts have let the ban stand while the lawsuits proceed.

“Access to stable housing is a crucial component of containing COVID-19 for every citizen of Massachusetts,” Judge Paul WilsonÌý. “The balance of harms and the public interest favor upholding the law to protect the public health and economic well-being of tenants and the public in general during this health and economic emergency.”

The cases from Massachusetts may offer a glimpse of how Ìýto the CDC order could play out.

By contrast, in Wisconsin, Gov. Tony Evers was one of the first governors to lift a state moratorium on evictions during the pandemic — thereby enabling about 8,000 eviction filings from late May to early September, according to a search of anÌýÌýof Wisconsin circuit courts.

Milwaukee, Wisconsin’s most populous city, has seen nearly half of those filings, which have largely hit the city’s , according to anÌýÌýanalysis.

In other states, housing advocates note similar disparities.

“Poor neighborhoods, neighborhoods of color, have higher rates of asthma and blood pressure — which, of course, are all health issues that the COVID pandemic is then being impacted by,” said Amy Nelson, executive director of the .

“This deadly virus is killing people disproportionately in Black and brown communities at alarming rates,” said Dee Ross, founder of the Indianapolis Tenants Rights Union. “And disproportionately, Black and brown people are the ones being evicted at the highest rate in Indiana.”

Across the country, officials at various levels of government have set aside millions in federal pandemic aid for housing assistance for struggling renters and homeowners. That includes $240 million earmarked inÌý, between state and county governments, $100 million inÌýÌýand $18 million inÌý.

In Wisconsin, residents report that a range ofÌýÌý— from application backlogs to onerous paperwork requirements — have limited their access to aid.

In Indiana, more thanÌýÌýfor that state’s $40 million rental assistance program before the application deadline. Marion County, home to Indianapolis, had a separate $25 million program, but it cut off applicationsÌýbecause of overwhelming demand.ÌýÌýpeople sat on the county’s waiting list in late August.

Of that massive need, Bradley, who works in economic development in Indiana, said: “We’re not confident that the people who need the help most even know about the program — that there’s been enough proactive outreach to get to the households that are most impacted.”

After Milwaukeean Robert Pettigrew saw that sign in the store window and reached out to the nonprofit Community Advocates, the group covered more than $4,700 of the Pettigrews’ rental payments, late charges, utility bills and court fees. The nonprofit also referred the couple to a pro-bono lawyer, who helped seal their eviction case — that means it can’t hurt the Pettigrews’ ability to rent in the future, and ensures the family will have housing at least through September. The CDC moratorium has added to that security.

The federal eviction moratorium, if it withstandsÌý, “buys critical time” for renters to find assistance through the year’s end, said , founding director of the Wake Forest Law Health Justice Clinic.

“It’s protecting 30 to 40 million adults and children from eviction and the downward spiral that it causes in long-term, poor health outcomes,” she said.

Doctor: Evictions Akin to ‘Toxic Exposure’

Megan Sandel, a pediatrician at Boston Medical Center, said at least a third of the 14,000 families with children that seek treatment at her medical center have fallen behind on their rent, a figure mirrored in .

Hospital officials worry that evictions during the pandemic will trigger a surge of homeless patients — and patients who lack homes are more challenging and expensive to treat. One Ìýfound that stable housing reduced Medicaid spending by 12% — and not because members stopped going to the doctor. Primary care use increased 20%, while more expensive emergency room visits dropped by 18%.

A year ago, Boston Medical Center and two area hospitalsÌýÌýin emergency housing assistance as community organizing focused on affordable housing policies and development. Now the hospitals are looking for additional emergency funds, trying to boost legal resources to prevent evictions and work more closely with public housing authorities andÌýÌýprograms.

“We are a safety-net hospital. We don’t have unlimited resources,” Sandel said. “But being able to avert an eviction is like avoiding a toxic exposure.”

Sandel said the real remedy for avoiding an eviction crisis is to offer Americans substantially more emergency rental assistance, along the lines of the $100 billion included in a package proposed by House Democrats in May and dubbed the . Boston Medical Center is among the 26 health care associations and systems that signed aÌýÌýurging congressional leaders to agree on rental and homeless assistance as well as a national moratorium on evictions for the entire pandemic.

