Pew Charitable Trusts

CHARLOTTESVILLE, Va. — Repeatedly rated one of the healthiest and happiest places to live in the United States, this medium-sized college town with spectacular views of the Blue Ridge Mountains tends to attract entrepreneurs, freelancers and creative types who can live anywhere they want because they’re not tied to a corporate job.

But this year, many of those untethered workers may be wishing they lived anywhere but here. Residents of Charlottesville and three surrounding counties who buy health insurance without employer support or government subsidies have been hit with the highest health insurance premiums in the country — more than three times the price they paid last year.

Premiums are also substantially higher than average, although not as high as in Charlottesville, in southwestern rural Georgia, certain Colorado ski resort towns, the Connecticut suburbs of New York City, and large parts of Wisconsin and Wyoming, among other places.

Charlottesville’s premium spike may be an anomaly. But insurance experts say it could be an indication of what might happen in other parts of the country next fall, when insurers post their final rates for 2019.

Nationwide, premiums for average-priced policies — according to a Kaiser Family Foundation analysis — offered on and off the health insurance exchanges created under the Affordable Care Act rose by more than a third compared with 2017. The biggest statewide hikes were in Iowa (88 percent), Utah (78 percent), New Hampshire (78 percent), Wyoming (72 percent), and Virginia (66 percent).

The underlying cause of the rate hikes is clear: efforts last year by the Trump administration and its allies in Congress to dismantle the Affordable Care Act — and promises of further attempts in the year ahead.

“It all added up to chaos and uncertainty in the insurance market,” said Sabrina Corlette, a Georgetown University research professor and insurance expert. “And uncertainty always leads to higher premiums.”

This year, a handful of Democratic-led states are gearing up to curb further rate hikes by enacting laws and adopting insurance regulations designed to shore up the traditional insurance industry and restore parts of the ACA, known as Obamacare.

At the same time, at least one Republican-leaning state has moved to further unravel the federal health law by encouraging insurance companies to offer cheap policies with fewer benefits. Others are expected to follow.

Both red and blue states are reacting to a series of federal actions.

The federal tax overhaul enacted in December repealed the individual mandate, which required everybody to have health insurance or pay a financial penalty. The requirement was designed to ensure that healthy people signed up for insurance so that premiums for everyone remained affordable.

Two months earlier, President Donald Trump withdrew billions in federal insurance industry subsidies that allowed insurers to keep premiums affordable while holding down copays and deductibles.

Around the same time, Trump also cut the health exchange enrollment period in half. And earlier in the year, he slashed the marketing budget for federal exchanges to further damage the health law by curtailing enrollment.

This year, both branches of government promise further attacks on the health law, including final actions on two administration proposals. One would encourage insurers to offer short-term policies with variable copays and deductibles, and the other would allow people to form groups to create so-called association health plans with cheap premiums and limited benefits.

States Respond

In Idaho, Republican Gov. Butch Otter followed the administration’s cues, signing an executive order this month that directs the state insurance agency to draft rules allowing insurance companies to offer cheap plans with stripped-down benefits.

Going in the opposite direction, California, Connecticut, the District of Columbia and Maryland are considering legislation that would recreate the Affordable Care Act’s individual mandate by requiring nearly all residents to enroll in a health plan or pay a fee. Massachusetts has a mandate on the books that it said it intends to enforce.

Taking a different tack — one that has been endorsed by members of both political parties — Alaska, Minnesota and Oregon have created so-called reinsurance programs designed to cover higher-than-average claims with state money and thereby reduce overall risk for insurance companies so they can offer consumers lower premiums.

Under the health law, the federal government can reimburse states for any money spent on reinsurance programs that results in lower premiums, and thus reduced federal tax subsidies, as long as the reimbursements do not exceed federal savings. Washington state and Wisconsin are considering similar programs this year.

In New Jersey, newly elected Democratic Gov. Phil Murphy signed an executive order this month directing state agencies to invest in greater outreach and education to encourage more people to sign up for coverage on the state insurance exchange when it opens in November. California and New York launched similar advertising and marketing campaigns last year for the same reason.

By encouraging more people to enroll, states can improve the odds that their insurance markets will stabilize and premiums will remain affordable.

“Consumers are still confused about health insurance subsidies, and they’re hearing a lot of bad news about the ACA,” said Sarah Lueck, an insurance analyst at the left-leaning Center on Budget and Policy Priorities. “States need to tell consumers that the market isn’t crumbling, because it’s not. There are still some really good deals out there.”

It’s too early to know how many other states will move this year to fill the policy gaps in the tattered Affordable Care Act. But consumer advocates are urging lawmakers and governors to act sooner rather than later.

“States need to prepare now if their initiatives are going to have the desired effect,” Lueck said. If states want to stabilize the insurance industry by establishing individual mandates or reinsurance programs, they need to have their policies in place before spring and summer, when companies are required to file preliminary rates for 2019, she said.

For states that want to follow New Jersey’s lead and beef up outreach and marketing for their insurance exchanges this year, there’s a little more time. Insurance exchange marketing typically doesn’t start until September, two months prior to open enrollment in November.

