Officials in Irvington, New Jersey, had an idea. To raise awareness about the dangers of opioid use and addiction, the township could host concerts with popular R&B artists like Q Parker and Musiq Soulchild. It spent more than $600,000 in 2023 and 2024 to pay for the shows, even footing the bill for VIP trailers for the performers. It bought cotton candy and popcorn machines.

In many cases, this type of community event would be unremarkable. But Irvington’s concerts stood out for their funding source: settlement money from companies accused of fueling the opioid overdose crisis.

As part of national settlements, more than a dozen companies that sold prescription painkillers are expected to pay state and local governments upward of $50 billion over nearly two decades. Governments are supposed to spend most of the windfall combating addiction. Officials who negotiated the settlements even outlined suggested uses and established other guardrails to avoid a repeat of the Tobacco Master Settlement Agreement of the 1990s, from which paltry amounts went to anti-smoking programs.

But there’s still significant flexibility with these dollars, and what constitutes a good use to one person can be deemed waste by another.

In Irvington, township officials said they used the money appropriately because the concerts reduced stigma around addiction and connected people to treatment. But acting state Comptroller Kevin Walsh called the concerts a “waste” and “misuse” of the settlements, which resulted from the overdose deaths of hundreds of thousands of Americans.

Similar disputes are intensifying nationwide as officials begin spending settlement money in earnest — all while grappling with slashed federal grants and looming cuts to Medicaid, the state-federal public insurance program that is the largest payer for addiction treatment.

To shed light on these discussions, KFF Health News and researchers at the Johns Hopkins Bloomberg School of Public Health and Shatterproof, a national nonprofit focused on addiction, conducted a yearlong effort to document settlement spending in 2024. The team filed public records requests, scoured government websites, and extracted expenditures, which were then sorted into categories such as treatment or prevention.

The result is a database of more than 10,500 ways settlement cash was used (or not) last year — the most comprehensive national resource of its kind. Some highlights include:

• States and localities spent or committed nearly $2.7 billion in 2024, according to public records. The bulk went to investments addiction experts consider crucial, including about $615 million to treatment, $279 million to overdose reversal medications and related training, and $227 million to housing-related programs for people with substance use disorders.
• Smaller, though notable, amounts funded law enforcement gear, such as night vision equipment, and prevention efforts that experts called questionable, such as hiring a drug awareness magician.
• Some jurisdictions paid for basic government services, such as firefighter salaries.
• The money is controlled by different entities in each state, and about 20% of it is untrackable through public records.

This year’s database, including expenditures and untrackable percentages, should not be compared with the one KFF Health News and its partners compiled last year, due to methodology changes and state budget quirks. The database cannot present a full picture because some jurisdictions don’t publish reports or delineate spending by year. What’s shown is a snapshot of 2024 and does not account for decisions in 2025.

Still, the database helps counteract a tendency toward secrecy among some of those in charge of settlement money and confusion among people trying to track it.

More than $237 million — about 9% of all trackable spending in 2024 — went to efforts broadly aimed at preventing addiction, according to public records. These ranged from putting on community awareness events, like the concerts in Irvington, to hiring mental health counselors in schools.

Many of the examples raised red flags for researchers, including:

• Suffield, Connecticut, held a 1950s-style sock hop, at which kids and seniors wore poodle skirts, posed with inflatable guitars, and pledged to remain drug-free.
• Vernon, Connecticut, hosted a mixed martial arts demonstration, at which a fighter spoke about his experience with addiction.
• Hardy County, West Virginia, spent $60,000 to repair a school track.

“There is no evidence” to back those efforts, said Linda Richter, who leads prevention-oriented research at the nonprofit Partnership to End Addiction.

Elected officials like the events because “you can announce to the community that you did something,” she said. But unless they’re part of larger initiatives that incorporate other approaches, such as screening students for mental health concerns or supporting parents struggling with addiction, they’re unlikely to have lasting impact.

