“I just pray. That’s all I can do,” High said. “They expect people to ‘shelter in place,’ but I don’t have anywhere safe to go.”

Other Oklahomans have had to adapt, too. , so residents who can afford to do so build or purchase their own shelters. But High can’t afford the kind he would need — one that would allow him to quickly roll his motorized chair inside. And few others see this as a problem.

“One person told me, ‘Put on a football helmet and go into your kitchen,'” High recalled with a bitter smile. “I’ve got a window in every room of this house, so there’s really no place for me to go.”

He wasn’t always in this situation. High chose this rental house in 2008 because of its proximity to a public elementary school that was officially designated as a public shelter. From his driveway, High can see the school down the street. It would take four minutes for him to roll down a ramp, travel along the sidewalk and enter the school gym.

But access to most places that have served as public shelters in the past, including that gym, ended a few years ago after fire officials and others argued that the public shelters . Effectively, that change in policy left Oklahomans like High to fend for themselves.

The protective gold standard for people who live in tornado-prone regions is a storm shelter, also known as a safe room. They can be purchased at big-box hardware stores, or specialty companies can build concrete shelters. The structures range in price from a few thousand to tens of thousands of dollars, depending on the size and materials. The base model is a concrete room set into the ground, usually in a backyard. To get inside, people must climb down a ladder or steep set of stairs. Above-ground models that are wheelchair-accessible cost more.

High relies on federal disability payments for his income and said he simply can’t afford to pay for his own shelter.

“What bill am I going to not pay, to try to save up $3,800? I live day to day. Every month is really rough,” he said.

Towns started closing public shelters in Oklahoma a few years ago, to avoid the costs of making them tornado-safe. There was no mandate that municipalities keep them open. High said he thinks the federal or state government needs to step in and help people with disabilities acquire their own storm shelters.

“We’re [in] Tornado Alley. We’re known for it. Why aren’t they helping to protect us?” he said. “Instead it’s, ‘Well, just duck your head and go in your house.'”

Climate Change Is Making Storms Worse

Data collected and analyzed by the Center for Public Integrity found that between 2009 and 2018 Oklahoma had the highest number of major disaster declarations in the country: Those included severe storms, floods, fires, ice storms and tornadoes. According to the , many such weather-related hazards are expected to become worse and more frequent because of .

“If you’re able to install a safe room in your home, or on your property, we recommend that you do that,” said Keli Cain, a spokesperson for the Oklahoma Department of Emergency Management. “It’s the safest place that you can be during a storm.”

Oklahoma has no state laws requiring homeowners or landlords to install storm shelters. Instead, the safety structures are marketed as a desirable amenity in some new housing developments.

If a community wants to open a storm shelter for the public, that’s up to local officials, Cain said. “Community shelters are funded on their own, either through bond issues or other funding methods,” she said.

There also is no database that Oklahomans can consult showing where public or wheelchair-accessible shelters are located. “We don’t have a listing of the community shelters,” Cain said. “They don’t have to register it through the state or anything, unless it’s funded by a [federal] grant program.”

Oklahoma does offer a storm shelter rebate program, funded by the Federal Emergency Management Agency. Cain said the annual grant is enough to help about 50 households a year install storm shelters, with applicants getting up to $2,000 to help cover the cost. But the grants are allocated randomly through a lottery system that doesn’t take socioeconomic status into account — and it’s restricted to homeowners. Renters, like John High, can’t apply for the grants.

Cain blamed FEMA rules for that exclusion, acknowledging its impact on people with disabilities.

“There is no specific program to help people with disabilities get a storm shelter,” Cain said. “Some people might have to leave their homes a couple hours before the storm, and go to a place that is safe.”

Many FEMA programs doÌýs, and that has .

Americans With Disabilities Act Turns 30

In July 1990, President George H.W. Bush signed the into law. The ADA attempted to break down barriers by requiring businesses, schools and other organizations to take basic steps to accommodate a range of health challenges, including impairments of sight, sound and mobility.

“Fifteen percent of the population is over the age of 65,” said Marcie Roth, CEO of the . “Within the next 40 years, this will grow to 1 in 4 people in the United States. In an emergency, you can count on the fact that people with disabilities will be affected.”

The ADA has been modified over the years to include emergency preparedness, but the problem remains, bursting into public consciousness after major weather events like Superstorm Sandy, which hit New York and New Jersey in 2012, and Hurricane Harvey, which devastated the Texas and Louisiana Gulf Coast in 2017. In the aftermath of those storms, Roth said, people with disabilities were left without access to vital medicines and care; she blames poor disaster planning on both the state and local levels.

As a consequence of those storms, and the resulting backlash from many in the disability community over the lack of planning, the federal government sent the statesÌý in emergency situations. But the implementation of those directives has been haphazard, Roth said, as evidenced by the devastation caused by , a deadly Category 4 hurricane that ravaged Puerto Rico, the Virgin Islands and Dominica in 2017.

“Interruption of medical care and disability services was the primary cause of almost 3,000 deaths following Hurricane Maria,” Roth said. “Emergency planning needs to be inclusive of the whole community, and it needs to be equally accessible to everyone in the community.”

is a former official at the Department of Housing and Urban Development specializing in housing and disability rights, and helped write the guidance sent to states. Now a civil rights lawyer in Washington, D.C., Pratt thinks Oklahoma may be violating the ADA.

“The idea that we don’t have to serve people with disabilities who are renters is not consistent with federal law,” said Pratt.

Federal civil rights laws, including the Fair Housing Act and the ADA,Ìý for people with disabilities in all disaster programs, Pratt said, .

“The programs that are being offered to assist people who are sheltering in their homes should be available to both homeowners and renters if they have disabilities and have disability-related needs,” she said. “There has to be an opportunity for a person with a disability to shelter.”

