Articles from December 2024

LAS VEGAS — Case manager Bryon Johnson flashed a light into a dark tunnel beneath the glitz of the Las Vegas Strip on a recent fall afternoon. He stepped into an opening in a concrete ditch littered with trash and discarded clothing to search an underground world for his homeless clients.

Beneath the Caesars Palace hotel and casino, Johnson found one of them stretched out on a plywood bed. Jay Flanders, 49, had sores across his back, up his arms, and into his fingers. The homeless man acknowledged occasional meth use and mental health concerns. He couldn’t recall exactly how long he’d lived underground, but it had been several years.

“Why don’t you come inside,” asked Johnson, trying to persuade Flanders to leave the tunnels. “Come get treatment.”

It’s Johnson’s job to coax homeless people out of drainage tunnels that stretch beneath Las Vegas, a perilous grid where people hide from law enforcement and shelter from extreme weather but risk being swept away by floodwaters. Drugs and alcohol are prevalent. Johnson tells clients they have a better shot at recovery above ground, where they can get medical care to treat chronic illnesses, such as diabetes, depression, and heart disease, and start drug and alcohol treatment programs.

Street medicine providers and homeless outreach workers who travel into the tunnels said they have noticed an uptick in the number of people living underground as housing costs have skyrocketed and local officials have adopted a zero-tolerance approach to homelessness. Caseworkers are also confronting a level of drug addiction that’s making it harder to get people, many suffering from mental illness and health conditions, to come aboveground for care.

“It’s meth. It’s fentanyl. It’s opioids. We’re seeing it more and more,” said Rob Banghart, vice president of community integration for the nonprofit homeless outreach organization Shine a Light, who lived in the tunnels for 2½ of the five years he was homeless, often using drugs.

Now sober for more than six years, Banghart recalled the tunnels providing a respite. “In that state of mind, I said to myself, ‘It’s got a roof; it’s out of the sun.’ It’s a little twisted, but it was a community.”

Outreach workers say more people are retreating underground. Though dark and damp, the tunnels provide cover from the harsh desert sun, warmth when temperatures drop, and privacy from society’s judgment above ground.

Constructed in the 1990s and measuring some 600 miles, the tunnels provide flood control for the city and outlying communities. Homeless outreach workers said 1,200 to 1,500 people live in them. Many have constructed elaborate shelters, often out of plywood and scraps of metal or brick below the casinos that define the Strip.

Tunnel living is not limited to Nevada. Across California’s Central Valley and its southern deserts, people unable to afford housing are retreating into caves and earthen tunnels, often dug into flood control berms, riverbanks, or along drainage canals, where people can escape the heat and law enforcement. In San Antonio, homeless people have constructed tunnel encampments, and in New York, homeless people have long retreated into subterranean existence in tunnels and defunct train corridors.

In Las Vegas, some tunnel dwellers said they hide to avoid constant encampment sweeps, which have increased nationally since the U.S. Supreme Court this year ruled that local authorities have a right to enforce sleeping or camping bans in public spaces, even when no shelter or housing is available.

Others said they go down to escape the unbearable weather. Triple digits are common in the summer; this year, Las Vegas climbed as high as 120 degrees. And the tunnels provide protection when temperatures drop into the 30s in the winter. It even snows there.

Street medicine providers are also trying to persuade homeless people to leave the tunnels to receive care. In addition to more drug and alcohol use, they have seen new problems with wounds and skin disorders associated with the street drug known as “tranq,” slang for the animal tranquilizer xylazine, which is often mixed with fentanyl or meth.

Tranq causes deep skin infections that, left untreated, can lead to bone infections and require amputation.

Flanders, the homeless man in the tunnels, had several of these skin sores, which he referred to as spider bites — a euphemism for the deep skin wounds caused by tranq. He estimated he has been to the emergency room at least 10 times this year, several times requiring hospitalization.

“One time I was there for six days; I almost lost a finger,” Flanders said, holding up the index finger that had been warped from a deep infection, as he started to tear up. Despite the risks, Flanders said, he still felt safer living in the tunnels than aboveground.

Las Vegas’ population boom has contributed to rising housing costs. The market rent for southern Nevada rose 20% from 2022 to 2023, according to a Clark County homelessness report — higher than the national average.

As more people get displaced, more retreat underground. And often, outreach workers say, it’s not just locals who can’t afford the rising cost of living who wind up homeless, but also out-of-towners. Some come to make it in the city’s booming entertainment industry, while others become homeless after losing it all at the casinos.