“Without action from Congress, we are going to see a tsunami of evictions,” the letter stated, “and its fallout will directly impact the health care system and harm the health of families and individuals for years to come.”

Groups representing landlordsÌýÌýof rental assistance, too, although some oppose the CDC order. They point out that property owners must pay bills as well and may lose apartments where renters can’t or won’t pay.

In Milwaukee, Community Advocates is helping the Pettigrews look for a more affordable apartment. Robert Pettigrew continues attending doctors’ appointments for his lungs, searching for safe work. He looks to the future with a sense of resolve — and a request that no one pity his family.

“Life just kicks you in the butt sometimes,” he said. “But I’m the type of person — I’m gonna kick life’s ass back.”

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Ellingen, who lives with complications from cerebral palsy, had little choice but to do the same — moving back to her parents’ home in Fond du Lac.

Matt Ford, whose arms and legs are paralyzed, already lived with his 76-year-old father, his primary caregiver, in a specially designed house in Verona. One of Ford’s other caregivers moved into his basement for a while, since it was easier for her to quarantine there rather than come and go and risk infection and transmission of the virus to Ford.

Jason Endres asked his care workers to stay away from the home he shares with his wife Julie in Eau Claire. With masks hard to come by, Endres feared the caregivers could inadvertently spread the virus, possibly ravaging his lungs, which have been weakened by spina bifida.

The novel coronavirus, which has infected nearly 13,000 Wisconsinites, has exposed vulnerabilities in the state’s health care programs, including those designed to serve older residents and those with disabilities.

Before the pandemic, Gov. Tony Evers in 2019 a state task force to address a chronic shortage of caregivers. A released in February described a “crisis” in the direct care workforce, with 20,655 vacant positions in Wisconsin’s long-term care facilities and residential settings, and an average workforce vacancy rate of nearly 26%.

For residents with disabilities who need caregivers in order to live and work independently, the pandemic is adding hurdles. These visiting aides take on demanding duties and are typically paid in Wisconsin.

Clients with disabilities and their caregivers must weigh how to keep each other safe during close interactions, especially as protective equipment remains scarce. Some caregivers have stuck around; others have quit. And many clients who lose their caregivers also lose independence.

Every respondent to an April of nearly 500 Wisconsinites with disabilities and older adults said the pandemic had disrupted their caregiving service. Wisconsin Watch conducted a dozen interviews with people with disabilities, their family members and caregivers across Wisconsin, revealing how the crisis has transformed each life in unique ways.

Help Is Hard To Find

Stacy Ellingen has navigated life from a power wheelchair since she was a child. Cerebral palsy has also affected her fine motor skills: She uses an enlarged keyboard and eye-gaze system to operate her design firm, Design Wheels, from her apartment in Oshkosh, where she lived independently before the pandemic. That computer setup is a key component of the independent life Ellingen has fought for. Now that she’s living with her parents, she doesn’t have access to that tool — or lifestyle.

“I’m not able to do much work while I’m at my parents’,” Ellingen said. During an interview over Zoom, she used an app on her phone to speak aloud. Ellingen requested interview questions in advance so she would have adequate time to enter her responses in the app.

Ellingen, who is featured in a about assistive technology, said she could not survive long without caregivers to help her.

“Many times I’ve skipped meals, gone without using the restroom and slept in my wheelchair because I didn’t have a caregiver,” Ellingen said.

This is not the first time a lack of help has forced her to return to her parents’ home, but Ellingen worries the pandemic will wreak long-lasting damage to an already thin caregiving workforce.

A May of 504 providers of disability services conducted by the nonprofit Survival Coalition of Wisconsin Disability Organizations showed costs rising and revenues plunging across the industry. Nearly 20% of surveyed businesses were unsure whether they would survive the pandemic.

In an ideal world, Ellingen said, she would have six or seven caregivers to fill work shifts, but that hasn’t happened for years. Ellingen was down to just three care workers at the pandemic’s outset, including the two UW-Oshkosh students who have since left town.

University students typically make up at least half of Ellingen’s support staff; each rarely stays with her longer than a year.