More than , and the state doesn’t track how many of them lack storm shelters.

Request For Financial Assistance

John High said he’d like to see the public shelters reopened.

“Some people don’t even know the shelters are gone yet,” he said. “If you don’t need something, you don’t think about it until it’s necessary.”

If the shelters don’t reopen, High said, he’ll keep trying to get financial assistance to get an accessible storm shelter in his home. He plans to put it in the garage so he can easily drive his wheelchair in, but so far he’s encountered a web of regulations.

“Every time I hear the tornado siren, I fear — I fear for my life,” he said. “If a tornado comes through here, I’m going to be dead.”

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Oklahoma sought $17 billion, blaming Johnson & Johnson’s marketing practices for fueling the crisis that has claimed the lives of 6,000 people in the state.

It’s the first ruling to hold a pharmaceutical company responsible for one of theÌýin American history.

Judge Thad Balkman delivered his decision from the bench after presiding over an eight-week civil trial in the college town of Norman, Okla.

“Defendants caused an opioid crisis that is evidenced by increased rates of addiction, overdose deaths and neonatal abstinence syndrome in Oklahoma,” Balkman said in the ruling.

Johnson & Johnson immediately released a statement saying that the company “plans to appeal the opioid judgment in Oklahoma.”

Oklahoma Attorney General Mike Hunter’s suit alleged that Johnson & Johnson, through its pharmaceutical subsidiary Janssen, helped ignite a public health crisis that has killed thousands of state residents.

Balkman, in the ruling, said the state made its case that Johnson & Johnson contributed to the state’s opioid crisis.

“The opioid crisis is an imminent danger and menace to Oklahomans,” Balkman said. “The state met its burden,” proving the company acted improperly with its “misleading marketing and promotion of opioids.”

The case is being closely watched by plaintiffs in other opioid lawsuits, particularly the roughly 2,000 cases pending before a federal judge in Ohio.

Initially, Hunter’s lawsuit included Purdue Pharma, the maker of OxyContin. In March,ÌýÌýwith the state for $270 million, about $200 million of which will fund an addiction research and treatment center at Oklahoma State University in Tulsa. Soon afterward,Ìý, including fraud, against the two remaining defendants.

Just two days before the trial began, one of those two defendants, Teva Pharmaceuticals, based in Israel, announced an Ìýwith the state.

Both companies deny any wrongdoing.

Johnson & Johnson marketed the opioid painkillers Duragesic and Nucynta. Lawyers for the company say that its products were highly regulated by the Food and Drug Administration, among other agencies, and that the state did not provide any evidence showing that the company’s sales practices helped fuel the crisis.

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Oklahoma Attorney GeneralÌýÌýlawsuit alleges Johnson & Johnson and its subsidiary Ìýhelped ignite the opioid crisis with overly aggressive marketing, leading to thousands of overdose deaths over the past decade in Oklahoma alone.

The trial took place over seven weeks in the college town of Norman. Instead of a jury, a state judge heard the case.

During closing arguments Monday, Hunter called the company the “kingpin” of the opioid crisis.

“What is truly unprecedented here is the conduct of these defendants on embarking on a cunning, cynical and deceitful scheme to create the need for opioids,” Hunter said.

The state urged Judge Thad Balkman, who presided over the civil trial, to find Johnson & Johnson liable for creating a “public nuisance” and force the company to pay more than $17 billion over 30 years to abate the public health crisis in the state.

Driving the opioid crisis home has been a cornerstone of Oklahoma’s lawsuit. In closing arguments Monday, one of the state’s attorneys, Brad Beckworth, cited staggering prescribing statistics in the county where the trial took place.

“What we do have in Cleveland County is 135 prescription opioids for every adult,” Beckworth said. “Those didn’t get here from drug cartels. They got here from one cartel: the pharmaceutical industry cartel. And the kingpin of it all is Johnson & Johnson.”

Johnson & Johnson’s attorney Larry Ottaway, rejected that idea in his closing argument, saying the company’s products, which had included the fentanyl patch Duragesic and the opioid-based pill Nucynta, were minimally used in Oklahoma.

He scoffed at the idea that physicians in the state were convinced to unnecessarily prescribe opioids due to the company’s marketing tactics.

“The FDA label clearly set forth the risk of addiction, abuse and misuse that could lead to overdose and death. Don’t tell me that doctors weren’t aware of the risks,” Ottaway said.

Ottaway played video testimony from earlier in the trial, showing Oklahoma doctors who said they were not misled about the drugs’ risks before prescribing them.

“Only a company that believes its innocence would come in and defend itself against a state, but we take the challenge on because we believe we are right,” Ottaway argued.

Johnson & Johnson Fought On After Settlements

Initially, Hunter’s lawsuit included Purdue Pharma, the maker of OxyContin. In March,ÌýÌýwith the state for $270 million. Soon after, , including fraud, against the two remaining defendants.

Just two days before the trial began, another defendant, Teva Pharmaceuticals of Jerusalem, announced anÌýÌýwith the state. The money will be used for litigation costs and an undisclosed amount will be allocated “to abate the opioid crisis in Oklahoma,” according to a press release from Hunter’s office.

Both companies deny any wrongdoing.

The Legal Liability Of ‘Public Nuisance’

Most states and more than 1,600 local and tribal governments are suing drugmakers who manufactured various kinds of opioid medications, and drug distributors. They are trying to recoup billions of dollars spent addressing the human costs of opioid addiction.

“Everyone is looking to see what’s going to happen with this case, whether it is going to be tobacco all over again, or whether it’s going to go the way the litigation against the gun-makers went,” says University of Georgia law professorÌý.

