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by Nick Grube, Honolulu Civil Beat

This article was produced for ProPublica’s Local Reporting Network in partnership with Honolulu Civil Beat. Sign up for Dispatches to get stories like this one as soon as they are published.

When the federal government stepped in to rent housing for survivors of the devastating 2023 fires on Maui, officials said they didn’t want to drive up rental rates or give landlords an incentive to evict tenants in order to secure lucrative government contracts.

On paper, the plan sounded good: It would rely on finding empty vacation rentals and second homes, which was consistent with Federal Emergency Management Agency policy.

But new reporting shows that FEMA didn’t take basic steps to ensure that happened: When the agency inked contracts with private companies to identify homes they could rent for survivors, it didn’t prohibit them from signing up properties that had been occupied by long-term residents.

Without such safeguards, and with FEMA offering rates well above what residents typically paid each month in rent, some landlords kicked out tenants and housed wildfire survivors for more money. Local economists warned that rents could rise across the small island and that Maui’s housing crisis could intensify — and both have come to pass, Civil Beat and ProPublica found.

A study of the impact of emergency housing programs on Maui’s economy, commissioned by FEMA itself, found that median rent rose 44% from early 2023 to June 2024. Though researchers concluded that was primarily due to the loss of so much housing in the fires, they said anecdotal evidence and hundreds of complaints to state agencies indicated that “the behavior of some landlords may have changed” in response to FEMA’s high prices, leading to increased rents and displacement.

Reporting by Civil Beat and ProPublica corroborates the researchers’ conclusion. Tenants, housing advocates, government officials and property owners have said that landlords have jacked up rents and that residents have been displaced by wildfire survivors or others who will pay more.

“It seemed pretty clear they were setting up a bounty system for removing long-term residents,” said Justin Tyndall, an associate professor at the University of Hawaii who co-wrote a report cautioning that FEMA’s housing program could cause residents to be displaced. “If you could just find a way to get your tenant to leave, then you would be eligible for these enormous rents from FEMA. So it’s unsurprising that people would find creative ways to try to tap into that money.”

When it launched the program, the agency did instruct potential contractors to lease units “not available to the general public.” David Greenberg, the head of Parliament LLC, one of the companies FEMA hired, said in an email that the agency made it clear that leasing properties from landlords who had forced out tenants, even if the company didn’t know about it, would cause Parliament to lose its contract. He said his employees sought out properties advertised as vacation rentals and were instructed to “explicitly ask owners and property managers if there were any existing tenants.”

FEMA officials told Civil Beat and ProPublica that the 1,362 properties in the agency’s housing program were primarily vacation rentals and second homes, though they didn’t know exactly how many. They also said FEMA’s policy allows for flexibility; because housing on the island was limited and their program couldn’t meet survivors’ needs with vacation rentals alone, the agency allowed any property owner to sign up as long as the home was safe and ready for move-in.

One nonprofit that also leased properties was more proactive in trying to prevent profiteering by landlords. The Council for Native Hawaiian Advancement, a prominent local nonprofit, ran the only nongovernmental leasing program after the fires. On the online application for its program, property owners had to attest that they were not evicting anyone in order to house survivors. They had to say what type of rental property they had and whether it was furnished. And if a landlord said a property was a short-term rental, staff tried to verify that through property tax records or Airbnb listings.

The online application for the Council for Native Hawaiian Advancement’s housing program told property owners they couldn’t evict anyone in order to house a wildfire survivor and required them to check a box promising they weren’t doing so. (Obtained by Honolulu Civil Beat and ProPublica. Highlighted by ProPublica.)

Additionally, if a landlord said a property was a long-term rental — the type of property FEMA hoped to avoid — CNHA requested prior leases and the names of previous tenants so staff could make sure no one had been pushed out, according to Skye Kolealani Razon-Olds, who oversees the nonprofit’s emergency housing and recovery efforts. When the nonprofit did lease long-term rentals, it offered lower rates than for vacation rentals. By contrast, FEMA said it generally set its rates to be competitive with what tourists typically paid.

“We knew the areas that were typically used for short-term rentals, we had deeper conversations with folks, and we were willing to say no,” Razon-Olds said. “Most of the stuff that we went for was short-term rental, so we knew that we weren’t going to be moving somebody.”

Bob Fenton, the FEMA regional administrator in charge of disaster relief after the fires, acknowledged that the agency didn’t require contractors to avoid long-term rentals. “It’s not like we put in the contract: must be in the vacation rental market,” he said. He said he wasn’t aware of FEMA’s contractors taking the steps that CNHA did but added that the agency is open to suggestions on how to improve the program. “Those are all ideas, recommendations, lessons learned that we’ll take into account as we continue to operate here,” he said.

In practice, it largely fell to FEMA’s contractors to ensure that their efforts to secure housing didn’t lead landlords to force people out. Greenberg, the head of Parliament, said his company refused to work with several landlords who were trying to evict current tenants. “If we caught even a whiff of impropriety, we would move on to the next unit.”

However, the online application that the company created for property owners didn’t ask anything about tenants or what type of rental it was — just the address, the number of bedrooms and bathrooms, when it would be available and additional information such as whether pets were allowed or if it was accessible for people with disabilities.

In response to allegations that companies like his were more focused on speed than vetting properties, Greenberg said, “I am proud of the balance we upheld in ensuring that all of our properties were compliant, owners were treated with respect, and the survivors living in our units were received with dignity.” He didn’t answer a question about whether his employees inquired about prior tenants.

Fenton acknowledged that the agency wouldn’t normally know if someone had been forced out before its contractor leased a unit. In “fewer than 10” cases, Fenton said, it learned that a landlord had improperly terminated a tenant’s lease in order to participate in FEMA’s program. It kicked those properties out.

Parliament was one of three companies hired by FEMA to manage properties; representatives of the other two, Lima Charlie Inc. and Aesthetic Home Investments, did not respond to questions from Civil Beat and ProPublica.

Two landlords who had rented to long-term tenants before the fires told Civil Beat and ProPublica that FEMA’s contractors spent little time vetting their properties. Hank Rapoza, a Maui-based real estate agent, said he contacted Parliament in December or January about leasing his two-bedroom condo in Wailea. He said a representative asked if the unit was vacant and didn’t inquire further when he said it was. The company offered him $7,500 a month, far more than the $3,500 he had charged before.

“The $7,500 was more than fair, so I said I’ll take it,” Rapoza said. “After I said that, I had a lease sent to me in three hours that I signed. That’s how fast they were.”

Steven Clark, the other landlord, said signing up for the program was remarkably easy. After the fires he listed a newly renovated three-bedroom home in Makawao, asking $4,000 a month. In November, he said, he was eating tacos from a food truck in Kahului when a representative of Lima Charlie called and offered him $8,000 a month. Clark said no one asked about previous tenants; the representative just wanted to know if the place was empty. Clark said it was. “They took me at my word,” Clark said. They struck a deal before he finished his lunch.

Struggling to Keep or Find Housing After Maui’s Wildfires? Tell Us Your Story.

by Molly Redden

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Donald Trump is entering his second term with vows to cut a vast array of government services and a radical plan to do so. Rather than relying on his party’s control of Congress to trim the budget, Trump and his advisers intend to test an obscure legal theory holding that presidents have sweeping power to withhold funding from programs they dislike.

“We can simply choke off the money,” Trump said in a 2023 campaign video. “For 200 years under our system of government, it was undisputed that the president had the constitutional power to stop unnecessary spending.”

His plan, known as “impoundment,” threatens to provoke a major clash over the limits of the president’s control over the budget. The Constitution gives Congress the sole authority to appropriate the federal budget, while the role of the executive branch is to dole out the money effectively. But Trump and his advisers are asserting that a president can unilaterally ignore Congress’ spending decisions and “impound” funds if he opposes them or deems them wasteful.

Trump’s designs on the budget are part of his administration’s larger plan to consolidate as much power in the executive branch as possible. This month, he pressured the Senate to go into recess so he could appoint his cabinet without any oversight. (So far, Republicans who control the chamber have not agreed to do so.) His key advisers have spelled out plans to bring independent agencies, such as the Department of Justice, under political control.

If Trump were to assert a power to kill congressionally approved programs, it would almost certainly tee up a fight in the federal courts and Congress and, experts say, could fundamentally alter Congress’ bedrock power.

“It’s an effort to wrest the entire power of the purse away from Congress, and that is just not the constitutional design,” said Eloise Pasachoff, a Georgetown Law professor who has written about the federal budget and appropriations process. “The president doesn’t have the authority to go into the budget bit by bit and pull out the stuff he doesn’t like.”

Trump’s claim to have impoundment power contravenes a Nixon-era law that forbids presidents from blocking spending over policy disagreements as well as a string of federal court rulings that prevent presidents from refusing to spend money unless Congress grants them the flexibility.

In an op-ed published Wednesday, tech billionaire Elon Musk and former Republican presidential candidate Vivek Ramaswamy, who are overseeing the newly created, nongovernmental Department of Government Efficiency, wrote that they planned to slash federal spending and fire civil servants. Some of their efforts could offer Trump his first Supreme Court test of the post-Watergate Congressional Budget and Impoundment Control Act of 1974, which requires the president to spend the money Congress approves. The law allows exceptions, such as when the executive branch can achieve Congress’ goals by spending less, but not as a means for the president to kill programs he opposes.

Trump and his aides have been telegraphing his plans for a hostile takeover of the budgeting process for months. Trump has decried the 1974 law as “not a very good act” in his campaign video and said, “Bringing back impoundment will give us a crucial tool with which to obliterate the Deep State.”

Musk and Ramaswamy have seized that mantle, writing, “We believe the current Supreme Court would likely side with him on this question.”

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The once-obscure debate over impoundment has come into vogue in MAGA circles thanks to veterans of Trump’s first administration who remain his close allies. Russell Vought, Trump’s former budget director, and Mark Paoletta, who served under Vought as the Office of Management and Budget general counsel, have worked to popularize the idea from the Trump-aligned think tank Vought founded, the Center for Renewing America.

On Friday, Trump announced he had picked Vought to lead OMB again. “Russ knows exactly how to dismantle the Deep State and end Weaponized Government, and he will help us return Self Governance to the People,” Trump said in a statement.

Vought was also a top architect of the controversial Project 2025. In private remarks to a gathering of MAGA luminaries uncovered by ProPublica, Vought boasted that he was assembling a “shadow” Office of Legal Counsel so that Trump is armed on day one with the legal rationalizations to realize his agenda.

“I don’t want President Trump having to lose a moment of time having fights in the Oval Office about whether something is legal or doable or moral,” Vought said.

Trump spokespeople and Vought did not respond to requests for comment.

The prospect of Trump seizing vast control over federal spending is not merely about reducing the size of the federal government, a long-standing conservative goal. It is also fueling new fears about his promises of vengeance.

A similar power grab led to his first impeachment. During his first term, Trump held up nearly $400 million in military aid to Ukraine while he pressured President Volodymyr Zelenskyy to open a corruption investigation into Joe Biden and his family. The U.S. Government Accountability Office later ruled his actions violated the Impoundment Control Act.

Pasachoff predicted that, when advantageous, the incoming Trump administration will attempt to achieve the goals of impoundment without picking such a high-profile fight.

Trump tested piecemeal ways beyond the Ukrainian arms imbroglio to withhold federal funding as a means to punish his perceived enemies, said Bobby Kogan, a former OMB adviser under Biden and the senior director of federal budget policy at the left-leaning think tank American Progress. After devastating wildfires in California and Washington, Trump delayed or refused to sign disaster declarations that would have unlocked federal relief aid because neither state had voted for him. He targeted so-called sanctuary cities by conditioning federal grants on local law enforcement’s willingness to cooperate with mass deportation efforts. The Biden administration eventually withdrew the policy.

Trump and his aides claim there is a long presidential history of impoundment dating back to Thomas Jefferson.

Most historical examples involve the military and cases where Congress had explicitly given presidents permission to use discretion, said Zachary Price, a professor at the University of California College of the Law, San Francisco. Jefferson, for example, decided not to spend money Congress had appropriated for gun boats — a decision the law, which appropriated money for “a number not exceeding fifteen gun boats” using “a sum not exceeding fifty thousand dollars,” authorized him to make.

President Richard Nixon took impoundment to a new extreme, wielding the concept to gut billions of dollars from programs he simply opposed, such as highway improvements, water treatment, drug rehabilitation and disaster relief for farmers. He faced overwhelming pushback both from Congress and in the courts. More than a half dozen federal judges and the Supreme Court ultimately ruled that the appropriations bills at issue did not give Nixon the flexibility to cut individual programs.

Vought and his allies argue the limits Congress placed in 1974 are unconstitutional, saying a clause in the Constitution obligating the president to “faithfully execute” the law also implies his power to forbid its enforcement. (Trump is fond of describing Article II, where this clause lives, as giving him “the right to do whatever I want as president.”)

The Supreme Court has never directly weighed in on whether impoundment is constitutional. But it threw water on that reasoning in an 1838 case, Kendall v. U.S., about a federal debt payment.

“To contend that the obligation imposed on the President to see the laws faithfully executed, implies a power to forbid their execution, is a novel construction of the constitution, and entirely inadmissible,” the justices wrote.

During his cutting spree, Nixon’s own Justice Department argued roughly the same.

“With respect to the suggestion that the President has a constitutional power to decline to spend appropriated funds,” William Rehnquist, the head of the Office of Legal Counsel whom Nixon later appointed to the Supreme Court, warned in a 1969 legal memo, “we must conclude that existence of such a broad power is supported by neither reason nor precedent.”

by Melissa Sanchez and Mica Rosenberg

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At first, she didn’t think much about the Nicaraguan asylum-seekers who began moving into town a few years ago. Rosa was an immigrant too, one of the many undocumented Mexican immigrants who’d settled nearly 30 years ago in Whitewater, a small university town in southeast Wisconsin.

Some of the Nicaraguans had found housing in Rosa’s neighborhood, a trailer park at the edge of town. They sent their children to the same public schools. And they got jobs in the same factories and food-processing facilities that employed many of Rosa’s friends and relatives.

Then Rosa realized that many of the newcomers with ongoing asylum cases could apply for work permits and driver’s licenses — state and federal privileges that are unavailable to undocumented immigrants. Rosa’s feelings of indifference turned to frustration and resentment.

“It’s not fair,” said Rosa, who works as a janitor. “Those of us who have been here for years get nothing.”

Her anger is largely directed at President Joe Biden and the Democratic Party for failing to produce meaningful reforms to the immigration system that could benefit people like her. In our reporting on the new effects of immigration, ProPublica interviewed dozens of long-established Latino immigrants and their U.S.-born relatives in cities like Denver and Chicago and in small towns along the Texas border. Over and over, they spoke of feeling resentment as they watched the government ease the transition of large numbers of asylum-seekers into the U.S. by giving them access to work permits and IDs, and in some cities spending millions of dollars to provide them with food and shelter.

It’s one of the reasons so many Latino voters chose Donald Trump this election, giving him what appears to be Republicans’ biggest win in a presidential race since exit polls began tracking this data. Latinos’ increased support for Trump — who says he could use the military to execute his plans for mass deportations — defied conventional wisdom, disrupting long-held assumptions about loyalties to the Democratic Party. The shift could give Republicans reason to cater to Latinos to keep them in the party’s fold.

On the campaign trail, Trump singled out Whitewater after the police chief wrote a letter to Biden asking for help responding to the needs of the new Nicaraguan arrivals. While some residents were put off by Trump’s rhetoric about the city being destroyed by immigrants, it resonated with many of the longtime Mexican-immigrant residents we interviewed. They said they think the newcomers have unfairly received benefits that they never got when they arrived illegally decades ago — and that many still don’t have today.

Among those residents is one of Rosa’s friends and neighbors who asked to be identified by one of her surnames, Valadez, because she is undocumented and fears deportation. A single mother who cleans houses and buildings for a living, Valadez makes extra money on the side by driving immigrants who don’t have cars to and from work and to run errands. It’s a risky side hustle, though, because she’s frequently been pulled over and ticketed by police for driving without a license, costing her thousands of dollars in fines.

One day two summers ago, one of her sons found a small purse at a carnival in town. Inside they found a Wisconsin driver’s license, a work permit issued to a Nicaraguan woman and $300 in cash. Seeing the contents filled Valadez with bitterness. She asked her son to turn in the purse to the police but kept the $300. “I have been here for 21 years,” she said. “I have five children who are U.S. citizens. And I can’t get a work permit or a driver’s license.”

When she told that story to Rosa one afternoon this spring, her friend nodded emphatically in approval. Rosa, like Valadez, couldn’t vote. But two of Rosa’s U.S.-born children could, and they cast ballots for Trump. One of Rosa’s sons even drives a car with a bumper sticker that says “Let’s Go Brandon” — a popular anti-Biden slogan.

Rosa said she is glad her children voted for Trump. She’s not too worried about deportation, although she asked to be identified solely by her first name to reduce the risk. She believes Trump wants to deport criminals, not people like her who crossed the border undetected in the 1990s but haven’t gotten in trouble with the law. “They know who has been behaving well and who hasn’t been,” she said.

Immigrants seeking asylum arrive in Philadelphia in December 2022. They had been bused in from Texas, which has sent thousands of immigrants to cities around the country this way during the Biden administration. (Photo by Ryan Collerd/AFP via Getty Images)

In the months leading up to the presidential election, numerous polls picked up on the kinds of frustrations felt by Rosa and her family. Those polls indicated that many voters considered immigration one of the most pressing challenges facing the country and that they were disappointed in the Biden administration’s record.

Biden had come into office in 2021 promising a more humane approach to immigration after four years of more restrictive policies during the first Trump administration. But record numbers of immigrants who were apprehended at the U.S.-Mexico border began to overwhelm the system. While the Biden administration avoided talking about the border situation like a crisis, the way Trump and the GOP had, outspoken critics like Republican Texas Gov. Greg Abbott amplified the message that things at the border were out of control while he arranged to bus thousands of immigrants to Democrat-controlled big cities around the country. In Whitewater, hundreds of Nicaraguans arrived on their own to fill jobs in local factories, and many of them drove to work without licenses, putting a strain on the small local police department with only one Spanish-speaking officer.

While the Biden administration kept a Trump expulsion policy in place for three years, it also created temporary parole programs and an app to allow asylum-seekers to make appointments to cross the border. The result was that hundreds of thousands more immigrants were allowed to come into the country and apply for work permits, but the efforts didn’t assuage the administration’s critics on the right or left. Meanwhile, moves to benefit undocumented workers who were already in the country were less publicized, said Kathleen Bush-Joseph, a policy analyst at the nonpartisan Migration Policy Institute.

The White House did not respond to requests for comment.

Conchita Cruz, a co-founder and co-executive director of the Asylum Seeker Advocacy Project, which serves a network of around 1 million asylum-seekers across the country, said that because of either court challenges or processing backlogs, Biden wasn’t able to deliver on many of his promises to make it easier for immigrants who’ve lived in this country for years to regularize their status.

“Policies meant to help immigrants have not always materialized,” she said.

Cruz said that while the administration extended the duration of work permits for some employment categories, backlogs have hampered the quick processing of those extensions. As of September, there were about 1.2 million pending work permit applications, according to U.S. Citizenship and Immigration Services data, with many pending for six months or more. USCIS said the agency has taken steps to reduce backlogs while processing a record number of applications.

Biden’s attempts to push for broad immigration reform in Congress, including a proposal his administration sent on his first day in office, went nowhere. Earlier this year, in an effort to prevent a political win for Biden before the election, Trump pressured Republicans to kill bipartisan legislation that would have increased border security.

Camila Chávez, the executive director of the Dolores Huerta Foundation in Bakersfield, California, said Democrats failed to combat misinformation and turn out Latino voters. She recalled meeting one young Latina Trump supporter while she knocked on voters’ doors with the foundation’s sister political action organization. The woman told her she was concerned that the new immigrant arrivals were bringing crime and cartel activity — and potentially were a threat to her own family’s safety.

“That’s our charge as organizations, to make sure that we are in the community and educating folks on how government works and to not vote against our own self-interests. Which is what’s happening now,” said Chávez, who is the daughter of famed farmworker advocate Dolores Huerta and a niece of Cesar Chávez.

Trump has made clear he intends to deliver on his deportation promises, though the details of how he’ll do it and who will be most affected remain unclear. The last time Trump was elected, he moved quickly to issue an executive order that said no “classes or categories” of people who were in the country illegally could be exempt from enforcement. Tom Homan, who Trump has picked to serve as his “border czar,” said during a recent interview with Fox & Friends that immigrants who were deemed to be a threat to public safety or national security would be a priority under a new administration. But he said immigrants with outstanding deportation orders will also be possible targets and that there will be raids at workplaces with large numbers of undocumented workers.

The Trump campaign did not respond to a request for comment.

Mike Madrid, a Republican strategist, said it’s wishful thinking to believe Trump will give any special treatment to undocumented immigrants who have been living and working in the U.S. for a long time. But he’s heard that sentiment among Latino voters in focus groups.

“They believe that they are playing by the rules and that they will be rewarded for it,” Madrid said. “Republicans have never been serious about legal migration, let alone illegal migration. They’re allowing themselves to believe that for no good reason.”

Sergio Garza Castillo, who owns a gas station and convenience store in Del Rio, Texas, had long voted for Democrats. But his frustration with border policy led him to vote for Trump this year. (Gerardo del Valle/ProPublica)

The Republican Party’s growing appeal to Latino voters was especially noticeable in places like Del Rio, a Texas border town. As ProPublica previously reported, Trump flipped the county where Del Rio sits from blue to red in 2020 and won it this year with 63% of the vote.

Sergio Garza Castillo, a Mexican immigrant who owns a gas station and convenience store in Del Rio, illustrates that political shift. Garza Castillo said he came to the U.S. legally as a teenager in the 1980s after his father, a U.S. citizen, petitioned and waited for more than a decade to bring his family across the border.

Ever since Garza Castillo became a U.S. citizen in 2000, he has tended to vote for Democrats, believing in their promise of immigration reform that could lead to more pathways to citizenship for long-established undocumented immigrants, including many of his friends and acquaintances.

But the Democrats “promised and they never delivered,” Garza Castillo said. “They didn’t normalize the status of the people who were already here, but instead they let in many migrants who didn’t come in the correct way.” He believes asylum-seekers should have to wait outside the country like he did.

He said he began to turn away from the Democrats in September 2021, when nearly 20,000 mostly Haitian immigrants seeking asylum waded across the Rio Grande from Mexico and camped out under the city’s international bridge near Garza Castillo’s gas station. Federal authorities had instructed the immigrants to wait there to be processed; some remained there for weeks, sleeping under tarps and blankets with little access to water and food. Garza Castillo said he and other business owners lost money when the federal government shut down the international bridge, an economic engine for Del Rio.

Some of the Haitian migrants were eventually deported; others were allowed into the U.S. to pursue asylum claims and given notices to appear in court in a backlogged immigration system that can take years to resolve a case. “That to me is offensive for those who have been living here for more than 10 years and haven’t been able to adjust their status,” Garza Castillo said.

He hopes Trump seizes on the opportunity to expand support from Latino voters by creating a path to citizenship for undocumented immigrants who’ve been here for years. “If he does that,” he said, “I think the Republican Party will be strong here for a long time.”

Anjeanette Damon, Nicole Foy, Perla Trevizo and Gerardo del Valle contributed reporting.

by Lizzie Presser and Kavitha Surana

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Wrapping his wife in a blanket as she mourned the loss of her pregnancy at 11 weeks, Hope Ngumezi wondered why no obstetrician was coming to see her.

Over the course of six hours on June 11, 2023, Porsha Ngumezi had bled so much in the emergency department at Houston Methodist Sugar Land that she’d needed two transfusions. She was anxious to get home to her young sons, but, according to a nurse’s notes, she was still “passing large clots the size of grapefruit.”

Hope dialed his mother, a former physician, who was unequivocal. “You need a D&C,” she told them, referring to dilation and curettage, a common procedure for first-trimester miscarriages and abortions. If a doctor could remove the remaining tissue from her uterus, the bleeding would end.

But when Dr. Andrew Ryan Davis, the obstetrician on duty, finally arrived, he said it was the hospital’s “routine” to give a drug called misoprostol to help the body pass the tissue, Hope recalled. Hope trusted the doctor. Porsha took the pills, according to records, and the bleeding continued.

Three hours later, her heart stopped.

The 35-year-old’s death was preventable, according to more than a dozen doctors who reviewed a detailed summary of her case for ProPublica. Some said it raises serious questions about how abortion bans are pressuring doctors to diverge from the standard of care and reach for less-effective options that could expose their patients to more risks. Doctors and patients described similar decisions they’ve witnessed across the state.

It was clear Porsha needed an emergency D&C, the medical experts said. She was hemorrhaging and the doctors knew she had a blood-clotting disorder, which put her at greater danger of excessive and prolonged bleeding. “Misoprostol at 11 weeks is not going to work fast enough,” said Dr. Amber Truehart, an OB-GYN at the University of New Mexico Center for Reproductive Health. “The patient will continue to bleed and have a higher risk of going into hemorrhagic shock.” The medical examiner found the cause of death to be hemorrhage.

D&Cs — a staple of maternal health care — can be lifesaving. Doctors insert a straw-like tube into the uterus and gently suction out any remaining pregnancy tissue. Once the uterus is emptied, it can close, usually stopping the bleeding.

But because D&Cs are also used to end pregnancies, the procedure has become tangled up in state legislation that restricts abortions. In Texas, any doctor who violates the strict law risks up to 99 years in prison. Porsha’s is the fifth case ProPublica has reported in which women died after they did not receive a D&C or its second-trimester equivalent, a dilation and evacuation; three of those deaths were in Texas.

ProPublica condensed 200 pages of medical records into a summary of the case in consultation with two maternal-fetal medicine specialists and then reviewed it with more than a dozen experts around the country, including researchers at prestigious universities, OB-GYNs who regularly handle miscarriages, and experts in maternal health.

Texas doctors told ProPublica the law has changed the way their colleagues see the procedure; some no longer consider it a first-line treatment, fearing legal repercussions or dissuaded by the extra legwork required to document the miscarriage and get hospital approval to carry out a D&C. This has occurred, ProPublica found, even in cases like Porsha’s where there isn’t a fetal heartbeat or the circumstances should fall under an exception in the law. Some doctors are transferring those patients to other hospitals, which delays their care, or they’re defaulting to treatments that aren’t the medical standard.

Misoprostol, the medicine given to Porsha, is an effective method to complete low-risk miscarriages but is not recommended when a patient is unstable. The drug is also part of a two-pill regimen for abortions, yet administering it may draw less scrutiny than a D&C because it requires a smaller medical team and because the drug is commonly used to induce labor and treat postpartum hemorrhage. Since 2022, some Texas women who were bleeding heavily while miscarrying have gone public about only receiving medication when they asked for D&Cs. One later passed out in a pool of her own blood.

“Stigma and fear are there for D&Cs in a way that they are not for misoprostol,” said Dr. Alison Goulding, an OB-GYN in Houston. “Doctors assume that a D&C is not standard in Texas anymore, even in cases where it should be recommended. People are afraid: They see D&C as abortion and abortion as illegal.”

Hope visits his wife’s gravesite in Pearland, Texas. (Danielle Villasana for ProPublica)

Doctors and nurses involved in Porsha’s care did not respond to multiple requests for comment.

Several physicians who reviewed the summary of her case pointed out that Davis’ post-mortem notes did not reflect nurses’ documented concerns about Porsha’s “heavy bleeding.” After Porsha died, Davis wrote instead that the nurses and other providers described the bleeding as “minimal,” though no nurses wrote this in the records. ProPublica tried to ask Davis about this discrepancy. He did not respond to emails, texts or calls.

Houston Methodist officials declined to answer a detailed list of questions about Porsha’s treatment. They did not comment when asked whether Davis’ approach was the hospital’s “routine.” A spokesperson said that “each patient’s care is unique to that individual.”

“All Houston Methodist hospitals follow all state laws,” the spokesperson added, “including the abortion law in place in Texas.”

