When the Indian Health Service can’t provide medical care to Native Americans, the federal agency can refer them elsewhere. But each year, it rejects tens of thousands of requests to fund those appointments, forcing patients to go without treatment or pay daunting medical bills out of their own pockets.

In theory, Native Americans are entitled to free health care when the Indian Health Service foots the bill at its facilities or sites managed by tribes. In reality, the agency is chronically underfunded and understaffed, leading to limited medical services and leaving vast swaths of the country without easy access to care.

Its Purchased/Referred Care program aims to fill gaps by paying outside providers for services patients might be unable to get through an agency-funded clinic or hospital, such as cancer treatment or pregnancy care. But resource shortages, complex rules, and administrative fumbles severely impede access to the referral program, according to patients, elected officials, and people who work with the agency.

The Indian Health Service, part of the Department of Health and Human Services, serves about 2.6 million Native Americans and Alaska Natives.

Native Americans qualify for the referred-care program if they live on tribal land — only 13% do — or within their nation’s “delivery area,” which usually includes surrounding counties. Those who live in another tribe’s delivery area are eligible in limited cases, while Native Americans who live beyond such borders are excluded.

Eligible patients aren’t guaranteed funding or timely help, however. Some of the Indian Health Service’s 170 service units exhaust their annual pool of money or reserve it for the most serious medical concerns.

Referred-care programs denied or deferred nearly $552 million in spending for about 120,000 requests from eligible patients in fiscal year 2022.

As a result, Native Americans might forgo care, increasing the risk of death or serious illness for people with preventable or treatable medical conditions.

The problem isn’t new. Federal watchdog agencies have reported concerns with the program for decades.

Connie Brushbreaker, a member of the Rosebud Sioux Tribe, has been denied or waitlisted for funding at least 14 times since 2018. She said it doesn’t make sense that the agency sometimes refuses to pay for treatment that will later be approved once a health problem becomes more serious and expensive.

“We try to do this preventative stuff before something gets to the point where you need surgery,” said Brushbreaker, who lives on her tribe’s reservation in South Dakota.

Many Native Americans say the U.S. government is violating its treaties with tribal nations, which often promised to provide for the health and welfare of tribes in return for their land.

“I keep having my elders here saying, ‘There’s treaty rights that say they’re supposed to be able to provide these services to us,’” said Lyle Rutherford, a council member for the Blackfeet Nation in northwestern Montana who said he also worked at the Indian Health Service for 11 years.

Native Americans have high rates of diseases compared with the general population, and a median age of death that’s 14 years younger than that of white people. Researchers who have studied the issue say many problems stem from colonization and government policies such as forcing Indigenous people into boarding schools and isolated reservations and making them give up healthy traditions, including bison hunting and religious ceremonies. They also cite an ongoing lack of health funding.

Congress budgeted nearly $7 billion for the Indian Health Service this year, of which roughly $1 billion is set aside for the referred-care program. A committee of tribal health and government leaders has long made funding recommendations that far exceed the agency’s budget. Its latest report says the Indian Health Service needs $63 billion to cover patients’ needs for fiscal year 2026, including $10 billion for referred care.

Brendan White, an agency spokesperson, said improving the referred-care program is a top goal of the Indian Health Service. He said about 83% of the health units it manages have been able to approve all eligible funding requests this year.

White said the agency recently improved how referred-care programs prioritize such requests and it is tackling staff shortages that can slow down the process. An estimated third of positions within the referred-care program were unfilled as of June, he said.

The Indian Health Service also recently expanded some delivery areas to include more people and is studying whether it can afford to create statewide eligibility in the Dakotas.

Jonni Kroll of the Little Shell Tribe of Chippewa Indians of Montana doesn’t qualify for the referred-care program because she lives in Deer Park, Washington, nearly 400 miles from her tribe’s headquarters.

She said tying eligibility to tribal lands echoes old government policies meant to keep Indigenous people in one place, even if it means less access to jobs, education, and health care.

Kroll, 58, said she sometimes worries about the medical costs of aging. Moving to qualify for the program is unrealistic.

“We have people that live all across the nation,” she said. “What do we do? Sell our homes, leave our families and our jobs?”

People applying for funding face a system so complicated that the Indian Health Service created flowcharts outlining the process.

Misty and Adam Heiden, of Mandan, North Dakota, experienced that firsthand. Their nearest Indian Health Service hospital no longer offers birthing services. So, late last year, Misty Heiden asked the referred-care program to pay for the delivery of their baby at an outside facility.

Heiden, 40, is a member of the Sisseton-Wahpeton Oyate, a South Dakota-based tribe, but lives within the Standing Rock Sioux Tribe’s delivery area. Native Americans who live in another tribe’s area, as she does, are eligible if they have close ties. Even though she is married to a Standing Rock tribal member, Heiden was deemed ineligible by hospital staff.