But the legal strategy is complicated. Unlike the tobacco industry, from whichÌý, the makers ofÌýprescription opioids manufacture a product that serves a legitimate medical purpose and is prescribed by highly trained physicians — a point that Johnson & Johnson’s lawyers made numerous times during the trial.

Oklahoma’s legal team based its entire case on a claim of public nuisance, which refers to actions that harm members of the public, including injury to public health. Burch says each state has its own public nuisance statute, and Oklahoma’s is very broad.

“Johnson & Johnson, in some ways, is right to raise the question: If we’re going to apply public nuisance to us, under these circumstances, what are the limits?” Burch said. “If the judge or an appellate court sides with the state, they are going to have to write a very specific ruling on why public nuisance applies to this case.”

Burch said the challenge for Oklahoma has been to tie one opioid manufacturer to all of the harms caused by the ongoing public health crisis, which includes people struggling with addiction to prescription drugs, but also those harmed by illegal street opioids, such as heroin.

University of Kentucky law professorÌý agreed that it’s difficult to pin all the problems on just one company.

“Companies do unethical or immoral things all the time, but that doesn’t make it illegal,” Ausness said.

If the judge rules against Johnson & Johnson, Ausness said, it could compel other drug companies facing litigation to settle out of court. Conversely, a victory for the drug giant could embolden the industry in the other cases.

Earlier in the trial, the state’s expert witness, Dr. Andrew Kolodny, testified that Johnson & Johnson did more than push its own pills — until 2016, it also profited by manufacturing raw ingredients for opioids and then selling them to other companies, including Purdue, which makes Oxycontin.

“Purdue Pharma and the Sacklers have been stealing the spotlight, but Johnson & Johnson in some ways, has been even worse,” Kolodny testified.

Kolodny said that’s why the company downplayed to doctors the risks of opioids as a general class of drugs, knowing that almost any opioid prescription would benefit its bottom line.

The state’s case also focused on the role of drug sales representatives. Drue Diesselhorst was one of Johnson & Johnson’s busiest drug reps in Oklahoma. Records discussed during the trial showed she continued to call on Oklahoma doctors who had been disciplined by the state for overprescribing opioids. She even continued to meet with doctors who had patients who died from overdoses.

But Diesselhorst testified she didn’t know about the deaths, and no one ever instructed her to stop targeting those high-prescribing physicians.

“My job was to be a sales rep. My job was not to figure out the red flags,” she said on the witness stand.

The Role And Responsibility Of Doctors

Throughout the trial, Johnson & Johnson’s defense team avoided many of the broader accusations made by the state, instead focusing on the question of whether the specific opioids manufactured by the company could have caused Oklahoma’s high rates of addiction and deaths from overdose.

Johnson & Johnson’s lawyer, Larry Ottaway, argued the company’s opioid products had a smaller market share in the state compared to other pharmaceutical companies, and he stressed that the company made every effort when the drugs were tested to prevent abuse. He also pointed out that the sale of both the raw ingredients and prescription opioids themselves are heavily regulated.

“This is not a free market,” he said. “The supply is regulated by the government.”

Ottaway maintained the company was addressing the desperate medical need of people suffering from debilitating, chronic pain — using medicines regulated by the Food and Drug Administration and the Drug Enforcement Administration. Even Oklahoma purchases these drugs, for use in state health care services.

Next Steps

Judge Thad Balkman is expected to announce a verdict in August.

If the state’s claim prevails, Johnson & Johnson could, ultimately, have to spend billions of dollars in Oklahoma helping to ease the epidemic. State attorneys are asking that the company pay $17.5 billion over 30 years, to help abate the crisis in the state.

Balkman could choose to award the full amount, or just some portion of it, if he agrees with the state’s claim.

“You know, in some ways, I think it’s the right strategy to go for the $17 billion,” Burch, the law professor, said. “[The state is saying] look, the statute doesn’t limit it for us, so we’re going to ask for everything we possibly can.”

In the case of a loss, Johnson & Johnson is widely expected to appeal the verdict. If Oklahoma loses, the state will appeal, Attorney General Mike Hunter said Monday.

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Oklahoma Attorney General Mike Hunter’s suit alleges Johnson & Johnson, the nation’s largest drugmaker, helped ignite a public health crisis that has killed thousands of state residents.

With just two days to go before the trial, one of the remaining defendants, Teva Pharmaceutical Industries of Jerusalem, announced an with the state on Sunday. The money will be used for litigation costs and an undisclosed amount will be allocated “to abate the opioid crisis in Oklahoma,” according to a press release from Hunter’s office.

In its ownÌý, Teva said the settlement does not establish any wrongdoing on the part of the company, adding Teva “has not contributed to the abuse of opioids in Oklahoma in any way.”

That leaves Johnson & Johnson as the sole defendant.

Court filings accuse the company of overstating the benefits of opioids and understating their risks in marketing campaigns that duped doctors into prescribing the drugs for ailments not approved by regulators.

The bench trial — with a judge and no jury — is poised to be the first of its kind to play out in court.

, a professor at Stanford Law school, said lawyers in the other cases and the general public are eager to see what proof Hunter’s office offers the court.

“We’ll all be seeing what evidence is available, what evidence isn’t available and just how convincing that evidence is,” she said.

Most states and more than 1,600 local and tribal governments are suing drugmakers and distributors. They are trying to recoup billions of dollars spent on addressing the fallout tied to opioid addiction.

Initially, Hunter’s lawsuit included Purdue Pharma, the maker of OxyContin. In March,ÌýÌýwith the state for $270 million. Soon after,Ìý, including fraud, against the remaining defendants. Teva settled for $85 million in May, leaving Johnson & Johnson as the only opioid manufacturer willing to go to trial with the state.

