Nebraska Counties Are Pooling Opioid Settlement Dollars With Regional Health Authorities

A public-records investigation into how Nebraska is spending its opioid settlement dollars found that many counties are not spending the money themselves. Instead, a growing share is being routed to the six regional behavioral health authorities that already deliver mental health and addiction treatment across the state.

The findings, published Sept. 30 by the nonprofit newsroom Flatwater Free Press — in partnership with journalism students at the University of Nebraska–Lincoln and co-published by Nebraska Public Media — came from records requests filed with all 93 counties, 16 cities and six behavioral health regions. The documents showed that 35 counties have combined to send more than $400,000 to their regional authorities, and that 43 other counties have received settlement money but have yet to spend any of it.

The reason is not indifference. It is arithmetic.

Why so many counties hand the money off

Nebraska is receiving payments that will eventually add up to more than $150 million over an 18-year period, part of national legal settlements with opioid manufacturers, pharmacies and distributors that total more than $50 billion across the country. But the money is allocated by population, and in a state with 93 counties that means a lot of very small checks.

Sheridan County, in the Panhandle, offers the clearest example. Its jail holds 26 people, and "on any given day," County Commissioner Bruce Messersmith said, almost every inmate is there because of an addiction-related problem. Yet the county — 2,470 square miles with no psychiatrist — closed its inpatient treatment center in 2023 and has a single free naloxone distributor and drug take-back site, in Gordon.

Sending settlement dollars to the state's Opioid Recovery Fund, Messersmith worried, meant the money might never find its way back to the Panhandle. Forwarding it to Region 1 kept it local, he said, calling the decision a "no brainer" — the region already has the expertise and the programs.

Greeley County reached the same conclusion. Commissioner Jordan Foltz said his board sends its share to Region 3 because that is where the county's residents already go for help — roughly five people a year. Region 3 spends upward of $3,500 per person on long-term treatment and re-entry support, he said, while Greeley has received a total of about $10,500 so far. "Dollar for dollar, you're getting it spent better giving it to people that are trained and that's what they do day to day," Foltz told Flatwater.

What Nebraska's own rules require

The county-to-region flow is not a workaround. It follows the structure the state itself created.

Nebraska's Opioid Prevention and Treatment Act (LB1124, 2020) dedicated settlement revenue to opioid-related treatment and prevention and created the state's Opioid Recovery Fund, which conditions spending on the terms of the settlement agreements. Under the 2021 distributor settlement — with AmerisourceBergen, Cardinal Health and McKesson — 70 percent of Nebraska's payments go into an abatement fund, while the remaining 30 percent is split between the state (15 percent) and eligible participating cities and counties (15 percent). Nebraska's maximum share of that agreement is $81,680,641; its share of the Janssen settlement tops out at $19,961,174, and its McKinsey share is $2,590,561.

Those settlements also required each state to stand up an opioid remediation advisory committee. Nebraska's version — the Nebraska Opioid Settlement Remediation Advisory Committee — makes recommendations to the Department of Health and Human Services and includes two local members from each of the six behavioral health regions, appointed by the League of Nebraska Municipalities and the Nebraska Association of County Officials.

Then, in 2024, lawmakers rewrote the spending rules. LB1355 renamed the state's opioid account the Nebraska Opioid Recovery Trust Fund and directed annual transfers of $400,000 for Overdose Fatality Review Teams, $1.25 million to a training fund and $3 million to a new Opioid Prevention and Treatment Cash Fund. Its stated legislative intent: 25 percent of the state's total settlement receipts to prevention and treatment, and 75 percent to an Opioid Treatment Infrastructure Cash Fund for capital projects. Critically for rural counties, the bill provides that money disbursed from the prevention-and-treatment fund is "distributed proportionally among the state's regional behavioral health authorities."

Counties are also required by law to contribute to their regional authority — about $1 in matching funds for every $3 of state general-fund support — and a few have begun using settlement dollars to cover that match.

The trade-off families should understand

Routing money through a region buys scale and oversight, and it also hands the spending decisions to a board rather than a county commission.

Mary Ann Borgeson, vice chair of the state advisory committee and a Douglas County Board member, told Flatwater that the six regions have each held local gatherings to set priorities, and that they must regularly report to the advisory committee — "more robust layers of oversight" than an individual county would have. Region 1 administrator Holly Brandt described a formal process: a strategic planning effort to set Panhandle priorities, then a grant application reviewed by a committee and board that includes county representatives.

The clearest payoff so far is a crisis stabilization center under development in Kimball, expected to open early next year with medical withdrawal and short-term residential services, plus a mobile crisis unit that can bring people in from places like Sheridan County. Region 1 has not yet spent the county-diverted dollars, Brandt said, and would first take the spending back to its full board and the contributing county commissioners.

The trade-off cuts both ways, researchers told Flatwater. Pooling makes sense because per-capita payouts are tiny, said Brandon Marshall, a professor of epidemiology at Brown University, but small communities could still put money to work locally on things like naloxone distribution at existing events. Magdalena Cerdá, a Yale School of Public Health professor, called it both sensible and concerning that localities are using settlement dollars to backfill broader behavioral health budgets — especially in Nebraska, where the regions absorbed a $15 million state budget cut in 2024, with Region 3 alone losing about $3 million.

The arrangement is also a contrast to how some other Nebraska counties have spent their shares. A separate Flatwater investigation published Sept. 15 found that at least nine counties and cities used settlement funds on law enforcement tools — including automated license-plate-reader cameras from Flock Safety — rather than treatment, prevention, naloxone or recovery housing. At least $88,800 went to law-enforcement-related purchases; Harlan and Valley counties spent more than $40,000 combined on Flock contracts.

What's next

As of December 2023, about $10 million had been distributed among Nebraska's six behavioral health regions, according to the National Academy for State Health Policy, which tracks state settlement decisions. Spending decisions at the regional level are not yet broken out in detail, and Nebraska law requires the regions and local public health departments to report on their use of the funds in even-numbered years.

For now, the practical upshot for Nebraska families is that the nearest treatment dollars may be administered by a regional authority, not a county office. The state's health department publishes a resource map of naloxone distributors and take-back sites, and each of the six regions maintains its own intake and grant processes.

Where to get help

If you or someone you care about is struggling with substance use, help is available now — no insurance or referral required.

• 988 Suicide & Crisis Lifeline — call or text 988, 24/7, for mental health or substance use crises.
• SAMHSA National Helpline — 1-800-662-4357 (1-800-662-HELP), free, confidential, 24/7, English and Spanish.
• FindTreatment.gov — search treatment options by location, insurance and payment type.

If someone is unresponsive, breathing slowly or turning blue, call 911, give naloxone if you have it, and stay with them until help arrives. Nebraska's Good Samaritan law protects people who call for help during an overdose.