But there’s another approach states can take at any time to protect their traditional insurance markets from the continued uncertainty created by attacks on the ACA from Congress and the Trump administration.

Once federal agencies finalize rules allowing cheaper, substandard health policies, states can prohibit those policies from being sold within their borders unless they comply with ACA consumer protections, according to a recent article by a group of consumer advocates in the policy journal Health Affairs.

New Jersey and New York already have such prohibitions, and Minnesota allows non-complying health plans to be sold only under limited circumstances.

Unsubsidized Consumers

Before the Affordable Care Act took effect in 2014, people who were self-employed, between jobs or working part time and were not offered employer-sponsored health plans typically had to pay the highest prices for health coverage because insurers considered the relatively small pool of individuals riskier than larger groups.

Many people who faced high-priced individual insurance policies took their chances and went without coverage. Others opted for cheaper plans with high out-of-pocket expenses and limited benefits.

For this group, the ACA’s consumer protections were a huge boon. Confident they could find affordable health insurance, many workers were able to strike out on their own for the first time.

Insurers were prohibited from refusing coverage to people with pre-existing conditions or charging people higher premiums because of their medical history. And although individual market premiums still tended to be higher than group plans, rates and coverage improved in the first four years after the federal health law took effect.

But last year’s revisions to the law may have changed all that.

As a result, many states can be expected to take action this year to protect this group of consumers from unreasonably high insurance premiums, said Timothy Jost, a retired law professor at Washington and Lee University in Virginia and an ACA expert. They will either be propping up the ACA and the traditional health insurance market, or further undermining the federal health law by promoting cheaper, lower quality policies, he said.

The result, he said, will be even greater disparities than already exist between states in the number of people who can afford quality health care coverage.

In fact, the Trump administration’s tactics are likely to bolster the overall proportion of Americans enrolled in Medicaid and federally subsidized exchange policies, said Joel Ario, a health care analyst with the law firm Manatt, Phelps and Phillips who worked in the Obama administration. That’s because the policies will remain affordable and people will enroll in them even without the coercion of the individual mandate, he said.

Left out will be people not covered by employer-sponsored insurance and with incomes too high to qualify for Medicaid or federal exchange subsidies. Nationwide, about 22 million people purchase insurance in the individual market, according to Kaiser. About 43 percent of them have incomes too high to qualify for federal tax subsidies on the exchange.

Charlottesville resident Sara Stovall is among them. She, and fellow residents Ian Dixon and Karl Quist, have hired an attorney to represent them and a group of more than 700 other locals who in November were hit with exorbitant premiums. They’re arguing in a case before the Virginia Insurance Bureau that the rates filed by Optima Health — a Virginia-based insurance carrier and the sole remaining provider of health coverage in their area — violated federal law.

But even if they win the case and the state orders Optima to issue refunds, they and the others in their group won’t personally benefit. The money would go to a regional insurance pool and ultimately would be deducted from future premiums for all policies.

Stovall, Dixon and Quist, all of whom had incomes just above the federal limit, could not afford their 2018 insurance premiums, roughly $3,000 a month for a family of four. Stovall, whose husband’s freelance photography business is growing, said their premiums would have been more than their mortgage payment.

Dixon, a self-employed software developer, said he and his family moved from Washington, D.C., to Charlottesville two-and-a-half years ago, when he quit his day job. “I heard there was a good startup community here,” he said. “But if individual insurance rates had spiked that year like they did this year, we never would have come here.”

NEW YORK — Five months into his job at a 24-hour walk-in behavioral health center here on Staten Island, Tarik Arafat has a new assignment. In three weeks, he’ll be on call for a nearby hospital to counsel people who have just been revived from an opioid overdose.

In recovery from drug addiction himself, Arafat, 25, said he understands why someone in a brightly lit emergency room who uses drugs would be more comfortable talking to him than to a medical professional. “My job is to open myself up and be like a toolbox for them,” he said.

Arafat’s mission, and that of other so-called recovery coaches, is not to convince overdose survivors to get into treatment, but to offer them advice on how to get started once they’ve decided they’re ready to quit. If they’re not interested in that moment, he’ll follow up with phone calls to see how they’re doing after they leave the hospital. He’ll also advise them on how to use drugs more safely, if that’s what they choose to do.

Nationwide, tens of thousands of opioid overdose victims have been saved over the last two decades by first responders, friends, family and bystanders who administered naloxone, an opioid overdose antidote.

But the majority of those who are rescued from near death go back to using drugs as soon as they leave the hospital, pushed by the brutal withdrawal symptoms that accompany an opioid overdose reversal.

In fact, the likelihood of a second overdose among those who survive their first is substantially higher, said Dr. Hillary Kunins, assistant commissioner for New York City’s alcohol and drug abuse agency.

To reduce those odds, New York City, Connecticut and Massachusetts are replicating a Rhode Island program that sends recovery coaches like Arafat to hospital emergency departments to meet overdose survivors and offer them support, whether it’s on the day of their ER visit or weeks or months later.

Officials in at least seven other states — California, Maine, North Carolina, Ohio, Oklahoma, Texas and Vermont — have been talking to the program’s founders over the last year about starting similar programs in their states. And New Hampshire and New Jersey have created similar programs.

