On the main floor of a former Catholic church in Bolivar, Pennsylvania, Botteicher runs a flower shop and cafe.

In the former church’s basement, she also operates a nonprofit organization focused on helping people caught up in the drug epidemic get back on their feet.

The nonprofit, , sits in a rural pocket of the Allegheny Mountains east of Pittsburgh. Her organization’s home county of Westmoreland has seen roughly drug overdose deaths each year for the past several years, the majority involving fentanyl.

Thousands more residents in the region have been touched by the scourge of addiction, which is where Botteicher comes in.

She helps people find housing, jobs, and health care, and works with families by running support groups and explaining that substance use disorder is a disease, not a moral failing.

But she has also talked publicly about how she has made to people who use drugs.

“When that person comes in the door,” she said, “if they are covered with abscesses because they have been using needles that are dirty, or they’ve been sharing needles — maybe they’ve got hep C — we see that as, ‘OK, this is our first step.’”

associated with syringe exchange services. The Centers for Disease Control and Prevention says these programs infections, and that new users of the programs are more likely to enter drug treatment and more likely to stop using drugs than nonparticipants.

This harm-reduction strategy is supported by leading health groups, such as the , the , and the .

But providing clean syringes could put Botteicher in legal danger. Under Pennsylvania law, it’s a misdemeanor to distribute drug paraphernalia. The includes hypodermic syringes, needles, and other objects used for injecting banned drugs. Pennsylvania is one of 12 states that do not implicitly or explicitly authorize syringe services programs through statute or regulation, according to a . A few of those states, but not Pennsylvania, either don’t have a state drug paraphernalia law or don’t include syringes in it.

Those working on the front lines of the opioid epidemic, like Botteicher, say a reexamination of Pennsylvania’s law is long overdue.

There’s an urgency to the issue as well: Billions of dollars have into Pennsylvania and other states from legal settlements with companies over their role in the opioid epidemic, and syringe services are among the eligible interventions that could be supported by that money.

The opioid settlements reached between drug companies and distributors and a coalition of state attorneys general included a list of the money. Expanding syringe services is listed as one of the core strategies.

But in Pennsylvania, where 5,158 people died from a drug overdose in 2022, the state’s drug paraphernalia law stands in the way.

Concerns over Botteicher’s work with syringe services recently led Westmoreland County officials to in opioid settlement funds they had previously approved for her organization. County Commissioner Douglas Chew defended the decision by saying the county “is very risk averse.”

Botteicher said her organization had planned to use the money to hire additional recovery specialists, not on syringes. Supporters of syringe services point to the cancellation of funding as evidence of the need to change state law, especially given the recommendations of settlement documents.

“It’s just a huge inconsistency,” said Zoe Soslow, who leads overdose prevention work in Pennsylvania for the public health organization . “It’s causing a lot of confusion.”

Though sterile syringes without a prescription, handing out free ones to make drug use safer is generally considered illegal — or at least in a legal gray area — in most of the state. In Pennsylvania’s two largest cities, and , officials have used local health powers to provide legal protection to people who operate syringe services programs.

Even so, in Philadelphia, Mayor Cherelle Parker, who took office in January, has she opposes using opioid settlement money, or any city funds, to pay for the distribution of clean needles, The Philadelphia Inquirer has reported. Parker’s position signals a in that city’s approach to the opioid epidemic.

On the other side of the state, opioid settlement funds have had a big effect for , a harm reduction organization. spending or committing $325,000 in settlement money as of the end of last year to support the organization’s work with sterile syringes and other supplies for safer drug use.

“It was absolutely incredible to not have to fundraise every single dollar for the supplies that go out,” said Prevention Point’s executive director, . “It takes a lot of energy. It pulls away from actual delivery of services when you’re constantly having to find out, ‘Do we have enough money to even purchase the supplies that we want to distribute?’”

In parts of Pennsylvania that lack these legal protections, people sometimes operate underground syringe programs.

The Pennsylvania law banning drug paraphernalia was never intended to apply to syringe services, according to , director of the at Temple University. But there have not been court cases in Pennsylvania to clarify the issue, and the failure of the legislature to act creates a chilling effect, he said.

Carla Sofronski, executive director of the , said she was not aware of anyone having faced criminal charges for operating syringe services in the state, but she noted the threat hangs over people who do and that they are taking a “great risk.”