But he still thinks the case is strong.

“We have looked at literally millions of documents, taken hundreds of depositions, and we are even more convinced that these companies are the proximate cause for the epidemic in our state and in our country,” Hunter said.

Precedent-Setting Case

The companies involved have a broad concern about what their liability might be, said University of Kentucky law professor Richard Ausness.

“This case will set a precedent,” he said. “If Oklahoma loses, of course they’ll appeal if they lose, but the defendants may have to reconsider their strategy.”

With hundreds of similar cases pending — especially a mammoth case pending in Ohio — Oklahoma’s strategy will be closely watched.

“And of course lurking in the background is the multi-state litigation in Cleveland, where there will ultimately be a settlement in all likelihood, but the size of the settlement and the terms of the settlement may be influenced by Oklahoma,” Ausness said.

‘There’s Nothing Wrong with Producing Opioids”

The legal case is complicated. Unlike tobacco, where , Ausness pointed out that opioids serve a medical purpose.

“There’s nothing wrong with producing opioids. It’s regulated and approved by the Federal Drug Administration, the sale is overseen by the Drug Enforcement Administration, so there’s a great deal of regulation in the production and distribution and sale of opioid products,” Ausness said. “They are useful products, so this is not a situation where the product is defective in some way.”

It’s an argument that has found some traction in court. Recently, a North Dakota judge dismissed all of that state’s claims against Purdue, a big court win for the company. In a written ruling that the state says it will appeal, Judge James Hill questioned the idea of blaming a company that makes a legal product for opioid-related deaths. “Purdue cannot control how doctors prescribe its products and it certainly cannot control how individual patients use and respond to its products,” the judge wrote, “regardless of any warning or instruction Purdue may give.”

Now the Oklahoma case rests entirely on a claim of public nuisance, which refers to actions that harm members of the public, including injury to public health.

“It’s sexy you know, ‘public nuisance’ makes it sound like the defendants are really bad,” Ausness said.

If the state’s claim prevails, Big Pharma could be forced to spend billions of dollars in Oklahoma helping ease the epidemic. “It doesn’t diminish the amount of damages we believe we’ll be able to justify to the judge,” Hunter said, estimating a final payout could run into the “billions of dollars.”

Hunter’s decision to go it alone and not join with a larger consolidated case could mean a quicker resolution for the state, Ausness said.

“Particularly when we’re talking about [attorneys general], who are politicians, who want to be able to tell the people, ‘Gee this is what I’ve done for you.’ They are not interested in waiting two or three years [for a settlement], they want it now,” he said. “Of course, the risk of that is you may lose.”

Looking For Treatment

Oklahoma has the second-highest uninsured rate in the nation and little money for public health. The state is trying to win money from the drug companies to pay for treatment for people like Greg, who is afraid he’ll lose his job if we use his last name.

Greg and his wife, Judy, said they haven’t been able to find the integrated treatment that Greg needs for both his opioid addiction and his bipolar disorder. It’s either one or the other.

“They don’t give you … a treatment plan for both,” Judy said. “They just say ‘Here, you can talk to this person.’ They don’t recognize that it’s like self-medicating.”

The couple live in Guthrie, Okla., about an hour north of the courthouse where the opioid trial will take place. Greg said he has been addicted to opioids for 11 years. People with prescriptions sell him their pills — sometimes Greg binges and takes 400 milligrams of morphine at once, a huge dose.

Of the $270 million Purdue settlement, $200 million is earmarked for an addiction research and treatment center in Tulsa, though no details have been released. An undisclosed amount of the $85 million Teva settlement will also go to abating the crisis. Judy said she hopes the treatment center will eventually help Greg.

“I wish he would stop using [opioids], but I love him. I’ll always be here,” she said.

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On Thursday, Ohio became the latest state toÌý. For a long time, Ohio Right to Life supported a more gradual approach to restrict the procedure and deemed what’s come to be called a “heartbeat bill” too radical — until this year. Restricting abortions after a fetal heartbeat can be detected basically bans the procedure after six weeks of gestation — before many women know they’re pregnant.

“We see the court as being much more favorable to pro-life legislation than it has been in a generation,” spokeswoman Jamieson Gordon said. “So we figured this would be a good time to pursue the heartbeat bill as the next step in our incremental approach to end abortion-on-demand.”

The Ohio law contains no exception for pregnancies that are the result of rape or incest; it does have an exception for the life of the mother.

Some say the rush to pass these bills is about lawmakers competing to get their particular state’s law before the Supreme Court. The state that helps overturn Roe v. Wade would go down in history.

More than 250 bills restricting abortions have been filed in 41 states this year, according to the Guttmacher Institute, a reproductive rights research and advocacy group.

“After the appointment of Justice [Brett] Kavanaugh, there really is just an environment in state legislatures to roll back abortion rights. And so we’re seeing these bans just fly through,” said , who monitors state laws at Guttmacher.

But the speed of passage of some of these laws masks divisions about strategy and commitment to the cause within the anti-abortion movement.

Tennessee Infighting Over ‘Heartbeat Bill’

In Tennessee, for instance, there’s a philosophical split between pragmatists and idealists.

A “heartbeat bill” in the state has had high-profile support, including from the Tennessee’s new governor. But the Republican attorney general such a law would be difficult to defend in court. And several Republicans, swayed by that logic, voted no for the legislation.

“This is an issue that is extremely important to me. It’s the reason I got into politics many years ago,” Republican state Rep. Bill Dunn said as the House approved the measure over his objection earlier this year. Dunn has said he wants to stop abortion, but that will require strategy. He pointed out that no heartbeat bill has ever been enforced. And recent laws in Iowa and Kentucky have been immediately blocked in court. The same is expected .