And when settlement funds pay for those one-offs, there’s less left for strategies “that we do know work,” Richter added.

School assembly speakers were also popular, with three Connecticut towns spending more than $30,000 total for former Boston Celtic Chris Herren to share his addiction story with students.

“You get 1,200 kids in the gym and you can hear a pin drop when he talks,” said Joe Kobza, superintendent of schools in Monroe. He described Herren’s talks to students and parents as “pretty impactful.”

But emotional impact isn’t necessarily effective, Richter said. Speakers often talk about drugs messing up their lives even though they’ve become wealthy celebrities. “The messages are so mixed,” she said.

Many local officials admitted their spending decisions weren’t evidence-based. But they meant well, they said. And they received little to no guidance on how to use the money.

Kelly Giannuzzi, Suffield’s former director of youth services, who organized the sock hop, said the goal was to raise awareness and combat loneliness.

Hardy County Commissioner Steven Schetrom said spending money on track repairs made sense, since he’d seen the positive impact the sport had on his son’s life. He wanted other kids to have the same opportunity.

David Owens, a spokesperson for Vernon, said the town’s mixed martial arts event was the kickoff to an ongoing campaign, meant to show people that athletics can help them build connections and avoid drugs. The event brought out young men, who are often difficult to reach, he said.

But the town has no way of knowing if the event had lasting traction.

In New Jersey, acting Comptroller Walsh released a report this summer calling on Irvington township officials to repay the settlement money spent on the concerts.

“If they’re going to hold big parties, that’s up to them and the taxpayers,” Walsh told KFF Health News. “But they can’t use opioid money for that.”

He also suggested the concerts were political rallies for the mayor, Tony Vauss.

Irvington officials strongly objected to the report and unsuccessfully sued Walsh to try to block its release. Vauss told KFF Health News it was “misleading and flat-out wrong.”

Vauss said the township distributed overdose reversal medications at the concerts and spread messages about seeking help. At least four people sought treatment on-site, the township said in its lawsuit.

“We felt as though we did everything correctly,” Vauss said.

However, some of the research Irvington cited in the lawsuit to support its case appeared irrelevant, such as a study in rural Ghana and a graduate thesis.

Irvington officials did not respond to questions about those citations.

As this dispute — and others like it nationwide — continue, people affected by the crisis say it’s crucial to remember the moral weight of these settlements.

It’s “blood money,” said Stephen Loyd, an addiction medicine doctor who was once addicted to opioids and has served as an expert in several opioid lawsuits.

He’s seen many family members lose parents, children, and siblings.

“I don’t know how I would look a family in the face” if this money isn’t used to prevent more losses, he said.

Read the methodology behind this project.

KFF Health News’ Henry Larweh; Shatterproof’s Kristen Pendergrass and Lillian Williams; and the Johns Hopkins Bloomberg School of Public Health’s Abigail Winiker, Samantha Harris, Isha Desai, Katibeth Blalock, Erin Wang, Olivia Allran, Connor Gunn, Justin Xu, Ruhao Pang, Jirka Taylor, and Valerie Ganetsky contributed to the database featured in this article.

The Johns Hopkins Bloomberg School of Public Health has taken a leading role in providing guidance to state and local governments on the use of opioid settlement funds. Faculty from the school collaborated with other experts in the field to create principles for using the money, which have been endorsed by over 60 organizations.

Shatterproof is a national nonprofit that addresses substance use disorder through distinct initiatives, including advocating for state and federal policies, ending addiction stigma, and educating communities about the treatment system.

Shatterproof is partnering with some states on projects funded by opioid settlements. KFF Health News, the Johns Hopkins Bloomberg School of Public Health, and the Shatterproof team that worked on this report are not involved in those efforts.

Subscribe to KFF Health News' free Morning Briefing.

The Trump administration must soon make a decision that will affect millions of Americans’ ability to access and afford mental health and addiction care.

