This story describes a lethal injection procedure used in state executions.

In May, a group of healthcare workers spent about an hour trying to establish complete IV access so they could inject Tony Carruthers, an inmate at the Riverbend Maximum Security Institution in Nashville, Tennessee, with a lethal dose of sedative.

Maria DeLiberato, an attorney for Carruthers, was in the room. She said the workers stuck his arms and feet with needles, to no avail. A doctor then tried to insert a central line through his collarbone and shoulder. That didn’t work, either.

Carruthers groaned in pain and blood oozed from puncture wounds, DeLiberato said in a news briefing.

After more than an hour, Gov. Bill Lee called the warden, ordering him to halt the execution attempt. He later granted Carruthers a one-year reprieve.

Now, as another approaches, doctors and nurses in the state say they want medical professionals removed from the execution process. They’ve also joined defense attorneys and nine Republican state lawmakers in demanding a moratorium on the death penalty and an overhaul of the state’s execution methods.

The doctors’ arguments echoed those the American Medical Association has made and in its code of ethics.

Tennessee is where the death penalty is legal, according to the Death Penalty Information Center, a nonprofit that offers data and analysis on issues surrounding capital punishment.

Governors in four of those states have halted all executions, citing and , such as being unable to obtain lethal injection drugs amid pharmaceutical companies’ refusal to sell them for use in executions. Lethal injection is still the primary nationwide, but some states may use , a , or .

Since the beginning of 2020, 170 people have been executed in 17 states, with most occurring in Florida, Texas, and Oklahoma. In that time, six states have had , according to the , which defines those as executions that include a departure from the protocol because of unanticipated problems and that cause more pain for the prisoner than anticipated, whether they ultimately end with a death or not. Several of the stories read like Carruthers’ — protracted but ultimately failed attempts to establish IV access.

Tennessee Health Workers’ Concerns

The IV team gave up on trying to place a typical line into Carruthers after several failed attempts, according to DeLiberato’s account. , physician Mark Fowler, a contractor for the state’s prison system, then tried to place a central line in a deeper vein. That’s a quasi-surgical procedure in which a plastic tube is inserted in the chest, groin, or neck. Fowler used a series of syringes, trying to insert the tube under Carruthers’ collarbone and then through his shoulder.

In an , Fowler said he hadn’t done such a procedure in the 12 years since he had stopped working in an emergency room, and didn’t know that placing a central line could be among his execution duties.

Fowler told NPR by phone on Sept. 24 that “the doctor does not participate in the execution. The only thing the doctor does is declare the person dead.” He did not have further comment.

Two months after the halted lethal injection, more than 40 doctors and nurses to Lee, calling on the Republican governor to pause executions and redesign the protocol to omit health workers from the process.

The letter said that Tennessee’s rules requiring the participation of pharmacists, physicians, and other healthcare workers in executions are at odds with medical ethics, as well as guidelines explicitly laid out by groups such as the American Medical Association. The doctors are to preserve life when there is hope of doing so and bars participation in executions.

“This means that the health care professionals who agree to take part in Tennessee’s executions are those willing to set aside their professional ethics,” the letter to Lee reads. “The problems that we have seen, such as in Mr. Carruthers’s case, are the predictable result of working with such unscrupulous actors.”

John Greer, a retired Nashville hematologist, said in a news conference about the letter that he wasn’t surprised the central line placement went awry.

“Placing a central line is not just sticking a needle in a person’s arm,” he said.

Greer said the doctor has to tap a large vessel above the heart. He said that it’s a risky procedure in which an error could cause a collapsed lung or heavy bleeding — and that only those with specific training and routine practice should attempt.

“And I cannot imagine that there would be someone who’s doing these routinely who would be involved in this procedure,” Greer said.

Some Republican state senators also hold on executions and an overhaul of the process, saying that “incompetent administration” of capital punishment gives its critics more ammunition.

This summer, Lee said he didn’t want a pause.

“The Department of Correction did exactly what they should,” he said. “It should not affect executions in the future.”

“It’s one of the most difficult things that we do in this state,” Lee said later. “But I am committed to making sure that it is done in the way that it should be.”

The state’s lethal injection protocol orders the prison to keep a curtain over the media witnesses’ viewing window until the IVs are established, so none of them could offer a visual account of the failed execution attempt.

A has been filed has been filed by the Reporters Committee for Freedom of the Press and news outlets including NPR member station WPLN. The lawsuit argues the lack of transparency during the IV placement process obscures problems like the ones that happened in Carruthers’ case.

There’s a broad understanding in the U.S. that the medical establishment doesn’t participate in executions, said , director of the Center for Bioethics and Humanities at the University of Colorado’s medical school.

“We came out of World War II with a whole bioethics and medical ethics enterprise that is really strongly opposed to medicine serving as an arm of the state and using specialized medical skills to hurt people or kill people,” Wynia said.

A history of medical abuses by government doctors — such as and unethical studies of in the U.S., and in Nazi Germany — forged that consensus, he said.

Wynia mentioned other nations where medical professionals still participate in executions.

“But they are, you know, Iran and Saudi Arabia and Russia, sort of authoritarian states, where medicine is an arm of the government,” Wynia said. “Medical involvement in executions ends up happening because medicine is unable to say, ‘No, we don’t do that.’”

Upcoming Execution

On Sept. 30, Tennessee is scheduled to execute Christa Pike, who was 18 years old when she and her boyfriend killed Colleen Slemmer.

Pike’s attorneys this year raised several concerns that the state’s lethal injection protocol would violate her rights. Among them is their contention that because she suffers from a platelet disorder, it’s likely she will need a central line placed. They also argued that she was at risk of needless suffering, alleging Carruthers’ execution showed that Fowler — who has that he will oversee Pike’s execution — is incompetent at placing central lines.

In June, they put all of those concerns to the Tennessee Supreme Court, asking for a special investigator to collect evidence and hold hearings to determine whether they warranted an order to delay her execution and design a method for only her.

The court did appoint a special investigator, Senior Judge Mark Ward. He held a series of hearings in Knoxville last month. Ward said he didn’t believe Pike’s rights would be violated by the process and submitted to the court.

On Sept. 23, the Tennessee Supreme Court , agreeing with Ward, saying none of the concerns amounted to a constitutional violation. On Sept. 28, Lee announced he would not grant her clemency.

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But their shared disenchantment with profit-driven healthcare has provided a unifying target: pharmacy benefit managers, known as PBMs. The Josephs’ frustration is focused on CVS Health. The conglomerate, which reported $400 billion in revenue last year, includes a major health insurer (Aetna), one of the country’s dominant PBMs (CVS Caremark), and America’s largest retail pharmacy chain.

“We hate CVS. I’m going to be straight-up,” Amye Joseph said.

She laments the lack of face-to-face interaction with pharmacists, prices that seem to rise without explanation, and pressure from the couple’s CVS Caremark drug plan to use CVS stores instead of their local pharmacy. “They’re not even a middleman,” she said. “They’re a money grab for CVS.”

PBMs were conceived as a way to manage prescriptions and hold down costs. But these middlemen have become bipartisan punching bags, accused of sucking up profits at the expense of employers, governments, and patients.

And while healthcare debates still divide Democrats and Republicans in Washington, D.C., taking on PBMs has become a unifying cause in an era of widespread frustration over rising healthcare costs.

In recent years, every state has imposed restrictions on PBMs. The Josephs’ home state of Tennessee, where the GOP has a lock on state government, is among a growing number looking to outlaw companies that own PBMs from also owning brick-and-mortar pharmacies, as CVS does.

That’s aligned conservative, business-friendly Republicans with Democrats traditionally more open to government regulation.

This legislative push reflects a feeling even in the GOP that the market for prescription drugs is being gamed, said Antonio Ciaccia, CEO of , a nonprofit think tank that tracks drug pricing.

“Republicans are looking at this issue, saying, We know what competition is supposed to do, and it isn’t happening,” said Ciaccia, a critic of the PBM industry. “This is not a free market.”

Charlie Joseph, a retired fire captain who now works as a custodian, was miffed when he realized he could save money on his blood pressure medication if he paid cash at his local pharmacy rather than using his CVS Caremark drug plan. He now buys a 90-day supply for the same price he would have paid for a 30-day supply through the CVS plan.

“Right now, it’s more of an inconvenience than anything else as far as it goes, but there’s no consistency,” he said. “The whole healthcare thing is just frustrating, on a good day.”

CVS spokesperson Phil Blando said the price of individual drugs can vary.

“Looking at the price of a single prescription does not reflect the value of a comprehensive pharmacy benefit,” he said in a statement. “Our focus remains delivering the lowest possible total cost and the greatest overall value for members and plan sponsors.”

