The was mandated by the Affordable Care Act. The health law required hospitals that meet federal tax standards to be nonprofits to perform a community health needs assessment (CHNA) every three years, followed by implementing a strategy to deal with issues confronting the community, such as preventing violence or lowering the rates of diabetes.

A in the journal Health Affairs shows spending in these areas has remained relatively stagnant.

The research showed average spending by tax-exempt hospitals on community benefits in 2010 was 7.6 percent of total operating costs and bumped to 8.1 percent by 2014. But the bulk of that spending goes toward unreimbursed patient care, such as charity care. The ACA was trying to spur more spending on broader community initiatives, which have remained below 1 percent of operating costs at the hospitals.

“This is not easy for hospitals to do,” said Gary Young, the study’s lead author and director of the Center for Health Policy and Healthcare Research at Northeastern University in Boston. “By tradition, by the nature of their resources, hospitals have not been oriented to prevention, they’ve been oriented to treatment.”

New efforts by the Republican-led Congress may complicate the effort. The repeal last month of the ACA’s penalties for most people who don’t have health insurance has some experts questioning how some of these hospitals will be able to spend more on community benefits. The Congressional Budget Office has estimated that because of that change about 13 million people would give up their coverage by 2027, which could drive up costs for hospitals because there would be more uninsured patients.

“Anything that destabilizes the system and takes money out of the hospitals’ revenue stream is going to negatively impact them,” said Gregory Tung, assistant professor at the University of Colorado’s School of Public Health. “It’s tough for hospitals to be navigating that uncertainty.”

Jill Horwitz, professor of law at UCLA who specializes in health issues, said hospitals have trouble planning community efforts when they are unsure of their finances.

“It’s a very difficult context in which to operate a stable system,” Horwitz said. “One day to the next, it’s hard to know what the rules are, what the reimbursement is going to be and what kind of insurance your patients will have.”

More than half of the hospitals in the United States are private, nonprofit organizations that are tax-exempt.

Lawrence Massa, president & CEO of the Minnesota Hospital Association, said the repeal of the ACA’s individual mandate penalties will change hospitals’ calculations.

“We certainly expect to see our uninsured rate go up as a result of repealing the individual mandate,” he said, “so that’s going to have an opposite type of effect of where we thought the trend was going to be because we changed the rules in the middle of the game.”

But it’s too early to tell how hospitals will respond, according to Massa. Many are still grappling with the new requirements.

The ACA was enacted in 2010, but the provision requiring community-based action did not come into effect until the end of March 2012, and enrollment in ACA marketplace plans didn’t begin until 2014. Hospitals began early investments for assembling the needs assessments in 2011 and 2012, Massa said.

“In the later years, they’ll be using that data and comparing and reporting to the IRS how they’ve changed their community benefits spending as a result of those community health needs assessments,” he said. “If everything stayed the way it was, I think we would know by 2020 whether this had the kind of impact that was anticipated.”

Young and his research colleagues acknowledged in their study that “certainly, more time is needed” to assess the full impact of the law’s requirements on spending for community benefits.

Nonetheless, Young said, many hospitals lack the means to provide greater preventive care in the community.

They don’t have the necessary infrastructure, “the personnel or the knowledge to develop those strategies,” he said. “They don’t have the resources to necessarily invest in those areas.”

Horwitz agreed. “If we’re going to require this high level of spending on community benefits and paying for patients who can’t afford care, something else has to give,” she said.

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Nelson, 29, needs treatment for bipolar disorder, depression and anxiety. But she does not drive, so she must use a van service to keep her appointments. It makes numerous stops along the highway, picking up other travelers, and usually doesn’t return to her home in New Richmond, W.Va., until day’s end.

“I’ll call and tell them I’m ready [after my appointment ends], but they tell me they’re waiting for someone else,” Nelson said as she described a typical trip.

Also in August, by the Appalachian Regional Commission highlighted the area’s high mortality rates in seven of the nation’s leading causes of death — including suicide. It also showed the region has fewer health care professionals compared with the rest of the country, specifically mental health care providers.