And federal money under the Comprehensive Addiction and Recovery Act and the 21st Century Cures Act is available through the Substance Abuse and Mental Health Services Administration to local jurisdictions that want to start pilot recovery coach programs.

Harm reduction

Called AnchorED, the Rhode Island program dispatches recovery coaches to the bedside of overdose survivors in every hospital in the state. The coaches let the survivors know what resources are available to help them quit, or how they can reduce their chances of a fatal overdose, if they choose to keep using.

In the three years since it started, AnchorED’s recovery coaches have counseled more than 2,000 overdose survivors, with 87 percent of them opting to engage in some type of recovery service after being discharged from the ER, according to Michelle Harter, director of the state-funded program.

Not all of those who engage in recovery services — such as detox, spiritual guidance, medication-assisted treatment, peer counseling, job training and nutrition programs — end up quitting drugs, Harter said. “But we help them get started on a recovery pathway of their choice.”

New York City’s recovery coach program, called Relay, is slated to begin this month. It will start by employing 18 recovery coaches to be on call at hospitals in three of the city’s hardest hit communities: Richmond University Medical Center on Staten Island, Montefiore Medical Center in the Bronx, and New York-Presbyterian/Columbia University Medical Center in Washington Heights.

The plan is to set up similar programs in seven more hospitals by 2019, at an annual cost of $4.3 million. While the hope is that more people will get into treatment, the city’s primary goal is to reduce overdose deaths, Kunins said.

In addition to offering overall support, recovery coaches in New York’s program will talk to survivors about where to find drug treatment and mental health services and how to pay for them, as well as how to reduce their risk of a fatal overdose.

They’ll distribute naloxone kits, train survivors and their friends and family on how to use them, and tell them where they can get clean syringes and needles to avoid contracting HIV/AIDS and hepatitis C.

Once patients leave the hospital, the recovery coaches will follow up with daily or weekly phone calls for 90 days, or longer. But recovery coaches will hand off the work of providing services to a team of addiction specialists, health care providers and case managers.

Here on Staten Island, Arafat will rely on his colleagues at Community Health Action of Staten Island, located in a freshly painted new headquarters on Bay Street, to provide counseling and support services and to make referrals to local mental health and addiction treatment providers. He’ll take calls about overdose patients from nearby Richmond University Medical Center during his regular shift, 4 p.m. to midnight. Two other recovery coaches will cover the rest of the day. They expect to receive roughly one call a day because the hospital is taking in on average 30 overdose survivors a month.

In general, the job of a recovery coach is to help overdose survivors stay alive and as healthy as possible and, when they’re ready, work on their own personal goals for recovery. “I know that no one could talk me into getting treatment until I was ready,” he said. “I feel like this is what I was meant to do.”

Recovery coaches — sometimes called peers, peer professionals, outreach workers or people with lived experience — are not new. They’ve been working with people with mental illness and drug addiction for decades and they have proven highly effective at gaining patients’ trust and engaging them in programs designed to improve their health and long-term survival. As the opioid epidemic spreads, their numbers are increasing.

More than 33,000 people died of an opioid overdose in 2015, and with the advent of fentanyl and other powerful synthetic opioids in the illicit drug supply, the number of deaths is increasing dramatically, according to the Centers for Disease Control and Prevention.

Lived experience

New York’s Kunins says the city’s experience with the HIV/AIDS epidemic in the 1980s will be helpful as it dispatches peer recovery coaches to hospitals to try to reduce overdose deaths. Back then, the city was among the first to enlist peer professionals to meet injection drug users at needle exchanges and warn them about the dangers of the deadly disease and offer them help, she said.

“What set us up to do this work is the availability of these recovery organizations throughout the city and our historical knowledge that it’s important to tell people about them,” she said.

In Rhode Island, George O’Toole was the first recovery coach dispatched to an emergency room when the program started, in July 2014. He was on call from 8 p.m. on Fridays to 8 a.m. on Mondays. But demand was so high hospitals started calling him throughout the week, too.

By 2015, AnchorED was sending recovery coaches to 10 hospitals around the clock, seven days a week. Today, O’Toole manages a staff of 20 coaches who assist not only opioid overdose survivors but people who come into emergency rooms for drug- or alcohol-related problems.

Anchor Recovery Community Centers, the umbrella organization that runs the Providence-based program, also offers a mobile outreach service. Recovery coaches meet people in homeless shelters, tent cities and soup kitchens in and around Providence to tell them about recovery services they can access. “Most of the people they talk to have no idea these services are available,” O’Toole said.

There are no hard numbers, but O’Toole guesses that only about one in five people who land in Rhode Island emergency rooms after an overdose consents to seeing a recovery coach. An emergency room nurse or doctor asks them if they would like to talk to someone about recovery and harm reduction services and most refuse, he said.

“I get that. They just overdosed. You ruined their high. They’re embarrassed, ashamed, and don’t want to hear about it,” he said. “The ones who agree may already be motivated. They realize they just died and got brought back to life, and they need a plan for how that isn’t going to happen again. That’s why we’re here.”