Unified Opposition

PBM officials say their industry has been unfairly maligned. “PBMs are the only part of the prescription drug supply chain working to lower drug costs, which makes PBMs the target of powerful groups, Big Pharma and pharmacists,” said Greg Lopes, a spokesperson for the Pharmaceutical Care Management Association, which represents PBMs across the nation.

“Drug manufacturers attempt to shift blame for high drug costs to PBMs in order to retain their profit margins and weaken PBMs’ ability to lower costs,” he said.

Drugmakers have worked for years to cast PBMs as unnecessary go-betweens, said Barak Richman, a lawyer and economist who studies healthcare competition at George Washington University. He called the fight between the two industries a corporate “cage match.”

“We have wildly passionate partisan divides on a lot of healthcare,” he said. “But there’s a lot of healthcare policy that I don’t think is obviously partisan.”

PBMs haven’t won over many Democrats or Republicans. Attorneys general from nearly 40 states and U.S. territories last year to congressional leaders arguing that “horizontal consolidation and vertical integration have transformed PBMs from useful administrative service providers into market-dominating behemoths.”

In state legislatures like Tennessee’s, shared ownership of PBMs and pharmacies has drawn particular fire. Independent pharmacies have little choice but to contract with major PBMs while also competing with the conglomerate-owned pharmacies. Many lawmakers have said they want to protect small businesses.

“If a corporation argues that its pharmacy cannot survive unless it is owned by the same entity that sets the reimbursement rate, then we’re not talking about a free market. We’re talking about control,” Tennessee state Sen. Bobby Harshbarger said in a February legislative hearing.

Harshbarger, a Republican who led the legislative push, is a pharmacist in a small city in northeastern Tennessee.

His mother, U.S. Rep. Diana Harshbarger (R-Tenn.), is also a pharmacist and has sponsored a similar PBM ownership ban . The Senate version has brought together some unlikely bedfellows, such as Sens. Elizabeth Warren (D-Mass.) and Josh Hawley (R-Mo.).

State Lawmakers vs. CVS

CVS officials argued the Tennessee legislation was misguided. “Any proposed reform should be evaluated based on whether it improves access to care, simplifies the patient experience, and enhances affordability,” Blando said.

It’s unclear whether the PBM ownership ban will do that in Tennessee. by the state legislature’s researchers concluded that the bill could drive up healthcare costs in the short term.

To fight the bill, CVS launched a $7 million , claiming it would have to close all its 134 pharmacies in the state, similar to its threat in neighboring Arkansas when state lawmakers there passed in 2025.

CVS also sent to Tennessee customers, asking them to contact their lawmakers to keep pharmacies open. from CVS helped kill a PBM ownership ban in Louisiana last year.

Sponsors of the legislation said closure wasn’t the only option: CVS could also divest either its stores or its PBM.

Tennessee lawmakers moved forward. State Sen. Rusty Crowe, a Republican from northeastern Tennessee, where the Josephs live, told his colleagues before the vote that they should consider the fierce resistance a sign that they were onto something.

“I learned when I was in the Vietnam War, when you start taking on flak, you know you’re over the damn target,” he said.

As with most votes in Tennessee’s legislature, Republicans didn’t need support from Democrats. But they got it anyway.

State Rep. Antonio Parkinson, a Democrat from Memphis, said he felt like he was voting in favor of lower drug prices and supporting “ma and pa” pharmacies. “If there’s a benefit to my people, I’m supporting it.”

CVS has not divested or closed its pharmacies in states that have passed ownership bans — the laws have yet to take effect. The Arkansas ban is being held up in court after CVS challenged the constitutionality of the law. CVS also sued in Tennessee, though the ownership ban doesn’t take effect until 2028.

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“Maybe this is my sign to try the full-time music thing,” Morgan recalled thinking. “Step one in that was: Get health insurance again.”

Austin bills itself as “the Live Music Capital of the World,” but it for the artists who provide the city with its cultural cachet — and help drive its tourism revenue.

Morgan has supported himself by patching together gigs with a number of bands. To help pay for health insurance, he turned to a local nonprofit, the , or HAAM.

“That’s part of being able to make this whole thing work,” Morgan said.

HAAM subsidizes the monthly insurance premiums of local musicians who purchase plans through the Affordable Care Act marketplace. To fund the roughly $4 million program, it works with Central Health, a public agency that provides healthcare resources for low-income residents of Austin and surrounding Travis County. Many of the performing artists pay $0 toward monthly premiums.

After more than a decade, including through the coronavirus pandemic, the assistance program has become an established and reliable financial support for Austin’s musician community.

This year, after Congress failed to extend pandemic-era subsidies, premiums skyrocketed for many ACA plans. A recent report found that 5 million people nationwide had . HAAM helped blunt the impact for its members. It has emerged as a potential model for other cities hoping to make healthcare more affordable for key populations and industries.

A Growing Idea

Texas had the among states, with 19% of people age 64 and under uninsured, as of 2024.

Even before the launch of the ACA marketplace in 2014, HAAM had spent a decade connecting musicians with free and low-cost care at clinics and hospitals in and around Austin. But roughly 85% of HAAM members remained uninsured, leaving them exposed when traveling to gigs in other cities and states.

“When the Affordable Care Act came out, and we knew it was here to stay, it really made sense for us to start getting our musicians fully insured,” said , HAAM’s chief strategy officer.

Similar nonprofits in other U.S. cities with strong live music cultures, such as , , and , help musicians get medical care. With the advent of the ACA, some of these organizations began helping musicians navigate the sometimes complex enrollment process for the online marketplaces, though they stopped short of pitching in on premiums.

But the team at HAAM recognized that without direct support to help pay premiums, many of their members would still struggle to retain coverage.

“When you think about the average HAAM member making about $30,000 a year, there’s no way that they would be able to spend a third of their income on healthcare,” Blair said.

The organization’s membership has grown by 77% to more than 3,300 people since HAAM began offering premium assistance, and more than 90% of members are now insured.

To help subsidize costs for members, HAAM partnered with Central Health, which is Travis County’s public hospital district — a type of health agency in Texas charged with using tax dollars to fund safety net healthcare for low-income residents. Central Health also operates the nonprofit , which offers marketplace insurance to Travis County residents.

To qualify, HAAM members must enroll in one of Sendero’s silver-level, or benchmark, plans. If their income is between one and two times the federal poverty level, Central Health pays the balance of their monthly premium after federal tax credits are applied. For members who fall above that income range, HAAM offers a more limited subsidy, covering 50% of their premium balances.

In 2017, HAAM helped set up a similar program in Denton, a college town north of Dallas that has served as a , from Meat Loaf to Norah Jones.

The Denton Music and Arts Collaborative works differently: It connects members with an independent insurance agent who helps them find the best health plan for their needs. The nonprofit then offers members a monthly subsidy of $100.

The subsidies are a way of keeping Denton’s culture of jazz and “weird art rock” alive, said the collaborative’s president, Jennifer Kapinos.

“More and more people were maybe graduating college and leaving and going to find better opportunities in other places,” Kapinos said. “People who had lived here a long time suddenly were finding it harder and harder to afford to be here.”

In Austin, other sectors have been watching HAAM’s work. In 2025, , a nonprofit that advocates for restaurant workers, launched a small pilot program with Central Health to help local food workers enroll in Sendero plans and cover their premiums.

Kit Abney Spelce, vice president of operations for Central Health, said partnering with an advocacy group focused on a particular workforce is key because simply announcing “free insurance for you” doesn’t mean people will sign up.

“We are very much dependent on our partner entity to go out and connect with the community, to have that relationship and that trust,” she said.

Navigating Federal Headwinds

Though premium payments often increase year over year, the 2026 plan year was particularly expensive, .

Citing medical and pharmacy costs, Sendero by an average of 16% for its enrollees. At the same time, Congress allowed the pandemic-era enhanced premium tax credits to expire, reducing the federal subsidies that many marketplace customers relied on.

“Our premiums for our members went up 60% from one year to the next,” Blair said.

HAAM stepped up its fundraising into 2026, but it wasn’t enough to cover everyone who requested assistance. They had to turn away hundreds of qualified people. Still, they were able to buffer existing members, said Spelce with Central Health.

“We’re going to make sure their monthly premium is paid every month,” she said.

A Viable, if Limited, Model

Beyond the eligible musicians they turned away in 2026, another population remains out of HAAM’s coverage reach for premium assistance: Austin’s poorest residents.

Under the ACA, the marketplace plans that HAAM helps subsidize are for low- and middle-income earners, but the people with the very lowest incomes — below 100% of the federal poverty level, set at — are supposed to be covered by expanded Medicaid.