Now, the family has had to cut into its grocery budget to help pay off more than $1,000 in medical debt.

“It was kind of a slap in the face,” Adam Heiden said.

White, the Indian Health Service spokesperson, said many providers offer educational materials to help patients understand eligibility. But the Standing Rock rules, for example, aren’t fully explained in its brochure.

When patients are eligible, their needs are ranked using a medical priority list.

Connie Brushbreaker’s doctor at the Indian Health Service hospital in Rosebud, South Dakota, said she needed to see an orthopedic surgeon. But hospital staffers said the unit covers only patients at imminent risk of dying.

She said that, at one point, a worker at the referred-care program told her she could handle her pain, which was so intense she had to limit work duties and rely on her husband to put her hair in a ponytail.

“I feel like I am being tossed aside, like I do not matter,” Brushbreaker wrote in an appeal letter. “I am begging you to reconsider.”

The 55-year-old was eventually approved for funding and had surgery this July, two years after injuring her shoulder and four months after her referral.

Patients said they sometimes have trouble reaching referred-care departments due to staffing problems.

Patti Conica, a member of the Standing Rock Sioux Tribe, needed emergency care after developing a serious infection in June 2023. She said she applied for funding to cover the cost but has yet to receive a decision on her case despite repeated phone calls to referred-care staffers and in-person visits.

“I’ve been given the runaround,” said Conica, 58, who lives in Fort Yates, North Dakota, her tribe’s headquarters.

She now faces more than $1,500 in medical bills, some of which have been turned over to a collection agency.

Tyler Tordsen, a Republican state lawmaker and member of the Sisseton-Wahpeton Oyate in South Dakota, says the referred-care program needs more funding but officials could also do a “better job managing their finances.”

Some service units have large amounts of leftover funding. But it’s unclear how much of this money is unspent dollars versus earmarked for approved cases going through billing.

Meanwhile, more tribes are managing their health care facilities — an arrangement that still uses agency money — to try new ways to improve services.

Many also try to help patients receive outside care in other ways. That can include offering free transportation to appointments, arranging for specialists to visit reservations, or creating tribal health insurance programs.

For Brushbreaker, begging for funding “felt like I had to sell my soul to the IHS gods.”

“I’m just tired of fighting the system,” she said.

Have you had an experience navigating the Indian Health Service’s Purchased/Referred Care program that you’d like to share with KFF Health News for our reporting? Tell us here.

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Christina Kashiwada was traveling for work during the summer of 2018 when she noticed a small, itchy lump in her left breast.

She thought little of it at first. She did routine self-checks and kept up with medical appointments. But a relative urged her to get a mammogram. She took the advice and learned she had stage 3 breast cancer, a revelation that stunned her.

“I’m 36 years old, right?” said Kashiwada, a civil engineer in Sacramento, California. “No one’s thinking about cancer.”

About 11,000 Asian American and Pacific Islander women were diagnosed with breast cancer in 2021 and about 1,500 died. The latest federal data shows the rate of new breast cancer diagnoses in Asian American and Pacific Islander women — a group that once had relatively low rates of diagnosis — is rising much faster than that of many other racial and ethnic groups. The trend is especially sharp among young women such as Kashiwada.

About 55 of every 100,000 Asian American and Pacific Islander women under 50 were diagnosed with breast cancer in 2021, surpassing the rate for Black and Hispanic women and on par with the rate for white women, according to age-adjusted data from the National Institutes of Health. (Hispanic people can be of any race or combination of races but are grouped separately in this data.)

The rate of new breast cancer cases among Asian American and Pacific Islander women under 50 grew by about 52% from 2000 through 2021. Rates for AAPI women 50 to 64 grew 33% and rates for AAPI women 65 and older grew by 43% during that period. By comparison, the rate for women of all ages, races, and ethnicities grew by 3%.

Researchers have picked up on this trend and are racing to find out why it is occuring within this ethnically diverse group. They suspect the answer is complex, ranging from cultural shifts to pressure-filled lifestyles — yet they concede it remains a mystery and difficult for patients and their families to discuss because of cultural differences.

Helen Chew, director of the Clinical Breast Cancer Program at UC Davis Health, said the Asian American diaspora is so broad and diverse that simple explanations for the increase in breast cancer aren’t obvious.

“It’s a real trend,” Chew said, adding that “it is just difficult to tease out exactly why it is. Is it because we’re seeing an influx of people who have less access to care? Is it because of many things culturally where they may not want to come in if they see something on their breast?”