“No. 1, it’ll probably never save a life if we go by what’s happened in the past,” Dunn argued on the Tennessee House floor.

But it was money that ultimately stopped the heartbeat bill this year in Tennessee. (It stalled in committee last week, though the state’s Senate Judiciary Committee agreed to review the bill this summer.)

Senate Speaker Randy McNally, who also opposes abortion, said he has no interest in wasting tax dollars to make a point.

Even worse, in the view of Republicans who voted against the heartbeat bill, the state could end up paying the legal fees for groups that defend abortion.

“That is a big concern,” McNally said. “We don’t want to put money in their pockets.

The last time Tennessee had a case that went to the U.S. Supreme Court, it cost roughly $1.9 million. The experience was enough to give a few anti-abortion crusaders some pause. They voted last week with Democrats for a Ìýon a heartbeat bill, vowing to study the issue over the summer.

Name-Calling In Oklahoma

Even if it doesn’t result in a case that upends abortion law, heavily Republican legislatures like Oklahoma’s want to be ready.

“If Roe v. Wade ever gets overturned, we won’t be prepared,” Republican Senate Pro Tempore Greg Treat said while explaining his so-called trigger bill at a committee hearing in February.

Treat’s legislation,Ìý, would “trigger” a state ban on abortion and make it a felony if Roe were overturned. A handful of states, including Arkansas, Kentucky, Louisiana, Mississippi, North Dakota and South Dakota, already have trigger laws on the books.

Oklahoma has some of the strictest abortion laws in the nation, such as mandatory counseling and a 72-hour waiting period. But the most conservative anti-abortion activists in the state want more immediate action. So theyÌý and other self-described “pro-life” Republicans with protests, billboards and flyers, accusing them of not being anti-abortion enough.

“I’ve been called every name in the book these past few weeks,” Treat said. “I’ve had my Christianity questioned. I’ve had a member of my own caucus hold a press conference and call me a hypocrite.”

In response, Treat abandoned the trigger bill.

Now he’s trying something else — anÌýÌýthat would reinforce that nothing in Oklahoma law “secures or protects” the right to abortion. But that’s still not anti-abortion enough for some.

“It’s going to add on to that legacy that we have of death and just status quo pro-life policy that does nothing,” said Republican state Sen. Joseph Silk.

Not Far Enough In Georgia

In Georgia, a “heartbeat bill” passed the legislature, but has paused at Republican Gov. Brian Kemp’s desk. Supporters of abortion rights , of course, but some anti-abortion activists aren’t happy either.

“It really just does not go far enough in the protection of innocent human life,” said Georgia Right to Life executive director Zemmie Fleck. Fleck argued that certain exceptions in his state’s bill — for abortions after rape or incest if the woman makes a police report — weaken it.

Gov. Kemp has until May 12 to sign or veto the measure.

Cost As No Object In Kentucky

The American Civil Liberties Union in Kentucky sued the day after a “heartbeat bill” was signed into law by Republican Gov. Matt Bevin. But even during his annual speech to the Kentucky legislature in February, Bevin acknowledged his intent to challenge Roe v. Wade.

“Some of these will go all the way to the U.S. Supreme Court. But at the end of the day, we will prevail because we stand on the side of right and we stand on the side of life,” Bevin said.

Kentucky has become accustomed to defending abortion restrictions in court. Currently,ÌýÌýfor a doctor to perform a common abortion in the second trimester has been suspended indefinitely.

It is unclear how much it costs Kentucky to defend abortion laws that are immediately challenged. In an emailed statement, Bevin administration spokesman Woody Maglinger wrote that the state is using in-house lawyers, and hasn’t hired outside counsel. He declined to provide a cost estimate on hours spent on these cases.

“It is impossible to place a price tag on human lives,” Maglinger wrote.

Lisa Gillespie and Marlene Harris-Taylor contributed to this report.

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Además de enviar dinero extra a 48 condados principalmente urbanos, a Washington, DC y a San Juan, Puerto Rico, el se enfoca en siete estados donde la transmisión rural del VIH es especialmente alta.

Funcionarios de salud y médicos que tratan a pacientes con VIH en esos estados dicen que cualquier financiamiento adicional será bienvenido. Pero agregan que las estrategias que funcionan en ciudades progresistas como Seattle no necesariamente serían eficaces en áreas rurales de Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma y Carolina del Sur.

La estigmatización en torno al VIH y al SIDA, y a la homosexualidad, son profundas en partes de Oklahoma, dijo la , directora médica del del Centro de Ciencias de la Salud de la Universidad de Oklahoma, en Oklahoma City. El instituto es una de las dos clínicas de VIH financiadas con fondos federales; la otra está en Tulsa, la segunda ciudad más grande del estado.

El desafío de mantenerse anónimo

La clínica de Salvaggio tiene seis consultorios en donde se atienden pacientes por horas y horas. La clínica solía emplear a un administrador de casos en el condado rural de Woodward, a poco más de dos horas al noroeste de Oklahoma City.

Pero Salvaggio dijo que terminó siendo un desperdicio de dinero. “Tuvimos que eliminar esa posición, porque nadie iba a verlo”, dijo Salvaggio. “Porque en esa pequeña ciudad, las personas no querían que las vieran entrar a la oficina del administrador de casos de VIH. Y eso solo puede significar una cosa”.

En Oklahoma, como en gran parte de los Estados Unidos, los tienen el mayor riesgo de infección por VIH. Otros grupos con riesgo elevado en Oklahoma incluyen a los latinos, las mujeres heterosexuales y los nativos americanos.