But Texas is one of 10 states that chose not to expand Medicaid after the ACA became law, so many of the poorest Texans remain uncovered.

With no federal subsidies available for that group, HAAM and Central Health have tried to develop separate solutions for this subpopulation. Central Health has its , an alternative to health insurance that gives low-income, uninsured people access to a network of local care providers. HAAM has also with primary care providers to serve its uninsured members — but Blair acknowledges it’s not an equivalent benefit to what Medicaid expansion would offer.

“It’s not a very sustainable solution, especially when there’s a really good alternative,” Blair said.

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Source: <a href=”; target=_”blank”>Centers for Medicare & Medicaid Services</a>

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51ÊÓƵ Health News will update this database as more states respond to emails and public records requests for their documents.

Note: Data collected as of Sept. 11, 2026. 51ÊÓƵ Health News reporters searched state websites, requested documents, and filed public records requests. 51ÊÓƵ Health News continues to collect documents.

Sources: Documents publicly posted online or released in response to 51ÊÓƵ Health News requests; <a href=”; target=_”blank”>Centers for Medicare & Medicaid Services</a>

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Nearly half of that money is , to be distributed by county commissioners and city councilors. The idea is that local leaders know their communities best and can do justice to these payouts, often described as “blood money” by people who’ve lost loved ones to an overdose.

But many local leaders have little to no training in addiction policy and may lack robust local health departments and policy guardrails to assist them.

That has resulted in spending decisions that many clinicians, researchers, and addiction recovery advocates say are unlikely to save lives or treat substance use disorders.

In New York, where is directly controlled by local governments, counties have spent tens of thousands of dollars on surveillance cameras, technology to help police access data on locked cellphones, and goggles that simulate being drunk, according to public records obtained by the nonprofit advocacy group and shared exclusively with 51ÊÓƵ Health News. Though the purchases were likely legal, many people consider them a slap in the face because they don’t directly help people struggling with addiction or their families.

Without oversight, counties have the chance “to go rogue” with this money, said , director of drug policy at VOCAL-NY, an advocacy organization that is tracking settlement money as part of its mission to serve people affected by the war on drugs.

When advocates and families of overdose victims raise concerns to the various state agencies that could hold localities accountable, those agencies often punt to one another, Budnella and other local advocates said.

It feels “like the where it’s like everybody’s pointing at each other,” Budnella said. “Somebody needs to be able to have the stick and slam their hand on the table and be like, ‘You’re doing this wrong and this is the consequence.’”

The experience in New York provides a microcosm of regulators evading oversight responsibility nationwide while varied interests vie for the financial windfall.

Years of data collected by 51ÊÓƵ Health News, the Johns Hopkins Bloomberg School of Public Health, and the addiction nonprofit Shatterproof have found that settlement money was spent on law enforcement gear, such as night-vision goggles and bulletproof vests; unproven prevention initiatives, such as a drug-awareness magician for kids; and budget stopgaps.

It’s unclear who should — or will — take action on such expenditures that many people harmed by the crisis consider questionable.

In each state, control of the money is split among various entities, creating a leadership vacuum. The federal government . Advocates and families who’ve lost loved ones have pushed for accountability but have limited power. A few states have passed new laws, but change is slow and uneven.

The require the majority of the money to be spent on “opioid remediation,” with . But the list is broad and open to interpretation. Further complicating the issue, many states — including New York — designate some portion of the settlement dollars as unrestricted, which allows for general spending.

Meanwhile, federal budget cuts have threatened addiction-related services and created more demand for funding. And though overdose deaths have decreased since , they still claim about 186 lives per day.

“We really are wasting this opportunity to use these funds to turn the epidemic around,” said , a Binghamton, New York, resident, whose 28-year-old son, Jeff Dugon, died of a heroin overdose in 2014.

He was a chef who loved to rib Pleus about her bad knife skills. She thinks of him and smiles every time she peels garlic the way he taught her. If the money could spare other families such heartache, that would give her solace.

“We need oversight,” said Pleus, who runs a nonprofit that is receiving opioid settlement cash from her county to serve people who use drugs and provide support groups for families.

In New York, there are three prime watchdog contenders: the Office of Addiction Services and Supports, the attorney general, and the comptroller.

The Lead State Agency

New York’s opioid settlement documents designate the as the “.”

It distributes a portion of settlement dollars via grants, according to recommendations from the state’s . It also has the power to “engage in oversight and audits of projects and programs” funded by settlement cash and “may withhold future funds” from local governments that do not comply with certain requirements, according to the agreement.

Agency spokesperson Jerry Gretzinger told 51ÊÓƵ Health News the office has not yet exercised its power to withhold funds but understands its oversight role.

“OASAS has a duty to ensure these funds are used responsibly and strategically to build programs that will have a lasting impact in reversing this crisis,” Gretzinger wrote in a statement.

The office is currently auditing 19 local governments’ use of the money to ensure compliance with “reporting and recordkeeping requirements,” he said. However, that may not encompass the broader question of whether money was spent on appropriate uses, which many advocates want addressed.

Some people are frustrated with the narrow role OASAS has carved out.

For example, required local governments for the first time to publicly report how they spent settlement money. OASAS on its site. But it does not review the accuracy or detail of that data, instead relying on “the information as it is provided” by localities, Gretzinger said.

“That doesn’t feel like oversight,” said , a deputy director at the Legal Action Center, which obtained public records about local spending in New York.

Members of the state’s Opioid Settlement Fund Advisory Board have also to provide more data and evaluation of how dollars are being used. But at a , OASAS Commissioner Chinazo Cunningham deflected.

“OASAS has no oversight over these portions of dollars,” she said of the 46% of settlement money that goes directly to counties and cities. “In terms of what kind of data each county collects,” she added, “we cannot dictate exactly what that information is.”

Click for Examples of spending decisions Local Spending That’s Fueling Calls for Oversight in New York

To uncover how opioid settlement cash is being spent, the nonprofit advocacy group filed public records requests with 56 New York counties and New York City, all of which are to disburse as they see fit.

Many of the responses showed spending on addiction treatment, recovery, and prevention initiatives that researchers and clinicians agree are a good use of money. Others surfaced questionable expenditures.

, for example, showed $150,000 in settlement cash directed to “Sheriff Jail” with no further description. The county did not respond to repeated inquiries for more details.

Sullivan County spent more than $30,000 on Cellebrite technology, used to extract data from cellphones, and more than $37,000 on Tasers. Though county officials didn’t respond to requests for comment, explained that those purchases came from unrestricted funds.

Such justifications rankle some families affected by the crisis, who say even if there aren’t legal restrictions on those dollars, there should be moral ones.

“Anything that is not directly tied to people who are struggling with opioid addiction or the loss of someone is a poor use of funds,” said , who lost a son to an overdose and now runs a nonprofit aimed at helping families dealing with addiction. Her organization has received settlement funds from Broome County, New York.

Records also revealed that many jurisdictions have yet to spend a significant portion of their money — a other .

Local officials say thoughtful planning takes time. But some advocates suspect ulterior motives. Millions of settlement dollars in bank accounts can generate sizable interest.

In March, it came to light that Nassau County had in interest accrued from unused opioid settlement funds to the county’s general fund, where it could be used for any purpose. County officials didn’t respond to requests for comment. The money was following public backlash.

Advocates suspect such attempts are happening elsewhere but are difficult to identify within complex budgeting documents.

It feels like “it’s up to us all — the organizers, the advocates, the service providers” — to be constantly watching, said , director of drug policy at the advocacy organization VOCAL-NY. “It’s frustrating.”

That’s why state agencies are being called on to step into an oversight role.

The Top Law Enforcement Officer

New York has been one of the leading national voices on prosecuting pharmaceutical companies that fueled the overdose crisis. Her office has issued on the topic, touting her role in securing billions of opioid settlement dollars for the state.

But when asked about the attorney general’s role in ensuring this windfall is spent appropriately, her office passed the buck to other agencies.

“While our partners in state and local governments distribute and oversee these funds, we will continue our work to hold accountable the companies responsible for fueling the spread of addictions and overdoses,” spokesperson Grant Fox wrote in a statement.

That stance contrasts starkly with many people’s views of the office’s responsibility.

A state senator, a member of the opioid settlement advisory board, and several advocates named the attorney general’s office as a key enforcement entity.

“The money is here because of their efforts,” said Democratic state , who chairs the committee on alcoholism and substance use disorders and has introduced of related to settlement funds. “I believe it is under the Office of the Attorney General to enforce.”

Budnella, the advocate with VOCAL-NY, agreed, saying, “It would be a shame for all of their work that they have done to secure all this funding for it to be misspent.”