The administration is facing a May 12 deadline to declare if it will defend Biden-era regulations that aim to enforce mental health parity — the idea that insurers must cover mental illness and addiction treatment comparably to physical treatments for ailments such as cancer or high blood pressure.

Although a federal parity law has been on the books since 2008, the regulations in question were issued last September. They represent the latest development in a nearly two-decade push by advocates, regulators, and lawmakers to ensure insurance plans cover mental health care equitably to physical health care.

Within the dense 166-page final rule, two provisions have garnered particular attention: first, that insurers provide “meaningful benefits” — as defined by independent medical standards — for covered mental health conditions if they do so for physical conditions. For example, if insurers cover screening and insulin treatment for diabetes, then they can’t cover screening alone for opioid addiction; they must also cover medications to treat opioid use disorder.

Second, insurers must go beyond the written words of their policies to measure how they work in practice. For example, are patients having to seek out-of-network care more often for mental than physical care? If so, and it relates to an insurer’s policies, then those policies must be adjusted.

In January, a trade association representing about 100 large employers sued the federal government, claiming the regulations overstepped the administration’s authority, would increase costs, and risked reducing the quality of care. The ERISA Industry Committee represents several Fortune 500 companies, such as PepsiCo and Comcast, which sponsor health insurance plans for their employees and would be directly affected by the new regulations.

ERIC’s lawsuit, filed days before President Donald Trump’s inauguration, puts the onus on the new administration to decide whether to defend the regulations. If it chooses not to, the rules could be scrapped.

Mental health clinicians, patients, and advocates are urging the administration to fight back.

“What we’re trying to do is make the spirit of parity a practical reality,” said Patrick Kennedy, a Democratic former U.S. representative who sponsored the 2008 parity law in the House and co-founded the Kennedy Forum, which advocates on mental health issues. This is “an existential issue for the country, public health, for every aspect of our society.”

A 2023 national survey found that more than 6 million adults with mental illness who wanted treatment in the past year were unable to receive it. Cost was one of the most common barriers.

This lack of treatment harms people’s physical health too, with research suggesting that undertreating depression can complicate chronic conditions, such as diabetes.

Kennedy hopes that connection will prompt support from the Trump administration, which has made chronic disease a central focus of its “Make America Healthy Again” agenda.

“You’re never going to get MAHA if you don’t integrate mental health,” Kennedy said, mentioning the broad health movement embraced by his cousin HHS Secretary Robert F. Kennedy Jr.

But James Gelfand, president and CEO of ERIC, said the regulations are a misguided attempt to solve the nation’s mental health care crisis.

People’s difficulty accessing therapy or medication has less to do with insurance policy and more to do with a severe shortage of mental health care providers, he said, adding, “No amount of penalties on employers” or new parity regulations “is going to change that dynamic until we get more of these providers.”

This point is at the heart of debate about parity issues. Is mental health care difficult to access because there are few providers, or are providers not accepting insurance because of low reimbursement rates? A recent study by the research institute RTI International suggests it has more to do with payment.

The departments of Justice, Labor, and Health and Human Services declined to comment for this article. The Treasury Department, which is also involved in the lawsuit, did not respond to requests for comment.

‘They Bank on You Just Giving Up’

Psychiatric nurse practitioner Gabrielle Abelard employs about 40 clinicians in her therapy practice, which serves about 2,500 clients across Massachusetts each year.

One of the programs she’s most proud to offer is intensive in-home therapy for children with serious behavioral challenges, such as intergenerational trauma, aggressive outbursts, and self-harm. Two clinicians visit the child’s home over months and work with the family, the child’s doctors, and school staff.

“A big part of the work being done is helping to keep children in school, helping to keep them out of the hospital and even out of jail,” Abelard said.

But insurance barriers sometimes hinder the services.

Abelard’s staff has to obtain prior authorization from insurers before they can provide care. Then they have to reapply for authorization every two, three, or six months, depending on the insurer. When that reauthorization is delayed, Abelard faces a dilemma: continue seeing clients knowing insurers may not pay for those services or leave clients without care until the reauthorization comes through.