The lack of sufficient mental health care access contributes to other health issues, such as chronic pain, substance abuse, nicotine-related diseases and more, Bailey said.

She said some cases make her nervous about whether she has the background to provide sufficient care. One of those is depression in adolescents. She said she prescribed one patient the antidepressant Prozac but fears that a bad reaction to the drug led the teen to attempt suicide.

Since that episode, “it makes me more nervous,” Bailey said. “But you know, at this point, I’m a month out of being able to get people in [to see a psychiatrist], unless I’m sending somebody to the hospital.”

The lack of mental health care professionals, specifically psychiatrists, is also an effect of Appalachia’s suffering economy, Butcher-Winfree said.

Most of the patients whom Bailey and Butcher-Winfree treat are insured by Medicare or Medicaid. The poverty level in Wyoming and McDowell counties is about 23 percent and 35 percent, respectively, according to 2015 figures from the Census Bureau.

The practice is a . It offers a sliding fee scale based on the patient’s ability to pay for those who live at or below the federal poverty level and receives federal subsidies for providing care to an underserved area. That funding is pivotal in helping to keep the practice financially viable, Butcher-Winfree said.

“For a private practice, it would be absolutely impossible to make a living and reimburse student debt,” she said.

She added that the rural location deters doctors as well. Butcher-Winfree drives an hour and a half each day from her home in Mercer County to the clinic.

One resource Bailey said will soon help is the Extension for Community Healthcare Outcomes (ECHO) program through West Virginia University. Specialists at the college are available for rural health care providers to consult on cases.

Bailey participates in the ECHO programs on hepatitis C and chronic pain. Soon she will be in a psychiatry program as well.

She said she presents patients’ cases to the hub participants, who in turn make suggestions for her.

“We can implement the care they would be receiving at a specialty center,” Bailey said. “That has helped drastically. But it’s still not quite enough yet.”

Update: This story was updated on Oct. 23 to add information about a telemedicine program that provides mental health support for some school children. 

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“There just aren’t any quality surgeons or specialists in our area,” Willhite said, when explaining why she went to a doctor in Laurel, Md.

Getting health care is a common problem for the residents of Hillsboro, a tiny hamlet in the middle of Appalachia with a population of just under 250 residents.

And the Appalachian region is in dire need of health care. This section of the U.S., long acknowledged to be among the most economically disadvantaged in the country, is showing a growing gap in health outcomes with the rest of the United States.

A  in the journal Health Affairs found disparities widening sharply between Appalachia and the rest of the country, driven by higher rates of infant mortality, smoking, obesity and early deaths from motor vehicle accidents and drug overdoses.

“Although life expectancy increased everywhere in the United States between 1990 and 2013, less rapid declines in mortality and slower gains in life expectancy among people in Appalachia have led to a widening health gap,” the study said.

The study focused on the 428 counties within the 13 states that . Gopal Singh, an author of the study and a senior health equity adviser at the Health Resources and Services Administration, found that counties with high rates of poverty have the highest infant mortality rate and lowest life expectancy. These areas are seen mostly in central and southern Appalachia.

The researchers found Appalachia lagged behind the rest of the country on health measures in the early 1990s — but only slightly. Infant mortality rates were not statistically different. And life expectancy was about 75 years — just 0.6 years shorter than that outside of the region.

But when the researchers analyzed data from 2009 to 2013, they found the infant mortality rate for Appalachia to be 16 percent higher than the rest of the country and the difference in life expectancy was 2.4 years.

When researchers examined specific demographic groups, some of the disparities were much greater. For instance, they noted a 13-year gap in life expectancy between black men in high-poverty areas of Appalachia (age 70.4) and white women in low-poverty areas elsewhere in the country (83).

According to the study, the association between poverty and life expectancy was stronger in Appalachia than the rest of the country.

“You do see a more rapid improvement in the rest of the country compared to Appalachia, but there are specific reasons why Appalachia I guess continues to fall behind,” said Singh, the lead author.