There’s urgency to solve this mystery because it’s costing lives. While women in most ethnic and racial groups are experiencing sharp declines in breast cancer death rates, about 12 of every 100,000 Asian American and Pacific Islander women of any age died from breast cancer in 2023, essentially the same death rate as in 2000, according to age-adjusted, provisional data from the Centers for Disease Control and Prevention. The breast cancer death rate among all women during that period dropped 30%.

The CDC does not break out breast cancer death rates for many different groups of Asian American women, such as those of Chinese or Korean descent. It has, though, begun distinguishing between Asian American women and Pacific Islander women.

Nearly 9,000 Asian American women died from breast cancer from 2018 through 2023, compared with about 500 Native Hawaiian and Pacific Islander women. However, breast cancer death rates were 116% higher among Native Hawaiian and Pacific Islander women than among Asian American women during that period.

Rates of pancreatic, thyroid, colon, and endometrial cancer, along with non-Hodgkin lymphoma rates, have also recently risen significantly among Asian American and Pacific Islander women under 50, NIH data show. Yet breast cancer is much more common among young AAPI women than any of those other types of cancer — especially concerning because young women are more likely to face more aggressive forms of the disease, with high mortality rates.

“We’re seeing somewhere almost around a 4% per-year increase,” said Scarlett Gomez, a professor and epidemiologist at the University of California-San Francisco’s Helen Diller Family Comprehensive Cancer Center. “We’re seeing even more than the 4% per-year increase in Asian/Pacific Islander women less than age 50.”

Gomez is a lead investigator on a large study exploring the causes of cancer in Asian Americans. She said there is not yet enough research to know what is causing the recent spike in breast cancer. The answer may involve multiple risk factors over a long period of time.

“One of the hypotheses that we’re exploring there is the role of stress,” she said. “We’re asking all sorts of questions about different sources of stress, different coping styles throughout the lifetime.”

It’s likely not just that there’s more screening. “We looked at trends by stage at diagnosis and we are seeing similar rates of increase across all stages of disease,” Gomez said.

Veronica Setiawan, a professor and epidemiologist at the Keck School of Medicine of the University of Southern California, said the trend may be related to Asian immigrants adopting some lifestyles that put them at higher risk. Setiawan is a breast cancer survivor who was diagnosed a few years ago at the age of 49.

“Asian women, American women, they become more westernized so they have their puberty younger now — having earlier age at [the first menstrual cycle] is associated with increased risk,” said Setiawan, who is working with Gomez on the cancer study. “Maybe giving birth later, we delay childbearing, we don’t breastfeed — those are all associated with breast cancer risks.”

Moon Chen, a professor at the University of California-Davis and an expert on cancer health disparities, added that only a tiny fraction of NIH funding is devoted to researching cancer among Asian Americans.

Whatever its cause, the trend has created years of anguish for many patients.

Kashiwada underwent a mastectomy following her breast cancer diagnosis. During surgery, doctors at UC Davis Health discovered the cancer had spread to lymph nodes in her underarm. She underwent eight rounds of chemotherapy and 20 sessions of radiation treatment.

Throughout her treatments, Kashiwada kept her ordeal a secret from her grandmother, who had helped raise her. Her grandmother never knew about the diagnosis. “I didn’t want her to worry about me or add stress to her,” Kashiwada said. “She just would probably never sleep if she knew that was happening. It was very important to me to protect her.”

Kashiwada moved in with her parents. Her mom took a leave from work to help take care of her.

Kashiwada’s two young children, who were 3 and 6 at the time, stayed with their dad so she could focus on her recovery.

“The kids would come over after school,” she said. “My dad would pick them up and bring them over to see me almost every day while their dad was at work.”

Kashiwada spent months regaining strength after the radiation treatments. She returned to work but with a doctor’s instruction to avoid lifting heavy objects.

Kashiwada had her final reconstructive surgery a few weeks before COVID lockdowns began in 2020. But her treatment was not finished.

Her doctors had told her that estrogen fed her cancer, so they gave her medicine to put her through early menopause. The treatment was not as effective as they had hoped. Her doctor performed surgery in 2021 to remove her ovaries.

More recently, she was diagnosed with osteopenia and will start injections to stop bone loss.

Kashiwada said she has moved past many of the negative emotions she felt about her illness and wants other young women, including Asian American women like her, to be aware of their elevated risk.

“No matter how healthy you think you are, or you’re exercising, or whatever you’re doing, eating well, which is all the things I was doing — I would say it does not make you invincible or immune,” she said. “Not to say that you should be afraid of everything, but just be very in tune with your body and what your body’s telling you.”

Phillip Reese is a data reporting specialist and an associate professor of journalism at California State University-Sacramento.

This article was produced by KFF Health News , which publishes California Healthline , an editorially independent service of the California Health Care Foundation . Supplemental support comes from the Asian American Journalists Association-Los Angeles through The California Endowment.