Ellingen said life with her parents involves major and minor annoyances. She must go to bed when they do — much earlier than she would prefer — lest she be left with no one to lift her into bed. She also has to live with her parents’ music, television and food preferences.

Still, Ellingen feels lucky; if not for her parents, she would likely live in a nursing home. The long-term care sector has experienced at least and more than from COVID-19.

“That’s the last place anyone wants to be — especially during the pandemic,” Ellingen said.

Caregiver Makes Sacrifices

Matt Ford, 55, also recruits his caregivers mostly from a nearby college campus — the UW-Madison. He typically finds new hires near the end of the spring semester, but not this year because the pandemic sent students home early.

Paralyzed in a diving accident in 1987, Ford needs help getting in and out of bed, preparing meals, using the bathroom and driving. His father provides most of that assistance, and two or three additional workers take shifts at his home.

Ford posts his needs for paid caregivers on UW-Madison’s student job board, often using creative ways to draw attention.

“I just started putting in there: ‘Grass-fed, free-range quad needs help,'” Ford said with a chuckle. (“Quad” is short for “quadriplegic.”)

Grace Brunette noticed the listing in spring 2016, when she was a UW-Madison senior. She has worked for Ford on and off since then.

Brunette is now finishing her studies in a at the UW School of Medicine and Public Health. When the pandemic struck, she no longer felt comfortable splitting her time between her apartment and Ford’s house. She moved into Ford’s basement to minimize contact with outsiders, including her family. The basement was designed specifically to accommodate a live-in aide — a need that seems inevitable as Ford’s father ages.

After spending the entire first two weeks quarantining in Ford’s house, Brunette now stays over three nights a week. Why stay during the pandemic?

“He only has one other caregiver. That would be really selfish of me to just say, ‘Sayonara, I’m going to go quarantine with my family,’ when he needs the help,” Brunette said.

In May, the Wisconsin Supreme Court sided with Republican legislative leaders to strike down Democratic Gov. Tony Evers’ “Safer at Home” order. The decision made Ford bristle at the thought that Wisconsinites might begin to take the pandemic less seriously. In an amicus brief before the ruling, advocacy groups argued that if the order were lifted, there would be increased risks of coronavirus infection to older adults and to people with disabilities.

“It does feel a little personal that no one is recognizing the efforts that we made — as vulnerable people who need caregivers in and out of our homes — and the sacrifices that the caregivers made,” Ford said.

“I don’t want people to go out of business either,” Ford added, referencing the push to reopen the state. “I do care about them. I have some empathy toward that. But I also don’t want to die.”

Brunette is still working for Ford, but the public health crisis makes it unclear how long she will remain. She was set to start clinical rotations as part of her physician assistant training in June, which would have taken her out of town — making her unavailable to work with Ford. But when a planned trip to Belize with her classmates was canceled and her clinical rotations for school were moved online, she stayed on the job.

As of now, her next rotation is scheduled to begin in August. Someone will need to fill Brunette’s shifts during the fall. Ford said that is typically one of the hardest times to recruit student caregivers.

Mask Shortage Adds Hurdles

Like many people with disabilities in Wisconsin, both Ellingen and Ford serve as de facto employers for their caregivers, meaning they are responsible for providing personal protective gear. They each get two boxes of gloves every month, paid for by the state’s Medicaid program. But Ford said he is struggling to get gloves from his supplier because of the surging demand during the pandemic.

Masks are even tougher to find. A relative of Ellingen offered to sew some cloth face coverings for her workers. Ford finds masks at the doctor’s office, where he might sneak out one or two after routine appointments. His other source is a neighbor with a carpet-cleaning business. As businesses reopen across Wisconsin, advocates are for the state to prioritize caregivers as protective equipment is distributed.

Gov. Evers announced a grant program for health care providers, including caregivers, in late May. The lack of masks has not dramatically altered either Ford’s or Ellingen’s caregiving plans. It is a different story for Jason Endres and his wife, Julie in Eau Claire.

“It’s really one of the big reasons why we haven’t had anyone come into the home,” Endres said. Without a ready supply of masks, the couple feels uncomfortable inviting even familiar workers into their home, considering that many of them visit multiple clients or other work sites.