Attorneys general in and have taken more active roles, issuing lists of ways opioid settlement money cannot be spent. The lists include many law enforcement expenditures that have raised concerns for advocates in New York.

James’ office did not respond to a specific question about whether she’d consider creating a similar list.

The Fiscal Watchdog

Some people have suggested that the state comptroller, as a steward of New York’s finances, could play an oversight role, perhaps by conducting or requiring audits.

Early this year, the Reason Foundation, a libertarian think tank, that would create audit requirements for organizations receiving settlement cash. The blueprint suggests recipients of more than $1 million in opioid settlements be required to undergo an independent review of financial statements and transaction testing to determine whether funds were used for their intended purpose. Smaller grantees, receiving less than $1 million, could simply provide an unaudited accounting of the funds.

It’s “not telling states what is and what isn’t an appropriate use,” said , a co-author of the Reason Foundation plan. “We’re simply trying to ensure recipients follow through with their promises.”

No state has adopted the model law yet. But the office of New York told 51ÊÓƵ Health News it is already conducting an audit.

The process, which began in February, “is looking at OASAS’ oversight” of the opioid settlement money, said spokesperson Mary Mueller. It includes settlement money controlled by the state and local governments.

Mueller said any future enforcement action “will depend on the results of our current work and our ongoing monitoring.”

The office is following in the footsteps of comptrollers and auditors in , , and , Tennessee, who have taken action on settlement cash.

These initial steps have given some advocates and researchers hope for the future of opioid settlement dollars, which are expected to flow for more than a decade.

“We’re already years in and we’ve seen the craziest stories” of this money and a , said , a co-author of the Reason Foundation’s model law. “If we can prevent that at least a little and have these funds be a bit more focused, I don’t think it’s too late.”

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More than a decade ago, Noon said, she was diagnosed with adult-onset Still’s disease, a rare type of inflammatory arthritis that can cause rashes, debilitating pain, and fevers. The disease upended her life.

She had been living a typical suburban life in Michigan, shuttling her two kids to activities like cheerleading, choir practice, and track. She was active in the PTA. She managed a bank.

She went from that to crawling to the bathroom because she was in so much pain, “just crying all day long” from being so sick.

Noon, who is disabled, said she couldn’t work for eight years — a time marked by hospital stays that stretched for weeks.

“I honestly thought I was going to die,” Noon said.

So it was a shock when Michigan denied her application for Medicaid benefits last year after she lost private insurance. Worse yet, it came down to an IT error, according to an attorney who helped Noon overturn the denial.

“I can’t afford my medical care. I have to have insurance,” said Noon, who has returned to working.

Deloitte, a multibillion-dollar global consulting firm, has operated Michigan’s Medicaid eligibility system under contracts worth roughly $768 million since 2006, according to contracts reviewed by 51ÊÓƵ Health News. Nationwide, Deloitte dominates this important slice of government business: At least 25 states have awarded the company contracts to build or run computer systems that control access to safety net benefits such as Medicaid.

Michigan’s system has incorrectly directed people with disabilities into skimpier benefits that cover limited care or has denied coverage completely, a 51ÊÓƵ Health News investigation found. Similar problems were at the center of a class-action suit in Tennessee, , and have occurred in Texas, according to interviews and state records.

The 51ÊÓƵ Health News investigations are based on statements from state officials, allegations and declarations in court documents, emails obtained through public records requests, state government information provided to Medicaid enrollees and applicants, and interviews with attorneys and patients or their caregivers.

In an emailed statement, Deloitte spokesperson Karen Walsh said it found “no system anomalies causing routine denials of Medicaid for people with disabilities.”

“There are many reasons why someone may no longer be eligible for a benefit they once received or believe they deserve,” Walsh said. “All of the eligibility systems we support are owned by the states and built to their unique specifications. We will continue to work at the direction of our state clients.”

Lynn Sutfin, a spokesperson for Michigan’s Department of Health and Human Services, said it “is not aware of any widespread or systemic issues” within Bridges, Michigan’s eligibility system for Medicaid, SNAP, and other benefits, “related to disability‑based eligibility pathways.” 

Since 2006, Deloitte’s contracts with the state have said the company is responsible for development, implementation, maintenance, operations, and enhancements to the Michigan system.

Computer system problems foreshadow trouble as states prepare to roll out the most significant and complicated changes to their Medicaid programs in years. Those changes, dictated by President Donald Trump’s landmark One Big Beautiful Bill Act, have states rushing to update their Medicaid computer systems.

Nationwide, on Medicaid have a disability, according to 51ÊÓƵ.

“When these administrative systems get overloaded, everyone gets impacted,” said Pamela Herd, a University of Michigan professor who researches bureaucratic obstacles to accessing government benefits. “The systems are going to be really, really strained.” 

In Michigan, Noon was eligible for Medicaid through a program that provides coverage to disabled adults who work. But the state’s computer system didn’t register that she is disabled and said she earned too much to qualify, according to documents reviewed by 51ÊÓƵ Health News and interviews with Noon and Anastassia Kolosova, a disability rights attorney who helped her.

Without Medicaid coverage, Noon paid hundreds of dollars out-of-pocket for prescriptions, after scrounging for discount coupons. She takes some of the drugs twice a day.

Without them, “I’m toast,” she said. It was stressful “not knowing if my medicine’s going to be $50 or $500 this month, because it changes constantly.”

Noon said her doctor agreed to fewer visits to avoid medical bills.

“It was kind of a nightmare,” Noon said.

‘I Just Wanted To Give Up’

Medicaid, a safety net health program jointly run by the federal government and states, people with low incomes or disabilities. State governments rely on companies like Deloitte to design and operate computer systems that assess whether people qualify for Medicaid or food aid through the Supplemental Nutrition Assistance Program, commonly known as food stamps.

That technology has a history of errors that deprive eligible people of benefits, earlier 51ÊÓƵ Health News investigations have shown. As reported previously, Kenneth Smith, a Deloitte executive who leads its national human services division, said Medicaid eligibility technology is state-owned and agencies “direct their operation” and “make decisions about the policies and processes that they implement.”

“They’re not Deloitte systems,” he said, noting Deloitte is one player among many who together administer Medicaid benefits.

States are under immense pressure to update their eligibility systems on a tight schedule to adhere to requirements in the Republicans’ sweeping 2025 tax and spending law. Companies including Deloitte, Accenture, and Optum are being paid millions in taxpayer funds to make the changes, which are projected to strip Medicaid from roughly 7.5 million people and SNAP from 2.4 million people by 2034.

Many coverage restrictions in the new federal law don’t apply to seniors, children, or people who are disabled, such as Noon. Nonetheless, the law’s demands on state agencies and the computer systems they oversee will disrupt benefits, advocates for Medicaid enrollees and other healthcare experts said in interviews.

The same systems also need to correctly classify why someone is eligible for Medicaid — and therefore which rules and restrictions apply.

The law’s SNAP restrictions began to take effect in 2025, and major Medicaid provisions begin later this year, generally after the midterm elections.

Kolosova is a supervising attorney with Disability Rights Michigan, a legal advocacy organization for people with disabilities. She said she has been unable to get a meeting with Michigan officials to understand the underlying problem that deprived Noon of health coverage.

State records show Deloitte has held contracts for at least 14 years for Bridges, Michigan’s eligibility system for Medicaid, SNAP, and other benefits. In its attempts to secure more business, the company often cites its nationwide footprint in Medicaid operations.

“Deloitte understands Bridges,” and its history in Michigan makes the company “the ideal vendor,” the firm said in its . Given Deloitte’s work on similar systems in 31 other states, , “Michigan benefits from our technical expertise drawn from across the nation.”

But advocates who work with people with disabilities say Michigan’s computer system has failed to recognize when certain adults should receive Medicaid benefits.

Problems aren’t unique to the Great Lakes State. Medicaid beneficiaries who brought a against Tennessee in 2020 said the state’s Deloitte-built system “does not reliably test for eligibility” for several categories of people with disabilities. The firm’s is worth $1.12 billion over a decade.

A federal judge in 2024 , ruling that Tennessee violated federal law and the U.S. Constitution. The lawsuit does not name Deloitte as a defendant.

In Michigan, a from the state’s Office of the Auditor General said government agencies “did not provide effective project administration” and failed to ensure that the state could “independently maintain and operate Bridges” because “the contractor did not transfer knowledge and skills” to state officials, according to the audit.

The auditor’s report said that, as a result, Deloitte’s original contract — valued at roughly $70 million — ballooned by $50 million over the initial cost, a 71% increase. State records show Michigan would go on to add millions more, bumping the cost of Deloitte’s initial contract to $124.1 million.