“People come here on vacation to gamble or try and make it, and they lose everything,” said Johnson, who works for Shine a Light, one of two organizations in Las Vegas that provide substantial outreach, housing referrals, and drug treatment services for homeless people in the tunnels.

“The housing market is insane; rents keep going up. A lot of people wind up down here,” said Johnson, who lived in the tunnels until he got sober with help from Shine a Light. “People just get stuck.”

Still, Nevada’s scorching heat and rains and monsoons pose a major threat to those living in the tunnels, though it’s unclear exactly how deadly life in them can be.

But Louis Lacey, homeless response director for the nonprofit Help of Southern Nevada, said homeless people living belowground put their lives at risk, often in the monsoon season when the tunnels flood. His organization coordinates with the city of Las Vegas and Clark County to get as many people as possible into shelters before the start of the rainy season, which typically runs from June to September.

“We go into the tunnels to make sure people who want to get out are out, but not everyone leaves, often because they don’t want to leave their belongings,” he said. “People die every year.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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

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ATLANTA — Deegant Adhvaryu completed his parents’ applications for Medicaid and food benefits in June. Then the waiting and frustration began.

In July, his parents, Haresh and Nina Adhvaryu, received a letter saying their applications would be delayed, he said. In August, the Adhvaryus started calling a Georgia helpline, he said, but couldn’t leave a message. It wasn’t until September, when they visited state offices, that they were informed their applications were incomplete.

The couple were mystified. They had Medicaid coverage when they lived in Virginia, before their recent move to metro Atlanta.

While they waited, Adhvaryu’s parents — ages 71 and 76 — delayed care, fearing they couldn’t afford it. They have Medicare, and, in Georgia, Medicaid pays for its premiums, copayments, and deductibles. The lack of extra coverage strained their fixed incomes.

“It was concerning,” Deegant Adhvaryu said, because his family lost a critical financial “lifeline.”

It took Adhvaryu’s parents until late October — more than 120 days after applying — to finally get their Medicaid cards in the mail. Federal rules require states to process most Medicaid applications within 45 days.

For years, Georgia’s public benefits system has been plagued by problems like the Adhvaryus’ — a glitchy website that’s often down for maintenance, a shortage of staff to process applications, and technology that malfunctions, according to consumer advocacy organizations, former state employees, and researchers.

But a KFF Health News analysis shows processing times have worsened since July 2023, when Georgia launched the nation’s only active Medicaid work requirement program, “Georgia Pathways to Coverage.” The program began three months after the state began redetermining the eligibility of all Medicaid enrollees following a covid-19 pandemic pause.

The percentage of Medicaid applicants waiting more than a month and a half to have their applications processed has nearly tripled in the first year of Pathways, the analysis of state and federal records found. Georgia had the slowest processing time in the country as of June, for income-based applications. Preliminary data from July puts the state as the second-slowest. The percentage of applications for financial and food assistance that take more than 30 days to process has also risen by at least 8 percentage points.

Pathways “is really bogging down” a system that was “already functioning relatively poorly,” said Leah Chan, director of health justice at the Georgia Budget and Policy Institute, a nonprofit research organization that supports full Medicaid expansion.

Georgia’s effort to run Pathways reveals the challenges that loom for states looking to launch Medicaid work requirements under a second Donald Trump presidency. His first administration approved them in more than a dozen states. On Nov. 5, South Dakota voters gave lawmakers the green light to seek a work requirement for its existing Medicaid expansion population.

Conservative lawmakers around the country would like to add work requirements to Medicaid, the state-federal insurance program for people with disabilities or low incomes, said Joan Alker, who leads Georgetown University’s Center for Children and Families. “If Georgia fails, that’s a big black eye for the Republican Party.”

Pathways is one of Republican Gov. Brian Kemp’s signature health policy initiatives and his alternative to fully expanding Medicaid eligibility under the Affordable Care Act. Applicants must document that they’re working, studying, or doing other qualifying activities for 80 hours a month in exchange for health coverage.

Consumer advocacy organizations, former state employees, and researchers say the initiative adds inefficiencies and bureaucracy that slow down other public programs, like the Supplemental Nutrition Assistance Program, or SNAP, and the Temporary Assistance for Needy Families program, or TANF.