“We Need to See the Doctor”

Hope and his two sons outside their home in Houston (Danielle Villasana for ProPublica)

Hope marveled at the energy Porsha had for their two sons, ages 5 and 3. Whenever she wasn’t working, she was chasing them through the house or dancing with them in the living room. As a finance manager at a charter school system, she was in charge of the household budget. As an engineer for an airline, Hope took them on flights around the world — to Chile, Bali, Guam, Singapore, Argentina.

The two had met at Lamar University in Beaumont, Texas. “When Porsha and I began dating,” Hope said, “I already knew I was going to love her.” She was magnetic and driven, going on to earn an MBA, but she was also gentle with him, always protecting his feelings. Both were raised in big families and they wanted to build one of their own.

When he learned Porsha was pregnant again in the spring of 2023, Hope wished for a girl. Porsha found a new OB-GYN who said she could see her after 11 weeks. Ten weeks in, though, Porsha noticed she was spotting. Over the phone, the obstetrician told her to go to the emergency room if it got worse.

To celebrate the end of the school year, Porsha and Hope took their boys to a water park in Austin, and as they headed back, on June 11, Porsha told Hope that the bleeding was heavier. They decided Hope would stay with the boys at home until a relative could take over; Porsha would drive to the emergency room at Houston Methodist Sugar Land, one of seven community hospitals that are part of the Houston Methodist system.

At 6:30 p.m, three hours after Porsha arrived at the hospital, she saw huge clots in the toilet. “Significant bleeding,” the emergency physician wrote. “I’m starting to feel a lot of pain,” Porsha texted Hope. Around 7:30 p.m., she wrote: “She said I might need surgery if I don’t stop bleeding,” referring to the nurse. At 7:50 p.m., after a nurse changed her second diaper in an hour: “Come now.”

Still, the doctor didn’t mention a D&C at this point, records show. Medical experts told ProPublica that this wait-and-see approach has become more common under abortion bans. Unless there is “overt information indicating that the patient is at significant risk,” hospital administrators have told physicians to simply monitor them, said Dr. Robert Carpenter, a maternal-fetal medicine specialist who works in several hospital systems in Houston. Methodist declined to share its miscarriage protocols with ProPublica or explain how it is guiding doctors under the abortion ban.

As Porsha waited for Hope, a radiologist completed an ultrasound and noted that she had “a pregnancy of unknown location.” The scan detected a “sac-like structure” but no fetus or cardiac activity. This report, combined with her symptoms, indicated she was miscarrying.

But the ultrasound record alone was less definitive from a legal perspective, several doctors explained to ProPublica. Since Porsha had not had a prenatal visit, there was no documentation to prove she was 11 weeks along. On paper, this “pregnancy of unknown location” diagnosis could also suggest that she was only a few weeks into a normally developing pregnancy, when cardiac activity wouldn’t be detected. Texas outlaws abortion from the moment of fertilization; a record showing there is no cardiac activity isn’t enough to give physicians cover to intervene, experts said.

Dr. Gabrielle Taper, who recently worked as an OB-GYN resident in Austin, said that she regularly witnessed delays after ultrasound reports like these. “If it’s a pregnancy of unknown location, if we do something to manage it, is that considered an abortion or not?” she said, adding that this was one of the key problems she encountered. After the abortion ban went into effect, she said, “there was much more hesitation about: When can we intervene, do we have enough evidence to say this is a miscarriage, how long are we going to wait, what will we use to feel definitive?”

At Methodist, the emergency room doctor reached Davis, the on-call OB-GYN, to discuss the ultrasound, according to records. They agreed on a plan of “observation in the hospital to monitor bleeding.”

A sonogram of Porsha’s firstborn on the fridge in the family home. She was excited to have a third child. (Danielle Villasana for ProPublica)

Around 8:30 p.m., just after Hope arrived, Porsha passed out. Terrified, he took her head in his hands and tried to bring her back to consciousness. “Babe, look at me,” he told her. “Focus.” Her blood pressure was dipping dangerously low. She had held off on accepting a blood transfusion until he got there. Now, as she came to, she agreed to receive one and then another.

By this point, it was clear that she needed a D&C, more than a dozen OB-GYNs who reviewed her case told ProPublica. She was hemorrhaging, and the standard of care is to vacuum out the residual tissue so the uterus can clamp down, physicians told ProPublica.

“Complete the miscarriage and the bleeding will stop,” said Dr. Lauren Thaxton, an OB-GYN who recently left Texas.

“At every point, it’s kind of shocking,” said Dr. Daniel Grossman, a professor of obstetrics and gynecology at the University of California, San Francisco who reviewed Porsha’s case. “She is having significant blood loss and the physician didn’t move toward aspiration.”

All Porsha talked about was her devastation of losing the pregnancy. She was cold, crying and in extreme pain. She wanted to be at home with her boys. Unsure what to say, Hope leaned his chest over the cot, passing his body heat to her.

At 9:45 p.m., Esmeralda Acosta, a nurse, wrote that Porsha was “continuing to pass large clots the size of grapefruit.” Fifteen minutes later, when the nurse learned Davis planned to send Porsha to a floor with fewer nurses, she “voiced concern” that he wanted to take her out of the emergency room, given her condition, according to medical records.

At 10:20 p.m., seven hours after Porsha arrived, Davis came to see her. Hope remembered what his mother had told him on the phone earlier that night: “She needs a D&C.” The doctor seemed confident about a different approach: misoprostol. If that didn’t work, Hope remembers him saying, they would move on to the procedure.

A pill sounded good to Porsha because the idea of surgery scared her. Davis did not explain that a D&C involved no incisions, just suction, according to Hope, or tell them that it would stop the bleeding faster. The Ngumezis followed his recommendation without question. “I’m thinking, ‘He’s the OB, he’s probably seen this a thousand times, he probably knows what’s right,’” Hope said.

But more than a dozen doctors who reviewed Porsha’s case were concerned by this recommendation. Many said it was dangerous to give misoprostol to a woman who’s bleeding heavily, especially one with a blood clotting disorder. “That’s not what you do,” said Dr. Elliott Main, the former medical director for the California Maternal Quality Care Collaborative and an expert in hemorrhage, after reviewing the case. “She needed to go to the operating room.” Main and others said doctors are obliged to counsel patients on the risks and benefits of all their options, including a D&C.

Performing a D&C, though, attracts more attention from colleagues, creating a higher barrier in a state where abortion is illegal, explained Goulding, the OB-GYN in Houston. Staff are familiar with misoprostol because it’s used for labor, and it only requires a doctor and a nurse to administer it. To do a procedure, on the other hand, a doctor would need to find an operating room, an anesthesiologist and a nursing team. “You have to convince everyone that it is legal and won’t put them at risk,” said Goulding. “Many people may be afraid and misinformed and refuse to participate — even if it’s for a miscarriage.”

Davis moved Porsha to a less-intensive unit, according to records. Hope wondered why they were leaving the emergency room if the nurse seemed so worried. But instead of pushing back, he rubbed Porsha’s arms, trying to comfort her. The hospital was reputable. “Since we were at Methodist, I felt I could trust the doctors.”

On their way to the other ward, Porsha complained of chest pain. She kept remarking on it when they got to the new room. From this point forward, there are no nurse’s notes recording how much she continued to bleed. “My wife says she doesn’t feel right, and last time she said that, she passed out,” Hope told a nurse. Furious, he tried to hold it together so as not to alarm Porsha. “We need to see the doctor,” he insisted.

Her vital signs looked fine. But many physicians told ProPublica that when healthy pregnant patients are hemorrhaging, their bodies can compensate for a long time, until they crash. Any sign of distress, such as chest pain, could be a red flag; the symptom warranted investigation with tests, like an electrocardiogram or X-ray, experts said. To them, Porsha’s case underscored how important it is that doctors be able to intervene before there are signs of a life-threatening emergency.

But Davis didn’t order any tests, according to records.

Around 1:30 a.m., Hope was sitting by Porsha’s bed, his hands on her chest, telling her, “We are going to figure this out.” They were talking about what she might like for breakfast when she began gasping for air.

“Help, I need help!” he shouted to the nurses through the intercom. “She can’t breathe.”

“All She Needed”

Hope with his son (Danielle Villasana for ProPublica)

Hours later, Hope returned home in a daze. “Is mommy still at the hospital?” one of his sons asked. Hope nodded; he couldn’t find the words to tell the boys they’d lost their mother. He dressed them and drove them to school, like the previous day had been a bad dream. He reached for his phone to call Porsha, as he did every morning that he dropped the kids off. But then he remembered that he couldn’t.

Friends kept reaching out. Most of his family’s network worked in medicine, and after they said how sorry they were, one after another repeated the same message. All she needed was a D&C, said one. They shouldn’t have given her that medication, said another. It’s a simple procedure, the callers continued. We do this all the time in Nigeria.

Since Porsha died, several families in Texas have spoken publicly about similar circumstances. This May, when Ryan Hamilton’s wife was bleeding while miscarrying at 13 weeks, the first doctor they saw at Surepoint Emergency Center Stephenville noted no fetal cardiac activity and ordered misoprostol, according to medical records. When they returned because the bleeding got worse, an emergency doctor on call, Kyle Demler, said he couldn’t do anything considering “the current stance” in Texas, according to Hamilton, who recorded his recollection of the conversation shortly after speaking with Demler. (Neither Surepoint Emergency Center Stephenville nor Demler responded to several requests for comment.)

They drove an hour to another hospital asking for a D&C to stop the bleeding, but there, too, the physician would only prescribe misoprostol, medical records indicate. Back home, Hamilton’s wife continued bleeding until he found her passed out on the bathroom floor. “You don’t think it can really happen like that,” said Hamilton. “It feels like you’re living in some sort of movie, it’s so unbelievable.”

Across Texas, physicians say they blame the law for interfering with medical care. After ProPublica reported last month on two women who died after delays in miscarriage care, 111 OB-GYNs sent a letter to Texas policymakers, saying that “the law does not allow Texas women to get the lifesaving care they need.”

Dr. Austin Dennard, an OB-GYN in Dallas, told ProPublica that if one person on a medical team doubts the doctor’s choice to proceed with a D&C, the physician might back down. “You constantly feel like you have someone looking over your shoulder in a punitive, vigilante type of way.”

The criminal penalties are so chilling that even women with diagnoses included in the law’s exceptions are facing delays and denials. Last year, for example, legislators added an update to the ban for patients diagnosed with previable premature rupture of membranes, in which a patient’s water breaks before a fetus can survive. Doctors can still face prosecution for providing abortions in those cases, but they are offered the chance to justify themselves with what’s called an “affirmative defense,” not unlike a murder suspect arguing self defense. This modest change has not stopped some doctors from transferring those patients instead of treating them; Dr. Allison Gilbert, an OB-GYN in Dallas, said doctors send them to her from other hospitals. “They didn’t feel like other staff members would be comfortable proceeding with the abortion,” she said. “It’s frustrating that places still feel like they can’t act on some of these cases that are clearly emergencies.” Women denied treatment for ectopic pregnancies, another exception in the law, have filed federal complaints.

In response to ProPublica’s questions about Houston Methodist’s guidance on miscarriage management, a spokesperson, Gale Smith, said that the hospital has an ethics committee, which can usually respond within hours to help physicians and patients make “appropriate decisions” in compliance with state laws.

After Porsha died, Davis described in the medical record a patient who looked stable: He was tracking her vital signs, her bleeding was “mild” and she was “said not to be in distress.” He ordered bloodwork “to ensure patient wasn’t having concerning bleeding.” Medical experts who reviewed Porsha’s case couldn’t understand why Davis noted that a nurse and other providers reported “decreasing bleeding” in the emergency department when the record indicated otherwise. “He doesn’t document the heavy bleeding that the nurse clearly documented, including the significant bleeding that prompted the blood transfusion, which is surprising,” Grossman, the UCSF professor, said.

Patients who are miscarrying still don’t know what to expect from Houston Methodist.

This past May, Marlena Stell, a patient with symptoms nearly identical to Porsha’s, arrived at another hospital in the system, Houston Methodist The Woodlands. According to medical records, she, too, was 11 weeks along and bleeding heavily. An ultrasound confirmed there was no fetal heartbeat and indicated the miscarriage wasn’t complete. “I assumed they would do whatever to get the bleeding to stop,” Stell said.

Instead, she bled for hours at the hospital. She wanted a D&C to clear out the rest of the tissue, but the doctor gave her methergine, a medication that’s typically used after childbirth to stop bleeding but that isn’t standard care in the middle of a miscarriage, doctors told ProPublica. "She had heavy bleeding, and she had an ultrasound that's consistent with retained products of conception." said Dr. Jodi Abbott, an associate professor of obstetrics and gynecology at Boston University School of Medicine, who reviewed the records. "The standard of care would be a D&C."

Stell says that instead, she was sent home and told to “let the miscarriage take its course.” She completed her miscarriage later that night, but doctors who reviewed her case, so similar to Porsha’s, said it showed how much of a gamble physicians take when they don’t follow the standard of care. “She got lucky — she could have died,” Abbott said. (Houston Methodist did not respond to a request for comment on Stell’s care.)

It hadn’t occurred to Hope that the laws governing abortion could have any effect on his wife’s miscarriage. Now it’s the only explanation that makes sense to him. “We all know pregnancies can come out beautifully or horribly,” Hope told ProPublica. “Instead of putting laws in place to make pregnancies safer, we created laws that put them back in danger.”

For months, Hope’s youngest son didn’t understand that his mom was gone. Porsha’s long hair had been braided, and anytime the toddler saw a woman with braids from afar, he would take off after her, shouting, “That’s mommy!”

A couple weeks ago, Hope flew to Amsterdam to quiet his mind. It was his first trip without Porsha, but as he walked the city, he didn’t know how to experience it without her. He kept thinking about how she would love the Christmas lights and want to try all the pastries. How she would have teased him when he fell asleep on a boat tour of the canals. “I thought getting away would help,” he wrote in his journal. “But all I’ve done is imagine her beside me.”

First image: Hope now wears his and Porsha’s wedding rings around his neck. Second image: Porsha’s son plays with cards capturing memories of his mother. (Danielle Villasana for ProPublica)

Mariam Elba and Lexi Churchill contributed research.

by Jodi S. Cohen and Jennifer Smith Richards

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week.

In the strongest rebuke yet of Illinois school districts that ask police to ticket misbehaving students, the state attorney general has declared that the practice — still being used across the state — is illegal and should stop.

The attorney general’s office, which had been investigating student ticketing in one of Illinois’ largest high school districts, found that Township High School District 211 in Palatine broke the law when administrators directed police to fine its students for school-based conduct, and that the practice had an “unjustified disparate impact” on Black and Latino students.

“We strongly encourage other districts and police departments to review their policies and practices,” the office told ProPublica.

But the attorney general’s office did not alert other districts of its findings, which came in July, and did not issue guidance that the common practice violates the law. That means its findings against the suburban Chicago district could have a narrow effect.

The office also said that it is not investigating other districts for similar civil rights violations.

In 2022, a ProPublica and Chicago Tribune investigation, “The Price Kids Pay,” revealed how local police officers were writing students tickets that resulted in fines of up to $750. The tickets, for violating local ordinances, are considered noncriminal offenses and can be punishable only by a fine. The misbehavior included having vape pens, missing class, and participating in verbal or minor physical altercations.

In response, Gov. JB Pritzker and two state superintendents of education said schools should not rely on police to handle student misconduct.

State lawmakers have tried several times to pass legislation intended to stop the practice by specifically prohibiting schools from involving police in minor disciplinary matters. But the bills have stalled. School officials have argued ticketing is a necessary tool to manage student behavior, and some lawmakers worried that limiting officers’ role in schools could lead to unsafe conditions.

Rep. La Shawn Ford, a Democrat from Chicago, told ProPublica this month that he plans to try again next year. “We don’t want police doing schools’ work,” Ford said.

He said revised legislation will aim to address school officials’ concerns and will make clear that school employees can still involve police in criminal matters.

“What will really address this is a state law that would have an impact on all Illinois schools. That is the only possible way I see because it is so pervasive across Illinois,” said Angie Jiménez, an attorney at the National Center for Youth Law, which has pushed for reforms in Illinois law.

Jimenez said fining students as discipline should have stopped more than nine years ago when state law banned doing so. “It is really shocking to me to see that less than a decade later, you are having this issue and we are still trying to come to the table to reach an agreement,” she said. “Meanwhile, our students and families are the ones that are being sacrificed in this process.”

Illinois State Board of Education spokesperson Lindsay Record said the agency continues to oppose the practice of issuing tickets to students. “ISBE is evaluating potential policy solutions for the issue,” Record said, though she did not elaborate on what those might be. Pritzker’s office did not respond to questions from ProPublica.

The attorney general’s office decided to focus its investigation on District 211 after officials reviewed a first-of-its-kind database published by ProPublica and the Tribune. The database documented nearly 12,000 tickets issued in dozens of districts over three school years, the reasons police ticketed students and, when available, the racial breakdown of students who received tickets.

The state investigation of District 211, which lasted two years, focused on the district’s two high schools in Palatine, a suburb northwest of Chicago. From 2018 through 2022, Palatine police ticketed students nearly 400 times, mostly at Palatine High School. Black and Latino students sometimes received tickets when white students were given lesser punishments or even offered help to cope with substance use, the investigation found. Palatine police ticketed Fremd High School students, too, but much less frequently.

“Police reports show that, typically, District administrators conducted the initial investigation, then called the school resource officer for service and directed the officer to issue a ticket to the student,” according to a letter Attorney General Kwame Raoul sent to the district in late July after his office concluded its investigation. Officers ticketed students even when police hadn’t witnessed the alleged misconduct, investigators found.

The attorney general’s office told District 211 that it should make it clear in school handbooks and agreements with local police that school administrators are prohibited from directing or asking police to issue tickets to students as a form of discipline, including for disorderly conduct or having tobacco or vaping products. District policies also should make clear that the preference is for alternative approaches, such as a substance abuse program.

Raoul’s letter noted that since the 2022-23 school year, the district and police department have “drastically reduced” the use of school-based ticketing.

The district, which enrolls nearly 12,000 students across three suburbs, has denied wrongdoing since the investigation began. A district spokesperson declined to answer questions from ProPublica and instead provided a letter an attorney for the district wrote to the attorney general’s office criticizing the findings.

“None of the administrators interviewed indicated that they ‘directed’ the School Resource Officers or other police officials to issue tickets or make arrests,” the attorney wrote, adding that only police have the authority to issue tickets. The letter said that school officials are required to report to law enforcement certain offenses, such as those involving weapons or drugs. In those serious matters, however, police can and do arrest students — not ticket them. The district’s response letter says it will review its student handbooks and policies. However, current high school handbooks still state that students can be sent to police for having vaping products.

The district’s records cited in the attorney general’s findings showed that in the 2021-22 school year, Black and Hispanic students received about 68% of the tickets issued at school, even though they accounted for only about 33% of district enrollment. White students made up 42% of district enrollment, but they received only 24% of the tickets.

The state investigators attributed that, in part, to school administrators choosing not to involve police in white students’ behavioral issues, offering them therapies instead of punishment.

The mother of a student ticketed in 2022 said that while she hopes district officials stop involving police in school conduct, she also thinks there should be a remedy for students ticketed in the past. Her son, who is Black, was a 16-year-old sophomore at Palatine High School when he received a $200 ticket for damaging a fence near the school. ProPublica reporters met the family when the teen and his mother attended a hearing to fight the ticket; it was dismissed after another student acknowledged he had caused the damage.

“I would hope that if they know they were doing it illegally, they would wipe all the tickets out. That is what they should do. If anyone had to pay fines, they should be reimbursed,” said the mother, who asked not to be identified to protect the privacy of her son, who graduated from high school in the spring and is now in college.

The attorney general’s office also focused on the village of Palatine, and investigators found that it, too, had violated the law. Palatine police issued truancy tickets to students for missing a single day of school or less, even though state law prohibits that as punishment. The village also set the fine at $200, even though the maximum amount permitted by state law is $100, investigators found.

The attorney general’s office recommended that the village change or repeal its ordinance. The village manager and the chief of the Palatine Police Department did not respond to questions from reporters.

While some schools have stopped involving police in minor student discipline matters in recent years, others have continued. ProPublica obtained new records from several districts in different parts of the state that had been spotlighted in “The Price Kids Pay.”

At Bradley-Bourbonnais Community High School southwest of Chicago, police have issued more than 60 tickets to students since the start of the 2023-24 school year for disorderly conduct, possession of tobacco or cannabis, and consumption of alcohol. The fines are as much as $175, and the school superintendent said the district is focused on providing a safe environment.

Officers in northwest suburban Carpentersville wrote dozens of tickets last school year at Dundee-Crown High School and at Carpentersville Middle School and have ticketed this year, too. A district spokesperson did not respond to a request for comment.

At East Peoria Community High School, in central Illinois, students continue to get tickets that cost from $75 to $450 for fighting and possession of tobacco or cannabis. Students as young as 12 at the nearby junior high school also have been issued tickets.

East Peoria High School Superintendent Marjorie Greuter said students no longer are ticketed for truancy and officers based at the school decide when to ticket students for other misconduct. She wrote in an email that if students could be ticketed outside of school for violating a local ordinance, “it is still our opinion that not doing so inside the building presents a safety concern.”

by Jennifer Berry Hawes and Mollie Simon

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week.

On May 14, the final day for submitting new bills in the Mississippi Legislature, a bold new package of them landed on the desks of Mississippi lawmakers. The plans called for the creation of a voucher program that paid for students to attend private schools.

A few weeks later, in the heat of mid-June, the governor urged lawmakers to support the $40 million program, promising it “will bear the sound fruit of progress for a hundred years after this generation is gone.” Public school support would continue, he assured. But vouchers would “strengthen the total educational effort” by giving children “the right to choose the educational environment they desire.”

It was 1964.

Key backers of the move included a group of white segregationists that had formed after the U.S. Supreme Court ruled state-mandated public school segregation unconstitutional.

Across the South, courts had already rejected or limited similar voucher plans in Alabama, Louisiana, Virginia and Arkansas. But Mississippi lawmakers plowed forward anyway and adopted the program. For several years, the state funneled money to white families eager for their children to attend new private academies opening as the first Black children arrived in previously all-white public schools.

Now, 60 years later, ProPublica has found that many of these private schools, known as “segregation academies,” still operate across the South — and many are once again benefiting from public dollars. Earlier this week, ProPublica reported that in North Carolina alone, 39 of them have received tens of millions in voucher money. In Mississippi, we identified 20 schools that likely opened as segregation academies and have received almost $10 million over the past six years from the state’s tax credit donation program.

At least eight of the 20 schools opened with an early boost from vouchers in the 1960s.

“The origins of private schools receiving public funds were with the segregation academies,” said Steve Suitts, a historian and the author of “Overturning Brown: The Segregationist Legacy of the Modern School Choice Movement.”

Most private schools receiving money from the voucher-style programs exploding across the country aren’t segregation academies. But where the academies operate, especially in rural areas, they often foster racial separation in schools and, as a result, across entire communities.

Despite the passage of decades, most segregation academies across Mississippi remain vastly white — far more so than the counties where they operate, federal private school surveys show. Mississippi is the state with the highest percentage of Black residents.

At 15 of the 20 academies benefiting from the tax credit program, student bodies were at least 85% white as of the last federal private school survey, for the 2021-22 school year. And among the 20, enrollments at five were more than 60 percentage points whiter than their communities. Another 11 were at least 30 percentage points whiter.

In 1964, the White Citizens’ Council was among those pushing for the voucher plan. The pro-segregation group was founded in the Mississippi Delta town of Indianola in the 1950s by Robert “Tut” Patterson, who sought to “save our schools if possible” from integration and “if that failed, to develop a system of private schools for our children.”

For Patterson, it was personal. His family, including a young daughter who would start school that fall, lived on what he called a “plantation” with 35 Black families. As he later told an interviewer, “We took care of them. We practically lived with them. We loved them. We tended to them, but I didn’t want to mingle my children with them.”

The state’s voucher program provided $185 to each student to help pay private school tuition — about $1,876 in today’s dollars. It aimed to give each child “individual freedom in choosing public or private schooling,” the bill’s preamble said.

Shortly after lawmakers adopted the plan, the Citizens’ Councils of America used its monthly journal to follow up with advice about “How To Start A Private School” and a “Sample Charter Of Incorporation.” Private schools sprouted up, particularly in public school districts under court desegregation orders or that had submitted voluntary desegregation plans to the federal government, court records show.

Over the voucher program’s first four years, the number of new segregation academies that received public dollars snowballed from two to 49. Among them, 48 enrolled no Black students. One did admit Black children — but only Black children.

John Giggie, a historian at the University of Alabama, directs its Summersell Center for the Study of the South and has studied the birth of these private schools. These days, people often “have no idea why these segregation academies opened,” he said. “It was one of the most aggressive moves that Southern governors took after the passage of the Brown case. That movement accelerated as the Civil Rights movement accelerated. It ripped across the region.”

As white families rushed to open academies, vouchers provided critical seed money. In the 1965-66 school year, vouchers covered more than a third of the total operating costs for at least 17 new academies.

One of the early takers was Central Holmes Academy, now Central Holmes Christian School. Vouchers paid more than 78% of the fledgling academy’s tuition bills for 210 students that school year. The school’s directors made their feelings about integration clear in a letter later cited in federal court in which they described “other schools” as “intolerable and repugnant.”

In 1968, Mississippi lawmakers increased each voucher to $240. The following January, Black families in Mississippi prevailed in a federal class-action lawsuit against the state challenging the vouchers’ constitutionality. A panel of federal judges found that the program supported “the establishment of a system of private schools operated on a racially segregated basis as an alternative available to white students seeking to avoid desegregated public schools.”

The program violated the Constitution, the judges ruled. Parents could choose segregated private schools for their children — but the voucher program involved the state in that discrimination.

In a way, it was too late. The academies were up and running.

“Clearly, the schools could not have survived as even semblances of educational institutions without these contributions,” the U.S. Department of Justice found after examining the academies’ finances as part of the federal lawsuit.

By then, state taxpayers had funded more than 5,000 vouchers.

The segregation academies continued for a time to receive other forms of public aid, including state-financed textbooks, deals on property and donations of public school equipment. But vouchers were dead.

Then, five decades after the court tossed its early voucher program, Mississippi’s Legislature found a way to reestablish private school funding.

In 2019, the state launched its Children’s Promise Act, which provides incentives to businesses to participate in a state-funded program for private schools. The program gives businesses a dollar-for-dollar tax credit — up to 50% of their total tax liability — for donations to certain educational charities, including private schools. The act aims to help children who are low income, living in foster care or diagnosed with chronic illnesses or disabilities.

But there is no public disclosure of how much the schools focus on any of these things. Their requests with the state to qualify for the donations — and therefore claims they make about how many students they serve in these categories — are not made public. But it is clear that the donations, refunded with tax dollars, are flowing into segregation academies.

In its latest annual report, the Midsouth Association of Independent Schools, founded in 1968 by a group of segregation academies, said the Mississippi tax credits are now a “crucial source of funding.” (The association’s ethics guidelines state any member school “shall not discriminate on the basis of race, sex, color, national, or ethnic origin in the administration of its admission practices.”)

ProPublica found that segregation academies represent at least a fifth of all schools benefiting from the tax credits.

Central Holmes is one. The school has received $812,150 from the tax credit-fueled donations since 2020. Those resources help it improve academic programs, update technology and facilitate professional development, said the school’s headmaster, Chris Terry.

As of the last federal private school survey, Central Holmes reported a student body that was 82% white — a shift from 95% white a decade ago but far from representative of the community around it. Holmes County is barely more than 15% white.

Terry, who’s been headmaster since 2022, noted that during that time, the school has had Asian, Hispanic and Black students “enjoying success.” Among them were a Black valedictorian and homecoming queen. “To me, this shows our school’s desire to move past the past and forge a new future for our students and families,” Terry said in an email.

He added that he couldn’t comment on the school’s origin because he wasn’t alive at the time.

Those who were alive when it opened in 1965 voiced differing visions for the future. In 1970, a Black legislator who represented Central Holmes’ district predicted that white students would return to public schools in “two or three years.” But Central Holmes’ board chair, a former legislator, disagreed. He predicted the school would “go on indefinitely.”

by Peter Elkind

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Update, Nov. 25, 2024: On Nov. 22, hours after this article was published, Lincare announced internally that “effective immediately, Greg McCarthy is no longer Chief Operating Officer. Greg is leaving Lincare to pursue other opportunities.”