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

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

The settlement brings the total amount the city has won from opioid companies to more than $322 million, Mayor Brandon M. Scott said. Baltimore’s lawsuit against the remaining companies is set to go to trial next week.

“This settlement marks another major victory for the City of Baltimore and further validates our decision to carry on in the fight to hold these companies accountable,” Scott said in a statement.

The city opted out of previous global settlements with Teva and other major opioid companies to pursue its own lawsuit in hopes of winning larger payouts. The settlement announced Monday is more than seven times what Baltimore would have received as part of a national settlement with Teva, the city said in a news release. Teva also will pay out the full $80 million by July 2025.

“In total, the city has now secured more than three times the total amount it would have received from all available global settlements with opioid defendants,” the city said.

The Teva deal is the fourth settlement announced in connection with the city’s opioid lawsuit, which alleges opioid manufacturers and distributors irresponsibly marketed addictive painkillers and failed to block unusually large orders of drugs to Baltimore pharmacies. More than half a billion legal opioids flooded the Baltimore area between 2006 and 2019; the city claims the glut contributed to its ongoing overdose crisis.

Teva Pharmaceuticals did not respond to a request for comment Monday afternoon.

Baltimore previously announced $45 million settlements with Allergan and CVS and a $152.5 million settlement with Cardinal Health, a major opioid distributor.

The city did not say how much of the Teva settlement will go to its outside counsel in the opioid lawsuit, the New York law firm Susman Godfrey. Nearly half of the Allergan settlement went to Susman Godfrey, an amount that included both attorney fees and a $5 million reimbursement for expenses the firm incurred during the litigation. Law firms that take cases on contingency typically keep about a third of any proceeds.

Under the Teva settlement, the city said it will allocate $5 million for education and outreach about the 988 suicide and crisis hotline, $3 million to Penn North Recovery Center and $2 million to the BMore POWER program of Baltimore Behavioral Health System, which is a outreach team of peers working to prevent overdoses.

“This new funding will allow Bmore POWER to expand its reach and connect with more people who use drugs and offer tools and information to ensure their safety and save lives in our communities,” Baltimore Behavioral Health System said in a statement Monday.

The remaining money will be distributed under a plan Scott outlined last month for how the city will manage the opioid settlement money. In an executive order, Scott established an opioid restitution fund and detailed guidelines for how the money can be used. The city also plans to create a Restitution Advisory Board to review grant applications and make recommendations for how to spend the money.

The executive order also created two new positions, an executive director of overdose response and an opioid restitution program manager who will support the advisory board.

“What an incredible woman,” said Dr. Susan J. Dulkerian, chair of Mercy Medical Center’s Department of Pediatrics.

“Her forte was her calm, kind empathy and demeanor toward her families and students. She was an extremely kind person,” Dr. Dulkerian said.

Celeste Woodward, daughter of Dr. Theodore E. Woodward, a noted University of Maryland medical educator and a Nobel Prize-nominated researcher in infectious diseases, and Dr. Celeste Woodard, a physician, was born in Baltimore and raised in Roland Park.

Dr. Woodward, who always used her maiden name professionally, was a 1964 graduate of Roland Park Country School.

She attended Wellesley College, the University of Pennsylvania Nursing School and the University of Maryland, College Park, but did not earn a bachelor’s degree.

“At Maryland, in her fourth year, they required her to take a course in public speaking, but she didn’t want to do that,” said her daughter, Grace Cleveland of Charlottesville.

Not having a bachelor’s degree did not deter Dr. Woodward from enrolling in medical school at the University of Maryland, from which she graduated in 1972.

While in medical school, she became the first female member of the Rush Medical Club, the oldest student medical club in the country.

She completed both an internship and residency in pediatrics at what was then D.C. Children’s Hospital, now Children’s National Hospital.

From 1974 to 1975, she completed a fellowship in infectious diseases at Maryland.

She was on the pediatric faculty at Maryland from 1975 to 1984 when she joined Mercy Medical Center as a pediatrician and was also an attending physician in the medical center’s outpatient clinic.

While at Mercy, she had a joint appointment at the University of Maryland Medical School, where, as a clinical professor of pediatrics, she continued to train and teach medical students.

“She was the consummate educator. She led by example, and while a woman of few words, they learned plenty from her and that her words meant a lot,” said Dr. Dulkerian.

“It wasn’t uncommon to see trainees or residents having confidential meetings in her office, and I know those confidential conversations meant a great deal to them,” she said.

Dr. Woodward, who was known as “Sis,” retired in 2004.

Roland Park Country School continued to be a thread throughout her lifetime, and in 1998, she became the second woman and first alumna to chair the RPCS board, while becoming the school’s longest-serving trustee.