The audit said maintaining the contract would result “in significant additional costs.”

Sutfin said that “the state is now fully capable of operating and maintaining Bridges independently.”

Deloitte’s in Michigan — worth $197.4 million — is set to expire in 2030.

Noon applied for Medicaid in August, she and Kolosova said. In September, the Michigan Department of Health and Human Services sent a notice denying her coverage, citing incorrect income information and stating she wasn’t disabled, according to Kolosova and state documents reviewed by 51ÊÓƵ Health News.

Noon said that when she called the state for help, state workers “didn’t know anything about” the Medicaid program she had applied to, Freedom to Work.

“I can’t tell you how many times I just wanted to give up,” she said.

For some people with disabilities, Medicaid is supposed to count only half their earnings when assessing whether they should receive benefits. That didn’t happen. Kolosova said she thinks Michigan’s eligibility system didn’t identify Noon as disabled, even though the state “already had all the information they needed” to show she was.

By failing to recognize her disability, the state used the wrong income 51ÊÓƵ and said Noon earned too much to qualify for Medicaid, she added. Deloitte and Michigan declined to respond to a detailed list of questions about Noon’s experience.

Kolosova said Disability Rights Michigan has seen a growing number of calls from people about Freedom to Work benefit denials. “Maybe two or three a month,” she said.

“There’s something wrong with the system if they’re relying on individual caseworkers to catch this,” Kolosova said. “The system needs to work.”

Enrolled in the Wrong Coverage

Noon’s experience isn’t the first time in recent years that people with disabilities have been denied benefits by Deloitte-run eligibility systems.

In Texas in 2023, Lilly Livingston, who has Down syndrome and is now 22, was abruptly cut off from Medicaid benefits, according to Livingston’s mother, Marie. She has undergone numerous surgeries to reconstruct her severely misaligned jaw, which caused sleep apnea and impaired her speech and chewing ability. She relied on an array of Medicaid services, including speech and occupational therapy.

When Livingston lost benefits, she was wrongly enrolled in Healthy Texas Women, a limited program that provides breast and cervical cancer screenings and family planning services.

“Trying to fix that was a nightmare,” Marie Livingston said.

Terry Anstee, an attorney with Disability Rights Texas, intervened.

In a September 2023 email with the subject line “URGENT,” Anstee begged a Texas Medicaid eligibility worker for help.

Some unknown “error” had occurred and stripped Livingston of her benefits, Anstee said in an email he sent to a state Medicaid staffer. “Lilly has had 2 major surgeries, and her recovery is contingent on Medicaid.”

It was clear that Livingston qualified for Medicaid through multiple paths, Anstee said: “It never made any sense.”

Deloitte declined to respond to a detailed list of questions about Livingston’s case. Jennifer Ruffcorn, a spokesperson for Texas Health and Human Services, confirmed that Livingston was erroneously enrolled in Healthy Texas Women. However, Ruffcorn said, Livingston did not experience a lapse in Medicaid coverage in 2023.

Anstee disputed the state’s characterization: “A glance in the system by a Texas HHS press officer or other staff 3 years after the fact may not tell the full story or show the issues that Ms. Livingston endured in August and September 2023. Ms. Livingston experienced lapses in coverage.”

The problem Livingston encountered in Texas was also reported in Michigan.

In 2024, mental health services advocates in Michigan raised red flags about a similar error: People with disabilities were being enrolled in a limited Medicaid program covering sexual health and family planning services. Plan First covers only services and treatment for sexually transmitted infections. It doesn’t provide the comprehensive coverage that people with disabilities require.

But some enrollees were “being automatically enrolled in Plan First,” Malcolm Kletke, a lobbyist representing the Community Mental Health Association of Michigan and other mental health providers, wrote to a Michigan health official, according to emails obtained by 51ÊÓƵ Health News through a public records request.

These enrollees had “long received Medicaid due to their disability,” and getting enrolled in the wrong plan meant losing access to “services essential to their recovery and quality of life,” Kletke wrote in September 2024 to Amy Epkey, a senior deputy director of the Michigan Department of Health and Human Services.

In fact, the state’s own records show that Medicaid enrollment for those with disabilities did decline.

Over roughly four years, enrollment in the Medicaid category that includes people with disabilities , according to the Michigan House Fiscal Agency, which provides nonpartisan analysis to lawmakers. The drop was unusual given people generally leave the program because of death or having recovered from a temporary disability, and it’s unlikely those numbers would balloon, said Robert Sheehan, who was the mental health association’s CEO at the time.

Sutfin said the state examined the decline in enrollment and found “several contributing factors, including post‑covid renewal patterns, changes in beneficiary circumstances and movement to other coverage categories.”

After inquiries from 51ÊÓƵ Health News, the Michigan health department acknowledged in April that it had made changes to “address concerns raised by advocates.”

Michigan’s computer system now prevents approval of Plan First benefits until all other coverage options are evaluated, Sutfin told 51ÊÓƵ Health News. Sutfin said the changes were implemented but “not to correct system errors.”

Sutfin said the state submitted a change request to Deloitte to address this problem. The fix was implemented in January 2025.

Until presented with Kletke’s email, the state had denied there were problems related to Plan First.

Even after the state addressed that issue, other problems persisted.

Noon’s coverage denial notice arrived in September. She fought with the state for months to reverse its decision, “paying cash for all of the medicines through these appeals over and over and over again.”

It was only in January that she was approved.

“I literally cried,” Noon said. “It was a really big deal.”

This article first appeared on 51ÊÓƵ Health News and is republished here under a .

We’re expecting our first baby boy in end of August. And when I think about what it’s going to feel like to take care of my wife and my new son and my mom, it’s a bit overwhelming.

If you are taking care of a child and you have a parent over 65, you’re among millions across the U.S. in the same life stage.

Nearly a quarter of all American adults — and half of all adults in their 40s — fall into this “sandwich generation” category, . And being in the middle of that sandwich can feel … intense.

“I have kind of prided myself on being self-sufficient. And in this season of life, that’s almost been laughable,” said Jason McAnally, a Nashville father of two who helps care for his aging dad.

HealthQ hosts Cara Anthony of 51ÊÓƵ Health News and Blake Farmer of Nashville Public Radio, both in the sandwich generation themselves, are your approachable guides to an unapproachable healthcare system. In this one-hour special about navigating health and caregiving, they tap researchers, physicians, experts, and their own personal experience to explore:

• Identity: When to start calling yourself a caregiver, and why it matters.
• FMLA: How to start a conversation with your boss about taking federally protected leave from work.
• Kids and mental health: How to know it’s time to take an anxious child to therapy.
• Early-onset cancer: What you need to know about spotting diseases that are on the rise among people under 50.

The HealthQ team acknowledges the messiness, the humor, and the beauty of this season of life. Come on the journey with us.

Can’t see the audio player? Visit kffhealthnews.org to listen.

This installment is part of HealthQ’s reporting on caregiving among the sandwich generation. For more, check out the series archive.

HealthQ is a health series from reporters Cara Anthony and Blake Farmer, approachable guides to an unapproachable healthcare system. It’s a collaboration between Nashville Public Radio and 51ÊÓƵ Health News.

This article first appeared on 51ÊÓƵ Health News and is republished here under a .

The drug is now marketed and sold across the state in roadside shops and small-town strip malls with little oversight from health authorities. Highway billboards advertise ivermectin as “Available Without a Prescription in Tennessee!” while dozens of pharmacies offer highly concentrated pills, sometimes at 10 or 20 times the potency of a standard tablet.

Ivermectin is a approved by the FDA for treating , which can generally be done with a single dose of three or four prescription-strength tablets. It is also used as a dewormer for horses and other livestock.

Its popularity surged during the pandemic as fringe doctors and anti-vaccine activists promoted it as a treatment for covid. have shown that ivermectin is against covid.

Nonetheless, it has since become a symbol of resistance against the medical establishment among conservatives and followers of the Make America Healthy Again movement, championed by Health and Human Services Secretary Robert F. Kennedy Jr.

Timothy Caulfield, a professor at the University of Alberta who studies health misinformation, said ivermectin became an “ideological flag” during the covid pandemic, opening the door for influencers to push the drug for other ailments to a “captured audience” even without proof it works for those conditions.

“This is really about profit. This is about political identity. This is about creating distrust in the existing biomedical community. This is about money,” Caulfield said in an interview with ABC News, which partnered with 51ÊÓƵ Health News to report on ivermectin.