For users of breathing machines made by Philips Respironics, recent years have been a nightmare in multiple acts. First came complaints of illnesses and injuries caused by the devices. Then came reports of deaths. Then came a large-scale recall that itself was beset by problems.

Now ProPublica has learned of another episode. As Philips struggled to execute its recall in 2022, it turned to its biggest distributor, a company called Lincare, to help ensure that replacement equipment would reach the patients who needed it most. But instead of sending those machines to vulnerable longtime users — what Philips expected — Lincare diverted thousands of machines to new customers, which resulted in greater profits. Some patients did not receive replacement breathing machines for as long as two years. Meanwhile, complaints to the FDA reporting deaths (561) and illnesses, injuries or malfunctions (116,000) associated with the recalled devices continued to climb.

Philips’ problems first surfaced publicly in June 2021, when the company warned that the noise-deadening foam lining its equipment, mostly CPAP machines, could break apart, sending potentially toxic particles and fumes into users’ throats and lungs. (Millions of people use such “continuous positive airway pressure” devices to treat sleep apnea, a condition that causes breathing to stop and start repeatedly during the night.)

Philips announced a recall. The company vowed to stop selling to new customers and dedicate its manufacturing capacity to replacing the recalled devices with safe, redesigned CPAP machines “as expeditiously as possible.” (The Philips recall, and the tangled history that led up to it, were the subject of a series of investigations by ProPublica and the Pittsburgh Post-Gazette.)

But the recall was marred by problems, and by the spring of 2022, many patients hadn’t received replacement devices. Some were informed by Philips that they might have to wait another year, meaning the company would fail to fulfill its plan to swap out all the recalled equipment by the end of 2022. That left even a patient who’d had a double lung transplant waiting for months on end.

Under pressure from the Food and Drug Administration, which regulates medical-device safety, Philips agreed to pursue a “prioritization approach,” providing new equipment first to the “most vulnerable” patients — those who depend on the breathing equipment the most. Philips pledged that all the safe devices it produced would go as quickly as possible to the sickest patients, according to a March 10, 2022, FDA notification order.

Lincare is America’s biggest distributor of breathing equipment. It buys tens of thousands of CPAP machines from Philips and other manufacturers every year, then collects up to 13 months of rental payments for providing them to patients, with Medicare and other insurers picking up most of the tab. Lincare also sells lucrative replacement supplies, such as masks, filters and hoses. The company has a lengthy history of misbehavior, including repeated instances of overcharging Medicare and elderly patients — Lincare has been placed on Medicare’s equivalent of probation four times in the past quarter-century — according to a recent investigation by ProPublica.

Lincare and most other distributors had refused to actively help Philips with the recall, according to four sources familiar with the recall. They complained that Philips wasn’t offering enough money to do the work of picking up old equipment and replacing it. Meanwhile, Philips’ CPAP woes had cut into Lincare’s profits, since there was a dearth of new machines to make money off while the recall was underway.

But a top Lincare executive found a way to exploit the recall to the company’s benefit. In late March 2022, Lincare’s chief operating officer, Greg McCarthy, unveiled a plan to his deputies that would ease the financial hit, according to Sam Markovic, then one of the company’s four regional vice presidents. McCarthy told them, in their regular Friday conference call, that he’d arranged for Philips to give Lincare 20,000 CPAP machines for free.

Philips had assured the FDA that it would direct that all of the new machines be sent to replace recalled devices, prioritizing customers who needed them the most. But that’s not what Lincare planned to do with its supply. Instead, according to Markovic, McCarthy told his deputies that Lincare would provide the devices to new customers. The company would make more money that way. Lincare could add more patients even as existing customers kept paying for supplies for their recalled machines. McCarthy ended the conference call, Markovic said, with his frequent admonition: “If you’re not growing, you’re dying!”

In a private conversation that was tape recorded, McCarthy later described how he had obtained the machines, according to Spence Hodges, then Philips’ top sales executive on the Lincare account, who was given a copy of the recording. In that conversation, McCarthy said he had let Philips believe that Lincare would use the machines to replace recalled devices that it owned and were needed for existing patients in long-term care facilities, such as assisted living and nursing homes.

This article is based on accounts from Markovic, other former Lincare employees and Hodges. Lincare, which has a history of litigation with its former executives, fired Markovic in 2022 and sued him for obtaining more than $100,000 in reimbursements for allegedly improper expenses; earlier this year, a judge issued a summary judgment in Lincare’s favor. Markovic disputes the allegations.

Philips declined to comment on Lincare’s role in the recall. But in a written statement, Philips confirmed that the new CPAP devices it provided were supposed to be used to replace recalled machines: “All of the decisions Philips Respironics has taken to allocate new and remediated devices in the United States are based solely on prioritizing patient needs. Our position has always been, and remains, that all devices manufactured to address the recall in the United States are intended for affected patients only.”

An FDA spokesperson declined to make officials available for interviews or comment on Lincare’s actions, but wrote, “Protecting impacted patients and ensuring they receive relief has been a high priority for the FDA throughout this recall.”

Lincare also declined to make executives available for comment. In response to a summary of this article’s findings, provided separately to a spokesperson and to COO McCarthy, the spokesperson emailed a two-sentence response: “We appreciate your questions. We take this matter seriously and are looking into it.” McCarthy did not provide any comment.

Lincare has some 700 locations in the U.S., including this one in Libby, Montana. (Rebecca Stumpf, special to ProPublica)

In early April 2022, shortly after their meeting with McCarthy, Lincare vice presidents began contacting local center managers around the country who would be receiving shipments of the otherwise scarce Philips CPAP machines, to pass on the COO’s orders that they be used for new patients. Markovic said he personally notified five managers in four states.

Several were surprised to learn that Lincare would have devices for new customers (or “setups,” in industry parlance). The new machines allowed one local center to exceed its monthly quota for new CPAP sales despite the recall, according to a former manager who requested anonymity. “I set up over a hundred in that time,” the former manager told ProPublica. “I just remember every time before I thought I had to cancel setups, there would be another two pallets of them [arriving]. It was just perfect timing.”

By June 2022, Hodges, Philips’ account executive for Lincare, had learned about Lincare’s plans. Hodges promptly reported what he had heard to Philips management, he told ProPublica. A few weeks later, he received the recording of McCarthy discussing how he’d misled Philips, he said, and turned that over to his bosses too. “All I know is that information was brought back to me,” he said, “and I went through the appropriate channels at Philips. I turned over everything and let them decide what to do with it.” It’s unclear what, if any, actions Philips took in response to that information.

Hodges, who left Philips in 2023 after 15 years at the company, said he was upset at the time. “People were having to wait,” he said. “To my mind, these devices were meant to be used by patients that needed their devices replaced, and I felt strongly that’s what they should be used for. Philips was doing their best to remediate as fast as they could.”

It’s not clear exactly how much longer some patients had to wait for new equipment because of Lincare’s diversion. It was only in October 2023 that Philips said it had fulfilled “over 99%” of requests made by patients who registered for the recall. (Those patients received new equipment or, in some instances, a payment.) That means that some users may have waited as long as two years for replacement equipment.

As ProPublica previously reported, Philips waited years to act on health complaints and internal concerns before issuing its recall, which involved both CPAP machines and ventilators, in June 2021. Since then, the company has faced an ongoing federal criminal investigation and more than 700 lawsuits. Since December 2023, Philips, without admitting fault, has agreed to $1.7 billion in settlements and a federal consent decree that indefinitely bars any new respiratory device sales in the U.S. and provides health monitoring and payments for affected customers.

Philips has long cultivated a cozy relationship with Lincare. Philips’ efforts to boost sales to Lincare and other distributors have led to three civil suits by the federal government claiming Philips gave the distributors kickbacks. In 2016, Philips agreed to pay $34.8 million to resolve claims that it illegally provided free call-center services in exchange for companies’ purchase of Philips CPAP masks. In 2022, it agreed to pay $24 million to resolve claims that it provided physician prescribing data to Lincare and other companies in exchange for equipment orders, and to pay $1.3 million for allegedly arranging interest-free loans for equipment purchases. (Philips denied wrongdoing in each of the cases.)

These days, Lincare and Philips are squaring off in court — with Lincare as the plaintiff. The company sued Philips in February in state court in Pennsylvania, where Philips manufactures its devices. Lincare is seeking payment for “many millions of dollars” in costs and losses that Lincare blamed on the recall, citing an indemnification provision in its contract with Philips. Philips has not filed a response to the lawsuit. In a public filing with the Securities and Exchange Commission, however, Philips said it is “engaging with certain of its business partners on the level of compensation they alleged to be entitled to” from the recall.

Tom Wilson, administrator of the 7,700-member CPAP Recall Support Group on Facebook, called Lincare’s actions in the recall “terrible.” In mid-2022, he said, many patients were still waiting for new, safe machines. Those with severe cases of apnea, unable to simply stop using their recalled devices, were especially frightened and desperate to get replacements. “You’ve got something that’s on your face eight hours a night, and you don’t know how safe or unsafe this equipment is.”

Do You Have a Tip for ProPublica? Help Us Do Journalism.

Doris Burke contributed research.

by Nicole Santa Cruz, Asia Fields and Ruth Talbot

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week.

When Stephenie came upon workers in Portland, Oregon, who had bagged up all of her belongings in a homeless encampment sweep, she desperately pleaded to get one item back: her purse. It contained her cash and food stamp card — what she needed to survive.

The crew refused to look for it, she said. The items workers had put in clear bags were headed to a city warehouse. Those in black bags were headed to a landfill.

They handed her a card with a phone number to call if she wanted to pick up her things.

Portland, Oregon, distributes cards to people whose belongings are stored after encampment removals. Stephenie, who is homeless, received a similar card after her belongings were taken. (Photo provided by Portland officials)

Pregnant and hungry, Stephenie was supposed to rest and avoid heavy lifting. She now had to start all over. In the days that followed last September, Stephenie slept on a sidewalk for the first time. She said she attempted suicide.

“I had nowhere to go — no place, no tent, no nothing. I couldn’t even feed myself,” she said. “The lowest point I’ve ever been in my life was after the sweep.”

If you or someone you know needs help, here are a few resources:

• Call the National Suicide Prevention Lifeline: 988

• Text the Crisis Text Line from anywhere in the U.S. to reach a crisis counselor: 741741

As homelessness has reached crisis levels, more cities are clearing tents and encampments in operations commonly called sweeps. Since a U.S. Supreme Court decision in June allowed cities to punish people for sleeping outside, even if there’s no shelter available, some have made their encampment policies more punitive and increased the frequency of sweeps.

Some cities have programs to store what they take, sometimes created in response to lawsuits. In theory, these storage programs are supposed to protect people’s property rights and make it easy to get their possessions back.

In reality, they rarely accomplish either objective, according to a ProPublica investigation of the policies in regions with the largest homeless populations.

ProPublica obtained records from 14 cities showing what was stored following encampment clearings. In Los Angeles and San Diego, thousands of encampments are removed each year, but the belongings taken from them are rarely stored, the records showed. San Diego, for example, removed more than 3,000 sites during 2023 but only documented storing belongings 19 times. In Seattle, the city removed nearly 1,000 encampments during a six-month period last year and stored belongings from just 55 of them.

This sign from Seattle indicates that nothing was stored after an encampment was cleared. (Asia Fields/ProPublica)

Even when possessions are stored, the records showed, people are rarely able to reclaim them. In Portland, which stores the most among the cities ProPublica reviewed, property was reclaimed 4% of the time during a recent 12-month period. In San Francisco, property was reclaimed roughly 12% of the time over 18 months; much of what the city stored was collected after contact with police. Records provided to ProPublica by Anaheim, California, showed nothing had been retrieved from January 2023 through May of this year.

Some cities did not address ProPublica’s questions about the low rates at which people are able to retrieve their belongings. But they broadly defended their encampment practices, saying that they balance the rights of people experiencing homelessness with public health needs.

In Portland, officials said they manage an extensive database of stored belongings and “share in the collective frustration in the difficulties in managing a system that works well for everyone.” When asked about the sweep in which Stephenie’s items were taken, they acknowledged that camp removals are harmful to unhoused people, but that they must also maintain city property and natural areas.

ProPublica heard from at least 95 people who had experienced encampment clearings in cities with programs to store belongings. Thirty said they tried to recover their belongings but hit obstacles, such as being unable to reach anyone at the facility or the site not having everything that was taken. Only one person got back all of his items.

The rest said they didn’t try, often because they didn’t know how to go about it, lacked phones or transportation, or thought, and in some cases saw, that their belongings had already been thrown away.

A section of the facility where Portland stores items taken in sweeps. A larger area not pictured contained shelves full of bags in May. City officials said they manage an extensive database of stored belongings. (Asia Fields/ProPublica) Rapid Response is contracted by Portland to handle sweeps. The company’s open-bed truck held items being thrown away, while the box truck had bags headed to storage. (Asia Fields/ProPublica)

The storage programs offer only an “illusion of compassion,” said Barbara DiPietro, senior director of policy for the National Health Care for the Homeless Council, a nonprofit research and advocacy group. People experiencing homelessness often endure encampment clearings multiple times, which “wears a human being down,” DiPietro said. “I’ve never heard anyone say they got their stuff back.”

Dozens of outreach workers and advocates in cities with storage programs echoed DiPietro’s statements. Advocates and people with lived experience said this deprives homeless people of belongings they need to survive on the street and forces them to reconstruct their lives and obtain new identification documents when they are taken.

“The loss of property was the harshest punishment many people felt they could face on the street,” said Chris Herring, an assistant professor of sociology at the University of California Los Angeles who researches homelessness.

Why Storage Doesn’t Work

Stephenie, who is homeless in Portland, describes the difficulties she encountered trying to retrieve her belongings after a sweep.

When Stephenie called to retrieve her belongings last October, no one answered the storage facility phone number. The line was staffed for limited hours. She left a message but couldn’t always keep her phone charged in case someone called back. When she finally reached a person, they provided the address and an appointment time. She had to take multiple buses and walk to get there.

As she sorted through the large clear bags at the warehouse, she realized her tent, most of her tarps and her cooking stove weren’t there. Nor was her purse or prenatal vitamins. Her engagement ring and the notes from her late fiance were also gone.

She left the bags behind.

“To go through all that trouble to get my stuff back and then to have nothing that I needed there, and to have that decided by somebody else who doesn’t even know me, it was traumatizing all in itself,” she said. “It was heartbreaking. It felt like losing everything all over again.”

In response to a prompt from ProPublica, Stephenie wrote about having her purse taken in a sweep. A Response to Lawsuits

Nearly half of the cities ProPublica examined created storage programs in response to lawsuits alleging they had violated people’s property rights by destroying belongings during encampment removals. Yet some of those cities, including Phoenix, continue to throw away possessions, according to advocates and people who sleep outside.

In December 2022, after a local advocacy group and unhoused people sued the city of Phoenix for violating the rights of homeless people, a chief U.S. district judge issued an injunction against seizing their property without advanced notice and ordered the city to store belongings for at least 30 days.

The city began storing belongings in May 2023. Since then, it has responded to 4,900 reports from the public involving encampments, according to city records through May. The city of Phoenix said workers, trained to assess which items are property and which are trash, found storable property at 405 of the locations it visited, and not all of those cases required storage because people may have removed their belongings prior to their arrival. The city stored belongings 69 times.

In June, the Department of Justice issued a report following a nearly three-year investigation, finding that the city and its police department destroyed belongings without providing adequate notice or an opportunity to collect them. Before property is destroyed, the city must provide notice, catalog the property and store it so people can retrieve their belongings, federal investigators wrote.

Benjamin Rundall, who represents the plaintiffs in the ongoing lawsuit, said he’s never encountered anyone whose belongings were stored by the city. “It’s just giving this appearance that they’re doing something when they’re not doing anything,” he said.

Over the summer, Mike Leeth was helping a friend move their things from a Phoenix alley, leaving his own camp unattended. He rushed back to find his own belongings — clothing, canned food and canopies for shade — were gone. “All of a sudden, I’m down to one set of clothes, and I can’t even wash them because I’m currently wearing them,” he said.

Leeth said the city has thrown away his belongings at least five times. He said he’s never been told that his property would be stored.

The city said in a statement that workers give notice and store unattended property, and that it’s “confident” its processes address encampments in a “dignified and compassionate manner.”

In other cities, lawsuits have continued long after storage programs were put into place.

Los Angeles, with the nation’s largest population of people sleeping outside, has in the last 30 years faced nearly a dozen lawsuits over the destruction of property in homeless camps, according to court records.

A 2019 lawsuit brought by seven people experiencing homelessness and two advocacy groups alleged the city has “codified” seizing and destroying belongings, rather than investing in bathrooms, hand-washing stations and trash cans for unhoused people. In April, a federal judge overseeing the case found that the city had altered documentation of what crews removed during cleanups.

The city declined to comment on the ongoing lawsuit.

In response to questions from ProPublica, the city of Los Angeles provided data showing that it only stored belongings 4% of the time during a three-month period in 2023. A spokesperson said the city recognizes the “importance of ensuring people have their personal belongings” and “works to not unnecessarily remove anyone’s belongings during cleanings.”

In April, when crews came to move Ismael Arias from where he was living on a sidewalk in a Los Angeles suburb, they took his plumbing tools, a Mexican coin collection given to him by his father and a baseball card collection he was planning to give to his son.

A friend drove him to reclaim his things. At the storage facility, he was given items to look through. “I said, ‘This is not my stuff,’ and they said, ‘Well, this is all we got,’” he said. “I was like, ‘What do you mean this is all you got?’”

ProPublica spoke to three others who attempted to retrieve belongings from Los Angeles storage facilities and found some or all of their things were missing.

Evidence in an ongoing lawsuit in San Francisco revealed that workers were not instructed how to distinguish between personal property that is unattended, abandoned property and property that’s mixed in with biohazards, Chief Magistrate Judge Donna Ryu wrote. Workers’ decisions “appear to give rise to the most disputes,” Ryu wrote in August. The city agreed to better train workers who handle the belongings of homeless people at removals.

The ruling came weeks after Mayor London Breed promised “a very aggressive” crackdown on encampments. Breed lost her race for reelection.

In August, two ProPublica reporters observed San Francisco public works employees clear an encampment of tents, plastic bins of clothing, a cot and bikes. Nothing was set aside to be stored. One employee did slip into his uniform’s oversized pocket a tin of baseball cards taken from the encampment; he then placed it in the cab of a work truck rather than the back, where other belongings were stacked. The city said it is investigating the incident.

A tin of baseball cards was taken from a San Francisco encampment and placed inside of a city vehicle. (Nicole Santa Cruz/ProPublica) Barriers to Claiming Property

In Portland two years ago, workers took Errol Elliott’s tools, clothing, electronics and makeshift tent near the church where he stayed. He was given information about storage but didn’t have a way to carry his things.

“How are you gonna pick it up when you have no car and you’ve got nine bags of stuff or two big trunks of tools?” he said. “How are you supposed to get that back? They act like it’s so easy to go and get it, but it’s not that easy.”

Portland officials said in this kind of situation, property was likely taken to storage.

But people in Portland and other cities told ProPublica that even if local officials promise to store belongings, they’re often difficult to retrieve. The programs don’t take into consideration the challenges of experiencing homelessness, which include lack of access to transportation and not having a phone, they said. This is further complicated by requiring an appointment to retrieve belongings or not widely distributing the address where items are stored.

Some cities, such as Seattle, Portland, Anaheim and San Jose, California, don’t publicize the addresses of their storage facilities because of concerns about security. Phoenix says it delivers belongings to people, but records show people there are rarely reunited with their property.

When people do figure out where to go, the journey can be long and require multiple trips.

In Denver, for instance, the storage facility is only open for limited hours. Some people have trekked to the warehouse only to be told their belongings were stored off-site and have to be retrieved, said Andy McNulty, an attorney who sued the city on behalf of people who live outside. When they return they’re told that their belongings weren’t stored, he said.

“It’s pretty common knowledge to folks on the street now that if the city takes your stuff, even if they say they’re going to store it, it’s gone,” McNulty said.

The city of Denver said that people receive a claim slip when their items are stored after an encampment removal. Flyers with contact information are also widely shared so people can arrange a pickup, the city said.

In Los Angeles, a sign giving notice of a June encampment clearing in the San Fernando Valley directed people to call or retrieve their items from The Bins downtown, which is about two hours away on public transit. Multiple people said the distance prevented them from getting their things back or that they were unable to reach anyone for more information on how to retrieve them.

The city stores belongings at 10 locations across Los Angeles, making it even more challenging for people to find their things.

Angel, who is homeless in Los Angeles, said she’s tried calling the number on city sweep notices multiple times. “In reality, it always goes to a busy line,” she said.

People who experienced encampment removals and researchers who study homelessness said the programs could be more effective by giving clearer notice, providing trash cans and garbage pickup and making sure people have detailed instructions on how to retrieve belongings.

Sonja Verdugo-Baumgartner, an advocate in Los Angeles who said she has experienced sweeps herself, said storage programs could be more productive if cities put effort into them. “But I don’t see the city or anybody being willing to take the time to do that,” she said. “And they can’t just do it for a few people, they need to do it across the board, for anytime they do a sweep.”

Stephenie, whose belongings were taken in Portland, said the experience was crushing.

“It keeps you in what we call a ‘homeless rut,’ where we can’t focus on anything else except being homeless,” she said. “We can’t focus on getting out of it and moving forward.”

She now lives in an RV, which makes it easier to haul her belongings when city workers show up. But she has to move the vehicle every few weeks to avoid being towed, and finding a spot to park is challenging. She’s noticed more cement blocks cropping up in parking spaces along the roadsides.

How We Reported This Story

ProPublica received records of personal property collected and returned to people after homeless encampment removals in 14 cities.

We verified that sweeps had occurred in the area and around the time that our sources described using additional interviews, city data, sweep schedules or media reports. We verified each person’s identity through public records. But we used only first names when people said the publication of their full names would pose safety risks or affect their ability to get jobs.

Have You Experienced Homelessness? Do You Work With People Who Have? Connect With Our Reporters.

Maya Miller contributed reporting.

by Amy Yurkanin

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

Register for our Nov. 21 virtual discussion, where our reporters take you inside ProPublica’s reproductive health coverage.

Georgia officials have dismissed all members of a state committee charged with investigating deaths of pregnant women. The move came in response to ProPublica having obtained internal reports detailing two deaths.

ProPublica reported in September on the deaths of Amber Thurman and Candi Miller, which the state maternal mortality review committee had determined were preventable. They were the first reported cases of women who died without access to care restricted by a state abortion ban, and they unleashed a torrent of outrage over the fatal consequences of such laws. The women’s stories became a central discussion in the presidential campaign and ballot initiatives involving abortion access in 10 states.

“Confidential information provided to the Maternal Mortality Review Committee was inappropriately shared with outside individuals,” Dr. Kathleen Toomey, commissioner of the state Department of Public Health, wrote in a letter dated Nov. 8 and addressed to members of the committee. “Even though this disclosure was investigated, the investigation was unable to uncover which individual(s) disclosed confidential information.

“Therefore, effective immediately the current MMRC is disbanded, and all member seats will be filled through a new application process.”

A health department spokesperson declined to comment on the decision to dismiss the committee, saying that the letter, which the department provided to ProPublica, “speaks for itself.” Georgia Gov. Brian Kemp’s office also declined to comment, referring questions to the health department.

Under Georgia law, the work of the maternal mortality review committee is confidential, and members must sign confidentiality agreements. Those members see only summaries of medical records stripped of personal details, and their findings on individual cases are not supposed to be shared with the public — not even with hospitals or with family members of women who died.

The health department’s letter states that there could be new steps to keep the board’s deliberations from public view. The letter said officials might change “other procedures for on-boarding committee members better ensuring confidentiality, committee oversight and MMRC organizational structure.”

Maternal mortality review committees exist in every state. They are tasked with examining deaths of women during a pregnancy or up to a year after and determining whether they could have been prevented.

Georgia’s had 32 standing members from a variety of backgrounds, including OB-GYNs, cardiologists, mental health care providers, a medical examiner, health policy experts and community advocates. They are volunteer positions that pay a small honorarium.

Their job is to collect data and make recommendations aimed at combatting systemic issues that could help reduce deaths and publish them in reports. The Georgia committee’s most recent report found that of 113 pregnancy-related deaths from 2018 through 2020, 101 had at least some chance of being prevented. Its recommendations have led to changes in hospital care to improve the response to emergencies during labor and delivery and to new programs to increase access to psychiatric treatment.

The health department’s letter states that the “change to the current committee will not result in a delay in the MMRC’s responsibilities.” But at least one other state has experienced a lag as a result of reshaping its committee. Idaho let its maternal mortality review committee legislation expire in July 2023, effectively disbanding the committee after lobbyist groups attacked members for recommending that the state expand Medicaid for postpartum women. Earlier this year, Idaho’s Legislature reestablished the committee, but new members weren’t announced until Nov. 15. There is now more than a yearlong delay in the review process.

Reproductive rights advocates say Georgia’s decision to dismiss and restructure its committee also could have a chilling effect on the committee’s work, potentially dissuading its members from delving as deeply as they have into the circumstances of pregnant women’s deaths if it could be politically sensitive.

“They did what they were supposed to do. This is why we need them,” said Monica Simpson, executive director of SisterSong, one of the groups challenging Georgia’s abortion ban in court. “To have this abrupt disbandment, my concern is what we are going to lose in the process, in terms of time and data?”

One objective of any maternal mortality review committee is to look at the circumstances of a death holistically to identify root causes that may be able to help other women in the future.

In the case of Candi Miller, the most prominent detail in a state medical examiner’s report of her death was that she had a lethal combination of painkillers in her system, including fentanyl. It attributed the cause of death to drug intoxication.

But the Georgia committee looked at the facts of the death with a different objective: to consider the broader context. A summary of Miller’s case prepared for the committee, drawn from hospital records and the medical examiner’s report, included that Miller had multiple health conditions that can be exacerbated by pregnancy, that she had ordered abortion pills from overseas and that she had unexpelled fetal tissue, which showed the abortion had not fully completed. It also stated that her family had told the coroner she didn’t visit a doctor “due to the current legislation on pregnancies and abortions.”

The committee found her death was “preventable” and blamed the state’s abortion ban.

“The fact that she felt that she had to make these decisions, that she didn’t have adequate choices here in Georgia, we felt that definitely influenced her case,” one committee member told ProPublica in September. “She’s absolutely responding to this legislation.”

For Miller’s family, the committee’s findings were painful but wanted. “It seems like that is essential information that you would share with the family,” said Miller’s sister, Turiya Tomlin-Randall, who was not aware of the committee’s work until ProPublica contacted her.

She also said it’s upsetting to hear that the committee’s members were dismissed partly as a result of her sister’s case being disclosed to the public. “I don’t understand how this is even possible,” she said.

The committee also investigated the case of Amber Thurman, who died just one month after Georgia’s six-week abortion law went into effect. The medical examiner’s report stated that Thurman died of “sepsis” and “retained products of conception” and that she had received a dilation and curettage, or D&C, and a hysterectomy after an at-home abortion.

When the committee members received a summary of her hospital stay, they saw a timeline with additional factors: The hospital had delayed providing a D&C — a routine procedure to clear fetal tissue from the uterus — for 20 hours, which Thurman needed for rare complications she’d developed after taking abortion medication. The state had recently attached criminal penalties to performing a D&C, with few exceptions. The summary showed doctors discussed providing the D&C twice, but by the time they performed the procedure it was too late. Committee members found that there was a “good chance” Thurman’s death could have been prevented if she had received the D&C sooner.

Doctors and a nurse involved in Thurman’s care did not answer questions from ProPublica for its September story. The hospital also did not respond to multiple requests for comment.

Thurman’s family also told ProPublica they had wanted the information about her death disclosed.

Some experts say that keeping the reports of maternal mortality review committees confidential is important for a committee to serve its purpose. They are set up not to assign blame but instead to create a space for clinicians to investigate broad causes of maternal health failures. But others say the lack of transparency can serve to obscure the biggest disruption to maternal health care in half a century.