The opioid epidemic has killed tens of thousands over the past two years and driven major reforms in state and local law enforcement and public health policies for people with addiction.

But another deadly but popular drug, methamphetamine, also has been surging in many parts of the country. And federal officials say that, based on what they learned as opioids swept the U.S., methamphetamine is likely to spread even further.

“The beginning of the opioid epidemic was 2000 and we thought it was just localized,” said Kimberly Johnson, director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration, or SAMHSA. “Now we know that drug outbreaks aren’t likely to stay localized so we can start addressing them sooner and letting other states know of the potential for it spreading.”

From Arizona, New Mexico and Oklahoma to Montana, Wisconsin and Minnesota and all across the South, inexpensive methamphetamine is flowing in from Mexico, fueling what police and epidemiologists say is an alarming increase in the number of people using the drug, and dying from it.

Nationwide, regular use of the inexpensive and widely available illicit stimulant increased from 3 percent to 4 percent of the population between 2010 and 2015, according to SAMHSA. At the same time, heroin use shot from 1 percent to 2 percent of the population.

The number of people using methamphetamine, also known as meth, crystal meth, crystal, crank, ice and speed, has been among the highest of any illicit substance for decades. But despite the stimulant’s harmful long-term effects on the body — including rotting teeth, heart and kidney failure, and skin lesions — its overdose potential is much lower than prescription painkillers and other opioids.

Still, overdose deaths from methamphetamine have spiked recently.

In 2014, roughly 3,700 Americans died from drug overdoses involving methamphetamine, more than double the 2010 number, according to the Centers for Disease Control and Prevention. In 2015, the most recent year for which federal data are available, nearly 4,900 meth users died of an overdose, a 30 percent jump in one year.

Early warnings

In Oklahoma, methamphetamine was involved in 328 overdose deaths last year, a sharp climb from 271 in 2015, and more than the combined deaths from prescription painkillers hydrocodone and oxycodone, according to Mark Woodward, a spokesman for the Oklahoma Narcotics Bureau.

In contrast to the last epidemic, which began in the 1990s, rural meth labs are now a rarity and the fires and explosions that captured headlines back then are practically nonexistent today, Woodward said. “A lot of people thought if meth labs are down, meth use is down.”

“But so much is coming in from Mexico, and it’s just as good as the domestic cooked product,” he said. “Why risk leaving a paper trail at a pharmacy when you have a buddy coming up from El Paso tonight with a cheap supply?”

The majority of methamphetamine now is smuggled across the Southwest border, according to the Drug Enforcement Administration’s 2016 National Drug Threat Assessment Summary.

Its purity is high and its street price is relatively low, much cheaper than heroin.

“While the current opioid crisis has deservedly garnered significant attention, the methamphetamine threat has remained prevalent,” the report warns.

Minnesota, a hot spot during the last methamphetamine epidemic, is experiencing a surge in admissions for treatment of methamphetamine addiction, according to the state Human Services Department.

In the upper Midwest and much of the rest of the country, 2005 was the peak year for methamphetamine use. After that, federal and state laws restricting the sale of an essential ingredient in methamphetamine, the over-the-counter cold medicine pseudoephedrine, led to a sharp decrease in U.S. meth labs.

As more meth started coming in from Mexico, the number of people seeking treatment began creeping up again and began to surge in many places in 2015. Last year, nearly 11,600 meth users were admitted for treatment in Minnesota, according to state data — a significant increase over the 6,700 who sought treatment for methamphetamine addiction in 2005.

Methamphetamine also is showing up in places that never experienced an earlier epidemic.

“What we’re seeing is that the use of methamphetamines has recently moved out of trailer parks and rural areas and into inner cities,” said Ken Roy, medical director of a major treatment facility, Addiction Recovery Resources, in New Orleans. “We’re seeing a lot of heroin addicts that also use methamphetamines. It used to be the only way we got meth patients was when they came to the hospital from rural areas.”

Different drugs

Opioid users experience a dreamlike state and typically nod off. But methamphetamine produces an entirely different high. Users experience a sense of elation and hypervigilance, and often become paranoid and aggressive.

“They may binge on meth for days without eating or sleeping, and they often start seeing things that aren’t there,” said Carol Falkowski, an addiction expert in Minnesota.

Death from a methamphetamine overdose also is very different from an opioid death. With opioids, which affect the part of the brain that controls breathing, high enough doses can shut down respiratory functions, quickly causing death.

With methamphetamine, death is typically caused by a stroke or heart attack, and is characterized by extreme sweating as the body overheats prior to death. Because methamphetamine represents a lower risk of overdose, many use it for decades, which often results in gradual organ failure and death. Those deaths are typically not counted in the overdose statistics.

Likewise, treatment for addiction to methamphetamine is different than for opioids. No FDA-approved medications exist to stop the cravings for methamphetamine, whereas three effective drugs are available to help people recover from opioid addiction.

As a result, methamphetamine treatment primarily consists of outpatient therapy, often after a brief stay in a residential facility.

People who stop using methamphetamine do not suffer the severe withdrawal symptoms such as the vomiting, muscle pain and other flu-like symptoms suffered by opioid users. But they do tend to become immobilized, sleeping a lot and binge eating, as well as suffering from severe depression, anxiety and drug cravings.