In 2016, the — Cambria, Crawford, and Luzerne — among 220 counties nationwide in an assessment of communities potentially vulnerable to the rapid spread of HIV and to new or continuing high rates of hepatitis C infections among people who inject drugs.

Kate Favata, a resident of Luzerne County, said she started using heroin in her late teens and wouldn’t be alive today if it weren’t for the support and community she found at a syringe services program in Philadelphia.

“It kind of just made me feel like I was in a safe space. And I don’t really know if there was like a come-to-God moment or come-to-Jesus moment,” she said. “I just wanted better.”

Favata is now in long-term recovery and works for a program.

At clinics in Cambria and Somerset Counties, provides free or low-cost medical care. Despite the legal risk, the organization has operated a syringe program for several years, while also testing patients for infectious diseases, distributing overdose reversal medication, and offering recovery options.

Rosalie Danchanko, Highlands Health’s executive director, said she hopes opioid settlement money can eventually support her organization.

“Why shouldn’t that wealth be spread around for all organizations that are working with people affected by the opioid problem?” she asked.

In February, in Pennsylvania was approved by a committee and has moved forward. The administration of Gov. Josh Shapiro, a Democrat, supports the legislation. But it faces an uncertain future in the full legislature, in which Democrats have a narrow majority in the House and Republicans control the Senate.

One of the bill’s , state hasn’t always supported syringe services. But the Republican from western Pennsylvania said that since his brother died from a drug overdose in 2014, he has come to better understand the nature of addiction.

In the , nearly all of Struzzi’s Republican colleagues opposed the bill. State Rep. said authorizing the “very instrumentality of abuse” crossed a line for him and “would be enabling an evil.”

After the vote, Struzzi said he wanted to build more bipartisan support. He noted that some of his own skepticism about the programs eased only after he visited Prevention Point Pittsburgh and saw how workers do more than just hand out syringes. These types of programs connect people to resources — overdose reversal medication, wound care, substance use treatment — that can save lives and lead to recovery.

“A lot of these people are … desperate. They’re alone. They’re afraid. And these programs bring them into someone who cares,” Struzzi said. “And that, to me, is a step in the right direction.”

At her nonprofit in western Pennsylvania, Botteicher is hoping lawmakers take action.

“If it’s something that’s going to help someone, then why is it illegal?” she said. “It just doesn’t make any sense to me.”

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Looking back, Reynolds realizes her mother was in the early stages of Alzheimer’s disease: “By the time we caught on, it was too late.”

Reynolds and her mother are among a large group of Americans grappling with the financial consequences of cognitive decline.

A shows are a possible warning sign — rather than only a product — of certain neurological disorders. This includes a of more than 81,000 Medicare beneficiaries that found people with Alzheimer’s and related dementias became more likely to miss bill payments up to six years before a formal diagnosis.

The reach of these conditions is enormous. One found nearly 10% of people over age 65 have dementia; more than twice as many are living with .

Missing the Signs of Declining Cognition

One weekday in the spring of 2018, Reynolds sat next to her 77-year-old mother, Jonnie Lewis-Thorpe, in a courtroom in downtown New Haven, Connecticut. She listened in discomfort as strangers revealed intimate details of their own finances in a room full of people waiting their turn to come before the judge.

Then it hit her: “Wait a second. We’re going to have to go up there, and someone’s going to be listening to us.”

That’s because the family home was in foreclosure. The daughter hoped if she explained to the judge that her mother had Alzheimer’s disease, which had caused a series of financial missteps, she could stop the seizure of the property.

Reynolds can’t pinpoint when Alzheimer’s crept into her mother’s life. A widow, Lewis-Thorpe had lived alone for several years and had made arrangements for her aging, including naming Reynolds her power-of-attorney agent. But Reynolds lived a 450-mile drive away from New Haven, in Pittsburgh, and wasn’t there to see her mom’s incremental decline.

It wasn’t until Reynolds began reviewing her mother’s bank statements that she realized Lewis-Thorpe — once a hospital administrator — had long been in the grip of the disease.

Financial problems are a common reason family members bring their loved ones to the office of , a neuropsychologist at the University of Texas at Austin Dell Medical School who specializes in cognitive issues.

“The brain is really a network, and there are certain parts of the brain that are more involved with certain functions,” said Hilsabeck. “You can have a failure in something like financial abilities for lots of reasons caused by different parts of the brain.”