As of Nov. 1, just 5,542 residents were participating in the work requirement program. Under a full Medicaid expansion program, nearly 300,000 Georgians would gain health coverage, according to the Robert Wood Johnson Foundation.

Georgia’s work requirement hasn’t been cheap to implement. An analysis by Chan’s think tank found about $13,360 in state and federal spending for each enrollee from January 2021 through June 2024, largely on administrative costs, not health benefits. That doesn’t account for the cost to prepare and submit the application for Pathways to the feds or the fees associated with legal fights over the program.

Officials in Georgia told KFF Health News that, as of June 30, Pathways had cost $40.6 million in state and federal funds.

Pathways also has increased the workload for state staffers who must manually verify complex eligibility requirements and monitor enrollees’ continued eligibility, according to consumer advocacy organizations, former state employees, and researchers.

The Kemp administration blames the processing slowdown of state benefits, in part, on what’s known as the Medicaid “unwinding,” which began in April 2023 as states had to redetermine the eligibility of all enrollees in the wake of the coronavirus pandemic.

“Georgia Pathways is an innovative, Georgia-specific program that has provided coverage to thousands of Georgians who otherwise would be without care,” said Garrison Douglas, a Kemp spokesperson.

Critics say the Pathways rollout stressed a system that’s had snags for years. In contrast, Chan pointed to North Carolina, which fully expanded Medicaid during the unwinding, covering more people for less than the cost per person of Pathways and without creating additional backlogs for other public benefits programs.

Waiting for benefits approval can have concrete consequences for people’s health and well-being, say doctors, researchers, and patient advocates.

Flavia Rossi, a pediatrician in Tifton, about 180 miles south of Atlanta, said some parents skip their kids’ checkups because they fear expensive out-of-pocket costs while waiting for Medicaid coverage for their children.

In October 2023, Ellenwood, Georgia, residents Gloria and William Felder, who have custody of a granddaughter, were told by the state that her Medicaid coverage had lapsed. William Felder said they reapplied three times but waited 11 months for her coverage to be restored, during which they spent over $1,500 on her care. “We wanted to make sure she had coverage,” he said.

After a health insurance navigator queried the state, Felder said, the state finally informed them in September that she had Medicaid again.

Georgia officials haven’t invested enough in the state agency that processes public benefits applications, said Laura Colbert, executive director of Georgians for a Healthy Future, a nonprofit policy advocacy organization. The problem is exacerbated by staffing shortages, high staff turnover, and outdated technology, she said.

In November 2023, the U.S. Department of Agriculture notified state officials that Georgia was “severely out of compliance” with timeliness standards for processing SNAP applications. A recent progress report details the scope of the issues: a system that incorrectly prioritizes applications, not enough staff to handle a backlog of nearly 52,000 new applications, and no system to promptly reassign applications when staff are off.

“These delays create real hardship, forcing families to make choices between paying for medicine, food, or rent while they wait for the support they’re entitled to,” Colbert said.

The state checked the eligibility of about 2.7 million residents when the pandemic-era Medicaid continuous coverage requirement ended. Nearly half a million Georgians lost coverage — including nearly 300,000 children, according to an analysis by Alker’s nonprofit.

Instead of investing more to ensure that people who were wrongly removed could reenroll, the state continues to pour money into the Pathways program, Alker said. She cited a recently launched $10.7 million ad campaign aimed at boosting Pathways enrollment with money from federal pandemic recovery funds.

The contract for that work was awarded to the consulting firm Deloitte, which has already received millions from Georgia to build and implement Pathways. It’s also responsible for the state’s Gateway technology system, which people use to access public benefits and Georgia officials have described as having ongoing problems, according to KFF Health News’ reporting.

Deloitte did not respond to a request for comment for this article. It previously told KFF Health News that it does not comment on state-specific issues.

In a November letter to KFF Health News, Deloitte spokesperson Karen Walsh said the firm’s clients — state governments — “understand that large system implementations are challenging due to the complexity of the programs they support, and that all IT systems require ongoing maintenance, periodic enhancements and upgrades to software and hardware, and database management.”

Deegant Adhvaryu had to help keep his parents afloat as they waited months to get approved for Medicaid and SNAP. He bought them groceries and helped cover their rent. Not every applicant is that lucky.

“There are people in the state of Georgia with far less financial resources, far less family connections to be able to help them that need these services,” he said.

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

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This story can be republished for free (details).