Salvaggio aplaude el objetivo de terminar con las transmisiones de VIH dentro de 10 años, pero dijo que no cree que sea factible en Oklahoma. El plan no reconoce las formas particulares en que diferentes poblaciones experimentan la epidemia, apuntó.

Por ejemplo, los nativos americanos en Oklahoma no pueden contar con el anonimato que proporciona una clínica de salud grande.

“Cuando entran a una clínica del Servicio de Salud para Indígenas, es posible que vean a su primo detrás del escritorio y al cuñado de su primo trabajando en registros médicos, y al novio de su sobrina que trabaja en la farmacia”, dijo Salvaggio.

Incluso si los nativos americanos tienen acceso a la atención de VIH en la clínica, dijo, “literalmente tienen miedo de ser rechazados”.

Se necesitan servicios de apoyo social

La ciudad natal de Ky Humble es Afton, Oklahoma, que tenía unos 800 habitantes cuando era pequeño. Humble pertenece a la Nación Cherokee y fue criado como bautista. No recuerda haber aprendido nada sobre el VIH cuando estaba en la escuela.

“Incluso si lo hice, claramente no fue suficiente”, dijo Humble. “Sabía que era gay en la escuela secundaria; creo que habría prestado atención”.

Cuando le diagnosticaron VIH hace seis años, a los 21, Humble sintió que su vida estaba terminando.

“Sabía que eso era una cosa importante, [pero] era muy ignorante”, recordó. “Me faltaban dos semanas para graduarme de la universidad, se supone que debes estar en la cima del mundo. Pero yo sentía que estaba bajo una sentencia de muerte”.

Llamó a su madre de inmediato, y la mamá condujo inmediatamente a través del estado para acompañarlo.

“Nos sentamos juntos y lloramos durante seis horas seguidas”, dijo Humble. “Y luego, de hecho, salimos y compramos varios libros sobre el VIH y comenzamos a leerlos, para tratar de averiguar qué estaba pasando”.

Hoy, Humble está sano. y recibe tratamiento médico regular para mantenerse así. Ahora vive en Oklahoma City, pero su familia todavía vive en su ciudad natal. Dijo que algunas personas en Afton saben que tiene VIH, y otras no.

“Es como salir a la luz como diabético”, dijo Humble. “No necesariamente le digo a las personas que soy VIH positivo. Es solo una parte de lo que soy; no me define”.

Dijo que es cautelosamente optimista que el plan de la administración Trump pudiera significar más fondos para la prevención del VIH en Oklahoma. Pero Humble dijo que los habitantes de las zonas rurales del estado también necesitan acceso a “servicios integrales”, como bancos de alimentos, terapia de salud mental y asistencia para transporte, para ayudarlos a lidiar con la enfermedad.

“Tengo amigos que tienen VIH y viven en áreas rurales, y solo el hecho de tener que llegar a las citas médicas es todo un reto”, dijo.

La tasa de no asegurados de Oklahoma es la segunda más alta de los Estados Unidos.

Exactamente cuánto dinero recibirá el plan del presidente para el VIH depende del Congreso. Pero incluso los métodos económicos y comprobados para combatir el VIH, como la distribución de condones, pueden ser difíciles de lograr en un estado que .

Las charlas informativas sobre el VIH con adolescentes a menudo se convierten en una clase básica de salud para disipar mitos, explicó Andy Moore, administrador de la clínica del Instituto de Enfermedades Infecciosas de la Universidad de Oklahoma.

“Hemos tenido adolescentes que preguntan cosas como ‘He oído que, si te tomas una Mountain Dew después del sexo, eso mata el esperma'”, contó Moore. Ellos realmente quieren saber si eso es verdad. “Tenemos que retroceder y explicarles qué es el sexo, cómo se hacen los bebés, los diferentes tipos de sexo, antes que podamos enseñarles sobre la prevención del VIH”, dijo.

Moore agregó que otro problema en Oklahoma es que a las personas se les diagnostica VIH en estadios muy avanzados, cuando ya tienen, o están por desarrollar, SIDA.

“Lo que indica que no se hicieron la prueba hasta que vivieron con la enfermedad durante seis, ocho, diez años”, dijo Moore. “Tenemos una de las tasas más altas de pruebas tardías”.

Salvaggio dijo que miles de personas en todo Oklahoma tendrían que hacerse una prueba de VIH para alcanzar la meta de la administración Trump. Y Oklahoma tiene la segunda tasa más alta en la nación de personas sin cobertura de salud, después de Texas, lo que significa que muchos no tienen un médico de atención primaria, por no hablar de , que puede usarse para prevenir la infección por VIH.

También es bajo la Ley de Cuidado de Salud a Bajo Precio (ACA). Por lo tanto, incluso si más personas se hicieran la prueba del VIH, no sería fácil lograr que los que lo necesitan reciban tratamiento, dijo Salvaggio.

Apuntó que, además, la atención médica en Oklahoma carece de fondos suficientes, y no podría hacer frente a una afluencia repentina de nuevos pacientes. “No sé qué haríamos con todos esos nuevos pacientes”, dijo. “No tenemos instalaciones para atenderlos, y no tenemos proveedores”.

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In addition to sending extra money to 48 mainly urban counties, Washington, D.C., and San Juan, Puerto Rico,ÌýÌýtargets seven states where rural transmission of HIV is especially high.

Health officials and doctors treating patients with HIV in those states say any extra funding would be welcome. But they say strategies that work in progressive cities like Seattle won’t necessarily work in rural areas of Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma and South Carolina.

Stigma around HIV and AIDS and around being gay runs deep in parts of Oklahoma, said , medical director of theÌý at the University of Oklahoma Health Sciences Center in Oklahoma City. The institute is one of two federally funded HIV clinics in Oklahoma; the other is in Tulsa, the state’s second-largest city.