Endres, 45, has reason to be cautious. He has spina bifida-linked scoliosis. Endres had rods inserted into his back as a teenager, but his spine remained somewhat crooked — and that spinal curvature has weakened his lungs.

His wife, Julie, has cerebral palsy. Both use power wheelchairs in their ranch-style home, which was built to accommodate their needs. Their decision to keep caregivers away from the house has added challenges during the pandemic. Take the task of changing bedsheets, for example: While a worker might finish in a matter of minutes, it takes the couple more than an hour to complete that chore.

“She would do it once a week,” Jason Endres said of one of the workers who helps the couple. “We’re lucky if we do it twice a month.”

As the pandemic continues, uncertainty is eating Endres up inside: “Are we going to live in this limbo for the rest of our lives? Is that going to be changing for the better or for the worse?

“I agree that we need to get the economy going,” Endres added. “But safety’s got to be first.”

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Jordan, 39, is a breast-cancer survivor who is taking social distancing seriously, so she put on a mask before opening the door.ÌýA woman handed Jordan a paper and said: “You’ve been served.”

The paper was a court summons that said Froedtert Memorial Lutheran Hospital, Inc. was suing Jordan for $7,150. Just three weeks before, Jordan had paid off a different $5,000-plus Froedtert debt linked to a hysterectomy that her insurance did not cover.

A lawsuit was the last thing Jordan expected during a viral pandemic.

“This lady came to my door. She didn’t have a mask on. She didn’t have gloves. And she looked at me like I’m crazy because I had a mask across my face,” said Jordan, who lives in Milwaukee and works as a caregiver at an assisted living facility outside of the city. “I’m high-risk,” she said.

Life in Wisconsin, as in the rest of the country, has been transformed by COVID-19 in the past three weeks. Wisconsin declared a public health emergency on March 12, yet firms representing health systems in the state continued to sue patients over medical debt.

Jordan is one of at least 46 people sued by Froedtert in small claims court since March 12. Those cases are among at least 104 similar suits filed statewide by health systems over the same period, according to an analysis of small claims cases by Wisconsin Public Radio and Wisconsin Watch.

, a spokesman for the hospital, said Tuesday that Froedtert “suspended filing small claims suits” as of March 18 in response to COVID-19.

“In addition, we continue to work with patients related to financial counseling and are allowing patients with financial hardship who are on a payment plan to defer payments while financial assistance is discussed with them,” he said.

Yet court records at the time showed at least 18 lawsuits filed on the hospital’s behalf since then, including 15 filed on March 31 alone. (The suit against Jordan was filed on March 17; she was served on March 29.) Schooff did not explain the discrepancy. All 18 of those cases have since been dismissed.

‘Really? In The Middle Of All This?’

Court records show that at least six additional health systems have also sued patients during the pandemic.

UW Health in Madison has filed 19 lawsuits since March 12. Marshfield Clinic, which covers northern, central and western Wisconsin, has filed at least 14 since that date, followed by Bellin Health, based in Green Bay (11); La Crosse-based Gundersen Health System (10); and Aspirus Grand View Health System, which serves parts of northern Wisconsin (3). Froedtert South, which serves southeastern Wisconsin, also filed one suit.

Bellin chief operating officer and chief financial officer said Thursday the health system ceased legal actions on debt collection on March 18, and that the nine suits filed since then were “an error and we apologize for that.”

The five other systems contacted for this story said they have since paused certain legal actions, which court records support.

Tom Russell, a UW Health spokesman, said the health system instructed its legal agencies on March 26 “to cease pursuit of any legal activity.”

“These should be stopped for now,” he said.

Tom Duncan, vice president and chief operating officer for Froedtert South, said his system has generally “suspended filing small claim suits” during the pandemic. “However, in rare circumstances, certain small claim suits may be filed to preserve Froedtert South rights. For example: If a medical debt has been in existence for six years, and the statute of limitations is about to end.”

One Madison resident described being “mortified” when a process server knocked on her family’s door on March 28 to serve papers for a UW Health lawsuit over $1,135.90 in medical debt. UW Health filed that lawsuit before March 26. In a phone interview, the resident asked not to be named in this story because she was embarrassed by the debt related to her husband’s heart condition.