“We know that the reports that have come out of that committee are anonymized and synthesized in order to provide a 50,000-foot view,” said Kwajelyn Jackson, executive director of Feminist Women’s Health Center in Atlanta, which provides abortion care. “But my worry is that in an effort to protect the state, there will be less information that will be available to people who could shift their actions, shift their protocols, shift their strategies, shift their behaviors in order to make a difference in maternal health outcomes.”

Two states did make shifts to their committees — Idaho, after members made a recommendation to expand Medicaid that Republicans opposed, and Texas, after a member publicly criticized the state.

In 2022, Texas committee member Nakeenya Wilson, a community advocate, spoke out against the state’s decision to delay the release of its report during an election year. The following year, the Legislature passed a law that created a second community advocate position on the committee, redefined the position and had Wilson reapply. She was not reappointed. The state instead filled one of the slots with a prominent anti-abortion activist.

Wilson said Georgia’s decision to dismiss its committee could cause greater harm.

“What message is being said to the families who lost their loved ones?” she said. “There’s going to be even less accountability for this to not happen again.”

Ziva Branstetter, Kavitha Surana, Cassandra Jaramillo and Anna Barry-Jester contributed reporting. Doris Burke contributed research.

by Heather Cherone, WTTW News, and Vernal Coleman, ProPublica, photography by Sarahbeth Maney, ProPublica

This story was co-published with WTTW News. ProPublica is a nonprofit newsroom that investigates abuses of power.

Sign up for Dispatches, a ProPublica newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week. WTTW News is Chicago’s PBS affiliate. Sign up for the Daily Chicagoan, a newsletter that explores the backstory of the city’s biggest issues.

Update, Nov. 25, 2024: Chicago Mayor Brandon Johnson announced he would alter his budget proposal to reverse a previous plan to make deep cuts in the number of Chicago Police Department personnel assigned to implementing changes required by the federal consent decree.

In the five and a half years since the Chicago Police Department agreed to extensive oversight from a federal judge, there have been bursts of activity to address the brutality and civil rights violations that led to the agreement.

Court hearings: more than a hundred. Meetings: hundreds. Money: hundreds of millions in Chicago taxpayer dollars allocated to making the court-ordered reforms, known as a consent decree, a reality.

But the record of actual accomplishment is meager.

Chicago police haven’t crafted a system for officers to work with residents to address threats to public safety.

They haven’t completed a mandatory study of where officers are assigned throughout the city and whether changes would help thwart crime.

And they have failed to move forward with a plan to alert police brass about which officers have been accused of misconduct more than once and might need counseling, retraining or discipline.

In fact, all told, police have fully complied with just 9% of the agreement’s requirements. And while excessive force complaints from citizens have dropped, complaints about all forms of misconduct have risen.

Sheila Bedi, an attorney who represented the coalition of police reform groups that sued the city years ago, called the faltering reform effort a “tragedy.”

“It has been a waste of time and money,” said Bedi, a Northwestern University law professor. “It has been nothing more than an exercise in pushing paper.”

A review by WTTW News and ProPublica of the efforts in Chicago since 2019 shows Bedi’s bleak view is supported by a range of assessments produced for the court and is also widely held among advocates, academics and officials following the process.

The goal is to emerge from the consent decree by 2027 with a police force finally ready to move beyond a long history of civil rights violations targeting Black and Latino Chicagoans. But the city is now on a path to devote substantial resources and large amounts of money to the reform effort for years beyond that. It’s a trajectory that echoes what happened in Oakland, where the police department continues to be marred by scandal and remains under federal court oversight more than 20 years into its consent decree.

No one in a position of power or oversight has pushed forcefully or effectively to make the process move faster, WTTW News and ProPublica found. Six permanent and interim superintendents have led CPD since 2019 and the city has had three mayors, all of whom vowed to implement the consent decree but failed to make good on those promises with money and other resources.

In addition, the Chicago City Council has repeatedly failed to exercise its authority to oversee CPD’s operations and demand quicker change. The council has approved $667 million to go toward implementing the decree since 2020, but at least a quarter of the city’s annual allotment goes unspent each year, a WTTW News analysis found.

At the same time, inside the federal courtroom, the court-appointed monitoring team has never demanded sanctions for the city’s slow pace. Similarly, judges overseeing the decree have not expressed concerns about the lack of significant advances.

No major city exemplifies the stubborn problems of police misconduct more than Chicago, where a series of civil cases and wrongful convictions have led to expensive court settlements that regularly cost the city more than $80 million a year. Distrust in the community now makes attacking the city’s crime rate even harder.

Now many of the city’s reform advocates have lost faith in the process and are increasingly concerned that the opportunity for lasting reform is slipping away. Surveys of Chicagoans completed as part of the consent decree show a clear drop in confidence that there will be lasting and positive change.

The process has its defenders, including current Illinois Attorney General Kwame Raoul, whose predecessor sued the city to force it to agree to federal court oversight. Raoul still believes the consent decree is the best way of “making these necessary reforms a reality.”

But he also appears to be losing patience. Raoul warned last week that he would seek sanctions against the city if Mayor Brandon Johnson did not reverse the planned cuts. “I must remind you that the consent decree is not optional,” Raoul wrote to the mayor. “The City of Chicago must deliver on its consent decree obligations.”

Johnson rarely speaks publicly about the need to reform the police department, instead focusing on efforts to improve officer morale and reduce crime. He declined to be interviewed for this story but has told reporters he is committed to ensuring CPD “engages in constitutional policing.”

Porscha Banks’ brother Dexter Reed was shot and killed by Chicago police during a traffic stop. She’s frustrated by the city’s lack of progress toward meaningful police reform

Porscha Banks, whose brother Dexter Reed was shot and killed in a barrage of police gunfire during a March 21 traffic stop, is among those who are frustrated by Chicago’s lack of progress toward meaningful reform. Four officers fired 96 shots at Reed in 41 seconds, hitting him 13 times, shortly after he shot and wounded an officer, according to a preliminary investigation.

The Civilian Office of Police Accountability has not completed its inquiry into the shooting and has not ruled whether the officers’ actions were justified. But reform advocates immediately seized on the incident as an example of how police tactics can lead to dangerous situations for both civilians and officers.

“Unless something changes, it is going to keep happening,” Banks said. “They are failing Black people. They are failing all of us.”

How Police Helped Stall the Process

At its core, the consent decree is designed to fix the shattered relationship between police and Chicago communities.

The goal is to increase communication and familiarity by having officers patrol the same geographic area of the city and report to the same supervisor on a consistent basis, instead of moving throughout the city to chase crime. As a first step, the consent decree required CPD to complete a study to determine whether officers are efficiently deployed to stop crime and respond to calls for help.

But it took more than five years to authorize the study. And now, more than five months after the Chicago City Council ordered it, the police department acknowledges it has yet to start in earnest.

“It is deeply embarrassing,” said Alderperson Matt Martin, who represents the North Side’s 47th Ward and authored the measure requiring the staffing study. He said that police leaders simply ignored the May 21 deadline set by aldermen. The contract to perform the study was not finalized until Oct. 24, according to records obtained by WTTW News.

Matt Martin, a Chicago alderperson, wrote a measure requiring the police department to complete a staffing study, but it has yet to get underway.

It’s not the first time Chicago has missed an opportunity to align the department with community needs.

In 2019, former Los Angeles Police Department Chief Charlie Beck took over as the city’s interim police superintendent for Mayor Lori Lightfoot. Beck’s first order of business was to reassign more than 1,100 detectives and gang intelligence and narcotics officers from citywide teams to work in Chicago’s 22 police districts.

The goal was to tie each of those officers directly to one of Chicago’s 77 community areas, a necessary change to make community policing a reality, said Beck, who led the LAPD through its own reform push that was widely hailed as lightning fast and successful.

But Beck was only an interim chief and led the CPD for less than six months before Lightfoot replaced him with former Dallas Police Chief David Brown. Brown quickly reversed those changes and reestablished teams of specialized officers that moved throughout the city to address crime hot spots.

Beck declined to comment for this article; Brown did not respond to requests for interviews.

Brown’s successor, Larry Snelling, who has been at the helm of CPD for more than a year, has not attempted to reorganize the department. While acknowledging that the reform effort is far from complete, Snelling often emphasizes that the department is making progress on most goals laid out in the consent decree.

CPD now has written policies addressing just under half the items included in the consent decree. It also has trained a majority of its officers on the new policies involving a little over a third of the items. To be in full compliance, CPD must prove to the monitoring team that officers are following the new policies over a sustained period of time. The most significant victory for the city has been providing officers with annual training on the department’s policies for use of force, the latest report from the monitoring team found.

But CPD has yet to reach full compliance on any part of the consent decree that involves community policing, unbiased policing or crisis intervention, records show.

Community trust is at the heart of another consent-decree misstep by the department, which for decades has failed to hold its officers accountable for misconduct, according to the federal probe that led to the decree. An early-warning system that would identify problematic officers and get them off the street was drawn up near the beginning of the consent-decree process but has yet to be implemented.

Police reform advocates say that Snelling is more committed to reform than his predecessor, but he rarely talks publicly about the consent decree. Snelling declined to be interviewed for this story.

As a candidate for mayor, Johnson promised to succeed where his predecessors failed and quickly implement the consent decree. But his main policing focus since taking office has been on reducing the number of people killed and shot in Chicago following a surge that coincided with the COVID-19 pandemic. Homicide rates have dropped in the last two years.

Johnson’s latest budget proposal, which closed a projected budget gap of $982 million, slashes the number of employees assigned to implementing the decree by 13%.

Questioned by WTTW News at a press conference, Johnson acknowledged Chicago’s long history of police violence against Black Chicagoans.

“Unfortunately, we’ve had a trail of destruction over the course of decades where there has been an erosion of the relationship between community and policing,” Johnson said. “What I can say is that it has gotten considerably better from where we started.”

Despite such assertions, critics of the reform push contend the mayor is ultimately responsible for the lack of progress during his time in office.

“I expected to see much more of the mayor and his administration step up and be present and be at the table,” said Craig Futterman, a professor of law at the University of Chicago who represented one of the coalition of groups that sued the city to force it to agree to judicial oversight.

“It’s been left to the police department, and that’s again like the fox guarding the henhouse.”

Efforts to assign each officer to a specific part of town where they could get to know the people were reversed when a new police superintendent was appointed. Delays Come Without Consequences in Court

What frustrates observers like Futterman is not just that police have dragged their feet; it’s that the formal mechanism for oversight hasn’t led to meaningful progress.

For instance, the monitoring team — which is made up of lawyers and public safety specialists — has the power to recommend to the judge that the city and CPD be punished for failing to meet the terms of the consent decree. While it has repeatedly highlighted the slow pace of reforms in its reports, the monitoring team has never demanded sanctions, despite pleas from the coalition of reform groups.

Barry Friedman, a professor at New York University who studies police reform and has advised CPD on implementing community policing policies, said he is baffled by this.

He cited the monitors’ unique position of power and the money going to their efforts. Chicago taxpayers have paid the monitoring team more than $20.4 million from the beginning of the decree through March 31, 2024, records show.

“For that amount of money, you should have a consent decree that is working,” Friedman said. “Five years in, one is entitled to ask what the city is getting out of the consent decree.”

Members of the consent decree monitoring team and the judge overseeing the case declined to be interviewed. The spokesperson for the judge and the team said they’re prohibited from doing so under the decree.

For its part, the Chicago City Council has not called out the CPD for its failures. The council had vowed to hold hearings about the progress of police reform every three months, but the last hearing took place in February. Alderperson Brian Hopkins, chair of the Public Safety Committee, and Alderperson Chris Taliaferro, chair of the Police and Fire Committee, did not respond to a request for comment about why no hearings have taken place for nine months.

Another factor in the slow pace is the structure of the oversight itself. To amend the agreement, all relevant parties must get involved — the state attorney general, the coalition of reform groups and City Hall. They have to exhaust efforts to negotiate a solution before asking the judge to resolve any stalemate.

Chicago police swarmed into Anjanette Young’s home in a raid on the wrong address. She often finds peace by visiting the lakefront.

The delays and compromises have led to unsatisfying results, as exemplified by the aftermath of the widely criticized raid on the home of Anjanette Young. In 2019, a group of male officers handcuffed Young, a social worker, inside her home while she was naked; they had raided the wrong address.

When Young and advocates for reform sought restrictions on raids, they ran into opposition from Lightfoot. They then asked that the consent decree be expanded to impose reforms.

That launched unfruitful negotiations between CPD’s leaders, city lawyers, attorneys for the coalition and the attorney general’s office that stretched for two years. U.S. District Judge Rebecca Pallmeyer resolved the dispute by rejecting almost all of the demands made by reform groups. She didn’t add any significant restrictions on police raids and didn’t bar no-knock warrants. Young was bitterly disappointed.

Porscha Banks’ quest for reforms in the aftermath of her brother’s killing has been similarly frustrating. Dexter Reed, whose car had tinted windows that made it almost impossible to see inside, was pulled over for a safety belt violation, according to the preliminary investigation.

For groups that had been sounding the alarm for years that CPD was aggressively using traffic stops to target Black and Latino drivers, Reed’s death was heartbreaking evidence that such tactics inevitably lead to volatile encounters. Banks has demanded officials ban traffic stops like the one that led to her brother's death.

CPD leaders and the monitoring team agreed just two months after Reed’s death to expand the consent decree to include traffic stops, but reform advocates and politicians pushed back. The consent decree is not capable of delivering the kind of urgent change the city needs, they told Pallmeyer; instead, the city’s new police oversight board should set the rules for traffic stops.

The request was a rejection of the consent decree process.

“I’m frustrated that despite what I have to believe is everyone’s best effort, it has not been good enough,” said Alderperson Daniel La Spata, whose ward is on the Northwest Side.

Pallmeyer has not ruled on that request yet.

Banks does not particularly care how reform is achieved. She just wants to see signs of hope.

“They just need to stop talking about it and fucking doing it,” Banks said.

Chicago Alderman Daniel La Spata is frustrated by the lack of progress toward police reform. An Opportunity May Be Slipping Away

Inside a room at Corliss High School on Chicago’s Far South Side, a few dozen residents assembled for a community meeting with police in a district that has long struggled with pervasive crime. These were people who care about their neighborhoods, the future of Chicago and the trajectory of policing here. And in interviews, many of them expressed skepticism.

Tony Little, who volunteers as a community liaison with CPD, said police today are more responsive to residents’ concerns than in the past, but there’s still room for improvement. “If they could just make sure officers, especially young officers, are aware of the community and get to know the neighborhood, that would build trust,” he said.

His wife, Malinda, is more pessimistic. Although the consent decree requires CPD to demonstrate that residents can trust officers to protect and serve them, those are no more than empty promises, she said. “Some of the individuals, they have an attitude that this is just a job. … They don’t care about the people.”

Such comments should come as no surprise to the police department or the monitoring team.

“By most indications, many Chicagoans are not feeling many of the changes that have been made by the city and the CPD so far,” the monitoring team wrote in its most recent assessment of the city’s progress.

The most recent survey conducted by the monitoring team, in 2022, found that 43.2% of Chicagoans were “doubtful” or “very doubtful” that police reform would have a lasting and positive effect, an increase of more than 10 percentage points since 2020.

The survey identified a similar decrease in the number of Chicagoans who said the police were doing a “good” or “very good” job in their neighborhood and citywide, while the number of Chicagoans who said the police were doing a “poor” or “very poor” job in the city as a whole grew to 42.7% in 2022, compared with 30.2% in 2020.

A billboard for the Chicago Police Memorial Foundation, which provides support for families of officers killed or seriously injured on the job.

“Of course there’s a lack of trust in the police,” said Roxanne Smith, a West Side resident and police reform advocate who was part of the coalition that sued the city. “We’re in a new generation and some things still haven’t changed. These things need immediate attention.”

Chicago Inspector General Deborah Witzburg, whose office was the first, and so far only, city department to fully comply with its obligations under the consent decree, said the reform effort is at a tipping point, much like a bicycle ridden too slowly.

“The risk is that you tip over for a lack of forward momentum,” Witzburg said.

Anjanette Young is now among those in Chicago who feel the tipping point is past.

“The consent decree is not the answer,” Young said. “It is just oversight on paper. We need a plan B. We need to do something else.”

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Jared Rutecki of WTTW News contributed data reporting.

by Cassandra Jaramillo, Kavitha Surana, Lizzie Presser and Ziva Branstetter

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Register for our Nov. 21 virtual discussion, where our reporters take you inside ProPublica’s reproductive health coverage.

Weeks after ProPublica reported on the deaths of two pregnant women whose miscarriages went untreated in Texas, state lawmakers have filed bills that would create new exceptions to the state’s strict abortion laws, broadening doctors’ ability to intervene when their patients face health risks.

The legislation comes after the lawmaker who wrote one of Texas’ recent abortion bans wrote an op-ed in the Houston Chronicle defending the current exceptions as “plenty clear.”

But more than 100 Texas OB-GYNs disagree with his position. In a public letter, written in response to ProPublica’s reporting, they urged changes. “As OB-GYNs in Texas, we know firsthand how much these laws restrict our ability to provide our patients with quality, evidence-based care,” they said.

Texas’ abortion ban threatens up to 99 years in prison, $100,000 in fines and loss of medical license for doctors who provide abortions. The state’s health and safety code currently includes exceptions if a pregnant woman “has a life-threatening physical condition aggravated by, caused by, or arising from a pregnancy that places the female at risk of death or poses a serious risk of substantial impairment of a major bodily function unless the abortion is performed or induced.” A separate exception exists that provides doctors with some legal protections if they perform an abortion for an ectopic pregnancy or in cases when a patient’s water breaks.

The bills, filed in the state House and Senate last week, create new health exceptions. They would allow doctors to induce or perform abortions necessary to preserve the mental or physical health of a patient, including preserving the patient’s fertility. Doctors could also provide abortions in cases where the fetus had an anomaly that would make it unable to survive outside the womb or able to survive only with “extraordinary medical interventions.”

State Rep. Donna Howard, who filed the bill in the Texas House, said ProPublica’s recent reporting adds to evidence that the current legislation is a threat to the safety of pregnant women in Texas and increases the urgency to make changes. “This is my reaction,” she said. “It’s one of extreme sadness and disbelief that we are at a point where we are allowing women to die because we haven’t been able to clarify the law,” she said.

Investigations by ProPublica have found that at least four women, including two in Texas, died after they could not access timely reproductive care in states that ban abortion. There are almost certainly others.

In Houston, Josseli Barnica died in September 2021, just days after the state’s six-week abortion ban went into effect. Barnica, 28, was miscarrying at 17 weeks, but doctors did not offer her the medical standard of care — to speed up labor or empty her uterus — for 40 hours, until after the fetal heartbeat had stopped. Her husband said she was told it would be a “crime” to intervene. This left her seriously exposed to infection, experts told ProPublica. Three days later, she died from an infection, leaving behind a young daughter.

Her death was “preventable,” according to more than a dozen medical experts who reviewed a summary of her hospital and autopsy records at ProPublica’s request; they called her case “horrific,” “astounding” and “egregious.”

The doctors involved in Barnica’s care at HCA Houston Healthcare Northwest did not respond to multiple requests for comment on her case. In a statement, HCA Healthcare said, “Our responsibility is to be in compliance with applicable state and federal laws and regulations,” and that physicians exercise their independent judgment. The company did not respond to detailed questions about its policy.

Nevaeh Crain, 18, made three trips to emergency rooms in rural southeast Texas last year for vomiting and abdominal pain, waiting 20 hours before doctors admitted her. Doctors insisted on two ultrasounds to document “fetal demise” as Crain’s vital signs grew more alarming. By the time they rushed to operate, sepsis had spread throughout her body and her organs failed.

Experts who reviewed a summary of Crain’s medical records for ProPublica said it may have been possible to save both the teenager and her pregnancy if she had been admitted earlier for close monitoring and continuous treatment.

Doctors involved in Crain’s care did not respond to several requests for comment. The two hospitals — Baptist Hospitals of Southeast Texas and Christus Southeast Texas St. Elizabeth — declined to answer questions about her treatment.

What Is A ‘Medical Emergency’?

The cases highlight how abortion laws can interfere with maternal health care, even for those who want to have a child.

Much of the confusion hinges on the definition of a “medical emergency.” In many cases, women experiencing a miscarriage or a pregnancy complication may be stable. But requiring them to wait for an abortion until signs of sickness are documented or the fetal cardiac activity stops violates the professional standard of care, putting them at higher risk that a life-threatening infection or other complications could develop and be harder to control.

Attaching criminal penalties to abortion procedures has led to a chilling effect, making some physicians more hesitant to care for patients experiencing pregnancy complications in general, doctors told ProPublica.

After ProPublica’s reporting, state Sen. Bryan Hughes, the author of one of the state’s abortion bans, wrote an op-ed in the Houston Chronicle. He said the women were “wrongfully denied care,” but he blamed media outlets including ProPublica for publishing stories that made doctors “afraid to treat the women.”

“When a mother’s life or major bodily function are in jeopardy, doctors are not only allowed to act, but they are legally required to act,” he wrote. “And contrary to what ProPublica would have us believe, Texas law does not prevent them from aiding their patients and saving their lives.”

He argued that the medical emergency exceptions in Texas’ new abortion bans use the same language as abortion laws from the 1800s. “We did not want to risk confusing medical providers by changing the definition,” he said. But that language was written at a time when many more women died in pregnancy and childbirth — before medical innovations such as suction devices to empty the uterus and lower the risk of sepsis helped make maternal care vastly safer.

Hughes is a licensed attorney who lists no medical training on his Senate webpage.

ProPublica repeatedly requested an interview with Hughes to further understand his interpretation of how doctors should apply the law in specific scenarios. He did not respond to a detailed list of questions and requests to comment for this article.

There is no state office that doctors can call to make sure their decisions in miscarriage cases do not violate the law. Yet Texas Attorney General Ken Paxton has made it clear he will not hesitate to prosecute doctors if the abortions they provide do not meet his interpretation of a medical emergency.

Last year, a Dallas woman asked a court for approval to end her pregnancy because her fetus was not viable and she faced health risks if she carried it to term. Paxton fought to keep her pregnant, arguing that her doctor hadn’t proved her situation was an emergency, and threatened to prosecute anyone who helped her. The courts sided with him, and the woman traveled out of state for the abortion.

Warnings From the Medical Community

After reading ProPublica’s stories, 111 Texas OB-GYNs signed a letter placing blame for the deaths squarely on state abortion law that “does not allow us as medical professionals to do our jobs.”

“The law does not allow Texas women to get the lifesaving care they need and threatens physicians with life imprisonment and loss of licensure for doing what is often medically necessary for the patient’s health and future fertility,” they wrote.

Their letter adds to years of warnings from the medical community and from patients themselves: 20 women who were denied abortions for miscarriages and high-risk pregnancy complications joined a lawsuit against the state. They asked the courts to clarify the law’s exceptions, but the Texas Supreme Court refused.

Dr. Austin Dennard, a Dallas OB-GYN, is one of the women represented in the lawsuit. She has seen the consequences of the laws from both sides. As a doctor, she has to call a hospital lawyer any time she wants to provide abortion care to patients facing emergencies. She also was personally affected when she was pregnant and learned her fetus had anencephaly — a condition in which the brain and skull do not fully develop. Texas’ law would have forced her to carry to term, putting her through more health risks and making her wait longer to try again for another pregnancy, so she traveled out of state for an abortion.

She said lawmakers have failed for years to listen to the doctors who have to navigate these laws.

In response to Hughes’s op-ed, she said: “We’re the ones with their boots on the ground. We’re the ones taking care of these patients, and we’re the ones telling you it is very nebulous and confusing, and we’re all terrified,” Dennard said.

State Sen. Carol Alvarado, who filed the Senate version of the bill, said she worked with physicians who represent major medical organizations to draft the exceptions.

“This bill is not about politics — it’s about ensuring that doctors can provide life-saving care without hesitation or fear of prosecution,” Alvarado said. “This bill is about restoring trust in our health care system and ensuring that no one has to endure the heartbreak of wondering whether more timely medical care could have saved their loved one.”

Molly Duane, a lawyer with the Center for Reproductive Rights who represents women who are suing the state, said the bill, if passed, could help save some lives, but cautioned that without removing the threat of criminal penalties, some doctors might still deny care.

“Exceptions don’t work in reality, no matter how clear they are,” Duane said. “We’ve seen hospitals turn away Texans facing life-threatening ectopic pregnancies, even though providing an abortion in these cases is legal under state law. As long as doctors face the threat of jail time and loss of license, they will be terrified to provide care.”

Where the Medical Board Stands

In his op-ed, Hughes said that the Texas Medical Board has issued guidance that an emergency doesn’t need to be “imminent” to keep physicians “from doing what is medically necessary” under the law.

But Dennard, echoing many doctors who spoke to ProPublica, said the board was “incredibly unhelpful.” The guidance instructed doctors on ways they could document why the abortion was necessary and still left open the question of how lawyers and courts might interpret “medically necessary.”

“None of them want to face the reality of the situation, which is that the laws that were put in place are directly harming pregnant people, and it is their fault,” she said.

The board, whose members are appointed by the governor, issued the guidance earlier this year after declining for more than two years to respond to questions about how the law should be interpreted, even as patients facing health risks publicly shared their stories of being denied abortion care and journalists asked the board to respond. The board issued guidance only after the Texas Supreme Court directed it to do so.

The president of the board, Dr. Sherif Zaafran, said in an interview that it would have been “inappropriate” to weigh in without that direction.

“Somebody could easily sue the medical board and say, ‘You shouldn’t have done this,’ and then we’d be in limbo also, and that could have actually dragged things out even longer.”

In the meantime, women’s lives were left in the balance.

Last year, lawmakers created a new exception for two conditions that the original law had not addressed: ectopic pregnancies and previable premature rupture of membranes, when a patient’s water breaks too early, causing a miscarriage.

But the exception is small comfort, some doctors say. It’s written in a way that only allows doctors to make an “affirmative defense” for a legal penalty. An affirmative defense, if found credible by a judge or jury, means the defendant wouldn’t be liable for the alleged acts even if he or she committed them.

“Nobody wants to be that poster child,” said Dr. Robert Carpenter, a Houston OB-GYN who signed the letter.

The Houston Chronicle also published 10 letters to the editor in response to Hughes’ editorial, eight of them arguing against his claim that the Texas abortion ban is clear.

Among them was Trevor M. Bibler, an assistant professor at Baylor College of Medicine’s Center for Medical Ethics and Health Policy.

“If doctors weren’t threatened with jail time and accused of murder just for upholding a basic standard of care, then these tragedies wouldn’t happen,” he wrote. “The possibility that the cause of these tragedies are the doctors who read the writings of the left-wing media rather than the law is absurd, disingenuous and not at all convincing. His law, not the media, is the cause.”

Howard said she’s hopeful the Texas Legislature will listen to the medical community and the public and create health and other exceptions in the abortion laws. She also pointed out that President-elect Donald Trump has said that he supports exceptions in cases of rape and incest, which Texas’ ban does not include. She filed a separate bill to propose such exceptions.

“It’s really just unbelievable, from a state that considers itself to be pro-life, that these obstacles will be put in place that are the antithesis of pro-life,” Howard said.

As other states assess whether to ban or protect abortion rights, Texas is providing an example of what to expect.

In Wisconsin, state Supreme Court Justice Jill Karofsky recently pressed an attorney for the state to explain whether an abortion ban on the books from 1849 would stop doctors from providing abortion care to patients who were experiencing miscarriages if the court allowed it to go into effect.

Describing Barnica’s case, she asked for clarification: “She suffered an infection that killed her because medical providers were unwilling or unable to give her the health care that she needed,” she said. “That’s a scenario that could easily — and perhaps has easily — play out here in Wisconsin under your interpretation of [the law], couldn’t it?”

“I’m not sure, Justice Karofsky,” the attorney responded. “I’m not a doctor.”

by Sarahbeth Maney

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week.