“She was full of integrity, empathy and had a willingness to work hard. We knew her as a compassionate physician,” said former head of school Jean Waller Brune, RPCS Class of 1960, who headed the school from 1992 to 2016.

“She was a person who lived her ideals. She was an alum of the school and a parent. Her daughter was a graduate of the school,” Ms. Brune said. “Sis was an inspiring person to work with and learn from. She definitely helped me as head of school. She gave sound advice, wisdom and was always willing to listen.”

Prior to moving to Charlottesville some years ago, she and her husband of 52 years, Dr. Mark Applefeld, a retired physician, lived in Poplar Hill, where they graciously hosted RPCS Class of 1964 reunion dinners.

Dr. Woodward was an avid tennis player, reader and baker. She was also an accomplished needlepointer and enjoyed making Christmas ornaments for her grandchildren.

She was a former longtime communicant of the Shrine of the Sacred Heart Roman Catholic Church in Mount Washington.

A celebration of life gathering for Dr. Woodward will be held on the RPCS campus, 5204 Roland Avenue, at 12:30 p.m. Sept. 14 in the Sinex Theater.

In addition to her husband and daughter, Dr. Woodward is survived by her son, Lewis Applefeld of Rye, New York; and five grandchildren.

The Green Prairie Independent School District canceled classes on Wednesday and Thursday, as well as multiple after-school events and extracurriculars. The City of Green Prairie earlier that day acknowledged the contaminant and encouraged residents not to use tap water.

The school district noted that grab-and-go lunches would be made available for students. City workers also distributed free bottled water to residents while officials worked to remedy the situation.

The city’s most recent update as of Thursday afternoon said its aviation director was delivering water samples to a lab in Corpus Christi.

Green Prairie Mayor Ron Jensen explained in a press conference the contaminant entered the water after firefighters used an environmentally friendly foam to extinguish a large fire.

“We may or may not have to go to a boil, which in my opinion is critical,” he said. “When you lose water pressure, there’s an automatic boil notice.”

Jensen explained the foam is nontoxic and will not cause irritation to eyes or skin. The do-not-use warning, he said, was out of an abundance of caution.

“We haven’t had any calls of anybody getting sick,” he said. “I’ve got to assume people showered in it last night. I’ve got to assume we had some people drink it. We have had no incidents of anybody having any health issues.”

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The study tested blood samples from more than 500 women.

All the women were about 10 weeks pregnant when the samples were initially taken, and scientists evaluated the samples for different forever chemicals.

Researchers found that those with higher blood levels of the chemicals both weighed more and had more body fat when they returned for a follow-up visit between 17 to 20 years later.

“If they have a chemistry that allows them to interact with the receptors on a cell surface and if that’s a cell that’s a fat cell, then it might be sending the signal for that cell to take on more fat,” said Nora Demers, an associate professor in the Department of Biological Studies at Florida Gulf Coast University.

PFAS are known to linger in the human body, interfere with hormones and cause a wide range of health problems. Considering the findings, researchers are stressing the need to recognize pregnancy as a sensitive time for chemical exposure that could lead to future heart issues.

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LOS ANGELES — In April, a group of Orange County parents flew to Sacramento to attend a conference hosted by Disability Voices United, an advocacy group for people with disabilities and their families.

They wanted to emphasize three issues to state officials at the event: the paucity of mental health care for children with developmental disabilities, the confusing mess of government systems meant to help them, and the gaps in availability of day-to-day caregiving.

Among them was Christine LyBurtus, a single mom living in Fullerton. Last fall, after repeated rounds of 911 calls and emergency hospitalizations, she had made the agonizing decision to move her son, Noah, who is autistic, into a state-operated facility for at least a year.

LyBurtus had struggled to find the support she needed to keep him at home. “Families are being forced to give up their children to group homes and treatment centers over 12 hours from their homes … or out of the state of California entirely,” she told the crowd at the conference.

“I beg you to hear us,” she said to state officials before turning from the microphone.

Despite the growing diagnosis of autism, which has been estimated to affect more than 2 million children and teens across the country, experts and advocates have bemoaned glaring gaps in services to meet the mental health needs of autistic youth.

Some researchers have estimated that upward of 90% of autistic youth have overlapping conditions like anxiety, depression or ADHD. Many have suffered alarming levels of trauma.

Yet “there are very few specialized facilities in the country that meet the unique needs of individuals with autism and co-occurring mental health conditions,” especially in crisis situations, said Cynthia Martin, senior clinical psychologist at the Child Mind Institute, which is based in New York.

Between 2020 and 2021, the number of California children and teens served by the state developmental disability system who were deemed to have “complex needs” — a state term for those who needed a range of crisis services or landed in a locked psychiatric ward — rose from 536 to 677, according to a report released last year by the California Department of Developmental Services.