“I couldn’t believe someone would do that,” she said about receiving legal papers during a pandemic. “They’re our bills, but really? In the middle of all of this?”

The woman said her husband offered the process server sympathy, apologizing that the man had to serve papers during a public health emergency.

The woman, who works for a Madison-based nonprofit, saw things differently. “That’s a choice, too. I wouldn’t be able to sleep at night.”

Medical Debts And State Response

Some hospitalsÌýhave stopped the practiceÌýof suing patients in recent months following investigative reporting by Kaiser Health News, , and other outlets.

, an attorney with Legal Action of Wisconsin, which provides free legal services to low-income people, said medical bills often fall below things like rent, utilities and food in the “hierarchy of bills and obligations.” Most people facing hospital lawsuits are working and “underinsured,” with plans that leave them on the hook for thousands of dollars in health bills, Roulette said.

, executive director of ABC for Health, a nonprofit public-interest law firm in Madison, called it stressful under normal circumstances to face a medical debt lawsuit.

“Today it’s a whole new ballgame,” he said, referring to workers who have lost their jobs and possibly health insurance during the pandemic.

Peterson saw a possible disconnect between some hospitals’ recent decisions to stop suing and the law firms they’ve retained.

“Are the hospitals communicating their own policies internally? And are they communicating with their hired guns out there, making sure that they back off?” Peterson asked.

Paycheck To Paycheck

The state of Wisconsin considers Blanche Jordan, the Milwaukee caregiver, an “essential” worker during the pandemic, meaning her job is not subject to the “Safer At Home” order. She works five days each week at an assisted living facility from 7 a.m. to 3 p.m., alternating work on the weekends. The pay — $15.75 per hour — barely covers her expenses.

Rent, health insurance, utilities and the nearly $300 in garnishments by Froedtert that recently ended, left Jordan with little of her $1,300 biweekly paycheck to spend on other necessities. She filed for bankruptcy in 2016 when, despite being insured, she said she could no longer afford to pay off her debts from treating her aggressive breast cancer.

That journey briefly left her homeless following an eviction, but she generally manages to pay her current landlord on time, Jordan said.

“I’m blessed to have a landlord that’s understanding because his wife died of breast cancer,” she said.

Jordan said her most recent medical debt stemmed from a hysterectomy that was separate from but related to her cancer treatment. She chose Froedtert to perform the procedure, considering it “the best hospital that we have in Wisconsin.”

What she did not realize, she said: Froedtert did not accept her insurance, which she purchased on a federal exchange created by the Affordable Care Act. Hospital administrators accepted and ran her insurance card, Jordan said, but never mentioned that her insurer would not cover the procedure.

In 2019, a judge in the Milwaukee County Small Claims Commissioner Court awarded Froedtert a judgment against Jordan for aboutÌý$5,300, including court fees, which the hospital claimed by garnishment of her wages. She finished paying that debt during the first week of March — only to be served papers for the alleged $7,150 debt three weeks later.

Jordan assumes this covers the remainder of the bill for her hysterectomy, which she remembers totaling around $12,000. Wisconsin caps small claims at $10,000.

She will eventually see her day in court, although it’s not clear when. The coronavirus postponed her court date to May 28, assuming court proceedings resume by then.

Until then, Jordan will continue to take care of people at the assisted living facility, and she will otherwise stay isolated at home, she said, likely playing Scrabble or Uno with her family.

This story is part of a partnership that includesÌý,Ìý,ÌýÌýand Kaiser Health News.

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“He was in complete crisis because he was admitting to me that he had lost control of his use of opioids,” recalled Gatzke-Plamann.

The patient had used opioids for several years for what Gatzke-Plamann called “a very painful condition.” But a urine screening one week earlier had revealed heroin and morphine in his system as well. He denied any misuse that day. Now he was not only admitting it, but asking for help.

Gatzke-Plamann is the only full-time family physician in the central Wisconsin village of Necedah, population 916. She wanted to help but had no resources to offer. She and the patient started searching the Internet while still on the phone, trying to find somewhere nearby that could help with addiction treatment. No luck.