Last month, reporter Anna Clark and I hosted an in-person photo gallery and group discussion about what motivated us to tell stories of Flint, Michigan, residents 10 years after the start of the water crisis and to talk about how we work to understand the communities we serve. As a visual fellow at ProPublica, I’m focused on documenting the lives of people in our stories through photography. Throughout history, photography has been a powerful tool for recording moments in time, providing visual evidence and evoking emotions that urge us to understand experiences outside of our own. Here are suggestions for aspiring visual storytellers who may find themselves in similar situations.

Ask “Why Does This Story Need to be Told?”

Anna and I previously worked in Flint in different capacities: I interned as a photojournalist at the Flint Journal; Anna wrote a book, “The Poisoned City: Flint’s Water and the American Urban Tragedy.” To us, Flint is not just a news story, it’s a complex place full of real people who have been and continue to be denied adequate resources and support. We wanted the public to know that generations of Flint residents still live with physical and psychological challenges. By sharing what Flint residents think accountability would look like, we were able to show how many feel betrayed by the failure to hold anyone criminally responsible. They also remain frustrated by how long it’s taking to fix the local water system and the lingering mental wounds that may never be repaired.

The photo essay gave a glimpse into the experience of three residents and how their present-day concerns, fears and decisions are shaped by the water crisis. Over about four months, I made frequent visits to Flint — stopping by nonprofits, churches, after-school programs and other places that are part of everyday life. I spoke with incredibly kind people. Some wanted to help me; others were hesitant, usually because they wanted to move on or felt things would never change. Robert McCathern, Teagan Medlin and Jacquinne Reynolds granted me a great deal of trust. They were able to open up and make themselves vulnerable because of their commitment to cultivating change for future generations. I tried to represent that through the environment in the photographs.

First image: Teagan Medlin, 25, holds her newborn baby, Audrina, at a recovery house where she lives temporarily. Second image: Pastor Robert McCathern approaches Tayler Armstrong, 9, and his grandmother Patricia Stewart-Burton while preaching during a Sunday service at Joy Tabernacle Church. Be Sincere With Your Approach

During the discussion at the visual storytelling event at Totem Books in Flint, we asked residents to ponder what type of stories resonate with them most, what questions they wish someone would ask them and who is one person they would like to interview. We discovered a common thread of wanting to feel more connected as neighbors and fellow human beings.

Then we flipped the exercise to challenge ourselves as journalists and receive questions from residents. “Why Flint?” one participant asked us. We told her how we’d come to admire the community and wanted to present a multidimensional view of it to readers. “Something about this place seems to get in people’s blood,” the participant told us, and it does seem that for a city of its size, Flint has attracted a disproportionate number of storytellers — even before the water crisis. And yet, some residents still wonder: What has changed? Over the past decade, Flint residents have been in the public eye not by choice, but as a result of a disaster created and prolonged by public officials. So what does that mean for us and our responsibility as storytellers?

Being in the business of transparency requires us to also be transparent with the communities we document. Without transparency, it’s hard to build mutual trust, especially in communities that have faced betrayal and have had little control over how their stories are shared with the world.

During the early stages of the project, before lifting my camera to make any photos, I listened to Flint residents and learned about their stories, then let what they told me naturally guide the photos I made. Early on, I also stressed that I believe their stories are important to share because people outside of Flint should know that for many Flint residents, the crisis is still not over.

I also should note that our stories go through many layers of revisions and fact-checking. From beginning to end, I tried to communicate how the project was developing and made sure that our sources were aware of how the story would be framed, how they would be portrayed and how they would be quoted. Once the story was published, I followed up to gauge how they were feeling, and later made them aware that photographs of them would appear at our gallery in Flint.

Jacquinne Reynolds, left, and Robert McCathern, who were both featured in ProPublica’s coverage, attend ProPublica’s live visual storytelling event. (Rocio Ortega/ProPublica) Look for Connection and Insight

The beauty of visual storytelling is that the story can always change shape. Let go of any assumptions and let the story lead you where it may. Anna and I learned so much by taking this approach.

We found that, after a decade, many residents are still waiting for the change they want to see. The flood of the resources and attention Flint initially received has dwindled. But one of the reasons I wanted to revisit this story is because of the people I’ve met and will continue to meet. The city has introduced me to people who care deeply about their community and embrace one another with generosity, care and compassion. And I learned about a host of local programs, from the Flint Rx Kids program that provides financial support for mothers to the McKenzie Patrice Croom Flint Community Water Lab, which trains youth to give back and provides free water testing. Although communities like Flint shouldn’t need to be resilient, we can learn from their empathy, advocacy and support for one another during hard times. My job is to make photographs, but a big part of the fulfillment I get is from making connections.

We closed out our event in Flint by making photographs of attendees that they could have as keepsakes. One woman, who told me she had recently been displaced from her home, said she was going to email the photos of herself to her grandchildren who live in another state. It reminded me that photographs are invaluable in many facets of our lives. They keep us connected.

by Annie Waldman

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For years, it was a mystery: Seemingly out of the blue, therapists would feel like they’d tripped some invisible wire and become a target of UnitedHealth Group.

A company representative with the Orwellian title “care advocate” would call and grill them about why they’d seen a patient twice a week or weekly for six months.

In case after case, United would refuse to cover care, leaving patients to pay out-of-pocket or go without it. The severity of their issues seemed not to matter.

Around 2016, government officials began to pry open United’s black box. They found that the nation’s largest health insurance conglomerate had been using algorithms to identify providers it determined were giving too much therapy and patients it believed were receiving too much; then, the company scrutinized their cases and cut off reimbursements.

By the end of 2021, United’s algorithm program had been deemed illegal in three states.

But that has not stopped the company from continuing to police mental health care with arbitrary thresholds and cost-driven targets, ProPublica found, after reviewing what is effectively the company’s internal playbook for limiting and cutting therapy expenses. The insurer’s strategies are still very much alive, putting countless patients at risk of losing mental health care.

Optum, its subsidiary that manages its mental health coverage, is taking aim at those who give or get “unwarranted” treatment, flagging patients who receive more than 30 sessions in eight months. The insurer estimates its “outlier management” strategy will contribute to savings of up to $52 million, according to company documents.

The company’s ability to continue deploying its playbook lays bare a glaring flaw in the way American health insurance companies are overseen.

While the massive insurer — one of the 10 most profitable companies in the world — offers plans to people in every state, it answers to no single regulator.

The federal government oversees the biggest pool: most of the plans that employers sponsor for their workers.

States are responsible for plans that residents buy on the marketplace; they also regulate those funded by the government through Medicaid but run through private insurers.

In essence, more than 50 different state and federal regulatory entities each oversee a slice of United’s vast network.

So when a California regulator cited United for its algorithm-driven practice in 2018, its corrective plan applied only to market plans based in California.

When Massachusetts’ attorney general forced it to restrict the system in 2020 for one of the largest health plans there, the prosecutor’s power ended at the state line.

And when New York’s attorney general teamed up with the U.S. Department of Labor on one of the most expansive investigations in history of an insurer’s efforts to limit mental health care coverage — one in which they scored a landmark, multimillion-dollar victory against United — none of it made an ounce of difference to the millions whose plans fell outside their purview.

It didn’t matter that they were all scrutinizing the insurer for violating the same federal law, one that forbade companies from putting up barriers to mental health coverage that did not exist for physical health coverage.

For United’s practices to be curbed, mental health advocates told ProPublica, every single jurisdiction in which it operates would have to successfully bring a case against it.

“It’s like playing Whac-A-Mole all the time for regulators,” said Lauren Finke, senior director of policy at the mental health advocacy group The Kennedy Forum. The regulatory patchwork benefits insurance companies, she said, “because they can just move their scrutinized practices to other products in different locations.”

Now internal documents show that United, through its subsidiary Optum, is targeting plans in other jurisdictions, where its practices have not been curbed. The company is focused on reducing “overutilization” of services for patients covered through its privately contracted Medicaid plans that are overseen by states, according to the internal company records reviewed by ProPublica. These plans cover some of the nation’s poorest and most vulnerable patients.

Internal company documents obtained by ProPublica reveal the strategy by Optum, a UnitedHealth Group subsidiary, to scrutinize and reduce outpatient mental health care. (Obtained by ProPublica)

United administers Medicaid plans or benefits in about two dozen states, and for more than 6 million people, according to the most recent federal data from 2022. The division responsible for the company’s Medicaid coverage took in $75 billion in revenue last year, a quarter of the total revenue of its health benefits business, UnitedHealthcare.

UnitedHealthcare told ProPublica that the company remains compliant with the terms of its settlement with the New York attorney general and federal regulators. Christine Hauser, a spokesperson for Optum Behavioral Health, said its process for managing health care claims is “an important part of making sure patients get access to safe, effective and affordable treatment.” Its programs are compliant with federal laws and ensure “people receive the care they need,” she said. One category of reviews is voluntary, she added; it allows providers to opt out and does not result in coverage denials.

ProPublica has spent months tracking the company’s efforts to limit mental health costs, reviewing hundreds of pages of internal documents and court records, and interviewing dozens of current and former employees as well as scores of providers in the company’s insurance networks.

One therapist in Virginia said she is reeling from the costly repercussions of her review by a care advocate. Another in Oklahoma said she faces ongoing pressure from United for seeing her high-risk patients twice a week.

“There’s no real clinical rationale behind this,” said Tim Clement, the vice president of federal government affairs at the nonprofit group Mental Health America. “This is pretty much a financial decision.”

Former care advocates for the company told ProPublica the same as they described steamrolling providers to boost cost savings.

One said he felt like “a cog in the wheel of insurance greed.”

Under ALERT

The year 2008 was supposed to mark a revolution in access to mental health care.

For decades, United and other insurers had been allowed to place hard caps on treatment, like the number of therapy sessions. But after Congress passed the ​​Mental Health Parity and Addiction Equity Act, insurers could no longer set higher copays for behavioral services or more strictly limit how often patients could get them; insurers needed to offer the same access to mental health care as to physical care. The law applied to most plans, regardless of whether federal or state regulators enforced it.

As access to services increased, so did insurers’ costs. Company documents show United was keenly aware of this threat to its bottom line.

But there was a loophole: Insurers could still determine what care was medically necessary and appropriate.

Doing so case by case would be expensive and time-consuming. But United already had a tool that could make it easier to spot outliers.

Called ALERT, the algorithmic system was created years earlier to identify patients at risk of suicide or substance use. The company redeployed it to identify therapy overuse.

Company and court filings reveal that ALERT comprised a suite of algorithms — totaling more than 50 at one point — that analyzed clinical and claims data to catch what it considered unusual mental health treatment patterns, flagging up to 15% of the patients receiving outpatient care.

The algorithms could be triggered when care met the company's definition of overly frequent, such as when patients had therapy sessions twice a week for six weeks or more than 20 sessions in six months. Therapists drew scrutiny if they provided services for more than eight hours a day, used the same diagnosis code with most clients or worked on weekends or holidays — even though such work is often necessary with patients in crisis.

The system was originally designed to save lives, said Ed Jones, who co-developed the algorithm program when he worked as an executive at PacifiCare Behavioral Health, which later merged with United. Using ALERT to limit or deny care was “perverting a process that was really pretty good,” he told ProPublica.

Once patients or therapists were flagged, care advocates, who were licensed practitioners, would “alert” providers, using intervention scripts to assess whether care was medically necessary. The calls felt like interrogations, therapists told ProPublica, with the predetermined conclusion that their therapy was unnecessary or excessive.

ProPublica spoke with seven former employees from Optum who worked with the ALERT system from 2006 through 2021. They requested not to be named in order to speak freely, some citing fears of retaliation.

Even though the reviews were purportedly intended to identify cases where care was inappropriate or violated clinical standards, several former care advocates said these instances were rare. Instead, they questioned care if it passed an allotted number of sessions.

“It had to be really extreme to help the client be able to continue with the care,” said one former care advocate, who was troubled by the practice. “Not everyone with depression is going to be suicidal, but they still need therapy to support them.”

The advocates often overruled a provider’s expertise, a former team manager said. “There was always this feeling, ‘Why are we telling clinicians what to do?’” he said. “I didn’t think it was OK that we were making decisions like that for people.”

If the advocates found fault with therapists’ explanations — or couldn’t persuade them to cut back on care — they elevated the case to a peer-to-peer review, where a psychologist could decide to stop covering treatment.

According to court records, regulators alleged United doled out bonuses to care advocates based on productivity, such as the number of cases handled, and pushed workers to reduce care by modifying a therapist’s treatment or referring therapists to peer review in 20% of assigned cases.

At one point, care advocates were referring 40%, regulators alleged in court filings. Each peer review tended to last less than 12 minutes, offering providers little time to prove they had a “clear and compelling” reason to continue treatment.

Former advocates described feeling like parts of a machine that couldn’t stop churning. “Literally, we had to tell the company when we were going to the restroom,” one advocate said, “and so you would do that and come back and your manager would say, ‘Well, that was a little long.’”

The former workers told ProPublica they were pressured to keep calls brief; the rush added to the tension as therapists pushed back in anger.

“There was an expiration date on those jobs because there was such a pull on you emotionally,” one former care advocate said.

Three of them quit, they told ProPublica, citing damage to their own mental health.

New York and federal regulators started looking into the practice around 2016. A California regulator and the Massachusetts attorney general’s office soon followed.

All concluded that while United may not have set official caps on coverage, it had done so in practice by limiting mental health services more stringently than medical care. Therefore, it was breaking the federal parity law.

While California and Massachusetts got United to scale back its use of ALERT within their jurisdictions, New York was able to stretch its reach by teaming up with the U.S. Department of Labor to investigate and sue the insurer. Together, they found that from 2013 through 2020, United had denied claims for more than 34,000 therapy sessions in New York alone, amounting to $8 million in denied care.

By using ALERT to ration care, United calculated that it saved the company about $330 per member each time the program was used, the regulators said in court records. Cut off from therapy, some patients were hospitalized. The regulators did not specifically address in court filings whether the treatment denials met medical guidelines.

The company, which denied the allegations and did not have to admit liability or wrongdoing, agreed to pay more than $4 million in restitution and penalties in 2021. Notably, it also agreed to not use ALERT to limit or deny care.

The final terms of the settlement, however, only applied to plans under New York and federal regulators’ jurisdiction.

Rebranded Reviews

ProPublica has reviewed documents behind Optum’s ALERT and Outpatient Care Engagement programs. (Obtained by ProPublica)

In the three years since the settlement, the company has quietly rebranded ALERT.

The Outpatient Care Engagement program continues to use claims and clinical data to identify patients with “higher-than-average intensity and/or frequency of services,” according to internal company documents, to ensure “that members are receiving the right level of care at the right time.”

Up to 10% of cases are flagged for scrutiny, public company documents show. If care advocates take issue with a case, they can elevate it to a peer review, which can result in a denial.

The advocates’ script is nearly the same as the one used for ALERT.

Care advocates are even calling therapists from the same phone number.

Overseen by the former director of ALERT, the team’s more than 50 care advocates are tasked with ensuring that “outpatient care follows clinical and coverage guidelines” and “reduces overutilization and benefit expense when appropriate,” according to company documents.

The team conducts thousands of reviews each month, targeting plans that are mostly regulated by states and fall outside of the jurisdictions of previous sanctions. Patients impacted include workers with fully insured plans and people covered by Medicaid.

Nearly 1 in 3 adults in the Medicaid program has a mental health condition, and a fifth of its members have a substance use disorder. “This is probably disproportionately sweeping up those that are most distressed, most ill and most in need of care,” Clement said.

Private insurers that manage Medicaid plans, also known as managed care organizations, are often paid a fixed amount per person, regardless of the frequency or intensity of services used. If they spend less than the state’s allotted payment, plans are typically allowed to keep some or all of what remains. Experts, senators and federal investigators have long raised concerns that this model may be incentivizing insurers to limit or deny care.

“They basically manage the benefits to maximize their short-term profit,” said David Lloyd, chief policy officer with the mental health advocacy group Inseparable and an expert on state-level mental health parity laws.

State regulators are supposed to be making sure private insurers that manage Medicaid plans are following the mental health parity laws. But this year, a federal audit found that they were failing to do so. “They are not well designed to essentially be watchdogs,” Lloyd said. “There’s very little accountability. Insurers can run roughshod over them.”

The internal records reviewed by ProPublica show the plans and geographic areas now scrutinized by the rebranded program. The team conducts two types of reviews, those considered “consultation” and those that question medical necessity.

For the first kind, the team flags members with high use (more than 30 sessions in eight months) or high frequency (twice-a-week sessions for six weeks or more) to engage their providers in “collaborative” conversations about the treatment plan.

Company documents reveal striking similarities between Optum’s ALERT and Outpatient Care Engagement programs. (Obtained by ProPublica)

Internal records indicate that the company uses this “consultation” model for about 20 state Medicaid programs, including Washington, Minnesota, Mississippi, Virginia and Tennessee. The company is also deploying the program with Medicaid plans in Massachusetts and, as of the fourth quarter of this year, New York, which are outside of the jurisdiction of the earlier state agreements.

While the Department of Labor does not have jurisdiction over Medicaid, a spokesperson said it “would be concerned about ‘consultation’ reviews that are conducted in a way that violates [the mental health parity act].” The department did not comment on whether it was investigating the insurer, as a matter of agency policy.

Company records show Optum is applying its more stringent review method, questioning medical necessity, to psychological testing services and a type of therapy to treat children with autism, known as applied behavior analysis, for people with Medicaid coverage in about 20 states. It is doing the same for routine therapy for its members with dual Medicare-Medicaid plans in about 18 states and Washington, D.C. Such plans are largely overseen by the Centers for Medicare & Medicaid Services, the federal agency responsible for overseeing both Medicare and Medicaid programs. While the dual plans are not subject to federal mental health parity laws, a CMS spokesperson said the agency was taking steps to “ensure that people enrolled in these plans have timely access to care.”

The internal company records reveal that Optum has continued to use quotas with its medical necessity reviews, setting productivity targets for how many cases its employees scrutinize. According to records from this year, the target was 160 reviews per employee, which the company exceeded with 180 reviews per employee.

Several state agencies that oversee Medicaid programs, including those in New York and Massachusetts, told ProPublica that they follow federal mental health parity laws and have strong monitoring practices to ensure that the private insurers that manage benefits are in compliance.

Katie Pope, a spokesperson for Washington’s Health Care Authority, told ProPublica that ALERT was discontinued three years ago but did not directly respond to questions about the current iteration of the program. Scott Peterson, a spokesperson for Minnesota’s Human Services Department, said that while United’s policies were compliant with federal parity laws, the company’s contract would expire at the end of the year. Last May, the state blocked for-profit insurers, like United, from participating in its Medicaid program.

Amy Lawrence, a spokesperson for Tennessee’s Medicaid program, said United’s outlier review practice entailed “voluntary collaborative conversations on best practices” and did not question the medical necessity of services nor result in denials of treatment. “There are no adverse consequences for providers who elect not to participate,” she said.

Mississippi’s, Louisiana’s and Virginia’s state Medicaid agencies did not respond to ProPublica’s questions. (Read all state responses.)

In response to ProPublica’s questions about its oversight of state Medicaid programs, a spokesperson for CMS said it was “actively engaged with states and other stakeholders to improve compliance and oversight of parity requirements.” (Read the full responses of federal agencies.)

Hauser, the spokesperson for Optum, told ProPublica that the company is committed to working with state Medicaid programs to ensure access to effective and necessary care. She said its new program was separate from ALERT, which she said had been discontinued. (She did not explain why the original ALERT program appears to be still operational in Louisiana, according to a recent company manual.) When the team conducts medical necessity reviews, she said, they are compliant with mental health parity law. (Read the company’s full response.)

Ringing Phones

Therapists who underwent the reviews told ProPublica that they felt the practice was intended to discourage them from providing necessary care, interfering with their ability to treat their patients.

This year, Oklahoma therapist Jordan Bracht received multiple calls from the team related to the care of two patients, who were both on United’s dual Medicare-Medicaid plan. “If we don’t hear back from you within a week,” a care advocate said in a voice message, “then the case will be forwarded to the peer review process to make a decision based upon the information available.”

Both of Bracht’s patients had diagnoses of dissociative identity disorder and required therapy twice a week. “Many of my clients are suicidal and would be hospitalized if I had to cut down the care,” Bracht told ProPublica.

Reviewers pushed for end dates for their therapy. “They really wanted me to nail down a discharge date,” she said. “We are really trying to keep this person alive, and it felt like they were applying their one-size-fits-all model. It doesn’t feel right.”

Virginia therapist Chanelle Henderson got a voice message in 2022 from the same number about her care of a patient with state Medicaid coverage. “We’d like to complete a clinical review,” the caller said. “We’ll follow up with one more call before the case is referred to the peer review process.”

When Henderson called back, a reviewer informed her that her practice had been flagged for providing longer sessions. Henderson tried to explain they were necessary to treat trauma, her practice’s specialty. “She had no trust in me as a clinician,” Henderson said of the reviewer.

The inquiry progressed to questions about other patients, including one who was being treated by a therapist under Henderson’s supervision. The reviewer said that the company did not cover sessions of supervised therapists at practices with less than 12 therapists. At the time, Henderson’s practice had eight.

The reviewer elevated her case, triggering an aggressive audit of the entire practice going back two years that threatened to shut it down.

Citing issues with supervision and longer sessions, United demanded the practice pay back about $20,000 for services it had already provided. Henderson and her business partner pushed back, hiring a biller to help submit hundreds of pages of additional notes and documentation. They also pointed out that during the audit, the company had even changed its policy to allow smaller practices to supervise therapists. United eventually decreased the penalty by half. Neither Optum, United nor Virginia’s Medicaid program directly responded to ProPublica’s questions about the case.

Bethany Lackey, who co-founded the practice with Henderson, said that the reviews felt like a pretext for additional scrutiny. “It’s all set up in order to catch someone doing something so that they can take back payments,” she said. “We all know that behind it is this more malicious intent of getting their money back.”

Bethany Lackey, left, and Chanelle Henderson (Kate Medley for ProPublica)

We’re Investigating Mental Health Care Access. Share Your Insights.

Maya Miller contributed reporting. Kirsten Berg contributed research.

by Jennifer Berry Hawes and Mollie Simon

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week.

Update, Nov. 20, 2024: The North Carolina legislature has voted to override the governor’s veto of funding for 54,000 children on the school voucher waitlist. The move could more than double the number of students receiving private school vouchers and send more money to segregation academies. In her speech opposing the move, Democratic Sen. Natasha Marcus pointed to ProPublica’s reporting about voucher funds going to those vastly white academies: “It’s not just their history. It is still their present.”

Private schools across the South that were established for white children during desegregation are now benefiting from tens of millions in taxpayer dollars flowing from rapidly expanding voucher-style programs, a ProPublica analysis found.

In North Carolina alone, we identified 39 of these likely “segregation academies” that are still operating and that have received voucher money. Of these, 20 schools reported student bodies that were at least 85% white in a 2021-22 federal survey of private schools, the most recent data available.

Those 20 academies, all founded in the 1960s and 1970s, brought in more than $20 million from the state in the past three years alone. None reflected the demographics of their communities. Few even came close.

Northeast Academy, a small Christian school in rural Northampton County on the Virginia border, is among them. As of the 2021-22 survey, the school’s enrollment was 99% white in a county that runs about 40% white.

Every year since North Carolina launched its state-funded private school voucher program in 2014, the academy has received more and more money. Last school year, it received about $438,500 from the program, almost half of its total reported tuition. Northeast is on track to beat that total this school year.

Vouchers play a similar role at Lawrence Academy, an hour’s drive south. It has never reported Black enrollment higher than 3% in a county whose population hovers around 60% Black. A small school with less than 300 students, it received $518,240 in vouchers last school year to help pay for 86 of those students.

Farther south, Pungo Christian Academy has received voucher money every year since 2015 and, as of the last survey, had become slightly more white than when the voucher program began. It last reported a student body that was 98% white in a county that was 65% white.

Segregation academies that remain vastly white continue to play an integral role in perpetuating school segregation — and, as a result, racial separation in the surrounding communities. We found these academies benefiting from public money in Southern states beyond North Carolina. But because North Carolina collects and releases more complete data than many other states, it offers an especially telling window into what is happening across this once legally segregated region where legislatures are rapidly expanding and adopting controversial voucher-style programs.

Called Opportunity Scholarships, North Carolina’s voucher program launched in 2014. At first, it was only for low-income families and had barely more than 1,200 participants. Then last fall, state lawmakers expanded eligibility to students of all income levels and those already attending private school, a move that sparked furious debate over the future of public education.

“We are ensuring that every child has the chance to thrive,” Republican Rep. Tricia Cotham argued. But Democratic Rep. Julie von Haefen pointed to vouchers’ “legacy of white supremacy” and called the expansion “a gross injustice to the children of North Carolina.”

So many students flocked to the program that the state now has a waitlist of about 54,000 children. Paying for all of them to receive vouchers — at a cost of $248 million — would more than double the current number of participants in the program. Republicans in the General Assembly, along with three Democrats, passed a bill in September to do just that.

Gov. Roy Cooper, a Democrat, vetoed the measure. But the GOP supermajority is expected to override it before the year’s end, perhaps as early as Nov. 19.

Opportunity Scholarships don’t always live up to their name for Black children. Private schools don’t have to admit all comers. Nor do they have to provide busing or free meals. Due to income disparities, Black parents also are less likely to be able to afford the difference between a voucher that pays at most $7,468 a year and an annual tuition bill that can top $10,000 or even $20,000.

And unlike urban areas that have a range of private schools, including some with diverse student bodies, segregation academies are the only private schools available in some rural counties across the South.

Josh Cowen, a professor of education policy at Michigan State, studies these barriers and sees where vouchers fall short for some: “Eligibility does not mean access.”

Rural roads and cotton fields surround Lawrence Academy in Merry Hill, North Carolina. The school, which opened in majority-Black Bertie County in 1968, has never reported Black enrollment higher than 3%. The area is part of the region’s Black Belt, where rich soils fueled cotton plantations. (Greg Kahn, special to ProPublica)

Of the 20 vastly white segregation academies we identified that received voucher money in North Carolina, nine were at least 30 percentage points more white than the counties in which they operate, based on 2021-22 federal survey and census data.

Otis Smallwood, superintendent of the Bertie County Schools in rural northeastern North Carolina, witnesses this kind of gulf in the district he leads. So many white children in the area attend Lawrence Academy and other schools that his district’s enrollment runs roughly 22 percentage points more Black than the county overall.

He said he tries not to be political. But he feels the brunt of an intensifying Republican narrative against public schools, which still educate most of North Carolina’s children. “It’s been chipping, chipping, chipping, trying to paint this picture that public schools are not performing well,” Smallwood said. “It’s getting more and more and more extreme.”

When a ProPublica reporter told him that Lawrence Academy received $518,240 last school year in vouchers, he was dismayed: “That’s half a million dollars I think could be put to better benefit in public schools.”

If lawmakers override the governor’s veto to fund the waitlist, Smallwood’s district could suffer most. In a recent report, the Office of State Budget and Management projected Bertie County could lose more of its state funding than any other district — 1.6% next year.

Bertie County Schools Superintendent Otis Smallwood worries that vouchers will drain resources from public schools, including the ones he oversees. (Greg Kahn, special to ProPublica)

Across the once legally segregated South, the volume of public money flowing through voucher-style programs is set to balloon in coming years. Georgia, Alabama, Arkansas, Louisiana, Florida and South Carolina all have passed new or expanded programs since 2023. (South Carolina’s state Supreme Court rejected its tuition grants in September, but GOP lawmakers are expected to try again with a revamped court.)

Voucher critics contend these programs will continue to worsen school segregation by helping wealthier white kids attend private schools; supporters argue they help more Black families afford tuition. But many of the states have made it hard to discern if either is happening by failing to require that the most basic demographic data be shared with the public — or even gathered.

This doesn’t surprise Cowen, who wrote the new book “The Privateers: How Billionaires Created a Culture War and Sold School Vouchers.” He said Southern legislatures in particular don’t want to know what the data would show because the results, framed by a legacy of racism, could generate negative headlines and lawsuit fodder.

States know how to collect vast troves of education data. North Carolina in particular is lauded among global researchers for “the robustness and the richness of the data system for public schools,” Cowen said.

North Carolina and Alabama are among the states that have gathered demographic information about voucher recipients but won’t tell the public the race of students who use them to attend a given school. In North Carolina, a spokesperson said doing so could reveal information about specific students, making that data not a public record under the Opportunity Scholarship statue.