Falkowski said that during the last methamphetamine epidemic, there was more emphasis on the way people behaved when using meth for long periods of time, and the threat they posed to public safety.

Health officials in places like Minnesota and Oklahoma say the health care providers who helped legions of people overcome methamphetamine addiction during the last epidemic are prepared for a new onslaught. But Johnson, the SAMHSA director, cautioned that the addiction treatment workforce has not grown in proportion to the growth in overall drug use since then.

Tackling a new meth addiction wave on top of an opioid epidemic could strain the nation’s health care system, she said. “I don’t think what we’ve done to scale up access to treatme nt for opioid disorders is going to be that helpful for methamphetamines.”

A bland, one-paragraph item that appeared this fall in a lightly read weekly newsletter from the city manager in Pasadena, California, has set off a firestorm in the online entertainment industry and in cities and states around the country. The issue: a plan to impose taxes on video streaming services like Hulu and Netflix.

Backers of the internet streaming levy say it’s just another step in governments’ attempts to adapt the tax code to the modern world. Consumers no longer get DVDs at the local Blockbuster Video store, where they paid sales tax. Now, they download movies and shows directly to their devices. Streamers should pay taxes too, the tax advocates argue.

But opponents object to the way some jurisdictions are going about the tax. Officials in Pasadena and other cities that have adopted similar rules, such as Benicia and Indio, California, argue that regulatory rules adopted nearly a decade ago give them the right to extend taxes to streaming services. Foes, led by the streaming industry, say the issue needs to go before the voters, or at the very least, city councils or state legislatures, before taxpayers start handing over more cash.

The move to impose taxes on internet streaming is another step in an effort by cities and states to tax services that are downloaded from far-flung companies that likely don’t have an office or other facility in that state. The so-called “Amazon tax” that some states are seeking to apply to out-of-state internet sales is one example. Taxing “cloud” services with a business-use levy is another. The taxes are akin to taxing electricity that a utility generates out-of-state, but is consumed in-state, or like cellphone taxes on wireless service.

Pennsylvania and the city of Chicago took the lead on what’s known as the Netflix tax, but not without controversy. As part of Chicago’s 2015 “cloud tax,” the city was ready to begin applying a 9 percent tax to digital entertainment. But news reports prompted an uproar and consumers have filed a lawsuit seeking to stop the tax, which has been temporarily suspended.

And in August, as part of Pennsylvania’s effort to address a $1.3 billion budget gap, the state extended its 6 percent sales tax to cover digital downloads, including music, videos, e-books, mobile apps and games.

At least 45 other cities were initially advised that they also could apply utility taxes like those charged for electricity and cable TV to video downloads, including San Bernardino, Glendale, Santa Monica, Culver City and Pico Rivera. The financial firm MuniServices, which helps cities with structuring and collecting utility taxes, worked with the cities on the tax. Their taxes range from 4.5 to 11 percent. Beyond that, streaming video services worry the utility tax extension or a form of entertainment or use tax could spread to other states and municipalities.

Now, according to MuniServices attorney Donald Maynor, the cities are reassessing and talking to the video industry about their products and how to fairly apply the tax.

“The whole idea was to treat everybody the same,” he said. “That way, we can keep our rates down and nobody gets a free ride.”

Joe Henchman, vice president of legal and state projects at the Tax Foundation, a nonpartisan tax research group, says governments are looking at emerging technologies and taking small bites of the tax apple, which stirs up opposition from affected industries or groups. “As new things emerge, very few proposals are structured as ‘Let’s tax all services,’” he said. “They are structured as ‘Let’s tax this service.’ That makes it a political thing.”

Despite the opposition, Henchman said, as the economy moves inexorably in the digital direction, the tax structure will follow. “That’s where the money is.”

Pasadena problem

In September, a memo from Pasadena’s director of finance, Matthew Hawkesworth, attached to the city manager’s newsletter said his office had determined that “all video programming” should be treated the same, “regardless of technology or service supplier.” That meant they would all be subject to a utility users tax of about 9 percent approved by voters in 2008, before streaming video services became so prevalent.

The 2008 referendum said the utility tax would apply to any transmission of “voice, data, audio, video or any other information.” It passed by a 58 to 42 percent margin.

In his memo, Hawkesworth specifically mentioned “Hulu, Netflix, Sling TV and Fullscreen Media.” He said the tax would take effect Jan. 1. Earlier projections estimated it would raise about $10 million a year.

News of the planned utility tax expansion drew quick complaints from Pasadena residents, and city officials said they would review the issue further. A spokesman called Hawkesworth’s memo “premature.”

“The notion of extending the 2008 voter-approved [utility users tax] to additional cable-like services is under review,” said city spokesman William Boyer. “There is no timeline for when the issue will be decided.”

Robert Callahan, the Internet Association’s California executive director, objected to using a utility tax to put an assessment on streaming video. “Utility taxes have been applied to water, sewer and cable TV. The idea that we are taxing Netflix and Hulu like water doesn’t make sense,” he said.