A Long Drive For Anonymity

Salvaggio’s clinic has six exam rooms where she sees patients, many of whom drive hours for treatment. The clinic used to employ a case manager in rural Woodward County, a little more than two hours’ drive northwest of Oklahoma City.

But Salvaggio said that ended up being a waste of money. “We had to let that position go, because nobody would go see her,” Salvaggio said. “Because they didn’t want to be seen walking into the HIV case manager’s office in that tiny town — that can only mean one thing.”

In Oklahoma, as in much of the U.S.,Ìý of HIV infection. Other groups with elevated risk in Oklahoma include Latinos, heterosexual women and Native Americans.

Salvaggio applauds the goal of ending HIV transmissions within 10 years but said she doesn’t think it’s feasible in Oklahoma. The plan fails to recognize the particular ways different populations experience the epidemic, she said.

Native Americans in Oklahoma, for example, can’t count on the anonymity of a large health clinic.

“When they go into an Indian Health Service clinic, it is possible that they will see their cousin behind the desk, and their cousin’s brother-in-law working in medical records, and their niece’s boyfriend working in the pharmacy,” Salvaggio said.

Even if Native Americans have access to HIV care at the clinic, she said, “they are literally in fear of being outed.”

Social Support Services Needed

Ky Humble’s hometown is Afton, Okla., which had a population of about 800 when he was growing up. He belongs to the Cherokee Nation and was raised a Southern Baptist. He doesn’t remember learning about HIV at all when he was in school.

“Even if I did, it clearly wasn’t enough,” Humble said. “I knew I was gay in middle school; I think I would have paid attention.”

When he was diagnosed with HIV six years ago, at age 21, Humble felt as if his life was ending.

“I knew that that was a thing, [but] I was very ignorant,” he recalled. “I was two weeks away from graduating from college — you’re supposed to be on top of the world. I thought it was a death sentence.”

He called his mom right away. She immediately drove across the state to be with him.

“We just sat there and cried for six hours straight,” Humble said. “And then we actually went [out] and bought several books on HIV, and just started reading them — to try to figure out what was going on.”

Today, Humble is healthy. HisÌý and he gets regular medical treatment to keep it that way. He now lives in Oklahoma City, but his family still lives in his hometown. He said some people back in Afton know he has HIV, and some don’t.

“It’s like coming out as diabetic,” Humble said. “I don’t necessarily tell people that I’m HIV-positive. It’s just part of who I am; it doesn’t define me.”

He said he is cautiously optimistic that the Trump administration’s plan could mean more funding for HIV prevention in Oklahoma. But rural Oklahomans, Humble said, also need access to “wraparound services” — such as food pantries, mental health therapy and transportation assistance — to help them deal with the disease.

“I have friends who have HIV and live in rural areas, and just getting to appointments is challenging,” he said.

Oklahoma’s Uninsured Rate Is Second-Highest In U.S.

Exactly how much money the president’s HIV plan will get is up to Congress. But even inexpensive, proven methods for fighting HIV — like distributing condoms — can be a tough sell in a state thatÌýcomprehensive sex education.

Informational HIV talks with teenagers often turn into a basic health class for dispelling myths, said Andy Moore, clinic administrator of the Infectious Diseases Institute at the University of Oklahoma.

“We’ve had teenagers write questions like ‘I’ve heard that if you douche with Mountain Dew after sex that it kills sperm,'” Moore said. They earnestly want to know if that’s true. “We have to back way up and explain what sex is, how babies are made, different types of sex — before we can teach them about HIV prevention,” he said.

Another issue in Oklahoma, Moore said, is that people aren’t getting diagnosed with HIV until they’re already sick because of AIDS, or close to that point.

“Which indicates that they didn’t get tested until they had been living with the disease for six, eight, 10 years,” Moore said. “We have one of the highest rates of late testing.”

Salvaggio said thousands of people across Oklahoma would need to be tested for HIV to reach the administration’s goal. And Oklahoma has the second-highest uninsured rate in the nation after Texas — meaning many people don’t have a primary care doctor, let alone , which can be used to prevent HIV infection.

It’s also one ofÌý under the Affordable Care Act. So, even if more people were tested for HIV, getting those who need it into treatment wouldn’t be easy, Salvaggio said.

Health care in Oklahoma is underfunded, she said, and couldn’t cope with a sudden influx of new patients. “I don’t know what we’d do with all those new patients,” she said. “We don’t have a facility to see them in, and we don’t have [the] providers.”

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

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In the ongoing, crowdsourced “Bill of the Month” investigation, Kaiser Health News and NPR received more than a dozen bills from people around the country on the hook for medevac helicopter rides that ranged from $28,000 to $97,000.

What gives? Why should a lifesaving flight come with a life-altering bill?

If an air ambulance service is not part of a patient’s insurance network, the operator can charge the patient for the portion of the bill the insurance company won’t cover — meaning the patient is on the hook for the undiscounted rate that the air carrier decides to charge.

“There’s nothing really they can turn to because of this regulatory blind spot, essentially, that air ambulances fall into,” said Erin Fuse Brown, an who specializes in health care billing. “There’s nothing that would protect them, that would allow them to push back on the extraordinary charges that they are billed when they get home from the hospital.”

This happens because the federal government treats air ambulance companies more like air carriers — like Southwest or American Airlines — than like hospitals or clinics. They are regulated by the Federal Aviation Administration. By law, states cannot set rules for them. That has meant they haven’t been required to participate in insurance networks, their prices are not capped, and they can charge patients the balance of the bills even after insurance has paid.

Congress now is hashing out its FAA reauthorization bill. The House passed an earlier version of the bill in May that would have allowed states to regulate air ambulances, including pricing and some billing practices. That provision was dropped from a that is expected to pass.