California has been working to build more facilities to house and support such youth, including STAR homes that provide “crisis stabilization” for roughly a year, like the one into which Noah moved. But the state has seen an uptick in the number of people in need of such programs, as well as more former residents boomeranging back for “further stabilization,” the state report said.

As of this summer, the STAR homes could accommodate only 15 teens across the state; the one that accepted Noah budgets for more than $1 million per resident annually.

There are other community facilities where developmentally disabled youth in crisis can be placed, but “there remains a critical need for a ‘can’t say no’ option for individuals whom private sector vendors cannot or will not serve,” the state report concluded.

Autistic people and their families have also lamented that they cannot find adequate help in their communities before they reach a crisis point. Researchers have found that mental health workers are often unprepared to work with people with intellectual or developmental disabilities or may chalk up symptoms to their disabilities, rather than overlapping needs.

“It’s pretty common for a mental health practitioner to turn away someone with a developmental disability or say, ‘I don’t serve that population,’” said Zoe Gross, director of advocacy for the Autistic Self Advocacy Network.

Alison D. Morantz, director of the Stanford Intellectual and Developmental Disabilities Law and Policy Project, called it a “scandal” that amid a scarcity of psychiatric beds for youth, “if a family member discloses that their child is on the autistic spectrum, they can say, ‘No thank you.’”

“It puts parents in impossible situations,” she said.

The biggest challenges for many families of autistic youth often surround aggression, which isn’t a core feature of autism, but the symptom of other issues that need to be uncovered, child and adolescent psychiatrist Dr. Matthew Siegel told a federal committee last year.

“You have to look underneath or in front of that … for what could be contributing or what is driving this aggression,” said Siegel, founder of the Autism and Developmental Disorders Inpatient Research Collaborative. He and other researchers have seen promising results from specialized units at hospitals, but few exist — “not even one per state.”

“Even specialized clinics that can work on these challenges are quite rare,” he said.

The Supreme Court has ruled that institutionalizing people with disabilities who could live in the community is discriminatory if a community placement “can be reasonably accommodated.” Federal investigations have, at times, faulted states for failing to provide needed services for people to stay in their homes or communities.

The law “requires that services are provided in the most integrated setting appropriate to the needs of a person with a disability,” according to the U.S. Department of Health and Human Services.

But the struggle to find needed services can end up pushing autistic people with mental health needs out of their communities. Bonnie Ivers, director of clinical services for the Regional Center of Orange County, said last year that “more and more families are having to review options that are outside of our county.”

Some Californians even go outside the state: As of June 2022, there were 49 youth with “complex needs” getting services outside of California, and an additional 33 “at risk of being referred to out-of-state resources,” according to the developmental services department.

In the following year, that number grew to 57 youth out of state — and an additional 64 who might be at risk of joining them. The numbers may actually be higher: The state agency says it learns about out-of-state placements only when families inform the regional centers that coordinate developmental disability services.

Nancy Bargmann, director of the California Department of Developmental Services, said their goal is to provide “a continuum of supports” so that families “don’t need to make that really hard decision of having their child not live at home.”

California has launched more than a dozen teams focused on crisis prevention, called START teams, which it says have helped keep people in their homes. Their services include connecting different systems that assist families, such as mental health providers and disability services.

But they do not yet exist everywhere in the state. California also has mobile “Crisis Assessment Stabilization Teams” — or CAST — that are meant for people who have exhausted other kinds of help or are at risk of having to move into more restrictive settings. There were three of them as of this spring, according to the developmental services department.

Judy Mark, president of the advocacy group Disability Voices United, argued it is counterproductive to try to stabilize a child away from his or her family. If at all possible, she said, California should be ensuring constant support in the home, which she argued would also be less costly than caring for a child in a STAR facility.

But disability services providers say that getting such caregivers has continued to be a challenge, with state rates for such workers outstripped by what they can earn elsewhere. Increases in those provider rates have been slowly phased in over time, with the next bump slated for January.

In many cases, “what you’d want to see is somebody, 24 hours a day, in the home helping the parent,” said Larry Landauer, executive director of the Regional Center of Orange County. But “that’s where we have been just drastically short on staffing.”

All the gaps in the system can come to a head when young people with developmental disabilities hit puberty, especially if they face “the inability to communicate in such a complex and confusing time,” said California Commission on Disability Access member Hector Ramírez, who is autistic and lives in the San Fernando Valley.

If autistic teens and their families cannot get the support they need, Ramírez said, it “has compounding consequences that result in people just getting worse — when they shouldn’t be getting worse.”

©2024 Los Angeles Times. Visit at latimes.com. Distributed by Tribune Content Agency, LLC.

Many would agree with you. We often hear people asking, “Where has the time gone? It just seems like yesterday.” 