After a hantavirus outbreak on a cruise ship earlier this year, unproven claims that ivermectin is effective against the virus have been spread by some popular social media accounts and right-wing figures, including former congresswoman . The World Health Organization says it has seen that shows ivermectin is an effective hantavirus treatment.

Tennessee’s ivermectin bill was shepherded by a Republican supermajority in 2022. Its passage blindsided state medical officials and handed a victory to medical groups that spread covid misinformation.

Some pharmacy websites now offer the drug as a treatment for covid, “long haul vax symptoms,” diabetes, or cancer — despite no evidence of its effectiveness for those purposes — while the largely gives pharmacists immunity from lawsuits or professional sanctions related to ivermectin.

The law was also a harbinger of legislation to come: More than two dozen states have since considered look-alike bills that would make the politicized medication available without a requiring a doctor visit. 

John Mafi, a UCLA internal medicine physician who has studied the rise of ivermectin among cancer patients, worries it will lure people away from proven treatments. He co-authored a new study in prescribing rates for ivermectin and another antiparasitic drug, particularly in the South. The rise followed a January 2025 episode of the Joe Rogan Experience podcast in which actor Mel Gibson claimed ivermectin and other drugs cured three friends with stage 4 cancer.

“It’s going back to 19th-century quack science,” Mafi said about off-label use of ivermectin. “It is alarming that I’m seeing this really unproven therapy being touted to so many potentially vulnerable Americans.”

The FDA says ivermectin can be . Tennessee has seen a small but concerning rise in signs of overuse. The Tennessee Poison Center, which fields calls from people exposed to drugs or toxic substances, received more than 60 calls for possible ivermectin poisoning in 2025, the most since 2021. They included reports of vomiting, blurred vision, neurological problems, and difficulty walking.

“People are taking this because they just feel unwell. It’s almost like a panacea now,” said Rebecca Bruccoleri, the poison center’s medical director. “I’ve heard rumblings on the internet of using ivermectin for an alternative cancer treatment, and we’re seeing it definitely in here.”

Pharmacist Paul Hughey has dispensed ivermectin under the new law at two Tennessee pharmacies: Mt. Juliet Pharmacy and Compound Rx. He estimated that “up to 20 people in a week” are buying ivermectin but that peak demand was double or triple that amount.

For years, Hughey said in an interview, customers have relayed emotional “testimonies” about the drug healing the sick, “especially with the cancer patients.”

“I’ll get a doctor call in and they say: ‘Guess what. So-and-so is cured.’ And it’s just amazing to hear that. So anybody who doubts that,” Hughey said, “I don’t really know that they’re practicing medicine. I think they’re just following the narrative.”

‘I’ve Taken Bucketloads of This Stuff’

The linchpin of Tennessee’s ivermectin market is , a conservative doctor to the creation of the 2022 ivermectin law. She has with pharmacies across the state empowering them to sell the drug.

Tennessee’s law to dispense ivermectin without a specific prescription for each patient, through a “collaborative pharmacy practice agreement” with a doctor who provides what is functionally a pre-written, nonspecific prescription for all potential customers.

In podcast interviews, Sibley has said she has made as many as 40 of these agreements with Tennessee pharmacies, which she said forward her the paperwork on each ivermectin customer. Before selling the drug, pharmacies are required to ask customers questions about medical conditions and medications that could cause complications if taken with ivermectin. Afterward, the collaborating physician also is expected to receive a record for each person who purchases ivermectin.

“We literally have folks coming from all over the world to get our ivermectin,” Sibley said on in February 2025. “As the collaborator for these pharmacies, I get every person’s sheet.”

“They’re from every state,” she said. “They’re from Canada. They’re from Europe.”

Sibley did not respond to requests for comment.

51ÊÓƵ Health News has independently confirmed that Sibley signed agreements with at least 10 pharmacies. The agreements say pharmacists shall dispense ivermectin only in Tennessee, where Sibley is licensed, although one of those pharmacies said friends and family in Tennessee can “.”

Hughey, the Tennessee pharmacist, said Sibley had prescribing agreements ready to go when the law was enacted. He credited her with advancing ivermectin sales throughout the state.

“Had Dr. Sibley not stepped in and really pushed forward, there’s no telling how hard it would have been,” Hughey said. “It would have been a lot less widespread.”

Sibley also works with Children’s Health Defense, the Kennedy-founded group that has become one of the nation’s most influential anti-vaccine organizations. In podcasts, Sibley has referred to the covid vaccine as a “” and “ that’s ever been produced.”

Separately, before Tennessee legislators in 2024 about an alleged plot to change the weather and block sunlight. The New York Times then included her .

Sibley has said in podcast interviews that she was told by God to treat covid patients. She said she has advocated for ivermectin ever since.

“God agrees with what I’m doing,” Sibley said in 2023 on the podcast , which is recorded in Nashville. “I wake up every day and I say: ‘Yes, sir. I’m reporting to duty.’”

In legislative and government hearings throughout 2022, Sibley testified that she had treated around 4,400 people with ivermectin, including some Tennessee lawmakers, all without taking payment. Sibley described ivermectin as “a wonder drug” and said making it more available “.”

“I’ve taken bucketloads of this stuff myself,” Sibley said . “I feel like I’ve been a good test subject.”

Sibley has said she dispenses ivermectin using treatment guidelines developed by Paul Marik, who in 2020 co-founded the Independent Medical Alliance, a medical group that has promoted ivermectin as an effective treatment for , , , and .

Some Tennessee pharmacies now follow those protocols, too. The protocols recommend patients take 1.5 to five times as much ivermectin as is normally prescribed to treat parasites, with the dose taken for days or weeks instead of just once.

Marik and other ivermectin proponents sued the FDA in 2022 after it discouraged the use of the drug for covid by tweeting: “You are not a horse. You are not a cow. Seriously, y’all. Stop it.” The agency settled the lawsuit with no admission of wrongdoing and deleted the viral tweet in 2024.

The American Board of Internal Medicine has revoked Sibley’s and Marik’s board certifications but declined to explain why. Sibley still holds a Tennessee medical license; Marik is based in Virginia and is not licensed. Sibley and Marik the internal medicine board’s actions.

In response to questions from 51ÊÓƵ Health News, Marik, through an Independent Medical Alliance spokesperson, said medical science benefits from “open discussion of ideas and treatments.”

“Many independent doctors have reported that treatments like Ivermectin, in conjunction with traditional treatments, are showing promise. These ideas should be explored,” alliance spokesperson Lynne Kristensen said in an emailed statement.

Marik testified in favor of Tennessee’s ivermectin legislation in 2022, telling lawmakers that it is necessary because people would otherwise buy animal-grade ivermectin in stronger dosages meant for livestock.

“They’re buying ivermectin from farm stores. We don’t know the quality,” Marik said at a March 2022 legislative hearing on the Tennessee bill. “So this would prevent that from happening.”

Tennessee Does Not Track Its Ivermectin Market

Arkansas, Idaho, Louisiana, and Texas enacted similar laws in 2025, and legislation that makes ivermectin available without the need for a doctor visit has been introduced or debated in at least 24 other states, according to a 51ÊÓƵ Health News analysis. That means half the country could be following Tennessee down an unlit path, because no one knows the full scope of its ivermectin market.

Tennessee does not effectively track which pharmacies offer ivermectin this way, and the state government has been unable to produce some foundational documents that pharmacies are legally required to file before they sell the drug, according to a 51ÊÓƵ Health News investigation.

Doctors and pharmacies are the Tennessee Department of Health when they sign agreements that allow ivermectin to be dispensed without patient-specific prescriptions, although it is not clear whether this consistently occurs.

In response to a 51ÊÓƵ Health News public records request for those ivermectin notifications filed by pharmacies, the agency over three months produced records from only 12 pharmacies, half of which have agreements with Sibley. The agency said it did not locate records related to at least 13 others that 51ÊÓƵ Health News has identified as selling ivermectin without requiring individual prescriptions.

Department of Health spokesperson Dean Flener said the agency would not answer questions about whether or how it regulates ivermectin or the pharmacies that distribute it.

Tennessee has said it does not track how much of the drug is sold in the state, and the amount is not well captured by federal or insurance data sources. That’s because the drug is often sold at compounding pharmacies, which make customized medications that are not FDA-approved and rarely covered by insurance. Drugmakers and wholesalers did not respond to questions about how much ivermectin they supply to pharmacies in the state.

Even the Independent Medical Alliance, one of ivermectin’s , says it doesn’t know how much is flowing through Tennessee.

States are getting pressure from clinicians ”who have had success with the use of ivermectin,” said IMA President Joseph Varon, a physician based in Houston. “That’s what happened in Texas, and that’s what happened in Tennessee.”