Here was a patient with a family and job who had spiraled into addiction because of doctor-prescribed pain pills, yet the community’s bare-bones health system left him on his own to find treatment — which he later did, 65 miles away. If that situation was going to change in Necedah, it was up to Gatzke-Plamann.

“That weekend I went home and I said, ‘I’ve got to do something different,'” she recalled.

In many ways, rural communities like Necedah have become the face of the nation’s opioid epidemic. Drug overdose deaths by population size in rural areas than in urban ones. Amid a Ìý in prescribing rates since 2012, rural doctors prescribe Rural Americans have fewer alternatives to treat their very real pain, and they disproportionately Ìýto effective addiction medication such as buprenorphine.

It used to be rare for primary care physicians outside big cities to take on the challenges of opioid misuse, according to Dr. , a professor of medicine at the University of Minnesota who researches chronic pain management. Now, Krebs said, it’s becoming increasingly common “out of necessity.”

“We just have a lot of people who need this kind of care, and they need it where they are,” Krebs said.

Both pain management and addiction treatment are specialties, calling for advanced training that many family physicians don’t have. Specialists tend to practice in larger towns and cities, said Dr. , speaker of the American Academy of Family Physicians Congress of Delegates, “so they’re not as accessible.”

For rural physicians, the burden of responding to the opioid epidemic falls squarely on their already loaded shoulders. And for Gatzke-Plamann, there was no question that she wanted to rise to the challenge.

Reducing Pain Pill Prescriptions

When Gatzke-Plamann came to Necedah in 2010, U.S. opioid prescriptions wereÌý. She estimates she inherited 25 to 30 patients with monthly opioid prescriptions. Soon she, like many of her peers , noticed a rise inÌýÌýandÌý.

Around 2012, she stopped taking on new patients using chronic opioid medications to focus on current opioid patients. She weaned many off opioids and tracked how many pills she prescribed for acute issues, like surgeries. Instead of defaulting to prescribing a month’s worth of pills for a patient who underwent a cesarean section, for example, she might prescribe only three to five pills.

“Most of the time those patients really only have that much pain for a couple of days,” Gatzke-Plamann said. “We don’t need to have those pain medications sitting in their medicine cabinets.”

Gatzke-Plamann helped shape her community’s wider discussion about opioids. That included joining the county’s substance abuse prevention coalition and educating her peers.

Today, the hospital Gatzke-Plamann is affiliated with sends her a monthly report of how many of her patients have opioid prescriptions. It varies each month, she said, but usually ranges from seven to 10.

Managing Chronic Pain Patients

For 62-year-old Necedah resident Michael Kruchten, the chronic pain he suffers stems from chemotherapy and radiation therapy treatments he received for lung cancer in 2011.

Kruchten is cancer-free now, but the treatments left him with permanent and severe nerve damage in his hands and feet.

“Sometimes it’s a burning — a continuous burning,” Kruchten said. “Sometimes it’s just like a sharp jolt of pain. And then sometimes it’s just pain, pain, pain.”

The pain was so bad he had to stop working at the ethanol plant in Necedah. Daily chores became challenging. The pain would keep him awake at night, leaving him pounding his pillow in frustration.

One reason there are more opioid prescriptions in the rural United States is that Americans living in those areasÌý. Rural communities skew older, meaning they disproportionately deal with painful conditions related to aging, such as arthritis. Injuries also appear to be more common in communities more dependent on physically demanding jobs, such as mining and logging.

For patients with chronic pain like Kruchten, Gatzke-Plamann tries to avoid prescribing opioids when she can, but alternatives are limited. ThoughÌý that physical therapy, exercise, psychotherapy or some combination of these techniques can help reduce the need for opioids, it’s not easy to get these treatments. The nearest physical therapy is in Mauston, a 17-mile drive south. Treatments such as cognitive therapy for pain require drives to Madison, Marshfield or La Crosse, each at least an hour away.

She first tried prescribing Kruchten two non-opioid medicines: gabapentin and then duloxetine. Neither helped enough. Eventually, she prescribed the opioid hydrocodone, finally allowing him to sleep.

“Without the sleep, I was a couch potato,” Kruchten said. “Once I started to get to sleep [at night], I got rid of my TV and the couch and started becoming more active.”