Callahan did not dismiss the idea that a modern society might need to change the way taxes are assessed, but said changes in the utility tax are not the way to go. Further, Callahan said that streaming companies would like to participate in any municipal or state discussion over taxation, rather than having administrators simply extend an existing tax to their product with no debate.

David Kline, spokesman for the California Taxpayers Association, an anti-tax group, brought up another problem endemic to taxing pixels rather than hardware: pixels are portable. What happens if you subscribe to Netflix in California, but watch “Orange is the New Black” while on vacation in Hawaii. Which state gets the tax?

“Is the city going to tax all your use of the service when it’s completely out of their jurisdiction?” he said. “That’s almost impossible to audit.”

Chicago suit

In 2015, Chicago announced it would extend the city’s 9 percent amusement tax and personal property lease transaction tax, such as that paid on the lease of a car or other equipment, to cover Netflix, Spotify and other streaming services. Like Pasadena, the decision was made administratively, without council action or a vote. The city estimated the extended tax would bring in about $12 million annually to the cash-strapped city.

The nonprofit Liberty Justice Center, a libertarian group that believes in “restraints on government power,” filed a class-action suit against the tax. “It looked to us like the city didn’t have authority to do this, particularly without city council action,” center attorney Jeffrey Schwab said.

The litigation put the brakes on the tax, which was to have taken effect Sept. 1, 2015.

The ruling was issued without comment in a routine list of administrative changes. It said that the city would now charge amusement tax on downloaded music like Spotify or “for the privilege of watching electronically delivered television shows, movies or videos … delivered to a patron in the city.”

A spokesman for the city’s legal department, Bill McCaffrey, said that the city remains “confident that the amusement tax properly applies to streaming video, music and games, and we will continue to defend against the ongoing litigation.”

Recently, the city filed a motion to dismiss the case, but the court rejected it.

Schwab said there’s a difference between the city’s amusement tax, which applies to shows and ball games, and the internet streaming tax. “If you buy a ticket to a Cubs game, you pay a 9 percent tax. But if you buy a ticket to a St. Louis Cardinals game, the city [of Chicago] doesn’t impose a tax on you. However, if you are a Chicago resident and you watch a Netflix movie in St. Louis you are taxed.”

Imagine, Schwab said, if there was a “Netflix of Poland.” Would Chicago impose a tax on residents who wanted to watch films in Polish? “That seems like it goes way beyond the four corners of Chicago.”

The number of grandparents who are raising their grandchildren is going up and increasingly it’s because their own kids are addicted to heroin or prescription drugs, or have died from an overdose. For some, it’s a challenge with little help available.

In 2005, 2.5 million children were living with grandparents who were responsible for their care. By 2015, that number had risen to 2.9 million.

Child welfare officials say drug addiction, especially to opioids, is behind much of the rise in the number of grandparents raising their grandchildren, just as it was during the crack cocaine epidemic of the 1980s and ’90s. An estimated 2.4 million people were addicted to opioids at last count.

Caseworkers in many states say a growing number of children are neglected or abandoned by parents who are addicted. That has forced them to take emergency steps to handle a growing crisis in foster care — and often to turn first to grandparents for help.

“Obviously, the numbers have grown because of the current national opioid epidemic,” said Maria Moissades, who heads Massachusetts’ Office of the Child Advocate. “You’ve got grandparents who thought they were going to spend their retirement fishing and traveling. Now they’re raising [as many as] five grandkids.”

Federal law requires that states consider placing children with relatives in order to receive foster care and adoption assistance. And grandmothers and grandfathers often are the first — and best — choice when state and local caseworkers have to take a child out of a home and find someone else to take custody, said Angela Sausser, executive director of the Public Children Services Association of Ohio, a coalition of public child safety agencies in the state.

“When we are seeking caregivers for a child, you want to see who that child has relationships with,” Sausser said. “You’re removing them from their [nuclear] family. To minimize the trauma and help them feel some normalcy, you obviously want to seek out whoever is closest to that child.”

In some instances, caseworkers say, grandparents are also struggling with addictions.

In Ohio, for instance, the opioid epidemic has grown so large that caseworkers sometimes have a hard time finding any relatives who can step up, said Kim Wilhelm, protective services administrator for Licking County (Ohio) Department of Job and Family Services.

For every child in foster care who has been placed with a relative, another 20 children are being raised by relatives outside the system, said Jaia Lent, deputy executive director of Generations United, a Washington, D.C.-based family research and advocacy group.

Many grandparents face a host of emotional and financial challenges in their renewed parenting role. And there are often few state or local resources to draw on for help.

Twenty-one percent of grandparents caring for grandchildren live below the poverty line, according to Generations United. About 39 percent are over 60 and 26 percent have a disability. And because many are not licensed in the system, they are not eligible for the same services and financial support as licensed foster parents.

“Can’t y’all make it easier for grandparents? That’s my request,” said Dot Thibodeaux, president and founder of the grassroots support group Grandparents Raising Grandchildren Information Center of Louisiana.

“Most of us are on Social Security,” she said. “When the family grows, the Social Security does not. You have to make do with whatever you were getting, and that’s kind of hard.”