‘An Unproven, Potentially Unsafe Drug’

Once signed by Tennessee Gov. Bill Lee, the state’s ivermectin law took effect immediately — even before the state’s physician and pharmacy licensing boards created rules to guide the process, which Tennessee law also requires. 

Some board members were shocked.

“We’re talking about an unproven, potentially unsafe drug,” Shant Garabedian, a doctor on the state’s Board of Osteopathic Examination, said of off-label ivermectin use during a . “It’s already law. Somehow it passes without our sort of input.”

In meetings that followed, at least five members of Tennessee’s medical boards voiced concerns about the law beyond safety and efficacy. Some said pharmacists could overcharge for a drug that normally costs pennies per pill. Some worried that a loosely regulated, cash-based ivermectin market might attract shady characters, especially because the law also shields prescribers from ivermectin-related civil lawsuits.

“This involves no clinical engagement,” Melanie Blake, then-president of the Board of Medical Examiners, said during a . “If they’re exempt from liability as well, I hate to think of things that individuals could do just to make money, but this would be one.” 

The boards eventually enacted regulations affirming that ivermectin could be dispensed without any diagnosis. Board members said the law left them no choice.

“This is more of a situation where, legally, the legislature has decided for us,” John McGraw, another board member, said in a . “This has sort of tied our hands in a lot of ways.”

The first known sale under the new law occurred in Sibley’s home of Johnson City, a city of about 74,000 people in northeastern Tennessee. According to a , Sibley entered into a collaborative agreement with pharmacist Josh Harrison at The Compounding Lab, which dispenses drugs for people and animals. 

The first customer was Bernadette Pajer, an anti-vaccine activist who has worked with Children’s Health Defense. In a of the Nashville podcast Rebunked With Scott Armstrong, Pajer said Sibley was a medical adviser for the group and described the first ivermectin sale.

“On that day, she was the doctor, he was the pharmacist making the sale, and I was the first customer,” Pajer said. “So that was pretty cool.”

Ivermectin pharmacies have spread across the state. In the suburbs of Nashville, Roman Pharmacy advertises ivermectin on at least four billboards along Interstate 65, and is mostly focused on the drug. Outside Knoxville, allows customers to order ivermectin for multiple sclerosis and Parkinson’s disease, or “to use it to detoxify.”

Roman Pharmacy did not respond to interview requests. Fresh Pharmacy declined an interview.

In Chattanooga, the Medicine Counter pharmacy says on its website that ivermectin should be taken “only as prescribed by your healthcare provider.” And yet the pharmacy sells some of Tennessee’s available without a prescription from a doctor — up to 21 times as strong as a standard tablet, for nearly $19 per pill — according to the 51ÊÓƵ Health News analysis.

Himanshu Patel, Medicine Counter’s head pharmacist, declined to be interviewed. He said in an email that the pharmacy operates in a “very competitive market” and that its strongest pills were below the maximum dose for humans evaluated by the FDA for safety purposes.

And then there is Compound Rx, which, in addition to selling ivermectin in its store, has built a website in preparation to ship nationwide. The site, which is in “test mode,” cannot currently make any sales. It also asks customers how they heard about the pharmacy, with a dropdown menu of answers that features right-wing figures such as Donald Trump Jr., Steve Bannon, Laura Ingraham, and Kevin Sorbo.

Who is not listed as an option? Your doctor.

Hughey, the Compound Rx pharmacist, said he wasn’t involved with the website, which he said may never launch.

The highly concentrated pills are a concern for Tennessee state Sen. Richard Briggs, who worries lawmakers have created a “dangerous” ivermectin market rife with “misleading advertising” about what the drug can actually do.

Briggs, who is a surgeon and the only Republican who voted against the ivermectin bill in 2022, said he planned to introduce legislation to rein in the sale of ivermectin when lawmakers reconvene in 2027.

“But it may be a hard sell, because with the anti-vaxxers and some of these other folks,” Briggs said. “We don’t base a lot of things that we do on science, data, or facts. To a lot of folks in the legislature, the facts are just an inconvenience.”

‘Enough Trouble With Ivermectin’

Lawmakers in at least seven states have considered ivermectin legislation this year, including Alabama, Florida, Oklahoma, and South Carolina. If enacted, these bills would allow people to obtain ivermectin without an individual prescription, like in Tennessee, or make it available over the counter.

Kennedy praised such legislation at an event in Texas last August.

“I think it’s a really good bill,” he said of Texas’ ivermectin legislation, according to . “I think Americans should have the choice.”

But proponents have hit roadblocks. A Utah bill failed to advance out of the state House this year. In Oklahoma, some lawmakers have put up a fight.

“I’m a scientific person. I need to see some research and some data that shows what we’re treating,” Oklahoma state Rep. Cynthia Roe, a Republican and nurse practitioner who opposes the state’s ivermectin bill, said in an interview. “And God forbid somebody start giving it to their kid.”

Back in Tennessee, one of the medical boards that was alarmed when the law was enacted in 2022 started to distance itself from ivermectin altogether.

In January, the Board of Medical Examiners grappled with how to punish Ricky Lee Jackson, a doctor who was licensed in Tennessee and had been sanctioned and fined by Washington state’s medical commission. The Tennessee board normally mirrors punishments from other states without hesitation. But the Washington case centered on Jackson prescribing ivermectin for covid, which in Tennessee no longer required a patient to see a doctor.

After a debate, the board voted to reprimand Jackson — but told its staff to ensure the public record made .

“This board has been in enough trouble with ivermectin,” member Keith Anderson said, according to a . “Maybe we ought to just leave that out.”

journalist Blake Farmer and reporter Adam Friedman contributed to this report.

This article first appeared on 51ÊÓƵ Health News and is republished here under a .

Their plan would have helped pay to treat low-income, uninsured patients.

But federal leaders overseeing the five-year, $50 billion Rural Health Transformation Program said no.

“It was not our decision,” said Lisa Letourneau, a senior adviser at Maine’s health department.

Letourneau told an audience of healthcare providers, advocates, and community groups during a March webinar that the change was “disappointing.”

Maine isn’t alone in having to make changes to plans pitched to win a share of the Trump administration’s new rural health fund.

Centers for Medicare & Medicaid Services Administrator Mehmet Oz when announcing the rural health program awards last year and said his agency would help states “turn their ideas into lasting improvements for rural families.”

But state officials and healthcare leaders said it’s also clear the agency wants to encourage specific policy changes and hold states accountable to the promises they made and rules they agreed to follow.

During the past six months, as states raced to meet the program’s looming federal deadlines, CMS staffers worked with state health departments to make a flurry of changes, including scrapping some initiatives. The federal agency to rescind existing funding — or reduce future awards — if states don’t follow rules or meet their goals. “We will take the money back” if states “don’t abide by what they wrote, if they don’t do a good job,” Oz said at an event this month in Washington, D.C.

Congressional Republicans created the Rural Health Transformation Program as a last-minute sweetener in their One Big Beautiful Bill Act last summer. The funding was intended to offset concerns about the anticipated in rural communities from the law, which is expected to reduce Medicaid spending by more than $900 billion over a decade.

On a call with reporters in December, Oz said “one of the smartest things the president and Congress” did when creating the program was to create a threat of “clawbacks,” or taking money back if states don’t do what they promised in their applications.

Oz went on to describe how the clawback mechanism gives governors leverage to press their legislatures to adopt the Trump administration’s priorities, such as instituting the presidential fitness test in schools.

“This gives you extra umph, a little bit of gusto to go after these issues,” he said.

That message was received loudly and clearly in Tennessee. Michael Hendrix, policy director for the governor’s office, said during a hearing that federal officials said the state “would be more competitive for more funding through policy change.” He said CMS also relayed that “some share of this year’s funding, if policies are not implemented, might be clawed back.”

The threat of rescinding funding has caused fear and confusion among health organization leaders, said Alan Morgan, CEO of the National Rural Health Association.

“We’re worried that facilities and organizations won’t apply for the grant money because of the fears of the clawbacks,” he said, adding that he would like the administration to clarify if federal officials could take back grant money that states have already awarded to rural health organizations.

While clawbacks are a “necessary, important tool” to address misuse of funds and ensure the money goes toward helping rural communities, they are also “a dangerous tool,” said Morgan, whose organization represents rural hospitals and clinics.

CMS did not respond to multiple requests for comment.

States must file progress reports . They then have to commit their first-year funding and Sept. 30, 2027, to spend it.

States are progressing at wildly different rates, with some still developing grant applications and others already distributing money, created by Morgan’s rural health association.

In late January, Iowa became . The tracker shows that most states have opened grant applications, but 11 others, including Wyoming, Maine, and Colorado, have yet to post any funding opportunities.