Can you remember sitting through a boring lecture? Five minutes may have felt like an hour. Or how about a boring sermon? That hour may have seemed like it was forever. Contrast that sense of time to being at a party. Time sprints by when having a good time, working on something you love and being engaged in new experiences. 

We know time does not slow down, it’s our perception of it that does. This is not a new concept. Psychologist William James wrote about the phenomenon of time perception in his Principles of Psychology in 1890. 

Here are some theories that affect our perception of time: 

Theory No. 1: Years are relatively smaller. As we age, each year is a smaller proportion of our time. For a 10-year-old, that birthday represents 1/10 of life which is a big portion. For an 80-year-old, University of Michigan psychology professor Cindy Lustig told the Huffington Post, that birthday is 1/80 of life which is a smaller portion that contributes to the feeling that it went by quickly. Each year feels shorter compared to the total time we have lived and therefore seems to go by faster. 

Theory No. 2: Theory of firsts. When we’re young, Diana Raab wrote in a Psychology Today piece, we encounter a lot of “firsts.” They might be our first kiss, our first love, getting our first car or the first day of college. It might be learning to swim or falling off a bike. We pay attention to the details of our unique and memorable experiences. The more details we can recall, the better we remember them. As we age, we have similar experiences over and over again, perceived time goes more quickly. 

Theory No. 3: Brain function. This helps explain the theory of firsts. Our brain lumps time together when the days or weeks are similar. So, for an 80-year-old who may be doing the same or similar things daily, time gets blended together in one’s mind, making it feel like it went by quickly. What seems new and exciting in a single day is what makes a day or month feel different, slowing our sense of time. (Note: Many 80-year-olds also experience new and familiar experiences daily). 

Theory No. 3a: More on brain function. Adrian Bejan, professor of mechanical engineering at Duke University, has a theory based on neural signal processing. With age, he notes the rate we process visual information slows down, contributing to our experience of time speeding up. In other words, “time does not go faster, we just go slower, cognitively speaking,” as quoted in a 2024 Huffington Post piece. 

So how to live a life where time moves more slowly?

• Fill your time with new experiences. It’s a way to counteract routine. A research study published in the Journal of Experimental Psychology found the perception of time is shorter when engaged in routine activities. So, accept challenges, learn new skills and ask questions. Just step outside the norm. 
• Make meaningful progress. Time passes quickly when we do not take action. Increasing productivity and making progress on projects and goals slows one’s perception of time and builds motivation. 
• Practice mindfulness. That means focusing on the present moment and being aware of what you are doing and where you are. It’s paying attention to details of an experience, incorporating all senses in the process. And make sure to take a few breaths. 
• Go outside to nature. Take time to observe the trees and clouds in the sky; listen to the birds and watch the dolphins and waves in the ocean. This magically slows down time and is calming, writes Raab in Psychology Today. 
• Take time for reflection. Consider journaling. This can be memories of one’s youth, a gratitude list or events of a vacation or just a day. One can also recall details of experiences and share them with others through conversation, photos or in writing.

So, yes, time seems to go by quickly with age. But that can change by filling our lives with new activities, learning something new, being reflective, enjoying nature and doing something that makes us feel useful and productive. Then we will not be going through the motions of life; rather we will savor our moments, days and months with satisfaction and pleasure. 

Thank you, D.L., happy birthday and thank you for your good question. Time is our gift. Let’s use it well. And let’s all make kindness the norm. 

Helen Dennis is a nationally recognized leader on issues of aging and the new retirement with academic, corporate and nonprofit experience. Contact Helen with your questions and comments at Helendenn@gmail.com. Visit Helen at HelenMdennis.com and follow her on facebook.com/SuccessfulAgingCommunity

“Her star burned very bright,” said her mother, Lynn Flanigan. “She was always a presence, you know? She’d come in, and people would just light up. Everybody would smile, and she was like a magnet.”

Maggie Flanigan, the daughter of Lynn Flanigan, a health care worker, and Daniel Flanigan, a restaurant worker, was born in Baltimore and raised in Towson.

Sailing became part of her life at an early age. Her parents, who are avid sailors, first took her on a boat when she was 5 weeks old. At 14 months, she earned her sea legs on a weeklong cruise with her family to Connecticut, but needed to relearn walking after returning to shore, her mother said.

Ms. Flanigan’s love of theater and singing bloomed in middle school at Loch Raven Technical Academy’s Performing Arts Magnet program, continuing through high school when she worked as a server and performer at a dinner theater in Timonium. Her passion for sailing continued in high school, as well, through volunteering with Special Olympics Sailing, which her parents helped found and coach internationally.

She graduated from Loch Raven High School in Towson in 2008 and attended Indiana University of Pennsylvania, where she studied nursing, psychology and choral music. While there, she helped found a sailing club and jazz performing group.