The study points to specific health problems, including lack of access to doctors and other providers, high rates of preterm births and low-weight births, and high rates of smoking-related diseases, such as lung cancer, chronic obstructive pulmonary disease and heart disease.

“Smoking-related diseases accounted for more than half of the life-expectancy gap between Appalachia and the rest of the country,” the study said.

Dr. Joanna Bailey treats some of Appalachia’s patients every day as a family medicine physician in Wyoming County, W.Va. She grew up there and said the lifestyle plays a large role in health outcomes. “I treat a lot of diabetes; I see a lot of high blood pressure; I see a lot of heart disease. I see a lot of obesity, because it is a place where it has been normalized quite a bit.”

“I think that the culture is such that getting those conditions under control is difficult for many reasons,” Bailey said.

The economic issues compound the situation, she said.

“There’s the problem of poverty,” she added. “A lot of people are on disability and they rely on food stamps to get their food for the month.” Many of Bailey’s patients pay someone to drive them to the grocery store. She said it’s difficult to coach them to buy healthful groceries when the food is good only for a few days.

“By the end of the month, they are back to eating cereal and Hamburger Helper,” Bailey said.

She thinks the widening health gap in recent years has accelerated with an increasing number of young people leaving the area for job opportunities.

“We’re left with an older, sicker population who can’t work or don’t work, and those people are notoriously sicker,” Bailey said.

Both Bailey and Singh agree that addressing the health gap requires socioeconomic change. The communities need better higher-education opportunities and infrastructure improvements, such as improved roadways so patients can more easily get to larger towns and cities to access health care.

Until then, Willhite and her family will continue to drive hours for care, such as the foot doctor in Laurel, whom she had consulted when she lived in Maryland.

“There are just absolutely so many (health) issues here in this region, you can’t begin to put your finger on one,” Willhite said. “It’s like a big vicious circle.”

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That was the day he realized he was addicted to opioids.

Hampton, now 36 and living in Los Angeles, said the prescription for his pain medication had run out and he didn’t realize he would face withdrawal problems.

“I hadn’t made this connection yet because I really didn’t know what was going on with my body,” he recalled of that day in 2004. His doctors, he said, never discussed possible side effects of the drugs they prescribed for him after he broke his ankle the year before, nor did they offer a plan to wean him off the drugs. He described his doctors’ prescribing behavior as “increase, increase, increase.”

Frightened and unable to kick his habit, he turned to heroin before finally getting treatment and dealing with his addiction.

Hampton’s experience is all too familiar for many people prescribed opioids for pain. But federal researchers reported Thursday they are seeing an important change in the trend lines for these potent drugs.

The amount of opioids prescribed in the United States peaked in 2010 and has been declining gradually since then as public health and law enforcement officials raised alarms about growing numbers of overdoses and offered new guidance to doctors about dispensing the drugs, according to .

Still, the amount in 2015 is three times higher than at the turn of the century, they said.

The study analyzed morphine milligram equivalents (MME) per capita and found that the metric — which accounts for differences in opioid drug type and strength — reached 782 MME in 2010 and fell to 640 MME in 2015.

The report, which analyzes prescription data from 2006 to 2015, also shows the wide disparities in opioid use across counties in the U.S.: Six times more opioids per resident were dispensed in the highest-prescribing counties than in the lowest-prescribing counties. The researchers found that the hardest-hit areas were non-urban counties with larger percentages of white residents, high numbers of diabetes and arthritis patients and high unemployment and Medicaid rates.

For instance, a CDC map showing prescription rates per person revealed that rates in California’s more rural and less populated northern counties dwarfed those in almost all other parts of the state.

“The amount of opioids prescribed in the U.S. is still too high, with too many opioid prescriptions for too many days at too high a dosage,” said the CDC’s acting director, Dr. Anne Schuchat.

Researchers said they did not yet have data for 2016 or 2017.

Among the significant findings, researchers said, was that the number of days an opioid prescription was supposed to last increased 33 percent in recent years. In 2006, the average supply was about 13 days, while in 2015 it was nearly 18.