State help

A handful of states are trying to help. In Louisiana, state lawmakers in June voted to establish a grandparents’ council in the governor’s office to study remedies for those tasked with raising grandchildren.

In New Mexico, lawmakers voted in February to set up a task force to study the issue and recommend concrete policy changes that could help grandparents, from legal and financial help to food and housing assistance.

A bill lingering in the Massachusetts Legislature would provide grandparents caring for their grandchildren with property tax relief. And Georgia lawmakers considered bills that would make it easier for grandparents to take grandchildren in their custody to the doctor or to enroll them in school, but failed to pass them.

The growing trend and the problems it can cause are being noticed by Congress too. In May, U.S. Rep. Danny Davis, D-Ill., introduced a bill that would, among other things, make it easier for grandparents caring for children to receive Temporary Assistance for Needy Families. It’s lingering in committee.

In September, U.S. Senate inaction effectively killed a bill that would have provided federal funding for substance abuse programs for families with children at imminent risk of entering foster care. The bill also would have allowed states to waive foster care licensing standards for grandparents and other relatives.

Barriers to help

Grandparents — especially those who don’t become licensed foster parents or legal guardians of their grandchildren — face a host of emotional and legal challenges in getting help.

Many of them often don’t want to apply for legal custody because that would mean taking their own children to court. Or if they apply for welfare, the state could try to make their own children, who may already be struggling with addiction, pay child support.

Licensed foster parents have access to services and can get financial assistance with everything from medical care to a clothing allowance. But to qualify, grandparents would have to go through a lengthy process and meet certain requirements.

To be a licensed foster parent, for instance, states have specific requirements about square footage and bedrooms for each child. This makes sense if a child is being placed with a stranger, but creates barriers for grandparents who may need to accommodate multiple grandchildren in their homes, Lent said.

Although Louisiana offers financial subsidies to help grandparents with the costs of raising children, few apply because they are unaware of the help. Others don’t qualify because they make too much money — even if they earn very little, Thibodeaux said.

“You almost have to be on the streets,” said Thibodeaux, who serves on the governor’s grandparents’ council.

Some child welfare advocates say that what’s needed is more help for “kinship care” — relatives taking in and raising the children who’ve been neglected.

“Everyone agrees that kinship care is the right thing, but there’s no money to pay for it,” said Moissades, the Massachusetts child advocacy official.

But there could be a payoff if some help was provided grandparents who aren’t part of the foster care system. According to analysis of foster care payments by Generations United, grandparents and other relatives raising children save taxpayers $4 billion each year by keeping the children out of the foster care system.

A multigenerational problem?

Back in the 2000s, some states passed legislation establishing “kinship navigator” programs that serve as one-stop shops linking grandparents and other relatives with services such as counseling, housing assistance and short-term financial help.

With these programs, other grandparents raising children often served as the “navigators” to advise on how to get help with everything from legal advice to parenting skills.

But in some states, budget crunches have made funding for some of these programs unstable, Lent said. In 2008, Congress passed the Fostering Connections to Success and Increasing Adoptions Act, which included competitive grants for kinship navigator programs. Some states used the money to create new programs, but not all are available statewide. Some states, including Florida and Ohio, have federally funded navigator programs that cover part of the state.

Today Connecticut, Delaware, New Jersey, New York and Washington state still have statewide, state-funded programs.

Child welfare workers say that more federal funding is needed if every state is to have a navigator program and offer services statewide.

Isabel Barreiro, of the Children’s Home Society of New Jersey, which is contracted by the state to serve as a kinship navigator in Central New Jersey, said she’s often limited in how much she can do to help her clients.

For example, she said, many of her clients live in public housing. Sometimes multiple grandchildren can be dumped on a grandparent’s doorstep, which forces her to try to find a bigger place to live. Barreiro said she doesn’t have the ability to make a bigger apartment magically appear.

State child welfare agencies have some power to intervene with housing, she said.

“Child protection services needs to do a better job of really stabilizing these families,” Barreio said. “Don’t place a child with a 60-year-old grandmother who’s in Section 8 housing, and not help her.”

On the Spokane Indian Reservation, in eastern Washington, a group of about 40 public school teachers gathered last month, in a field of reeds that stretched as high as their heads.

Before harvesting the reeds, or tules, to make mats, they prayed. Later, they left tobacco as a gift. By learning the rituals of the Spokane tribe, the teachers of the Wellpinit School District hope to connect the culture to their lessons to get their students — almost all of whom are indigenous — to be more engaged.

In Washington and across the U.S., Native American students struggle more than any other student group to attend school consistently and graduate on time.

But this year more states — especially those with large Native American populations such as South Dakota and Washington — are trying to help by training teachers, working with tribes to create policies and programs, embedding culture in lessons, and giving more money to schools with many Native American students.

At the same time, a new federal law has incited conversation about how states and school districts should involve tribes in education.

The Every Student Succeeds Act, which last year replaced No Child Left Behind, places new requirements on all states and some school districts. For the first time, they must engage in “timely and meaningful consultation” with tribes when making annual plans. If they don’t, they could lose federal aid through programs such as Title I, for schools that serve mainly low-income families.