Agreements For Long-Term Opioid Patients

Gatzke-Plamann’s efforts to carefully manage opioid use with chronic pain patients is supported by other efforts in the community.

Around 2016, Mile Bluff Medical Center — the hospital in Mauston with which Gatzke-Plamann is affiliated — standardized a medication treatment agreement with patients, laying out rules for opioid prescriptions.

Patients such as Michael Kruchten must agree to stipulations before getting a new prescription. That includes getting pills from only one doctor and filling prescriptions at just one pharmacy while also submitting to random pill counts and urine screenings. Kruchten is something of a model patient in that regard, according to Gatzke-Plamann.

“You come in for appointments regularly and you’re always on time and you’re respectful with the staff,” she told him as they reviewed the contract at an appointment in November.

Gatzke-Plamann can stop prescribing opioids to patients who violate the agreement. But the contracts aim less to punish than to keep communication open. Reviewing the contract with a patient allows them to revisit the risks and warning signs of addiction.

On his recent visit, Kruchten told the doctor he took only one hydrocodone pill instead of his usual two the previous night, saying it was “satisfactory” in curbing the pain.

“And that’s good that you don’t take it to just put yourself to sleep,” Gatzke-Plamann said. “Because it’s not a sleep medicine. You understand that. We’ve talked about that one before.”

“Yep,” Kruchten agreed.

Addressing The Rural Addiction Treatment Gap

The Friday call for help in 2016 made Gatzke-Plamann realize Necedah was missing a crucial resource in solving the pain puzzle: addiction treatment.

“We don’t have as many resources here,” Gatzke-Plamann said of the surrounding Juneau County, one of the Ìýin the state. “When I see that there’s a need for something, it’s on me to do something about that.”

She said that’s why she decided to get the required training to prescribe the addiction medicine buprenorphine.

Research shows buprenorphine effectively treats addiction, but the medicine is particularly scarce in rural America. More thanÌý — more than one-fifth of the country’s rural population — live in counties without a single clinician licensed to prescribe the drug. (The rural-urban disparity in access has, however, shrunk since 2017.)

In Wisconsin, 18 of 72 counties lack a buprenorphine provider, and 14 of those unserved counties are rural.

Gatzke-Plamann is in Juneau County licensed to prescribe buprenorphine. The other is a physician assistant she supervises.

Catina Stoflet is among the buprenorphine patients who benefit.

Stoflet, 35, got addicted to prescription opioids as a 16-year-old in 2001, during theÌý. She started getting kidney stones in high school. She’s had many surgeries to remove the painful obstructions.

That first prescription was for Tylenol 3, a combination of acetaminophen and the opioid codeine. Doctors soon escalated her to stronger drugs: Vicodin, Percocet, oxycodone.

“It was right around the time that people didn’t know what [opioids were] doing to you,” Stoflet said.

Stoflet said she spent years in recovery beginning in 2007. But she relapsed in 2014, progressing to heroin and methamphetamine. Last year, she decided to quit for good. Stoflet said her primary care doctor introduced her to Gatzke-Plamann, who had recently begun prescribing buprenorphine.

Just like Gatzke-Plamann’s opioid patients, buprenorphine patients must sign contracts, agreeing to participate in a treatment program that includes counseling.

Stoflet works with a counselor and community recovery specialist at the Roche-A-Cri Recovery Center in Friendship, about 20 miles from Necedah. The center opened in September 2018. Without its additional resources, Gatzke-Plamann said, she would not feel comfortable prescribing buprenorphine.

“I am just one part of their treatment plan,” Gatzke-Plamann said. “They need the counseling. They need the psychosocial support. They need the group meetings.”

Doctors like Gatzke-Plamann have an important role to play in the opioid crisis by treating patients where they live, said Erin Krebs of the University of Minnesota. But, she added, funding models don’t always encourage this kind of work.

“I’m not sure we’ve done all we can do to really support small practices taking on this effort,” said Krebs. “There’s hope for people with opioid problems, and we have treatments that work. And so I think the more we can hear about clinicians who are tackling these problems in their own communities and having success the better.”

This story is part of a partnership that includes , , and Kaiser Health News.

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