According to the report, the decrease in opioid use may be related to publication of national guidelines in 2008 and 2010 that drew attention to increased dangers of high-dosage opioids. Prescription rates began to drop after that, which “might reflect growing awareness among clinicians and patients of the risks associated with opioids.”

Still, the variations in prescription practices across the country suggest better guidance is needed, the researchers wrote.

While the research shows progress, opioids are still being massively over-prescribed, said Dr. Andrew Kolodny, co-director of opioid policy research at the Heller School for Social Policy and Management at Brandeis University.

“Opioid prescribing has not come down that much,” Kolodny said. “We are just now beginning to see intervention.”

The study pointed out that efforts by Ohio, Kentucky and Florida to more closely regulate opioid prescriptions have helped drive down use.

Nationally, however, overdose death rates continue to climb, the study noted.

“Health care providers have an important role in offering safer and more effective pain management while reducing risks of opioid addiction and overdose.” Schuchat said.

Greg Williams, co-founder of Facing Addiction, agreed. Williams supports making education for providers mandatory, to ensure appropriate prescribing. And he said it is necessary for physicians to talk about addiction as a possible side effect with their patients.

This was something never done in Hampton’s case.

“The report is showing us that we have made very little progress,” Kolodny said. “We still have a very long way to go.”

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People with mental health disorders represent 16 percent of the U.S. population.

The findings are worrisome, the researchers reported. They had expected that physicians were more conservative in prescribing these painkillers to people with mental illness.

“We are prescribing way too much opioids,” said Dr. Brian Sites, an anesthesiologist at Dartmouth-Hitchcock Medical Center in New Hampshire and one of the study’s researchers. “And that prescription behavior is resulting in significant morbidity in the country.”

“Because patients with mental health disorders are a vulnerable population, [they’re] probably more likely to develop addiction and abuse,” he added. Sites suggested that physicians consider using different criteria when prescribing opioids for people with mental illness.

“The opioids are prescribed primarily for pain,” but patients with mental illness find that the drugs alleviate their mental issues too, said Dr. Edwin Salsitz, an attending physician in the Division of Chemical Dependency of Mount Sinai Beth Israel Medical Center in New York who was not involved in the study. And this, he said, is what can lead to long-term use.

The study, published in the Journal of the American Board of Family Medicine, found that nearly 19 percent of Americans with a mental health illness use prescription opioids, while the same is true for only 5 percent of those without a mental health condition.

According to the federal Centers for Disease Control and Prevention, the from 1999 to 2015, yet the amount of pain adults experience remained the same. In addition to that, more than 183,000 people died from overdoses related to prescription opioid use during this time.

With no objective scale for measuring pain, doctors are hampered in treating patients with chronic discomfort.

“Since [pain is] a subjective phenomenon, it’s very difficult to measure those things and to treat because some patients [report] 10-out-of-10 pain forever,” Sites said.

Dr. Andrew Saxon, director of the Addiction Psychiatry Residency Program at the University of Washington, said that “most people with chronic pain who end up on opioids do have a co-occurring psychiatric disorder.” Yet too often the drugs don’t provide lasting relief, he said.

“We have found that opioids for most of these people in the long term improve their subjective sense of pain for a little bit, but they don’t usually improve people’s level of function,” said Saxon, who was not involved in this study.

Many opioid patients, and especially those with mental health issues, should be offered an alternative treatment, said Saxon, who also is chairman of the American Psychiatric Association’s council on addiction.

“It actually turns out … that the best treatment for chronic pain is going to be behavioral interventions, not medications,” he explained. That involves teaching people to understand the underlying cause of their pain and skills to better cope with it, the psychiatrist said.

Sites said alternatives to opioids could include cognitive behavioral therapy, acupuncture, meditation techniques and physical therapy.

“The idea is that we want to improve the health and well-being of the patient. And if that’s not occurring, we need alternatives to opioids,” Sites said.

Update: This story was updated on June, 27, 2017, to note that Dr. Andrew Saxon also chairs the American Psychiatric Association’s council on addiction.

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