Some of the reasons are due to normal aging, as Reynolds had assumed about her mother. But when a person’s cognition begins to decline, the problems can grow exponentially.

Dementia’s Causes — And Sometimes Ruthless Impact

Dementia is a syndrome involving the loss of cognitive abilities: The cause can be one of several neurological illnesses, like Alzheimer’s or Parkinson’s, or brain damage from a stroke or head injury.

In most cases, an older adult’s dementia is progressive. The first signs are often memory slips and changes in high-level cognitive skills related to organization, impulse control, and the ability to plan — all critical for money management. And because the causes of dementia vary, so do the financial woes it can create, said Hilsabeck.

For example, with Alzheimer’s comes a progressive shrinking of the hippocampus. That’s the catalyst for memory loss that, early in the course of the disease, can cause a person to forget to pay their bills.

Lewy body dementia is marked by fluctuating cognition: A person veers from very sharp to extremely confused, often within short passages of time. Those with frontotemporal dementia can struggle with impulse control and problem-solving, which can lead to large, spontaneous purchases.

And people with vascular dementia often run into issues with planning, processing, and judgment, making them easier to defraud. “They answer the phone, and they talk to the scammers,” said Hilsabeck. “The alarm doesn’t go off in their head that this doesn’t make sense.”

For many people older than 65, mild cognitive impairment, or MCI, can be a precursor to dementia. But even people with MCI who don’t develop dementia are vulnerable.

“Financial decision-making is very challenging cognitively,” said , a specialist in geriatrics and memory care at the University of Pennsylvania’s Penn Memory Center. “If you have even mild cognitive impairment, you can make mistakes with finances, even though you’re otherwise doing generally OK in your daily life.”

Some mistakes are irreversible. Despite Reynolds’ best efforts on behalf of her mother, the bank foreclosed on the family home in the fall of 2018.

Property records show that Lewis-Thorpe and her husband bought the two-bedroom Cape Cod for $20,000 in 1966. Theirs was one of the first Black families in their New Haven neighborhood. Lewis-Thorpe had planned to pass this piece of generational wealth on to her daughters.

Instead, U.S. Bank now owns the property. A 2021 tax assessment lists its value as $203,900.

Financial Protections Are Slow to Come

Though she can’t prove it, Reynolds suspects someone had been financially exploiting her mom. At the same time, she feels guilty for what happened to Lewis-Thorpe, who now lives with her: “There’s always that part of me that’s going to say, ‘At what point did it turn, where I could have had a different outcome?'”

Karlawish often sees patients who are navigating financial disasters. What he doesn’t see are changes in banking practices or regulations that would mitigate the risks that come with aging and dementia.

“A thoughtful country would begin to say we’ve got to come up with the regulatory structures and business models that can work for all,” he said, “not just for the 30-year-old.”

But the risk-averse financial industry is hesitant to act — partly out of fear of getting sued by clients.

2018’s , the most recent major federal legislation to address elder wealth management, attempts to address this reticence. It gives immunity to financial institutions in civil and administrative proceedings stemming from employees reporting possible exploitation of a senior — provided the bank or investment firm has trained its staff to identify exploitative activity.

It’s a lackluster law, said Naomi Karp, an expert on aging and elder finances who spent eight years as a senior analyst at the Consumer Financial Protection Bureau’s Office for Older Americans. That’s because the act makes training staff optional, and it lacks government oversight. “There’s no federal agency that’s charged with covering it or setting standards for what that training has to look like,” Karp said. “There’s nothing in the statute about that.”

One corner of the financial industry that has made modest progress is the brokerage sector, which concerns the buying and selling of securities, such as stocks and bonds. Since 2018, the Financial Industry Regulatory Authority — a nongovernmental organization that writes and enforces rules for brokerage firms — has required agents to make a reasonable effort to get clients to name a “.”

A trusted contact is similar to the emergency contact health care providers request. They’re notified by a financial institution of concerning activity on a client’s account, then receive a basic explanation of the situation. Ron Long, a former head of Aging Client Services at Wells Fargo, gave the hypothetical of someone whose banking activity suddenly shows regular, unusual transfers to someone in Belarus. A trusted emergency contact could then be notified of that concerning activity.

But the trusted contact has no authority. The hope is that, once notified, the named relative or friend will talk to the account holder and prevent further harm. It’s a start, but a small one. The low-stakes effort is limited to the brokerage side of operations at Wells Fargo and most other large institutions. The same protection is not extended to clients’ credit card, checking, or savings accounts.