Some consumer protections remain in the . An aviation consumer advocate with the Department of Transportation would be responsible for handling patient complaints and could pursue enforcement or “corrective action” against unfair or deceptive practices, including air ambulance operators.

The Deregulation Game

Air ambulances were in their infancy when air travel was in the 1970s. Since then, the air ambulance sector has had little oversight, especially of the positioning of bases. That has led to vast deserts of coverage and other areas, like on the Oklahoma border, with a saturated market and multiple carriers.

With no cap on pricing and high fixed costs, such as helicopters and trained personnel ready to fly at a moment’s notice, Greg Hildenbrand, executive director of Life Star of Kansas, a nonprofit air ambulance service and secretary of the , said increased competition has driven prices up, instead of down.

“The numbers of patients per helicopter has dropped, but we still have to spread the same costs per base over fewer numbers of patients, and so that has driven costs up considerably,” he said.

The rise in price is dramatic. Take Air Methods, the nation’s largest air ambulance company, whose pricing greatly influences the market. Its average helicopter transport costs increased from $13,000 in 2007 to $49,800 in 2016, according to a .

Because air ambulance providers accept much lower reimbursement rates from Medicare and Medicaid patients — and may not receive any payment from uninsured patients — the impact of these rate hikes has fallen almost entirely on private health care insurers and their members.

Hildenbrand, a 20-year veteran of the industry, said insurance companies are fed up.

“I think we’ve reached a tipping point in the industry where insurance companies are saying, ‘No, we’re not going to continue to pay these rates,’ and so then patients get balance-billed $40,000 or something after their insurance has paid. I don’t think it’s a sustainable system,” he said.

As billed charges have soared, more insurers have started limiting their reimbursements to air medical providers. Air Methods has responded by hiring patient advocates who go through the appeals process with the insurance company. Ultimately, if the insurance company won’t pay, the patient is on the hook.

The House-Senate compromise bill would also set up a council of industry representatives, led by the Department of Transportation, which oversees air ambulances. The group would include air ambulance providers and insurance company representatives, among others, and would write and re-evaluate consumer protections, including balance-billing practices. The legislation also establishes a complaint hotline for patients, similar to one available for commercial airline passengers.

It’s a step in the right direction, said Fuse Brown of Georgia State University, but the regulatory council might not go far enough.

“The task of the committee would be to come up with additional consumer protections that haven’t been specified in the bill,” she said. “It’s unclear at this point whether the committee would come up with protections that would substantively provide consumer protections.”

This story is part of a reporting partnership between , and Kaiser Health News.

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The Oklahoma agency in charge of substance abuse has been told by the state’s legislature to cut more than $2 million from this fiscal year’s budget.

“Treatment dollars are scarce,” saidÌý, president of the Oklahoma Behavioral Health Association, which represents addiction treatment providers.

It’s like dominoes, Tate said. When you cut funding for treatment, other safety-net programs feel the strain.

“Any cuts to our overall contract,” he said, “really diminish our ability to provide the case management necessary to advocate for homes, food, shelter, clothing, primary health care and all the other things that someone needs to really be successful at tackling their addiction.”

In just three years, Oklahoma’s agency in charge of funding opioid treatment has seen more than $27 million dollars chipped away from its budget — thanks to legislative gridlock,ÌýÌýand a drop in oil prices (with the additional loss in state tax revenue that resulted).

Jeff Dismukes, a spokesman for Oklahoma’s Department of Mental Health and Substance Abuse Services, says the already lean agency has few cost-cutting options left.

“We always cut first to administration,” he said, “but there’s a point where you just can’t cut anymore.”

The agency may end up putting off payments to treatment providers until July — the next fiscal year. Tate says that could be devastating.

“Very thinly financed, small rural providers are probably at risk of going out of business entirely — up to and including rural hospitals,” he said.

Getting treatment providers to open up shop in rural areas is really hard, even in good times, and more financial uncertainty could make that problem worse. In the meantime, according to an Oklahoma state commission’sÌý,Ìýjust 10 percent of Oklahomans who need addiction treatment are getting it.

That statistic is similar in Colorado. And as 2018 began, Colorado’s escalating opioid crisis got worse, when the state’s largest drug and alcohol treatment provider, Arapahoe House,Ìý.

The facility provided recovery treatment to 5,000 people a year. Denise Vincioni, who directs another treatment center, the Denver Recovery Group, says other facilities have scrambled to pick up the patients.

Most of Arapahoe’s clients were on Medicaid. Autumn Haggard-Wolfe, a two-time Arapahoe House client who is now in recovery, worries the facility’s closing will have dire consequences, especially for people who need inpatient care, as she did.

“I feel like the only other option right now in therapy would be jail for people,” she said, “and people die in there from withdrawing.”

Arapahoe House’s CEO blamed its closure on the high cost of care and poor government reimbursement for services.

The mother of Colorado state lawmakerÌýÌýstruggled with addiction, and was treated at Arapahoe House. Pettersen says treatment centers rely on a crazy quilt of funding sources and are chronically underfunded — often leaving people with no treatment options.

“We have a huge gap in Colorado,” Pettersen said, “and that was before Arapahoe House closed.”

She isÌýÌýin the state to increase funding for treatment. But to get tens of millions of dollars in federal matching funds, Colorado lawmakers need to approve at least $34 million a year in new state spending.

That price tag may simply be too high for some lawmakers. But either way, she added, “It’s going to take a lot to climb out of where we are.”

Colorado did get new federal funds to fight theÌýÌýthrough the 21st Century Cures Act, passed in December of 2016, but it was just $7.8 million a year for two years — divvied up among a long list of programs.

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

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).