Continuing services has cost her tens of thousands of dollars, she said, and months of bureaucratic hurdles to obtain back payments from insurers.

“They bank on you just giving up,” she said.

A goal of the landmark 2008 Mental Health Parity and Addiction Equity Act was to decrease dilemmas such as Abelard’s.

But the bipartisan law primarily emphasized easy-to-measure treatment limits, saying insurers could not impose higher deductibles or copays for mental health care than they did for physical health care. What received less attention was how insurers should handle other limitations, such as prior authorization or fail-first requirements for patients to try certain therapies before they would be eligible for others.

As a result, true parity remained elusive, said Deborah Steinberg, a senior health policy attorney at the nonprofit Legal Action Center.

In 2020, Congress tried to address this through a new law, signed by Trump in his first term. The law required insurance plans to systematically analyze differences in certain treatment limitations for mental and physical health care and submit those analyses upon request to states and the federal governments.

As the federal government reviewed some of those analyses, it discovered numerous parity violations. In a 2022 report, it detailed how some insurance plans covered nutritional counseling for diabetes, but not for anorexia or bulimia. Another plan required precertification for all outpatient mental health and addiction services but only for a select few outpatient medical and surgical services.

The regulations issued in September aimed to provide insurers more guidance on the 2020 law and close loopholes that allowed such disparities, Steinberg said.

‘Supply Is the Biggest Problem’

One of the biggest changes in the new regulations was the focus on outcomes, such as how often patients go out of network for mental versus physical care.

Steinberg called the provision “a really important change.” But Gelfand, president of the employer association suing to stop the regulations, said it ignores the complexity of mental health care.

Many factors outside employers’ and insurers’ control affect how often a patient goes out of network, he said, including the availability of providers in the area, regional variations in clinical practices, and the patient’s personal preference.

Mental health clinicians know there’s high demand for their services, so they have a lot of market power. That “is creating the bad behavior from these providers,” Gelfand said, such as refusing to accept insurance and not submitting out-of-network bills on clients’ behalf.

“Supply is the biggest problem,” Gelfand said.

However, the RTI International study challenged that premise, with the authors noting that primary care physicians are in shorter supply than behavioral health providers yet have much lower out-of-network use.

The authors point to insurance reimbursements as the culprit instead. The study found that insurance reimbursements for behavioral health visits are, on average, 22% lower than for medical or surgical office visits. The low pay creates a disincentive for psychologists and psychiatrists to join insurance networks.

But the fix may not be as easy as raising reimbursement rates. Companies are already paying increasingly high premiums for employees’ health insurance and many are concerned about sustaining these benefits.

ERIC has championed other strategies, such as reforming medical education and residency programs to produce more mental health care providers, increasing telehealth services, and training primary care doctors to address basic mental health concerns. The organization often lobbies state and federal lawmakers, writes letters to regulatory agencies, and testifies before Congress on these issues.

Narrowly focusing on insurance regulations could have unintended consequences, Gelfand said. Increased costs for health plans may get passed on to consumers. Or, in an attempt to keep costs down, insurers may narrow the size of their physical health care networks to match the mental health ones. In a worst-case scenario, employers could stop providing mental health benefits altogether.

Advocates say that’s unlikely, since many employees have come to expect this type of coverage, and employers recognize that providing mental health benefits can increase worker productivity and retention.

Patrick Kennedy also pointed to the bigger picture around these issues: If people do not have insurance coverage for mental health care, they’re more likely to end up in crisis at the hospital or in the criminal justice system, he said. Their children may be sent to foster care. Taxpayers finance those systems.

“We all end up picking up the tab for not enforcing parity,” he said.

But what calculation the Trump administration makes — and whether it defends or drops the new regulations — remains to be seen.

Subscribe to KFF Health News' free Morning Briefing.