During summer breaks, she worked as a certified sailing instructor at Baltimore County Sailing Center. She once saved the life of a fellow instructor who fell out of a boat, hitting their head and becoming unconscious in the water.

Ms. Flanigan held several jobs in retail, life insurance and health care, working at Sheppard Pratt and Greater Baltimore Medical Center while also participating in community theater organizations as a performer and costumer, creating a plus-sized costume collection. After leaving the health care system during the coronavirus pandemic, she leaned deeper into her love of sewing, working at a dressmaking shop in Pikesville.

In 2021, she moved to Annapolis to work as a canvas fabricator at Quantum Sails, working on designs for sail covers and biminis, or sun protectors. She joined the Annapolis sailing community, crewing on J/105 racing boats and others in regattas while helping friends on the side with wedding tailoring.

Ms. Flanigan often went to karaoke in downtown Annapolis at Stan and Joe’s or Middleton Tavern, said Allison Gingerich, a friend.

“Anyone that she met was always touched by her in a different way in the sense that she was just very kind, very openhearted — the kind of person you could talk to about pretty much anything,” Gingerich said.

Last year, Ms. Flanigan, Ms. Gingerich and three others competed in the J/105 Women’s Regatta in Annapolis wearing hot pink Hawaiian print shirts and white skirts, winning an award for best-dressed crew — a trophy that did not exist until they arrived on the racecourse.

This year, regatta organizers created the Maggie Flanigan Perpetual Trophy, which was given to the best-dressed crew.

She is survived by her parents, Lynn and Daniel Flanigan, of Towson; two brothers, Ryan Flanigan, of Nottingham, and James Flanigan, of Timonium; her maternal grandmother, Jackie Flournoy, of Hunt Valley; her nephew and godson, Brooks Flanigan; and numerous aunts, uncles and cousins.

A celebration of life was held Aug. 30 in Pasadena, with family and friends wearing bright colors and glitter in her memory.

Rates rose slightly less last year, with an average increase of about 4%. Marylanders, however, will continue to have some of the most affordable individual market rates in the country in 2025, the insurance administration said in a news release Thursday.

A new insurance carrier — Wellpoint Maryland — also was approved by the insurance administration to sell 10 plans both on and off the Affordable Care Act individual marketplace, bringing the total number of carriers to five. Regardless of where Marylanders live in the state, they will have the choice of at least four insurance carriers for next year, the release said.

The rates approved by the insurance administration are about 0.5% lower on average than originally requested by insurance carriers, saving state residents an estimated $6.4 million in premium costs, the administration said.

Next year’s rate increase was driven by an overall increase in the cost of claims, according to the insurance administration, which is charged with regulating the state’s $42 billion insurance industry. On average, the costs of prescription drugs rose 10.2%, physician costs rose 8.5% and hospital costs rose 4.3%.

In Maryland, federal and state subsidies that encourage younger and healthier residents to purchase insurance help keep costs low for everyone, the insurance administration said. About 80% of people who purchase their individual market plan on Maryland Health Connection — the state’s health insurance exchange — receive some reductions in premium costs through federal tax credits.

The state’s reinsurance program — a fund through which insurers are reimbursed for a portion of the costs from patients who require the most expensive care — also helps stabilize the market and keep rates low, the administration said. The approved 2025 rates are about 17% lower than they were in 2018, before the program began. The state’s waiver from the U.S. Centers for Medicare and Medicaid, which allows the reinsurance program to exist, is approved through 2028.

“The success of the Reinsurance program continues to be evident,” Acting Maryland Insurance Commissioner Joy Hatchette said in Thursday’s release. “Maryland premiums will continue to be amongst the lowest and most affordable in the nation.”

About 271,000 Marylanders will be affected by the approved rates next year, though overall costs and how much rates increased vary between plans.

A 40-year-old living in the Baltimore metro region, for example, could pay anywhere from $41 per month more for the lowest cost silver plan than they paid last year — if they’re covered by CareFirst’s PPO plan — or $40 less, if they’re covered by Optimum Choice. Costs for the silver HMO plan from CareFirst, the No. 1 choice plan on the exchange from its dominant insurer, increased by $20 a month for the same person.

In Thursday’s news release, Hatchette advised Marylanders to work closely with health insurance agents and advisers when reviewing plans to make sure they take advantage of any opportunities to offset the costs of their premiums.

The insurance administration also approved an average rate increase of 0.3% for dental plans in the individual market, where about 96,000 Marylanders purchase insurance.

About 227,000 Marylanders are enrolled in small group market plans, which are geared toward businesses with 50 or fewer employees. Rates for these plans will increase by an average of 4.5%. More than 225 plans will be offered in the small group market this year.