The new law also funds programs related to Native American education, such as Native American language immersion programs.

Separate from the federal efforts, Minnesota last year and South Dakota this year passed bills that increased funding for some schools with large Native American populations. The extra money will allow schools to update their curriculum with more references to indigenous culture and history.

Washington last year began requiring school districts to put Native American culture, government and history into lessons when updating their curriculum.

This year, a new University of Washington training program gives teachers certificates in teaching the culture. California created a similar program last year.

Cultural Differences

Native American teens are more likely than teens from any other racial group to not be in school and not be working, according to a 2016 report.

The disparities start when the children are young: More than half of 3- and 4-year-old Native American children are not enrolled in preschool, the report found.

The report also outlines problems at home. Native American students are the most likely to have parents who lack secure employment. Thirty-six percent live in poverty, compared to the national average of 22 percent.

Students attending Wellpinit schools in Washington often don’t have internet at home or a reliable way of getting to school, educators say. They face domestic violence, homelessness and the loss of close family members.

Also, schools on or near reservations are run in many different ways, making it hard for students to get a consistent education, said Ahniwake Rose, executive director of the National Indian Education Association, a nonprofit that advocates for Native American, Alaskan Native and Native Hawaiian students.

The vast majority of indigenous students — about 93 percent — attend public schools, on or off reservations. The rest attend schools either run by the federal Bureau of Indian Education or run by a tribe.

All those schools are run differently, and yet a student could end up going back and forth between them, Rose said.

Some states are giving tribes more control over education and that will help, Rose said.

“We know if we are more engaged in our kids’ education, they are going to do better,” Rose said. “Just give us a seat at that table.”

New Mexico passed a law, in 2009, requiring all state agencies to collaborate with tribes when making policies and programs that affect Native Americans or Alaska Natives. The governor now meets with Indian nation, tribe and pueblo leaders once a year to talk through issues.

But many Native American students’ performance in school has since worsened. Reading, math and science test scores were mostly down from 2010 to 2014, according to a state report.

And the students still have the worst attendance and the lowest four-year graduation rate.

Cultural Lessons

Part of the reason why Native American students struggle in school is that they are taught from a “white-privileged point-of-view,” said Washington state Democratic Sen. John McCoy, a member of the Tulalip tribe who supported the new law there that requires districts to add Native American culture to their curriculum.

“That has to stop,” he said. “We have to teach history, the good, bad and ugly, but it has to be taught correctly. By giving the true history, Native students in school can start feeling better about themselves.”

Strong Native American language and culture programs have been found to lower attrition, enhance student-teacher and school-community relations, and improve attendance and the rate of students who go to college, according to a 2011 report by Arizona State University.

Cultural programs can only go so far, however, as a 2003 study indicates.

The study found that cultural programming moderately improved student outcomes — but students also needed to see strong parental involvement, solid instruction, supportive, caring teachers, and a safe and drug-free environment in order to improve.

Education sometimes isn’t valued highly enough on reservations in South Dakota, where 11.5 percent of students are Native Americans or Alaskan Natives, said Democratic state Sen. Troy Heinert, a member of the Rosebud Sioux tribe. He used to teach at a school on his reservation, and one of his sons still goes there.

Transportation is a big issue, he said. Some students have to take a bus more than 30 miles, one way, to get to school. If they miss the bus, they miss school.

The rural nature of the community means educators need to tailor lessons to what children know and understand, he said. Teachers shouldn’t use the example of a skyscraper to teach geometry, “when our kids have only seen them on the internet,” he said. “But we can use teepees. We have those here.”

More Funding

South Dakota will try to improve outcomes for Native American students a few schools at a time. A law that passed this year provides $1.7 million for a specialist to work with up to three schools for three years to redesign their approaches to teaching, including embedding culture in the curriculum. The program is modeled after a public charter school in New Mexico.

Another law, passed this year, aims to improve teacher recruitment and retention for schools with large Native American populations. The state struggles with that in rural areas, because there’s not enough housing, too much crime and too much poverty, Heinert said.

Under the law, the state will pay the tuition and fees for “para-educators,” or teaching assistants, who go to college to become teachers. Many para-educators now live on reservations but don’t have the qualifications to teach, said Mato Standing High, the state’s director of Native American education.

Minnesota also will give more funding to schools with large Native American populations this year, said Dennis Olson, the state’s director of Native American education.

The state used to spend about $2.1 million a year on this effort in 32 school districts that were selected based on need. It now spends $9 million a year on all school districts with more than 20 Native American students, or about 138 districts.

Schools will use the money for whatever they see fit — from tweaks to the curriculum to supports for students to training for teachers.

In Washington, the Wellpinit teachers learning how to make tule mats were the first to participate in the new certification program at the University of Washington.

The teachers are learning how to better acknowledge their students’ culture in lessons, to help them connect to what they are taught, said Kim Ewing, principal of Wellpinit Elementary School.

Since storytelling is a Native tradition, a language arts teacher could have one student tell a story while another writes it down. A math teacher could teach students how to use algebra to count the tules in a field.

If the richness of the community can be applied in the classroom, Ewing said, “that makes a huge difference in learning.”