A Financial Industry Reluctant to Help

When she was at the Consumer Financial Protection Bureau, Karp and her colleagues put out a set of recommendations for companies to better protect the wealth of seniors. The included proposals on employee training and changes to fraud detection systems to better detect warning signs, such as atypical ATM use and the addition of a new owner’s name to an existing checking account. “We would have meetings repeatedly with some of the largest banks, and they gave a lot of lip service to these issues,” Karp said. “Change is very, very slow.”

Karp has seen some smaller community banks and credit unions take proactive steps to protect older customers — such as instituting comprehensive staff training and improvements to fraud detection software. But there’s a hesitancy throughout the industry to act more decisively, which seems to stem in part from fears about liability, she said. Banks are concerned they might get sued — or at least lose business — if they intervene when no financial abuse has occurred, or a customer’s transactions were benign.

Policy solutions that address financial vulnerability also present logistical challenges. Expanding something as straightforward as use of trusted contacts isn’t like flipping a light switch, said Long, the former Wells Fargo executive: “You have to solve all the technology issues: Where do you house it? How do you house it? How do you engage the customer to even consider it?”

Still, a trusted contact might have alerted Reynolds much sooner that her mom was developing dementia and needed help.

“I fully believe that they noticed signs,” Reynolds said of her mother’s bank. “There are many withdrawals that came out of her account where we can’t account for the money. … Like, I can see the withdrawals. I can see the bills not getting paid. So where did the money go?”

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Avellaneda said she wants people to avoid the financial risk of a medical emergency: “I have health insurance right now, and I feel very, very peaceful. So I want my community to know that.”

The process is simple: By checking a box, taxpayers trigger a “qualifying event,” enabling them to sign up for insurance outside the traditional open enrollment period and access subsidies that can bring the cost of that insurance down, if their income is low enough. Doing so also allows Maryland’s comptroller to share a person’s income information with the state’s insurance exchange, created under the Affordable Care Act.

After checking the box, people receive a letter with an estimate of the kind of financial assistance they qualify for, whether subsidies for an exchange-based plan, Medicaid, or, for eligible minors, the Children’s Health Insurance Program. Also, a health care navigator may call taxpayers offering them enrollment assistance.

Avellaneda said most of her clients who apply end up qualifying for subsidized insurance. Many are surprised because they had assumed financial assistance was available only to those with extremely low incomes. Avellaneda thought this as well until she did her own taxes a couple of years ago.

“I was one of the persons that thought that I couldn’t qualify because of my income,” said Avellaneda, with a chuckle.

A growing number of states — including Colorado and Massachusetts — are using tax forms to point people toward the lower-cost coverage available through state insurance marketplaces; by next year, it will be , including California, Maine, and New Jersey. Illinois is working on a program as well.

“We all file taxes, right? We all know we’re filling out a bazillion forms. So what’s one more?” said , executive director of the Pennsylvania Health Access Network, who advocated for Pennsylvania to create a program modeled on Maryland’s.

Often, efforts to enroll people in health insurance are scattershot because the data sets of uninsured people are incomplete. This can lead outreach workers to try to find people who have submitted unfinished Medicaid applications to try and sign them up for coverage.

But nearly everyone has to file tax paperwork, and that existing infrastructure helps states connect the dots and find people who are open to signing up for insurance but haven’t yet.

“It’s hard to imagine more targeted outreach than this. I think that’s one reason it’s become popular,” said , who researches the impact of state and federal policy on private insurance quality and access at Georgetown University.

The rise of these initiatives, known as easy enrollment, is happening at a time of incredible churn for health insurance.

The end of some policies launched during the height of the covid-19 pandemic is forcing people to or find new insurance if they make too much money to qualify. At the same time, marketplace subsidies created in response to the pandemic through the end of 2025 via the Inflation Reduction Act. So having a simple way to connect people to health care coverage and make the most of federal dollars is a good idea, said , a health policy researcher at the University of Pittsburgh.

He cautions that these initiatives won’t get everyone covered. Data bears this out: Only about 10,000 Marylanders have gotten insurance this way since 2020, less than 3% of that state’s uninsured population. The number in Pennsylvania is estimated to be small, too. Still, it’s a step in the right direction.

“Uninsurance in general is extremely costly to society,” said Drake. “Whatever we can do here to make signing up for health insurance easy, I think, is an advantage.”

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