CMS’ tight control over state programs is one reason for such disparity in progress.

Instead of typical grants, the rural health program uses cooperative agreements, which require a back-and-forth partnership, said Charlie Sagona, a grant specialist at Assel Grant Services, a consulting firm that helps organizations manage grants.

“You are going to be working very, very closely with them; things will ebb and flow and change and move,” said Sagona, who is helping several large hospital systems interested in winning some of the rural funding.

Kate Sapra, deputy director of CMS’ Office of Rural Health Transformation, said at a May event that the agency has “many avenues of oversight.” Staffers are tracking applications for state funding and “looking to see when contracts are executed,” she said.

Sapra said the agency wants to “have conversations with states before they get to the point” of putting out something that’s not allowed. It’s “really important to us” for the funding to reach rural providers, she added.

Sapra said her office has filled about half of 30 new slots for project officers. The officers and the states check in “at least twice a month, if not on a weekly basis.”

Vermont Medicaid Director Jill Mazza Olson, who led her state’s rural health application, said the officers are “very responsive.”

Vermont is one of the states that had to ditch or tweak its plans. Olson said the state pulled its plan to increase housing for rural healthcare workers after federal officials said they would evaluate the proposal based on the agency’s guidelines for construction projects at healthcare facilities. Those rules allow only “minor” renovations to existing buildings or campuses.

In Colorado, state leaders changed grant eligibility rules after they “received feedback” from CMS and healthcare providers, said Marc Williams, a spokesperson for the state’s Department of Health Care Policy and Financing.

Wyoming legislators and state officials spent months designing, discussing, and voting on a plan to invest most of its award into a perpetuity fund that could have generated $28.5 million for the state to spend every year, “forever,” according to .

The state had to pull the idea because it “was a degree too innovative for CMS to swallow,” said Republican state Sen. Charles Scott, a veteran lawmaker and cattle rancher. “This whole thing has been a bit of a disappointment to us in Wyoming.”

Stefan Johansson, director of the state’s health department, said Wyoming’s final spending plan wasn’t approved until mid- to late May. He said the department hopes to begin awarding money in late summer or early fall.

“Make no mistake — it is a very compressed timeline,” he said.

Across the country, Maine was forced to rework its plan to reimburse hospitals and clinics when they provide to certain uninsured patients.

Letourneau said during her March remarks that federal officials rejected this idea because “provider payments had to be more directly linked to a rural transformation kind of activity.”

Lindsay Hammes, a spokesperson for Maine’s health department, told 51ÊÓƵ Health News that funding will instead help providers transition to reimbursement models that aren’t based on how many patients they treat.

Reworked plans call for spending $28.5 million to support providers, Letourneau said in March.

“But there definitely will be more strings attached.”

51ÊÓƵ Health News correspondent Darius Tahir contributed to this report.

This article first appeared on 51ÊÓƵ Health News and is republished here under a .

But in December, that changed. The Tobiassens decided to cancel their insurance when Rebecca saw the cost of their monthly premiums would jump from $130 to more than $550.

“It makes no sense,” she said. “It’s not worth it anymore.”

The couple own and are the only employees of a small auto shop just west of Appalachian State University in the North Carolina mountains. Rebecca worries about her husband, whose work as a mechanic can be dangerous. A spring once shot a metal ball joint into their garage wall like a gun. A heavy object crushed Ross’ thumb. In 2020, Ross became mostly blind in one eye after repeatedly getting metal shards in it and developing an infection in his cornea.

The Tobiassens are among the Americans who canceled their ACA coverage after Congress allowed enhanced tax credits that helped pay for insurance plans to expire at the end of 2025. The Tobiassens benefited from those tax credits — like expected to drop or be dropped from their coverage as the year progresses, unable to keep up with the higher costs.

Established by the Biden administration’s American Rescue Plan Act during the covid pandemic, the expanded subsidies reduced monthly premiums for many families and prompted a tidal wave of new sign-ups, doubling ACA enrollment to .

The Centers for Medicare & Medicaid Services is expected to on how many people are no longer covered under the ACA, but an , citing Wakely Consulting Group research, showed enrollment could drop from over 22 million at the end of 2025 to as low as 16.5 million in 2026. 

In North Carolina, individual ACA sign-ups for 2026 were down 22% compared with the year before, a greater drop than any other state, amounting to a decrease of more than 213,000 people, . While the Tobiassens’ two teenage daughters remain on Medicaid, Rebecca said the new prices showed that the federal government doesn’t care about families like hers.

“We’ve known that you don’t care about us,” she said, “but you’re making it plain and simple now.”

The couple’s insurance hadn’t helped them cover all their medical needs. When the pain from Ross’ eye infection worsened five years ago, Rebecca insisted he go to a specialist, who told them that fixing the eye through cornea replacement surgery and require Ross to take six months off.

Ross chose a less expensive treatment to kill nerves in the eye instead.

The couple know they’re taking a risk by not being insured. If something were to happen, they could face an enormous medical bill.

Ross, 47, said the blindness in the one eye doesn’t significantly affect his job. He works long hours, sometimes into the night to keep up with demand.

“I try not to think about it too much,” he said. “I just work.”

Uninsured, With No Backup Plan, After Obamacare Became Unaffordable

Rebecca Tobiassen, 44  
Sugar Grove, North Carolina 

Rebecca Tobiassen owns a small auto repair shop with her husband, Ross, in the western North Carolina mountains. She says their family could no longer afford Affordable Care Act insurance after tax credits expired last year and their monthly premiums shot up from $130 to more than $550. They have no immediate plans to sign up for coverage elsewhere and are saving up for out-of-pocket expenses instead. “We just need to be able to afford to get help when we seriously hurt ourselves,” she said of the U.S. healthcare system. 

Katie Alexander oversees volunteers for Pisgah Legal Services, a western North Carolina nonprofit that helps low-income people secure health insurance. Alexander has helped North Carolina and Tennessee residents try to get ACA marketplace plans since Obamacare’s launch. She said she’s never seen anything like this year. 

Nearly 100 Pisgah clients, out of about 700 that Alexander’s team worked with during open enrollment, decided to drop insurance this year, and many others chose cheaper ACA plans with less coverage, Alexander said. 

Alexander said the people who have dropped their coverage include Lyft and Uber drivers. They’re trying to start their own businesses. They are artists and people who can work only part-time, because they’re chronically ill. Some are unable to get insurance through their employers, or they make too much to be on Medicaid.

“Even for folks who don’t have chronic illnesses,” Alexander said, “there’s just this nagging at the back of your mind, kind of constantly, of: ‘Don’t get hurt. Don’t get sick. Because you can’t afford that.’”

ACA premiums and deductibles steadily increased for years starting in 2022, then spiked during the enrollment period for 2026 plans, . The Tobiassens have seen every dip and rise in plan costs since 2014 when the plans launched. They joined immediately and paid about $30 a month, Rebecca Tobiassen said.  

“You actually felt like you were benefiting,” she said.

But through the years as the marketplace became more expensive, the couple made concessions, switching at one point from a silver plan — historically the — to a bronze. The plan mostly provided for the couple’s basic needs.

As they saw their deductibles and premiums rise over more than a decade, Rebecca feared the day would come when they could no longer afford even the cheapest plan.

“Plans are unaffordable, no matter how you cut it,” said , a healthcare policy researcher at the University of Colorado Anschutz School of Medicine. “It’s just who is shouldering the unaffordability.” 

Gidwani and health economist , in a , found that most bronze plans, the cheapest ACA options for many, would be unaffordable without subsidies for the average person using the federal healthcare coverage.

Without subsidies, many families using these plans don’t make enough to afford premiums or deductibles, Gidwani’s research shows.

People who drop health insurance also change what’s known as the “risk pool,” Gidwani said, when a group of people share financial hazards. 

If healthier people drop out of the risk pool, fewer people subsidize the people who get sick, Gidwani said. That means premiums for the people who get sick will increase again in the future, she added.

“That becomes what we call a death spiral,” Gidwani said.

Even if the subsidies hadn’t expired, taxpayers would have borne an estimated over the next decade to cover them, Gidwani’s study noted.

After dropping coverage they’d relied on for 11 years, the Tobiassens have no plans to return to the ACA marketplace. They looked into alternative options through a faith-based healthcare organization but decided to go without.

For now, they don’t have a plan B. They’ve set aside some money for a medical emergency. And if their savings run out, Rebecca Tobiassen said, they have a couple of last resorts to lean on: credit cards or family members.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact 51ÊÓƵ Health News and share your story.

This article first appeared on 51ÊÓƵ Health News and is republished here under a .