For its $120 million tax credit program, Georgia does not collect racial demographic information or per-school spending. ProPublica was able to identify 20 segregation academies that signed up to take part, but it’s unclear how many are receiving that money or what the racial breakdown is of the students who use it.

“Why should we not be allowed to know where the money is going? It’s a deliberate choice by those who pass these laws,” said Jessica Levin, director of Public Funds Public Schools, a national anti-voucher campaign led by the nonprofit Education Law Center. “There is a lack of transparency and accountability.”

Advocacy groups that support widespread voucher use have resisted some rules that foster greater transparency out of concern that they might deter regulation-averse private schools from participating. Mike Long, president of the nonprofit Parents for Educational Freedom in North Carolina, is among those trying to rally as much private school buy-in for vouchers as possible.

“Their fear is that if they accept it, these are tax dollars, and therefore they would have to submit to government regulation,” Long said. “We’ve lobbied this legislature, and I think they understand it very well, that you can’t tie regulation to this.”

Pungo Christian Academy opened in 1968 in the small town of Belhaven. It last reported a student body that was 98% white in a county that was 65% white. (Greg Kahn, special to ProPublica)

The share of Black students who have received vouchers in North Carolina has dropped significantly since the program's launch. In 2014, more than half the recipients were Black. This school year, the figure is 17%.

That share is unlikely to increase if lawmakers fund all 54,000 students on the waiting list. Because lower-income families were prioritized for vouchers, the applicants who remain on the list are mostly in higher income tiers — and those families are more likely to be white.

More Black parents don’t apply for vouchers because they don’t know about them, said Kwan Graham, who oversees parent liaisons for Parents for Educational Freedom in North Carolina.

Graham, who is Black, said parents haven’t voiced to her concerns that, “I’m Black, they don’t want me” at their local private schools. But she’s also not naive. Private schools can largely select — and reject — who they want.

The nonprofit Public Schools First NC has tallied admissions policies that private schools receiving vouchers use to reject applicants based on things like sexuality, religion and disability. Many also require in-person interviews or tours. Rather than overtly rejecting students based on race, which the voucher program prohibits, schools might say something like, “Come visit the school and see if you’re the ‘right fit,’” said Heather Koons, the nonprofit’s communications and research director.

Northeast Academy, Lawrence Academy and Pungo Christian all include nondiscrimination statements on their websites.

Back when segregation academies opened, some white leaders proudly declared their goal of preserving segregation. Others shrouded their racist motivations. Some white parents complained about federal government overreach and what they deemed social agendas and indoctrination in public schools. Even as violent backlash against integration erupted across the region, many white parents framed their decisions as quests for quality education, morality and Christian education, newspaper coverage and school advertisements from the time show.

Early on, Southern lawmakers found a way to use taxpayer money to give these academies a boost: They created school voucher programs that went chiefly to white students.

Courts ruled against or restricted the practice in the 1960s. But it didn’t really end.

“If you look at the history of the segregation movement, they wanted vouchers to prop up segregation academies,” said Bryan Mann, a University of Kansas professor who studies school segregation. “And now they’re getting vouchers in some of these areas to prop up these schools.”

More recently, Lawrence and Northeast academies both grew their enrollments while receiving voucher money even as the rural counties where they operate have lost population. Over three decades of responding to the federal private schools survey, both academies have reported enrolling almost no nonwhite children. And Pungo Christian has raised its average tuition by almost 50% over the past three school years. During that time, the small school has received almost $500,000 in vouchers.

None of the three academies’ headmasters responded to ProPublica’s request to discuss its findings or to lists of questions. And none have ever reported more than 3% Black enrollment despite operating in counties with substantial — even majority — Black populations.

Cotton farming and other agriculture remains an important part of the economy in Northampton County, a rural expanse in northeastern North Carolina that has lost population in recent years. Despite that decline, Northeast Academy has seen its enrollment grow and has received more voucher funding each year. (Greg Kahn, special to ProPublica)

One of the Democrats who helped Republicans expand North Carolina’s voucher program was Shelly Willingham, a Black representative whose district includes Bertie County, home of Lawrence Academy. He said he doesn’t love vouchers, but the bills have included funding for issues he does support.

He also said he encourages his constituents to take advantage of the vouchers. If there were any effort to make it more difficult for Black students to attend those schools, “then I would have a big problem,” Willingham said. “I don’t see that.”

Another Democrat who voted with Republicans was state Rep. Michael Wray, a white businessman and former House minority whip — who graduated from Northeast Academy.

Wray, whose voting record on vouchers over the years has been mixed, did not respond to multiple ProPublica requests to discuss his views. In 2013, he voted against the budget bill that established the Opportunity Scholarships. And in a recent Q&A with the local Daily Herald newspaper, when asked if he supports taxpayer money funding private schools, he responded: “I believe that when you siphon funds away from our public school budgets, it undermines the success of our schools overall.”

Democrat Rodney Pierce, a public middle school teacher, recently won a seat in the North Carolina House of Representatives. (Greg Kahn, special to ProPublica)

Rodney Pierce, a Black 46-year-old father and public school teacher, saw the voucher expansion in the state budget bill Wray voted for and felt history haunt him. Pierce had only one white student in his classes last year at Gaston STEM Leadership Academy. But about 30 miles across the rural county, white children filled Northeast Academy.

Pierce taught history, with a deep interest in civil rights. He’d studied the voucher programs that white supremacists crafted to help white families flee to segregation academies.

“This stuff was in the works back in the 1960s,” Pierce said.

He was so outraged that he challenged Wray, a 10-term incumbent, for his state House seat. Pierce won the Democratic primary earlier this year by just 34 votes. He faced no opponent in November, so come next year he will cut the House’s support of vouchers by one vote.

“Particularly in the Black community, we care about our public schools,” he said.

Many Black families also have little to no relationship with their local private schools, especially those that opened specifically for white children and are still filled with them. The only times Pierce had set foot on Northeast Academy’s campus was when he covered a few sporting events there for the local newspaper.

People there were nice to him, he said, but he felt anxious: “You’re in an academy you know was started by people who didn’t want their children to go to school with Black children.”

His own three kids attend public schools. Even with vouchers, he said, he wouldn’t send them to a school founded as a segregation academy, much less one that still fosters segregation. He finds it insulting to force taxpayers, including the Black residents he will soon represent — about half of the people in his district — to pay to send other people’s children to these schools.

How We Analyzed Whether Segregation Academies Were Getting Public Money

We set out to determine whether states adopting voucher-like programs have provided funds to private schools founded to avoid integration. ProPublica previously developed a list of about 300 schools in the South that likely opened as segregation academies between 1954 and 1976 and that continue to operate. This original list was developed with data from the National Center for Education Statistics’ Private School Universe Survey, which includes schools’ student racial demographics. This survey is voluntary, and some known segregation academies — like an estimated quarter of all private schools — did not complete the survey or have reported different opening years over time. We did not include those institutions in our data. We examined only schools that responded to the most recent published survey in 2021-2022, as it included their racial demographics. This means our findings likely represent an undercount of schools.

Over time, many schools that opened as segregation academies have come to look more like their communities. Among the likely segregation academies we identified, we wanted to specifically examine those that remain vastly white and unrepresentative of their communities. To find these, we narrowed our list to those that were at least 85% white as of the most recent private school survey and were whiter than the county where they are located, based on census data. We compared both the total population and the population under 18 to make this determination. We included three schools with a total enrollment of 843 students that were 85% white when rounded to the nearest percentage point.

To assess which of those remaining schools may have benefitted from taxpayer money, ProPublica requested and gathered (where publicly available) per-school funding amounts from 10 southern states’ programs that support private schools. These included vouchers, individual education savings accounts and tax credits for scholarships or donations. The programs have existed for different numbers of years, and in some cases have expanded in eligibility and financial impact over time. In eight states, we received at least one year of per-school funding or recipient information. In two of these, we also got school-level demographics, with some limits to protect student privacy.

We then compared the names of schools from those eight states to the original list of likely segregation academies that remain vastly white and identified 64 schools that have benefitted from some form of taxpayer dollars, ranging from a total of $2,700 to over $4 million for a single school across multiple years. An additional 26 schools in Georgia and Florida have opted to accept state vouchers or scholarship participants, but we do not know whether they have actually enrolled student recipients.

Among the 64 schools that had benefited from a documented amount of state money, only a handful were in Virginia, Tennessee, Louisiana and Arkansas. In South Carolina, we identified 12 segregation academies getting vouchers, but only from a program focused on special needs students, and we were only able to get data up to the 2022-2023 school year. We focused our reporting on North Carolina, Mississippi and Alabama because each of these states had at least five years of available data and had sent millions of dollars to segregation academies through their state programs.

Help ProPublica Report on Education

by Renee Dudley, with research by Doris Burke

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

In the summer of 2021, President Joe Biden summoned the CEOs of the nation’s biggest tech companies to the White House.

A series of cyberattacks linked to Russia, China and Iran had left the government reeling, and the administration had asked the heads of Microsoft, Amazon, Apple, Google and others to offer concrete commitments to help the U.S. bolster its defenses.

“You have the power, the capacity and the responsibility, I believe, to raise the bar on cybersecurity,” Biden told the executives gathered in the East Room.

Microsoft had more to prove than most. Its own security lapses had contributed to some of the incursions that had prompted the summit in the first place, such as the so-called SolarWinds attack, in which Russian state-sponsored hackers stole sensitive data from federal agencies, including the National Nuclear Security Administration. Following the discovery of that breach, some members of Congress said the company should provide better cybersecurity for its customers. Others went further. Sen. Ron Wyden, a Democrat who chairs the Senate’s finance committee, called on the government to “reevaluate its dependence on Microsoft” before awarding it any more contracts.

In response to the president’s call for help, Microsoft CEO Satya Nadella pledged to give the government $150 million in technical services to help upgrade its digital security.

On the surface, it seemed a political win for the Biden administration and an instance of routine damage control from the world’s largest software company.

But Microsoft’s seemingly straightforward commitment belied a more complex, profit-driven agenda, a ProPublica investigation has found. The proposal was, in fact, a calculated business maneuver designed to bring in billions of dollars in new revenue, box competitors out of lucrative government contracts and tighten the company’s grip on federal business.

The White House Offer, as it was known inside Microsoft, would dispatch Microsoft consultants across the federal government to install the company’s cybersecurity products — which, as a part of the offer, were provided free of charge for a limited time.

But once the consultants installed the upgrades, federal customers would be effectively locked in, because shifting to a competitor after the free trial would be cumbersome and costly, according to former Microsoft employees involved in the effort, most of whom spoke on the condition of anonymity because they feared professional repercussions. At that point, the customer would have little choice but to pay for the higher subscription fees.

Two former sales leaders involved in the effort likened it to a drug dealer hooking a user with free samples. “If we give you the crack, and you take the crack, you’ll enjoy the crack,” one said. “And then when it comes time for us to take the crack away, your end users will say, ‘Don’t take it away from me.’ And you’ll be forced to pay me.”

If we give you the crack, and you take the crack, you’ll enjoy the crack. And then when it comes time for us to take the crack away, your end users will say, ‘Don’t take it away from me.’

—former Microsoft sales leader

The company, however, wanted more than those subscription fees, former salespeople said. The White House Offer would lead customers to buy other Microsoft products that ran on Azure, the company’s cloud platform, which carried additional charges based on how much storage space and computing power the customer used. The expectation was that the upgrades would ultimately “spin the meter” for Azure, helping Microsoft take market share from its main cloud rival, Amazon Web Services, the salespeople said.

In the years after Nadella made his commitment to Biden, Microsoft’s goals became reality. The Department of Defense, which had resisted the upgrades for years due to the steep cost, began paying for them once the free trial ended, laying the groundwork for future Azure consumption. So did many civilian agencies. The White House Offer got the government “hooked on Azure,” said Karan Sondhi, a former Microsoft salesperson with knowledge of the deals. “And it was successful beyond what any of us could have imagined.”

But while Microsoft’s gambit paid off handsomely for the company, legal experts told ProPublica the White House Offer deals never should have come to pass, as they sidestep or even possibly violate federal laws that regulate government procurement. Such laws generally bar gifts from contractors and require open competition for federal business.

Accepting free product upgrades and consulting services collectively worth hundreds of millions of dollars is “not like a free sample at Costco, where I can take a sample, say, ‘Thanks for the snack,’ and go on my merry way,” said Eve Lyon, an attorney who worked for four decades as a procurement specialist in the federal government. “Here, you have changed the IT culture, and it would cost a lot of money to go to another system.”

Microsoft defended its conduct. The company’s “sole goal during this period was to support an urgent request by the Administration to enhance the security posture of federal agencies who were continuously being targeted by sophisticated nation-state threat actors,” Steve Faehl, the security leader for Microsoft’s federal business, said in a statement. “There was no guarantee that agencies would purchase these licenses,” and they “were free to engage with other vendors to support their security needs,” Faehl said.

Pricing for Microsoft’s security suite was transparent, he said, and the company worked “closely with the Administration to ensure any service and support agreements were pursued ethically and in full compliance with federal laws and regulations.” Faehl said in the statement that Microsoft asked the White House to “review the deal for antitrust concerns and ensure everything was proper and they did so.”

The White House disputed that characterization, as did Tim Wu, a former presidential adviser who told ProPublica he discussed the offer with the company in a short, informal chat prior to the summit but provided no signoff. “If that’s what they’re saying, they’re misrepresenting what happened on that phone call,” he said.

A current White House official, in a statement to ProPublica, sought to distance the administration from Microsoft’s offer, which it had previously heralded as an “ambitious” cybersecurity initiative.

“This was a voluntary commitment made by Microsoft … and Microsoft alone was responsible for it,” the White House official said in the statement. Furthermore, they said the decisions to accept it were “handled solely by the respective agencies.”

“The White House is not involved in Agency decisions regarding cybersecurity and procurement,” the official said.

The official declined to comment on the legal and contracting concerns raised by experts but noted in the statement that the White House “is broadly concerned” about the risks of relying too much on any single technology vendor and “has been exploring potential policy steps to encourage Departments and Agencies to diversify where there is concentration.” Cybersecurity experts say that such concentration can leave users vulnerable to attack, outages or other disruption.

Yet the White House summit ushered in that very type of concentrated reliance, as well as the kind of anticompetitive behavior that the Biden administration has pledged to stamp out. Former Microsoft salespeople told ProPublica that during their White House Offer push, they advised federal departments to save money by dropping cybersecurity products they had purchased from competitors. Those products, they told them, were now “redundant.” Salespeople also fended off new competitors by explaining to federal customers that most of the cybersecurity tools they needed were included in the upgraded bundle.

Today, as a result of the deals, vast swaths of the federal government, including all of the military services in the Defense Department, are more reliant than ever on a single company to meet their IT needs. ProPublica’s investigation, supported by interviews with eight former Microsoft employees who were involved in the White House Offer, reveals for the first time how this sweeping transformation came to be — a change that critics say leaves Washington vulnerable, the very opposite of what Biden had set out to achieve with his summit.

“How did Microsoft become so pervasive of a player in the government?” said a former company sales leader. “Well, the government let themselves get coerced into Microsoft when Microsoft rolled the stuff out for free.”

President Joe Biden and Microsoft CEO Satya Nadella at a June 2023 event (Chris Kleponis/CNP/Bloomberg via Getty Images) “Everything That We Do Is Designed to Generate a Return”

The federal government is one of Microsoft’s largest customers and “the one that we’re most devoted to,” the company’s president, Brad Smith, has said. Each day, millions of federal employees use the Windows operating system and products like Word, Outlook, Excel and others to write reports, send emails, analyze data and log on to their devices. But in the months before Biden’s summit, the SolarWinds hack put that relationship to the test.

Discovered in late 2020, SolarWinds was one of the most damaging breaches in U.S. history and underscored the federal government’s vulnerability to a state-sponsored cyberattack.

Authorities established that Russian hackers exploited a flaw in a Microsoft product to steal sensitive government documents from the National Nuclear Security Administration and the National Institutes of Health, among other agencies. What they didn’t know, as ProPublica reported in June, was that one of the company’s own engineers had warned about the weakness for years, only to be dismissed by product leaders who were fearful that acknowledging it would undermine the company’s chances of winning a massive federal cloud computing contract.

But Microsoft’s known involvement was enough for Congress to summon Smith to testify in February 2021. Lawmakers focused on how Microsoft packaged its products into tiers of service — with advanced security tools attached to only the most expensive license, known to government customers as the G5.

At the time, many federal employees used a less expensive license known as the G3. As a result, they didn’t have access to the security features that might have alerted them to an intrusion and aided subsequent investigations.

Some lawmakers, like then-Rep. Jim Langevin of Rhode Island, accused the company of unfairly up-charging customers for what they considered to be basic security. “Is this a profit center for Microsoft?” he asked Smith during the hearing.

Smith replied: “We are a for-profit company. Everything that we do is designed to generate a return, other than our philanthropic work.”

Amid the criticism, Microsoft soon announced that it would provide federal customers with a “one-year free trial of Advanced Audit,” a tool that could help the government detect and investigate future attacks. Over the months that followed, Microsoft was “surprised there was not as aggressive of an uptake of Advanced Audit” as the company had wanted, Faehl, Microsoft’s federal security leader, told ProPublica. It would be a “lesson learned” going forward, he said.

That May, Biden signed an executive order requiring federal agencies to bolster their cyber defenses, declaring that “protecting our Nation from malicious cyber actors requires the Federal Government to partner with the private sector.” He added, “In the end, the trust we place in our digital infrastructure should be proportional to how trustworthy and transparent that infrastructure is, and to the consequences we will incur if that trust is misplaced.”

“Parting of the Red Sea”

Around that time, Anne Neuberger, a White House deputy national security adviser, called Smith and requested that Microsoft develop an initiative to announce at Biden’s White House cybersecurity summit that August. Like Langevin, the administration believed that the company’s advanced suite of cybersecurity tools, including ones intended to counter threats on user devices, should be included in the government’s existing licenses and that products should be delivered to customers with the most secure settings enabled by default. (Neither Neuberger nor Smith granted interview requests.)

Giving away a bundle of advanced security features permanently was a nonstarter inside Microsoft, an executive told ProPublica. But Smith spearheaded a team to develop an offer that appeared to be a compromise.

Federal customers could have free, limited-time access to the upgraded G5 security capabilities and to consultants who would install them. “It was at the behest of the Administration that Microsoft provided enhanced security tools, at no cost, to agencies as soon as possible to level up their security baseline,” Faehl told ProPublica.

While the deal achieved the administration’s goal of better protection for the federal government, it also served Microsoft’s interests. Microsoft salespeople had been trying, unsuccessfully, for years to convince federal customers to upgrade to the G5. Department and agency officials balked at the higher price tag when they already had other vendors providing some of the same security capabilities. The G5’s retail price is nearly 60% more than the G3’s.

“We knew that this was a golden window that nobody could have foreseen opening up because we had been pushing” for the G5 upgrade “for years, and things were going very slow,” said a former Microsoft sales leader involved in the strategy. With the White House Offer, it was “like Moses leading us through the parting of the Red Sea, and we just rushed through it.”

We knew that this was a golden window that nobody could have foreseen opening up.

—former Microsoft sales leader

Faehl told ProPublica that sales of the G5 had been slow prior to SolarWinds because federal customers wrongly believed “that they had sufficient security capabilities already in place.” He said the attack was “a wakeup call showing the status quo perspective to be insufficient.”

Microsoft was well aware of the possible legal implications of its offer. More than two decades ago, the U.S. Department of Justice sued the company in a landmark antitrust case that nearly resulted in its breakup. Federal prosecutors alleged that Microsoft maintained an illegal monopoly in the operating system market through anticompetitive behaviors that prevented rivals from getting a foothold. Ultimately, the Justice Department settled with Microsoft, and a federal judge approved a consent decree that imposed restrictions on how the company could develop and license software. Although the decree had long since expired, it nonetheless continued to loom large in the corporate culture.

When it came to the White House Offer, company insiders were “mindful of the concerns about Microsoft making products free that smaller companies sell,” an executive told ProPublica. A spokesperson explained, “That was the impetus for asking the administration to review it.”

The “review” consisted of a phone call between Microsoft’s Smith and Wu, who was Biden’s special assistant for technology and competition policy.

“Brad was like, ‘We think security is important, and we want to give the federal government better security,’” Wu recalled.

But, according to Wu, Smith said Microsoft’s lawyers were “overly paranoid” about antitrust concerns, and he was looking to “calm his own lawyers down.”

“I made it clear there was no ability in the White House to sign off on antitrust,” which is in the purview of the Justice Department or the Federal Trade Commission, Wu said. “I’m smart enough not to say, ‘Oh yeah, that’s fine with me.’ I’m not crazy.”

I made it clear there was no ability in the White House to sign off on antitrust. I’m smart enough not to say, ‘Oh yeah, that’s fine with me.’ I’m not crazy.

—Tim Wu, former presidential adviser

After the news organization asked Microsoft about Wu’s account, a spokesperson walked back the company’s original written statement, saying that Faehl was misinformed. “The White House arranged a call and we described details of our security offer and how it was structured to avoid antitrust concerns,” the spokesperson said. “It was an informal conversation and at no time did we ask for formal antitrust approval.”

Wu also told ProPublica that he felt pressure from the National Security Council’s Neuberger, who “wanted to get this deal done” in the wake of SolarWinds and other cyberattacks. “She pushed me to get on the phone with Brad,” he said. “I feel in some ways in retrospect I should not have even spoken with him. But I felt that I should help the NSC for what they presented as a formalistic exercise to help the national security.”

“The End Game”

After the White House summit, Microsoft’s sales teams quickly mobilized to sell the “WHO,” as it became known to insiders. The free consulting services were a crucial part of the strategy, former salespeople said. As Sondhi put it, “Just because you give the product away for free doesn’t mean they’re going to use it because it’s a pain in the ass to install new software and retrain staff.” The company wanted to avoid a repeat of the disappointing participation in the earlier Advanced Audit offer.

The consultants would work inside the agencies, where they would have government-provided desks, phones and internet, as well as access to federal computer networks, according to one proposal reviewed by ProPublica. From their perches in the bureaucracy, they would get the products up and running and train federal employees on how to use them. This would make the upgrades “sticky,” as they became ingrained in employees’ daily lives, former salespeople said.

Microsoft covered the free product upgrades for up to a year, the company told ProPublica. Faehl called the free upgrades “a short term option for protection while agencies put long term procurement plans in motion.” Or, as sales teams told customers, they “should not have to wait to be secure until they can procure.” The company also noted the offer came at a significant cost to Microsoft, “with no guarantee of renewal once the deal expired.”

But sales teams said they knew customers who accepted the White House Offer were unlikely to undo the intensive work of installing the upgrades when renewal time rolled around, locking them into the G5 for the long haul. Wes Anderson, a Microsoft vice president who oversaw teams working with the Defense Department, asked his staff to prepare forecasts showing which customers were expected to become paying G5 users at the end of the White House Offer, three people who worked in sales told ProPublica.

“It was explicit that this was the end game,” one former Microsoft sales leader who worked inside the Defense Department told ProPublica. “You will do whatever you need to do to get that software installed, operational and connected so the customer has their runway to renew.”

It was explicit that this was the end game. You will do whatever you need to do to get that software installed, operational and connected.

—former Microsoft sales leader

(On Oct. 30, two weeks after the news organization sent Microsoft questions for this story, the company announced in an email to employees that Anderson would be leaving Microsoft. Neither Anderson nor Microsoft commented on the departure. On the topic of Anderson’s request of his staff, the company said, “Forecasting is part of the rhythm of business for organizations in nearly every industry.”)

Salespeople pitched the White House Offer as “the easy button,” people familiar with the strategy told ProPublica. “Our argument was, ‘We have this whole suite of goodness,’” said a former Microsoft employee who worked with the Department of Defense. “‘You should upgrade because it will take care of everything rather than having a bunch of vendors that each do one of the 20 things that the G5 can do.’” Faehl told ProPublica the license bundles help federal customers “avoid the hassles of managing multiple contracts and licenses” and close security gaps by replacing a “patchwork of solutions” with “simplified, comprehensive protection.”

For the most part, as they predicted, the Microsoft sales teams found receptive audiences across the government. To help ingratiate themselves, they invoked their association with the White House in their pitches. In one example, from June 2022, a Microsoft representative wrote to Veterans Affairs officials to explain that, “working in conjunction with the White House,” it would provide “a no cost offer of professional services to provide hands-on assistance” to deploy the upgrades.

Money for Nothing?

As consultants fanned out across the federal government to turn on the new features, there was a sense of unease among some employees about the nature of the deals. Typically, the government obtains products and services through a competitive bidding process, selecting from a variety of proposals from different vendors. The White House Offer was different.

“No matter how you wanted to polish the turd, there was the appearance of no-bid contracts,” said a former Microsoft consultant involved in the WHO.

The federal government may receive so-called gratuitous — or free — services from donors as long as both parties have a written agreement stating that the donor will not be paid for the goods or services provided. Such agreements were in place for the consulting services in the White House Offer, the company said.

No matter how you wanted to polish the turd, there was the appearance of no-bid contracts.

—former Microsoft consultant

Those agreements may have helped Microsoft pass the “laugh test,” said Lyon, the former federal procurement attorney. “But just because something is technically legal does not make it right,” she said.

Other contracting experts said federal departments and agencies should have been more skeptical about accepting free products and consulting services from Microsoft, given the implications for competition and national security.

The cost and difficulty of switching from the Microsoft products presents a classic example of “vendor lock-in,” said Jessica Tillipman, associate dean for government procurement law studies at George Washington University Law School. “The free services are allowing the government to bypass a competitive procurement process and locking them in for future procurements,” she said.

Tillipman said that, in the future, the government should consider restrictions on gratuitous services in IT in order “to ensure you’re not locked in with a vendor who gets their foot in the door with a frighteningly expensive” giveaway.

“This is all designed to undermine future competitions,” she said.

This is all designed to undermine future competitions.

—Jessica Tillipman, associate dean, George Washington University Law School

James Nagle, a former Army contracting official and practicing attorney who specializes in the federal contracting process, went even further, saying that the White House Offer potentially violated existing law.

The Federal Acquisition Regulation, which governs government procurement, says that employees may not accept “gratuities,” or anything of value “from anyone who has or is seeking to obtain Government business.” And, as employees involved with the White House Offer told ProPublica, Microsoft was seeking future contract upgrades and new Azure revenue.

While “gratuities” are typically considered to be perks such as free meals, sports tickets or other gifts for personal use, Nagle argued that the rule could apply to the White House Offer, though he said he was not aware of any prior case using his interpretation. He compared it to a car manufacturer providing a government agency with a fleet of cars for a year for free because it wants the agency to procure that fleet for its staff. “Any contracting officer would say, ‘No, you can’t do that,’” Nagle said. Once employees get used to the cars, they’re reluctant to switch, he said, and the “impermissible gift” would create a built-in bias toward that manufacturer.

“That’s the problem here,” Nagle said. “This is not truly gratuitous. There’s another agenda in the works.”

Microsoft did not use the so-called gratuitous services agreements to give away the G5 upgrades, as it did for the consulting services. Instead, Faehl told ProPublica, the company considered them “a 100% discount” added to existing customer contracts. He said making this type of “strategic investment is … common practice among companies” and that contract teams on both sides reviewed the deals. Nagle viewed it differently, characterizing the free products as a “loss leader designed to lead to future sweetheart deals.”

Federal vendors may be banned from government contracting for violating the Federal Acquisition Regulation, though such an outcome would be highly unlikely for a vendor as large as Microsoft, Nagle said. Nonetheless, individual employees on both sides of improper deals in the past have been held accountable, he said.

Skirting fiscal law, however, may have set the stage for an even more serious legal concern, said Christopher Sagers, a professor of antitrust law at Cleveland State University in Ohio. Microsoft’s actions, Sagers said, might constitute what is known in antitrust law as “exclusionary conduct,” opening the door for illegal monopoly. “Microsoft, rather than competing on the merits, took steps to exclude competitors by making its product sticky in advance of opportunities for competition,” he said. The company used “an already dominant position to further cement their position.”

Microsoft disputed that point.

“We don’t believe our offer raised antitrust concerns, and we constructed it specifically to avoid any such issues,” a company spokesperson said. “We talked informally with a White House staffer about this.”

Wu, however, said the company did not make clear to him the financial and competitive implications of the offer.

“There is no way that was discussed,” Wu told ProPublica. “The only thing that Brad mentioned was upgrading federal agencies, offering them better stuff.” Upon hearing the news organization’s findings, he said: “That is a lot darker than it sounded. Once you’re in somewhere, it’s very hard to leave.

“Now I’m starting to feel guilty in some weird way about playing a role in a big deal that cost taxpayers money,” Wu said.

Taking Out the Competition

Former Microsoft salespeople said that all of the customers within the Defense Department who signed on to the White House Offer — including all the military branches — ultimately upgraded to the G5 and began paying for it when the time came to renew their agreements in 2022 and 2023.

A Defense Department spokesperson said in a written statement that the department followed federal acquisition law and “conducted internal tests and evaluations of multiple vendor capabilities.” The upgrade, the spokesperson said, was “crucial” to meeting the department’s cybersecurity objectives. The department declined to answer follow-up questions, including to specify which vendors it evaluated before deciding on the G5.

John Sherman, the department’s chief information officer at the time of the White House Offer dealmaking, defended both the government’s decision and Microsoft’s strategy. “I am sure Microsoft, like any company, would be trying to increase their business with any customer,” he told ProPublica.

He added, “We didn’t have any particular preference for Microsoft in terms of favoritism or anything like that, but we knew it worked, which is why we wanted to proceed with that.”

Many civilian agencies also upgraded to the G5 during this timeframe, said Sondhi, who now works at Microsoft competitor Trellix as chief technology officer for the company’s public-sector business.

For Microsoft, winning more government business was only half the picture. It also saw the White House Offer as an opportunity to knock out its competitors.

During and after their sales push, Microsoft salespeople advised government departments and agencies to remove competing products from their IT lineups to cut costs, saying the Microsoft bundle would render those other products redundant. Internally, employees called it the “take-out” strategy. “The play is: ‘You’re paying for it in the G5. It’s a waste of government money to have both,’” a former sales leader who worked with the Defense Department told ProPublica.

Sondhi said that in a typical scenario, an upgrade to the 5-level can displace the existing work of a half dozen vendors or more. Executives from cybersecurity companies Trellix and Proofpoint, for example, told ProPublica they lost federal business in the wake of the White House Offer deals.

The White House Offer also enhanced Microsoft’s competitive position by reducing the likelihood that the government would open bidding for cybersecurity products in the future, given the cornucopia of offerings in the G5. Within the company, this was known as “taking opportunities off the street,” former sales leaders said.

The fallout impacted companies that were in the midst of completing the authorization process the government requires of vendors providing cloud-based services. Several told ProPublica that cybersecurity contract opportunities are now scarce.

“We are chipping away, but it’s largely, by far, a Microsoft-owned landscape,” an executive at one competing vendor told ProPublica.

Faehl dismissed those complaints, saying that customers kept the upgrades because they performed well and that competitors “should look inward to see why their products do not meet or exceed Microsoft results.”

Reckoning With the “Monoculture”

Microsoft has something few other companies possess: a panoply of products that span the IT ecosystem. Rivals say the company leveraged its existing dominance in certain products — like the Windows operating system and classic workplace applications — to gain dominance in others, namely cybersecurity and cloud computing.

“No one has the kind of capital that Microsoft does,” Sondhi said. “They can just absorb the cost of the giveaway until the customer’s first bill.”

A coalition backed by some of Microsoft’s major competitors, including Google and Amazon, has raised similar issues with the Federal Trade Commission, which in 2023 gathered public comments on the business practices of cloud computing providers. Among the FTC’s areas of ongoing interest: “Are there signs that cloud markets are functioning less than fully competitively, and that certain business practices are inhibiting competition?”

Competition is not the only issue at stake. As Washington has deepened its relationship with Microsoft, congressional leaders have raised concerns about what they call a cybersecurity “monoculture” in the federal government. Some, like Wyden and Sen. Eric Schmitt, a Republican from Missouri, have blasted the Defense Department in particular for “doubling down on a failed strategy of increasing its dependence on Microsoft.”

“Although we welcome the Department’s decision to invest in greater cybersecurity, we are deeply concerned that DoD is choosing not to pursue a multi-vendor approach that would result in greater competition, lower long-term costs, and better outcomes related to cybersecurity,” the two lawmakers wrote in a letter to Sherman, then the department’s chief information officer, in May.

Microsoft’s Faehl pushed back. “The suggestion that our customers are any more at risk because they use Windows, or Azure, or Office is wrong,” he said. “We partner closely with our security competitors because we see them as partners against threat actors we face in common.”

Still, just last year, Chinese hackers exploited Microsoft security lapses to breach the email accounts of senior U.S. officials. Investigating the attack, the federal Cyber Safety Review Board faulted the company for a “cascade of … avoidable errors” and pressed it to overhaul its security culture. Microsoft has since pledged to place security “above all else.” In June, Smith told Congress that Microsoft would strive to establish a “culture that encourages every employee to look for problems, find problems, report problems, help fix problems and then learn from the problems.”

It’s learning from the successes, too. The same week that Smith testified before Congress, and nearly three years after Nadella made his commitment at Biden’s summit, Microsoft made a new offer, this time to “support hospitals serving more than 60 million people living in rural America.”

The playbook was familiar. In its announcement, the company said that eligible hospitals could have the private-sector equivalent of the G5 “at no cost for one year.” As before, Faehl said Microsoft made the commitment “at the behest of the White House.”

by Corey G. Johnson

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

A U.S. senator this week criticized the gun industry for secretly harvesting personal information from firearm owners for political purposes, calling it an “invasive and dangerous intrusion” of privacy and safety.

In a letter sent to the National Shooting Sports Foundation on Tuesday, Sen. Richard Blumenthal, D-Conn., questioned the legality of the “covert program” in which firearms manufacturers for years shared sensitive customer information with political operatives.

Blumenthal cited a ProPublica investigation that found some of America’s most iconic gunmakers secretly participated, even while the gun industry presented itself as a privacy protector and fought against government and corporate efforts to track firearms ownership.

At least 10 gun industry businesses, including Glock, Smith & Wesson and Remington, handed over hundreds of thousands of names, addresses and other private data — without customer knowledge or consent — to the NSSF, which then entered the details into what would become a massive database. The database was used to rally gun owners’ electoral support for the industry’s candidates running for the White House and Congress.

Blumenthal, who chairs a Senate subcommittees on privacy, gave the NSSF a Nov. 21 deadline to answer several questions. He wanted to know more about which companies contributed information to the database, the type of customer details shared and whether the data is still being used by the organization or by others.

The senator, who served as Connecticut’s attorney general for two decades and has consistently supported legislation to reduce gun violence, said he was also “disturbed” by “glaring discrepancies” between what ProPublica uncovered and the NSSF’s previous responses to his office.

In 2022, Blumenthal sent the NSSF a list of questions after reading leaked documents that made a passing reference to the database. In its response, the NSSF would not acknowledge the database’s existence.

“The secretive compilation and sharing of private information by NSSF and its partners seems to have violated federal consumer protection laws and created substantial data privacy and safety risks for lawful gun owners,” Blumenthal wrote.

The customer information initially came from decades of warranty cards filled out and returned to gun manufacturers for rebates and repair or replacement programs. A ProPublica review of dozens of warranty cards from the 1970s through today found that some promised customers their information would be kept strictly confidential. Others said some information could be shared with third parties for marketing and sales. None of the cards informed buyers their details would be used by lobbyists and consultants to win elections.

Violating a promise of strict confidentiality on warranty cards or failing to mention that consumer information could be given to the NSSF may qualify as a deceptive practice under the Federal Trade Commission Act, privacy and legal experts said. Under the law, companies must follow their privacy policies and be clear with consumers about how they will use their information.

The NSSF did not respond to messages seeking comment. Previously, the group defended the data collection, saying in a statement to ProPublica that any suggestion of “unethical or illegal behavior is entirely unfounded.” The statement said “these activities are, and always have been, entirely legal and within the terms and conditions of any individual manufacturer, company, data broker, or other entity.”

Glock and Smith & Wesson did not previously respond to ProPublica’s requests for comment. In the years since the data sharing program was launched, Remington has been split into two companies and sold. Remarms, which owns the old firearms division, said it was unaware of the company’s workings at the time. The other portion of the company is now owned by Remington Ammunition, which said it had “not provided personal information to the NSSF or any of its vendors.”

Founded in 1961 and currently based in Shelton, Connecticut, the NSSF represents thousands of firearms and ammunition manufacturers, distributors, retailers, publishers and shooting ranges. While not as well known as the chief lobbyist for gun owners, the National Rifle Association, the NSSF is respected and influential in business, political and gun-rights communities.

For two decades, the organization has raged against government and corporate attempts to amass information on gun buyers. As recently as this year, the NSSF pushed for laws that would prohibit credit card companies from creating special codes for firearms dealers, claiming the codes could be used to create a registry of gun purchasers.

As a group, gun owners are fiercely protective about their personal information. Many have good reasons. Their ranks include police officers, judges, domestic violence victims and others who have faced serious threats of harm.

The gun industry launched the data harvesting approximately 17 months before the 2000 election as it grappled with a cascade of financial, legal and political threats.

Within three years, the NSSF’s database — filled with warranty card information and supplemented with names from voter rolls and hunting licenses — contained at least 5.5 million people. The information was central to what NSSF called its voter education program, which involved sending letters, postcards and later emails to persuade gun buyers to vote for the firearms industry’s preferred political candidates.

Because privacy laws shield the names of firearm purchasers from public view, the data NSSF obtained gave it a unique ability to identify and contact large numbers of gun owners or shooting sports enthusiasts. The NSSF has credited its program for helping elect both George W. Bush and Donald Trump to the White House.

In April 2016, a contractor on NSSF’s voter education project delivered a large cache of data to Cambridge Analytica, a political consulting firm credited with playing a key role in Trump’s narrow victory that year, according to internal Cambridge emails and documents. The company later went out of business amid a global scandal over its handling of confidential consumer data.

The data given to Cambridge included 20 years of gun owners’ warranty card information as well as a separate database of customers from Cabela’s, a sporting goods retailer with approximately 70 stores in the U.S. and Canada.

Cambridge combined the NSSF data with a wide array of sensitive particulars obtained from commercial data brokers. It included people’s income, their debts, their religion, where they filled prescriptions, their children’s ages and purchases they made for their kids. For women, it revealed intimate elements such as whether the underwear and other clothes they purchased were plus size or petite.

The information was used to create psychological profiles of gun owners and assign scores to behavioral traits, such as neuroticism and agreeableness. With the NSSF supporting Trump and pro-gun congressional candidates, the profiles helped Cambridge tailor the NSSF’s political messages to voters based on their personalities.

by Max Blau

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

To uncover the truth about a pernicious insurance industry practice, staffers with the New York state attorney general’s office decided to tell a series of lies.

So, over the course of 2022 and 2023, they dialed hundreds of mental health providers in the directories of more than a dozen insurance plans. Some staffers pretended to call on behalf of a depressed relative. Others posed as parents asking about their struggling teenager.

They wanted to know two key things about the supposedly in-network providers: Do you accept insurance? And are you accepting new patients?

The more the staffers called, the more they realized that the providers listed either no longer accepted insurance or had stopped seeing new patients. That is, if they heard back from the providers at all.

In a report published last December, the office described rampant evidence of these “ghost networks,” where health plans list providers who supposedly accept that insurance but who are not actually available to patients. The report found that 86% of the listed mental health providers who staffers had called were “unreachable, not in-network, or not accepting new patients.” Even though insurers are required to publish accurate directories, New York Attorney General Letitia James’ office didn’t find evidence that the state’s own insurance regulators had fined any insurers for their errors.

Shortly after taking office in 2021, Gov. Kathy Hochul vowed to combat provider directory misinformation, so there seemed to be a clear path to confronting ghost networks.

Yet nearly a year after the publication of James’ report, nothing has changed. Regulators can’t point to a single penalty levied for ghost networks. And while a spokesperson for New York state’s Department of Financial Services has said that “nation-leading consumer protections” are in the works, provider directories in the state are still rife with errors.

A similar pattern of errors and lax enforcement is happening in other states as well.

In Arizona, regulators called hundreds of mental health providers listed in the networks of the state’s most popular individual health plans. They couldn’t schedule visits with nearly 2 out of every 5 providers they called. None of those companies have been fined for their errors.

In Massachusetts, the state attorney general investigated alleged efforts by insurers to restrict their customers’ mental health benefits. The insurers agreed to audit their mental health provider listings but were largely allowed to police themselves. Insurance regulators have not fined the companies for their errors.

In California, regulators received hundreds of complaints about provider listings after one of the nation’s first ghost network regulations took effect in 2016. But under the new law, they have actually scaled back on fining insurers. Since 2016, just one plan was fined — a $7,500 penalty — for posting inaccurate listings for mental health providers.

ProPublica reached out to every state insurance commission to see what they have done to curb rampant directory errors. As part of the country’s complex patchwork of regulations, these agencies oversee plans that employers purchase from an insurer and that individuals buy on exchanges. (Federal agencies typically oversee plans that employers self-fund or that are funded by Medicare.)

Spokespeople for the state agencies told ProPublica that their “many actions” resulted in “significant accountability.” But ProPublica found that the actual actions taken so far do not match the regulators’ rhetoric.

“One of the primary reasons insurance commissions exist is to hold companies accountable for what they are advertising in their contracts,” said Dr. Robert Trestman, a leading American Psychiatric Association expert who has testified about ghost networks to the U.S. Senate Committee on Finance. “They’re not doing their job. If they were, we would not have an ongoing problem.”

Most states haven’t fined a single company for publishing directory errors since 2019. When they do, the penalties have been small and sporadic. In an average year, fewer than a dozen fines are issued by insurance regulators for directory errors, according to information obtained by ProPublica from almost every one of those agencies. All those fines together represent a fraction of 1% of the billions of dollars in profits made by the industry’s largest companies. Health insurance experts told ProPublica that the companies treat the fines as a “cost of doing business.”

They’re not doing their job. If they were, we would not have an ongoing problem.

—Dr. Robert Trestman, an American Psychiatric Association expert, speaking about insurance regulators

Insurers acknowledge that errors happen. Providers move. They retire. Their open appointments get booked by other patients. The industry’s top trade group, AHIP, has told lawmakers that companies contact providers to verify that their listings are accurate. The trade group also has stated that errors could be corrected faster if the providers did a better job updating their listings.

But providers have told us that’s bogus. Even when they formally drop out of a network, they’re not always removed from the insurer’s lists.

The harms from ghost networks are real. ProPublica reported on how Ravi Coutinho, a 36-year-old entrepreneur from Arizona, had struggled for months to access the mental health and addiction treatment that was covered by his health plan. After nearly two dozen calls to the insurer and multiple hospitalizations, he couldn’t find a therapist. Last spring, he died, likely due to complications from excessive drinking.

Health insurance experts said that, unless agencies can crack down and issue bigger fines, insurers will keep selling error-ridden plans.

“You can have all the strong laws on the books,” said David Lloyd, chief policy officer with the mental health advocacy group Inseparable. “But if they’re not being enforced, then it’s kind of all for nothing.”

The problem with ghost networks isn’t one of awareness. States, federal agencies, researchers and advocates have documented them time and again for years. But regulators have resisted penalizing insurers for not fixing them.

Two years ago, the Arizona Department of Insurance and Financial Institutions began to probe the directories used by five large insurers for plans that they sold on the individual market. Regulators wanted to find out if they could schedule an appointment with mental health providers listed as accepting new patients, so their staff called 580 providers in those companies’ directories.

Thirty-seven percent of the calls did not lead to an appointment getting scheduled.

Even though this secret-shopper survey found errors at a lower rate than what had been found in New York, health insurance experts who reviewed Arizona’s published findings said that the results were still concerning.

Ghost network regulations are intended to keep provider listings as close to error-free as possible. While the experts don’t expect any insurer to have a perfect directory, they said that double-digit error rates can be harmful to customers.

Arizona’s regulators seemed to agree. In a January 2023 report, they wrote that a patient could be clinging to the “last few threads of hope, which could erode if they receive no response from a provider (or cannot easily make an appointment).”

Secret-shopper surveys are considered one of the best ways to unmask errors. But states have limited funding, which restricts how often they can conduct that sort of investigation. Michigan, for its part, mostly searches for inaccuracies as part of an annual review of a health plan. Nevada investigates errors primarily if someone files a complaint. Christine Khaikin, a senior health policy attorney for the nonprofit advocacy group Legal Action Center, said fewer surveys means higher odds that errors go undetected.

Some regulators, upon learning that insurers may not be following the law, still take a hands-off approach with their enforcement. Oregon’s Department of Consumer and Business Services, for instance, conducts spot checks of provider networks to see if those listings are accurate. If they find errors, insurers are asked to fix the problem. The department hasn’t issued a fine for directory errors since 2019. A spokesperson said the agency doesn’t keep track of how frequently it finds network directory errors.

Dave Jones, a former insurance commissioner in California, said some commissioners fear that stricter enforcement could drive companies out of their states, leaving their constituents with fewer plans to choose from.

Even so, staffers at the Arizona Department of Insurance and Financial Institutions wrote in the report that there “needs to be accountability from insurers” for the errors in their directories. That never happened, and the agency concealed the identities of the companies in the report. A department spokesperson declined to provide the insurers’ names to ProPublica and did not answer questions about the report.

Since January 2023, Arizonans have submitted dozens of complaints to the department that were related to provider networks. The spokesperson would not say how many were found to be substantiated, but the department was able to get insurers to address some of the problems, documents obtained through an open records request show.

According to the department’s online database of enforcement actions, not a single one of those companies has been fined.

(Anson Chan, special to ProPublica)

Sometimes, when state insurance regulators fail to act, attorneys general or federal regulators intervene in their stead. But even then, the extra enforcers haven’t addressed the underlying problem.

For years, the Massachusetts Division of Insurance didn’t fine any company for ghost networks, so the state attorney general’s office began to investigate whether insurers had deceived consumers by publishing inaccurate directories. Among the errors identified: One plan had providers listed as accepting new patients but no actual appointments were available for months; another listed a single provider more than 10 times at different offices.

In February 2020, Maura Healey, who was then the Massachusetts attorney general, announced settlements with some of the state’s largest health plans. No insurer admitted wrongdoing. The companies, which together collect billions in premiums each year, paid a total of $910,000. They promised to remove providers who left their networks within 30 days of learning about that decision. Healey declared that the settlements would lead to “unprecedented changes to help ensure patients don’t have to struggle to find behavioral health services.”

But experts who reviewed the settlements for ProPublica identified a critical shortcoming. While the insurers had promised to audit directories multiple times a year, the companies did not have to report those findings to the attorney general’s office. Spokespeople for Healey and the attorney general’s office declined to answer questions about the experts’ assessments of the settlements.

After the settlements were finalized, Healey became the governor of Massachusetts and has been responsible for overseeing the state’s insurance division since she took office in January 2023. Her administration’s regulators haven’t brought any fines over ghost networks.

The industry doesn’t take the regulatory penalties seriously because they’re so low.

—Mara Elliott, San Diego’s city attorney

Healey’s spokesperson declined to answer questions and referred ProPublica to responses from the state’s insurance division. A division spokesperson said the state has taken steps to strengthen its provider directory regulations and streamline how information about in-network providers gets collected. Starting next year, the spokesperson said that the division “will consider penalties” against any insurer whose “provider directory is found to be materially noncompliant.”

States that don’t have ghost network laws have seen federal regulators step in to monitor directory errors.

In late 2020, Congress passed the No Surprises Act, which aimed to cut down on the prevalence of surprise medical bills from providers outside of a patient’s insurance network. Since then, the Centers for Medicare and Medicaid Services, which oversees the two large public health insurance programs, has reached out to every state to see which ones could handle enforcement of the federal ghost network regulations.

At least 15 states responded that they lacked the ability to enforce the new regulation. So CMS is now tasked with watching out for errors in directories used by millions of insurance customers in those states.

Julie Brookhart, a spokesperson for CMS, told ProPublica that the agency takes enforcement of the directory error regulations “very seriously.” She said CMS has received a “small number” of provider directory complaints, which the agency is in the process of investigating. If it finds a violation, Brookhart said regulators “will take appropriate enforcement action.”

But since the requirement went into effect in January 2022, CMS hasn’t fined any insurer for errors. Brookhart said that CMS intends to develop further guidelines with other federal agencies. Until that happens, Brookhart said that insurers are expected to make “good-faith” attempts to follow the federal provider directory rules.

Last year, five California lawmakers proposed a bill that sought to get rid of ghost networks around the state. If it passed, AB 236 would limit the number of errors allowed in a directory — creating a cap of 5% of all providers listed — and raise penalties for violations. California would become home to one of the nation’s toughest ghost network regulations.

The state had already passed one of America’s first such regulations in 2015, requiring insurers to post directories online and correct inaccuracies on a weekly basis.

Since the law went into effect in 2016, insurance customers have filed hundreds of complaints with the California Department of Managed Health Care, which oversees health plans for nearly 30 million enrollees statewide.

Lawyers also have uncovered extensive evidence of directory errors. When San Diego’s city attorney, Mara Elliott, sued several insurers over publishing inaccurate directories in 2021, she based the claims on directory error data collected by the companies themselves. Citing that data, the lawsuits noted that error rates for the insurers’ psychiatrist listings were between 26% and 83% in 2018 and 2019. The insurers denied the accusations and convinced a judge to dismiss the suits on technical grounds. A panel of California appeals court judges recently reversed those decisions; the cases are pending.

The companies have continued to send that data to the DMHC each year — but the state has not used it to examine ghost networks. California is among the states that typically waits for a complaint to be filed before it investigates errors.

“The industry doesn’t take the regulatory penalties seriously because they’re so low,” Elliott told ProPublica. “It’s probably worth it to take the risk and see if they get caught.”

California’s limited enforcement has resulted in limited fines. Over the past eight years, the DMHC has issued just $82,500 in fines for directory errors involving providers of any kind. That’s less than one-fifth of the fines issued in the two years before the regulation went into effect.

A spokesperson for the DMHC said its regulators continue “to hold health plans accountable” for violating ghost network regulations. Since 2018, the DMHC has discovered scores of problems with provider directories and pushed health plans to correct the errors. The spokesperson said that the department’s oversight has also helped some customers get reimbursed for out-of-network costs incurred due to directory errors.

“A lower fine total does not equate to a scaling back on enforcement,” the spokesperson said.

Dr. Joaquin Arambula, one of the state Assembly members who co-sponsored AB 236, disagreed. He told ProPublica that California’s current ghost network regulation is “not effectively being enforced.” After clearing the state Assembly this past winter, his bill, along with several others that address mental health issues, was suddenly tabled this summer. The roadblock came from a surprising source: the administration of the state’s Democratic governor.

Officials with the DMHC, whose director was appointed by Gov. Gavin Newsom, estimated that more than $15 million in extra funding would be needed to carry out the bill’s requirements over the next five years. State lawmakers accused officials of inflating the costs. The DMHC’s spokesperson said that the estimate was accurate and based on the department’s “real experience” overseeing health plans.

Arambula and his co-sponsors hope that their colleagues will reconsider the measure during next year’s session. Sitting before state lawmakers in Sacramento this year, a therapist named Sarah Soroken told the story of a patient who had called 50 mental health providers in her insurer’s directory. None of them could see her. Only after the patient attempted suicide did she get the care she’d sought.

“We would be negligent,” Soroken told the lawmakers, “if we didn’t do everything in our power to ensure patients get the health care they need.”

Paige Pfleger of WPLN/Nashville Public Radio contributed reporting.

by Talia Buford

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

ProPublica’s Emerging Reporters Program provides support and mentorships to college students who are pursuing careers in investigative journalism and need additional training and financial support to help advance their goals.

Participants receive a $9,000 stipend, a trip to the annual NICAR investigative journalism conference, occasional training and presentations by speakers. They’ll also be paired one-on-one with ProPublica journalists who can help counsel them on stories, build their connections in the industry and expose them to the varied paths for careers in investigative journalism. Past Emerging Reporters have gone on to work at The New York Times, The Associated Press, Fresnoland, Capital B and other outlets.

Our goal is to encourage the next generation of journalists who seek to shine a light on abuses of power and produce stories of moral force that provoke change. In choosing the class, we look for students who demonstrate an early dedication to journalism as a career, through internships, work at local news outlets or work at campus publications. And where those opportunities — which are often unpaid — aren’t accessible, we look for other ways the student has shown an eagerness and a drive to learn the craft.

The 2024-25 academic year’s class of exceptional student journalists are from New York, Connecticut, Georgia, North Carolina and Washington, D.C. Throughout the application process, we were impressed by their experience and their desire to pursue ambitious, important stories so early in their careers. Through their work, the students have shown not only a commitment to careers in investigative journalism, but a desire to build trust and have impact in the communities they cover.

As they look forward to a post-undergrad future, like any good investigative journalist, they’re thinking about how they can do more in-depth, exciting work.

Through narrative, this year’s Emerging Reporters have set their sights on covering issues around public transit, affordable housing, the environment and climate change. They want to use audio to make their investigations accessible and digestible to the average listener. Some already work part time for local outlets on pressing community issues, while others are working for print and broadcast student media organizations.

Meet our 2024 class:

Aisha Baiocchi

Aisha Baiocchi is a senior studying journalism and international comparative studies through her dual enrollment at the University of North Carolina at Chapel Hill and Duke University. She is passionate about community journalism and bilingual reporting in Spanish. She is the special projects editor for her university’s independent student paper, The Daily Tar Heel. She was previously a metro intern at the Tampa Bay Times and participated in the National Association of Hispanic Journalists’ student project.

Amira McKee

Amira McKee is a senior at Columbia University studying sociology. She is head of investigations at the Columbia Daily Spectator, the campus newspaper, and also is an intern at NBC’s Investigative Unit. Over the summer, she interned with The Current, a Georgia-based nonprofit investigative newsroom, investigating traumatic injuries at Hyundai’s first U.S. electric vehicle plant. McKee has had internships at ABC New York and the Bronx Times. She also participated in the 2024 Politico Journalism Institute and the Dow Jones News Fund business reporting program. Her reporting interests include labor, policing and economic inequality.

Chaya Tong

Chaya Tong is a senior at Emory University studying biology and English. She is a part-time investigative reporter at The Atlanta Journal-Constitution. As an intern, Tong has covered Georgia state politics and policy for the Georgia Recorder, covered breaking news for The Daily Beast, and worked on investigative teams with The Chronicle of Higher Education and The Washington Post. She recently reported in Jackson, Mississippi, covering race and inequity for The Clarion-Ledger. Tong hopes to continue covering issues of race and politics as a journalist after graduation.

Trinity Webster-Bass

Trinity Webster-Bass is a senior broadcast journalism major and Afro-American studies minor at Howard University. She is president of the Howard chapter of the Ida B. Wells Society for Investigative Reporting and contributes to The Hilltop as an audio producer for “The HillTalks” podcast. Her media experience includes internships at WJCT-FM, an NPR affiliate in Jacksonville, Florida, and WHUR-FM’s music department at Howard University. She was also the producer of “Queer Seminar,” the third episode of the “1619: The College Edition” podcast in collaboration with Spotify. Webster-Bass is interested in using investigative storytelling through audio reporting to amplify the voices of individuals from diverse backgrounds.

Terell Wright

Terell Wright is a senior at Connecticut College studying political economy and minoring in history. He is a contributor to Connecticut Public Radio and The Day. His reporting on Gen Z's struggle to find affordable housing in the region won a 2023 Publick Occurrences award from the New England Newspaper & Press Association for The Day. Wright interned at The Wall Street Journal covering the economy during the 2024 presidential election. Wright is a National Association of Black Journalists scholarship recipient and a Dow Jones News Fund alum. He is interested in humanizing national trends impacting underreported communities.

Cedeem Gumbs contributed research.

by Peter Elkind

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

For Lincare, paying multimillion-dollar legal settlements is an integral part of doing business.

The company, the largest distributor of home oxygen equipment in the United States, admitted billing Medicare for ventilators it knew customers weren’t using (2024) and overcharging Medicare and thousands of elderly patients (2023). It settled allegations of violating a law against kickbacks (2018) and charging Medicare for patients who had died (2017). The company resolved lawsuits alleging a “nationwide scheme to pay physicians kickbacks to refer their patients to Lincare” (2006) and that it falsified claims that its customers needed oxygen (2001). (Lincare admitted wrongdoing in only the two most recent settlements.)

Such a litany of Medicare-related misconduct might be expected to provoke drastic action from the Department of Health and Human Services, which oversees the federal health insurance program that covers 1 in 6 Americans. Given that most of Lincare’s estimated $2.4 billion in annual revenues are paid by Medicare, HHS wields tremendous power over the company.

Sure enough, as part of the 2023 settlement, HHS placed Lincare on the agency’s equivalent of probation, a so-called corporate integrity agreement. The foreboding-sounding document includes a “death penalty” provision: Any “material breach” of the probation agreement, which runs for five years, “constitutes an independent basis for Lincare’s exclusion from participation in the Federal health care programs.” Such a ban could effectively kill Lincare’s business.

That sounds dire. Except that before that corporate integrity agreement was signed in 2023, Lincare was under the same form of probation, with the same death penalty provision, from 2018 to 2023, and violated its terms. From 2006 to 2011, Lincare was similarly on probation and also violated the terms, according to the government. And before that — well, you get the picture. Lincare has been on probation four times since 2001. And despite a pattern not only of fraud, but of breaking its probation agreements, Lincare has never been required to do more than pay settlements that amount to pennies relative to its profits.

This is not an aberration. While HHS routinely imposes the death penalty on small operations, it has never barred a national Medicare supplier like Lincare from continuing to do business with the government. Some companies, it seems, are too big to ban.

Lincare’s lengthy record of misbehavior isn’t a surprise to people in the medical equipment business. What is surprising is the federal government’s willingness to pull its punches with a company that has fleeced taxpayers and elderly customers again and again.

Federal officials have never pursued the company executives who oversee this behavior even though two of them, Chief Operating Officer Greg McCarthy and Chief Compliance Officer Jenna Pedersen, have worked at Lincare through all four of the company’s probationary periods. No one has faced criminal charges for activity the government’s own investigators deemed fraud.

Medicare has continued to pay Lincare billions even as many of the company’s customers revile it. Evaluations on customer-review websites are lacerating, and complaints to state attorneys general abound. On the Better Business Bureau’s website, 888 reviewers gave Lincare an average score of 1.3 out of 5. They cite dirty and broken equipment, charges that continue even after equipment has been returned, harassing sales and collection calls, and nightmarish customer service. As one person wrote in April, Lincare is “running a scam where they have guaranteed income” and “the customer can’t do a thing.”

Bauer’s oxygen concentrator and Lincare’s Libby, Montana, storefront. The company has 1.8 million customers in 48 states. (Rebecca Stumpf, special to ProPublica)

HHS has always been reluctant to cut off big suppliers. Medicare’s first objective is to make sure nothing interrupts the flow of medications, devices and services to beneficiaries. And were HHS to seek to ban Lincare, the company would surely launch a long, costly legal war. But even if the cost of such combat reached many millions of dollars, it would still be a tiny fraction of the amount lost to fraud, which is yet another contributor to the soaring medical costs that bedevil the country. “This is taxpayer money,” said Jerry Martin, a former U.S. attorney who represented an ex-Lincare executive in a whistleblower suit against the company. “We need to pay people that don’t have four corporate-integrity agreements.”

Weak enforcement is not the only problem. Lincare is paid to rent oxygen equipment to patients, with HHS covering most of the monthly bills. But those rental fees often add up to many times what it would cost simply to buy the equipment. “If this were a rational country,” Bruce Vladeck, who ran Medicare from 1993 to 1997, told ProPublica, “the government would buy a million [oxygen] concentrators and pay Amazon or somebody to deliver them.”

In a seven-month investigation, ProPublica examined how Medicare’s largest provider of home medical equipment has managed to take advantage of its customers for a quarter of a century while fending off meaningful enforcement. ProPublica interviewed more than 60 current and former employees and executives, Medicare and Justice Department officials, patient advocates, and health care experts. ProPublica also reviewed dozens of court cases involving Lincare and thousands of pages of internal company documents, sales presentations and emails.

The investigation reveals a dismal picture of a company with a sales culture that depends on squeezing infirm and elderly patients and the government for every penny. Lincare employees are pressured to sell — whether a customer needs a product or not — on pain of losing their jobs.

And the company’s record of misbehavior and conflict extends far beyond its sales and billing practices. Lincare has paid $9.5 million in settlements for data breaches and mishandling patient and employee records. It has faced claims of violating wage rules, harassing customers with sales and collection calls, and tolerating racist comments to an African American employee. (Lincare lost the latter suit at trial and is appealing.) The company has repeatedly sparred in court with former executives, including a 2017 suit in which longtime executive Sharon Ford claimed that the company had cheated her out of a $1 million bonus. (A judge ruled in favor of Ford at trial before the case was overturned on appeal.) Ford testified that Lincare had earned an industry reputation as “The Evil Empire.” And when Lincare’s CEO, Crispin Teufel, resigned last year to become CEO of a rival company, Lincare sued him for breach of contract and misappropriating trade secrets. Teufel ultimately admitted to downloading confidential company records and was blocked from taking the new job. (Teufel did not respond to requests for comment. His replacement, Jeff Barnhard, took over as Lincare’s CEO in July 2023.)

Lincare declined multiple requests to make executives available for interviews. After ProPublica provided a lengthy document listing every assertion in this article, along with separate such letters to executives McCarthy and Pedersen, the company responded with a three-paragraph statement. It asserted that Lincare is “committed to delivering high-quality and clinically appropriate equipment, supplies, and services” but acknowledged “missteps in the past.” The company said its “new leadership” had “commenced a comprehensive review of our policies and procedures to help ensure we are complying fully with all state and federal regulations” and that “investments and enhancements we have made over the last several months will help prevent these issues from repeating in the future.” Lincare did not respond to follow-up questions requesting examples of the steps the company says it’s taking, including whether it has terminated any executives as part of this push.

When ProPublica asked a top Medicare enforcer why Lincare had eluded banishment, her answer suggested she views probation as a continuing ed class rather than a harsh punishment. “It’s like taking a college course,” said Tamara Forys, who is in charge of administrative and civil remedies for HHS’ Office of Inspector General. “At the end of the day, it’s really up to you to change your corporate culture and to study, to learn to pass the class … to embrace that and take those lessons learned and move them forward.” A spokesperson for the Centers for Medicare and Medicaid Services, which runs Medicare, declined to comment on Lincare but said the agency “is committed to preventing fraud and protecting people with Medicare from falling victim to fraud.”

There’s little incentive to refrain from misbehaving in an environment that tolerates bad behavior, said Lewis Morris, who was chief counsel to HHS’ Office of Inspector General from 2002 to 2012. “As long as that [settlement] check is less than the amount you stole, it’s a good business proposition."

Indeed, Lincare has counted on the government’s tepid response, two former company executives told ProPublica. Top management, they said, responds to fraud warnings by conducting a cost-benefit analysis. “I’ve sat in meetings where they said, ‘We might have $5 to $10 million risk — if caught,’” said Owen Kirk Staggs, who ran one of Lincare’s businesses in 2017 and fell out with the company. “‘But we’ve made $50 million. So let’s go for it. The risk is worth the reward.’”

Longtime friends Ben Montgomery and Brandon Haugen worked together in Lincare’s operation in Libby and noticed billing irregularities. (Rebecca Stumpf, special to ProPublica)

Libby, Montana, provides a glimpse of the way Lincare operates. Oxygen is an urgent need in this mountain town of 2,857. Libby suffers from the lingering effects of “the worst case of industrial poisoning of a whole community in American history,” in the words of the Environmental Protection Agency. An open-pit vermiculite mine, which operated from 1963 to 1990, coated the area — and residents’ lungs — with needle-like asbestos fibers. More than 2,000 Libby citizens have been diagnosed with respiratory diseases since then; some 700 have died.

Hundreds of ailing residents relied on Lincare for home concentrators, which provide nearly pure oxygen extracted from room air. Medicare and Medicare Advantage plans (which the government also funds) covered 80% of the monthly rental of about $135; patients paid the remaining 20%.

In 2020, Brandon Haugen noticed something suspicious in Lincare’s bills. Haugen was a customer service representative at the company’s local distribution site, one of 700 such locations around the country. (Lincare serves 1.8 million respiratory patients in 48 states.)

Lincare was allowed to charge patients and their insurers for a maximum of 36 months under federal rules. After that point, patients could use the equipment without further charge. Lincare, however, kept billing local patients and their Medicare Advantage plans far beyond 36 months — in some cases, for years. To Haugen, this looked like fraud.

Haugen conferred with center manager Ben Montgomery. The two, who had grown up in the area, had been buddies since seventh grade, after getting to know each other at summer Bible camp. Then 38, earnest and just beginning to gray out of their boyishness, the two men were concerned. The patients the men dealt with were their neighbors.

A regional Lincare manager assured them that charging beyond 36 months for Medicare Advantage patients “is the correct way to bill.” Skeptical, Montgomery raised the issue with Lincare’s headquarters in Clearwater, Florida. Lincare’s compliance director told him, according to Montgomery, that “it’s the patients’ problem to fix it if they want it to stop”; that was “just how it worked.” Further questions, sent to Lincare’s chief compliance officer, Pedersen, went nowhere. “It seemed pretty obvious they were well aware of this,” Montgomery told ProPublica. “For me, these were my customers that you were screwing over.”

Among them was Neil Bauer, now 80, who lives in a ramshackle house “out in the boondocks,” as he put it, 38 miles southeast of Libby. Bauer spent his career as a barber, head of investigations for the county sheriff’s department and a member of the local school board. He’s been on oxygen for more than a decade and quickly gets short of breath. “I can’t do stuff so much now,” he said. His wife is on oxygen, too. “We just have a sick family,” Bauer said.

How Lincare Billed Over $16,000 for a Breathing Device that Costs $799

Neil Bauer needed an oxygen concentrator to cope with asbestosis. Rather than buying one — which costs about $799 today — Medicare Advantage rented one from Lincare and paid 80% of the monthly charges. Bauer covered the remaining 20%. Companies can bill for a maximum of 36 months, after which patients are entitled to use the equipment without further charge.

*This calculation undercounts the amounts Lincare billed; $27.35 for Bauer (and $109.40 for Medicare) represent the amounts Lincare was charging at the end of the time Bauer was billed. The monthly charges were higher earlier in the period, but ProPublica could not gain access to all of Bauer’s account statements, so we used the lower, more conservative figures.

Lincare had kept billing Bauer for his concentrator for seven years after it was supposed to stop. The monthly copays weren’t huge, but they added up to $2,325 that he shouldn’t have been charged over that period, a daunting sum for Bauer, who lives on a fixed income — and a hefty mark-up over the cost of the equipment, which can be purchased online for $799. For its part, Medicare Advantage paid Lincare $9,299 for Bauer’s concentrator during this period, along with another $5,760 for the months Lincare was legally permitted to bill. All told, the rental payments to Lincare, during authorized and unauthorized periods, were $16,547 for that one $799 piece of equipment. “We paid forever,” said Bauer. “Never was I told that we could have one without having to pay anything.”

Haugen and Montgomery studied billing records. Among the customers in their tiny office, Lincare was improperly charging at least 33 people and their Medicare plans. The two began to wonder how far this problem extended. An employee in Idaho confirmed the same practice was occurring there. “In my mind,” Montgomery said, “I went, ‘This is Libby, Montana. Multiply that by every center in the country. This is obviously a lot bigger deal.’”

Montgomery and Haugen had seen enough. On Jan. 18, 2021, they emailed a joint resignation letter to Lincare’s top management, recounting their concerns about billing that “likely affects thousands of patients company wide.” Citing the lack of response from corporate officials, they wrote, “we can only conclude that this is a known issue that is being covered up by Lincare.”

Haugen had 10 children. Montgomery had four. Neither man had another job lined up. “Had this not happened,” said Montgomery, who had been at the company for 13 years, “I would have seen myself retiring from Lincare.”

Instead, they became whistleblowers. They retained a law firm and sued Lincare in Spokane, Washington, the site of Lincare’s regional headquarters. After federal prosecutors decided to back the case, Lincare settled in August 2023. The company admitted to overbilling Medicare plans and patients across the country for years and paid $29 million to settle the matter, with $5.7 million of that going to Montgomery, Haugen and their lawyers. Dan Fruchter, the assistant U.S. attorney leading the government’s case, told ProPublica that the overbillings likely involved “tens of thousands” of patients.

Lincare agreed to its fourth stint of probation with HHS; the new corporate-integrity agreement took effect on the day after the previous one expired. The conduct Montgomery and Haugen flagged had gone on for years while the company was already on probation. But Lincare got the government lawyers to agree that nobody would try to impose the Medicare death penalty. Lincare asserted in the settlement that it had installed software (which it did only after learning of the government investigation) that will prevent billing beyond 36 months. Lincare promised to ensure “full and timely” compliance with the agreement and prevent future wrongdoing.

“We paid forever,” said Bauer, seen at his house outside Libby. He didn’t realize at the time that Lincare had been wrongly billing him for years. (Rebecca Stumpf, special to ProPublica)

Medicare fraud, including in the “durable medical equipment” category that Lincare operates in, has long been an intractable problem. It cost the U.S. Treasury an estimated $60 billion in 2023 alone.

The government deploys large sums to try to stop it. HHS’ inspector general’s office has a $432 million budget and a staff of 1,600. Those resources are effectively extended by whistleblowers — most of the cases against Lincare have been such suits — who can receive a percentage of a civil settlement if they reveal wrongdoing, and by federal prosecutors, who can also bring cases or join those filed by whistleblowers. Last year HHS recovered $3.2 billion from fraudulent schemes.

But the agency’s enforcers have wielded their biggest deterrent almost entirely against small perpetrators. In 2023, they banned 2,112 small firms and individuals from Medicare reimbursement.

HHS hasn’t done the same with companies that operate on a national scale. Forys, the agency enforcer, said she worries that expelling a big provider from Medicare could leave customers in the lurch. In April, Inspector General Christi Grimm defended her office’s work in congressional testimony but also asserted that its resources are inadequate. A lack of staff keeps it from even investigating “between 300 and 400 viable criminal and civil health care cases” annually, she testified, as well as more than half the fraud referrals from Medicare’s outside audit contractors.

A different reason for going easy on big companies was suggested by Vladeck, the former Medicare chief. Seeking to bar a large supplier for repeatedly violating probation would require exhaustive documentation and years of litigation against squadrons of well-paid corporate lawyers. As a result, Vladeck said, “there’s a real incentive, from a bureaucratic point of view, to just slap their wrist, give them a kick and make them apologize. … It’s a cost of doing business.”

There are steps enforcers could take, but almost never do, that would make companies take notice, according to Jacob Elberg, a former federal prosecutor who is now a professor at Seton Hall Law School. (Among his publications is a 2021 law review article titled “Health Care Fraud Means Never Having to Say You’re Sorry.”) Elberg’s research shows that HHS and prosecutors tend to negotiate far smaller civil settlements than the law allows, and they rarely prosecute company executives. They also almost never take cases to trial. In short, enforcers have long signaled to companies that they’re looking for a smooth path to a cash payment rather than a stern punishment for a company and its leaders. “It is generally a safe assumption,” Elberg said, “that the result will be a civil settlement at an amount that is tolerable.”

For its part, Congress may soon be weighing a new law that would reshape how the oxygen industry is paid by Medicare. But rather than clamp down on corporations, the legislation seems poised to do the opposite. A new bill called the SOAR (Supplemental Oxygen Access Reform) Act would hand companies like Lincare hundreds of millions more, by raising reimbursement rates and eliminating competitive bidding among equipment providers. Advocates say the legislation will help patients by making some forms of oxygen more available and improving service. But along the way it will reward Lincare and its rivals.

Congress has a history of treating oxygen companies generously. For years, lawmakers set Medicare reimbursements for oxygen equipment at levels that even HHS, in 1997, characterized as “grossly excessive.” Over the succeeding decade and a half, Lincare took advantage, snatching up hundreds of small suppliers and becoming the industry’s largest player.

In 2006, under pressure to reduce costs, Congress approved steps to curb oxygen payments, including the introduction of competitive bidding and the 36-month cap on payments for equipment rentals. But even those strictures were watered down after the industry poured money into political contributions and lobbyists, who warned that cuts would harm elderly patients.

Lincare compensated by amping up strategies that generated profits, with little apparent regard for Medicare’s rules, which say it will reimburse costs for equipment only when there is evidence of “medical necessity.” The company aggressively courted doctors and incentivized sales, through bonuses the company paid for each new device “setup.” According to a 2016 commission schedule, reps could earn $40 for winning an order for a new sleep apnea machine, $100 for a new oxygen patient and $200 for a noninvasive ventilator. The entire staff of each Lincare center could receive a small bonus for signing up a high percentage of new patients for automatic monthly billing. Patients who refused auto-billing, a company document advised, should be warned they might face “collection activity” and service cutoffs. “Sales is our top priority!” declared a 2020 PowerPoint to train new hires.

Once it had a customer, Lincare would pitch them more costly products and services. One way Lincare did this was through a program called CareChecks. Promoted as a “patient monitoring” benefit, CareChecks were aimed, according to a company presentation, at generating “internal growth.” If a patient exhibited a persistent phlegmy cough, Lincare could persuade their doctor to prescribe a special vibrating vest to loosen chest mucus. Nebulizer patients might be candidates for home oxygen. Patients using apnea devices were potential candidates for ventilators. “We’d make patients think we were coming in clinically to assess them,” a former Lincare manager said, “when really it was to make money off of them.”

Selling replacement parts could also be lucrative. At Lincare call centers that sold items like hoses, masks and filters for CPAP machines (used to treat apnea), hundreds of commissioned agents in Nashville, Tennessee, and Tampa, Florida, were equipped with programs displaying what items each patient was eligible for under Medicare. By law, patients had to request replacement parts. But frequently, that wasn’t what happened, according to Staggs, who oversaw the CPAP business in 2017. He discovered that top salespeople, whose bonuses could total $8,000 a month, averaged just a few minutes on the phone per order. That wasn’t nearly enough time to identify what items, if any, customers actually needed. Staggs listened to recorded calls and found that, after reaching customers, agents often placed them on hold until they hung up, then ordered them every product that Medicare would cover.

At Lincare, results were closely tracked and widely shared in weekly emails displaying the best and worst performers in each region. Notes taken by one manager show supervisors’ performance demands during weekly conference calls: “Unacceptable to miss goal … stop the excuses … If this is not being done, wrong [center manager] in place … If you’re not getting O2 and not getting Care Checks — you shit the bed. Stop accepting mediocre, lazy responses ….”

“If we didn’t meet our quota, they were going to chop our heads,” said former Illinois sales rep Sandra Gauch, who worked for Lincare for 17 years before joining a whistleblower suit and quitting in 2022.

One salesperson was so fearful of missing her quota, according to Gauch, that she signed her mother up for a ventilator that she didn’t need. A company audit in 2018 found that only 10 of 56 ventilator patients at one center were using them consistently. Some patients hadn’t used their devices for years. Yet Lincare kept billing Medicare.

Lincare has 700 locations around the country, including this one in Libby, where widespread asbestos contamination left thousands with serious breathing problems. (Rebecca Stumpf, special to ProPublica)

Only one thing mattered as much as maximizing new equipment rentals, according to former employees and company documents: minimizing customers’ attempts to end rentals. A call to retrieve breathing equipment meant that it was no longer wanted or being used, and Lincare was supposed to retrieve it and promptly stop billing Medicare and the patient. The person’s health might have improved. They might have gone into the hospital — or died. The reason didn’t matter; at Lincare, “pickups” were a black mark, deducted from employees’ performance scores, jeopardizing their bonuses and jobs.

As a result, employees said, such requests were dreaded, delayed and deterred. Clinical staff were sent to “reeducate” customers to keep using their devices. Patients were told they’d need to sign a form stating they were acting “against medical advice.”

Lincare managers made it clear that pickups should be discouraged. In a 2010 email, an Ohio center manager instructed subordinates: “As we have already discussed, absolutely no pick-ups/inactivation’s are to be do[ne] until I give you the green light. Even if they are deceased.” In 2018, an Illinois supervisor emailed her deputies that pickups were barred without her explicit approval: “Not even Death that I don’t approve first.”

In February 2022, Justin Linafelter, an area manager in Denver, responded to the latest corporate email celebrating monthly “Achievement Rankings” for oxygen sales by pointing out that almost all of the centers atop the rankings had at least 150 “pending pickups,” customers who weren’t using their equipment but whom the company appeared to still be billing. “Some of these centers are just ignoring pickups to make this list.”

That was only one of Linafelter’s concerns. In July of that year, he emailed headquarters, saying he no longer had “the resources to be successful at my job.” The customer service staff in Denver had been cut in half, Linafelter explained, and he’d been barred from hiring replacements. Denver’s remaining staff was “at a point of exhaustion,” threatening patient care.

The morning after Linafelter expressed concerns to Lincare in 2022, he was summoned to a conference call with the head of HR and fired, for what he was told was a “corporate restructuring.” Linafelter, who had worked at Lincare for nine years, said, “I got thrown away like a piece of trash.”

Other former employees offer similar accounts. In 2020, Jillian Watkins, a center manager in Huntington, West Virginia, repeatedly alerted supervisors that Lincare was improperly billing for equipment that patients weren’t using. Lincare blocked her from firing a subordinate who’d falsified documents supporting the charges, then fired Watkins, citing “inadequate direction and leadership.”

Then came a series of turns. Pedersen, the chief compliance officer, effectively confirmed Watkins’ assertions, belatedly alerting the government about $486,000 in improper billings by Lincare. But Pedersen blamed the billings on Watkins, writing to Medicare that the company had “terminated” her to “prevent [the problem] from recurring.” After Watkins sued, Pedersen admitted in a deposition that Watkins’ firing “had nothing to do with the overpayment.” In April 2024, a federal judge ruled that Watkins had presented “a prima facie case of retaliation.” The suit was privately settled in mediation.

Staggs, too, was ousted, he said, after he warned top Lincare executives about improper practices at the CPAP call centers. Staggs emailed a Lincare HR officer: “Patients are being shipped supplies that they never have ordered. … This is fraud and I have gotten zero support or attention to this matter when I raise the issue to my leadership.” Only months after starting, he was fired in November 2017. He later filed a whistleblower suit; Lincare denied wrongdoing. After the U.S. attorney’s office in Nashville declined to join the case in 2022, Staggs withdrew the action.

Staggs’ account of improper billings matches an industry pattern that appears to continue to this day. In a 2018 report, HHS’ inspector general estimated that Medicare had paid more than $631 million in improper claims for CPAP and other supplies over a two-year period. Another HHS analysis identified an additional $566 million in potential overpayments for apnea devices.

The agency’s oversight “was not sufficient to ensure that suppliers complied with Medicare requirements,” the 2018 report concluded. Six years later, HHS has not taken public action against Lincare relating to CPAPs.

Today, fraudulent billing among Medicare equipment providers remains a “major concern,” according to the inspector general. The agency says it continues to review the issue.

Doris Burke contributed research.

by Aliyya Swaby, ProPublica, and Paige Pfleger, WPLN/Nashville Public Radio

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week.

On the second day of school this year in Hamilton County, Tennessee, Ty picked out a purple bunny from hundreds of other plushies in his room. While his mom wasn’t looking, the 13-year-old snuck it into his backpack to show to his friends.

It was the 10th anniversary of his favorite video game franchise, Five Nights at Freddy’s, and Bonnie the bunny is one of the stars. Ty has autism and Bonnie is his biggest comfort when he gets agitated or discouraged. No one other than Ty, not even his mom, is allowed to touch Bonnie.

Ty was new to Ooltewah Middle School, located just east of Chattanooga. In class that morning, he told his teacher he didn’t want anyone to look in his backpack, worried they would confiscate his toy, according to Ty and his mom. When the teacher asked why, Ty responded, “Because the whole school will blow up,” he and his mom recalled.

School officials acted quickly, Ty’s mom said: The teacher, who had only known Ty for one day, called a school administrator, who got the police involved. They brought Ty to the counselor’s office and found Bonnie in the backpack. As Ty stood there, he said, confused about what he had done wrong, the police handcuffed him and patted him down before placing him in the back of a police car.

“I think they thought an actual bomb was in my backpack,” Ty told ProPublica and WPLN. But he didn’t have a bomb. “It was just this, right here,” he said, holding Bonnie. “And they still took me to jail.”

The sheriff’s department issued a press release about the incident stating that police checked the backpack and it was “found to not contain any explosive device.” ProPublica and WPLN are using a nickname for Ty at his mother’s request, to protect his identity because he’s a minor. The sheriff’s department didn’t respond to questions about Ty’s case. The Hamilton County School district, which includes Ty’s school, declined to respond, even though his mother signed a form giving officials permission to do so.

Ty’s arrest was the result of a new state law requiring that anyone who makes a threat of mass violence at school be charged with a felony. The law does not require that the threat be credible. ProPublica and WPLN previously reported on an 11-year-old with autism who denied making a threat in class and was later arrested at a birthday party by a Hamilton County sheriff’s deputy.

Advocates had warned Tennessee lawmakers during this year’s legislative session that the law would be particularly harmful for students prone to frequent outbursts or disruptive behavior as a result of a disability.

Lawmakers did include an exception for people with intellectual disabilities. And according to Ty’s mom and a school district psychological report, Ty has an intellectual disability as defined by Tennessee statute, in addition to autism. But the family’s lawyer said there is no evidence that law enforcement took that into consideration — or even checked to see if Ty had a disability — before handcuffing and arresting him.

The law doesn’t state how police should determine whether kids have intellectual disabilities before charging them. Rep. Cameron Sexton, the Tennessee House speaker and Republican co-sponsor of the law, said Ty’s case shows that “there may need to be more training and resources” for school officials and law enforcement.

Rep. Bo Mitchell, a Nashville Democrat who co-sponsored the law, said he hoped the exception for kids with intellectual disabilities would be enough to keep students like Ty from being arrested. “No one passed that law in order for a child with any type of disability to be charged,” he said.

But he said the law was still necessary to help prevent hoax threats that disrupt learning and terrify students. “I don’t know whose level of trauma is going to be the greatest: the kids in the classroom wondering if there’s an active shooter roaming their halls or a kid that didn’t know better and says something like that and gets arrested,” Mitchell said. “It’s a no-win situation.”

The state does not collect information about how the felony law, which went into effect in July, has applied to kids with disabilities like Ty. Data from Hamilton County provides a limited glimpse. In the first six weeks of the school year, 18 kids were arrested for making threats of mass violence. A third of them have disabilities, more than double the proportion of students with disabilities across the district.

Before the academic year began, Ty’s mom sent an email to school officials asking for their help to make her son’s transition to eighth grade as smooth as possible.

Ty’s specialized education plan states that he is social and friendly with other students but regularly has outbursts and meltdowns in class due to his disability. He struggles to regulate his feelings when asked to follow classroom guidelines and to understand social situations and boundaries.

Federal law prohibits his school from punishing him harshly for those behaviors, since they are caused by or related to his disability. But Ty’s principal later told his mom in an email that Tennessee’s threats of mass violence law requires school officials to report the incident to police.

When Ty’s mom got the phone call that her son was going to be arrested, she said it was her worst fear come true: Her son’s autism was mistaken for a threat. “Once you looked at his backpack, if there was nothing in there to hurt anyone, then why did you handcuff my 13-year-old autistic son who didn’t understand what was going on and take him down to juvenile?” she said.

Disability rights advocates said kids like Ty should not be getting arrested under the current law. And they tried to push for a broader exception for kids with other kinds of disabilities.

In a meeting with Mitchell before the law passed, Zoe Jamail, the policy coordinator for Disability Rights Tennessee, explained that the legislation could harm kids with disabilities who struggle with communication and behavior — such as those with some developmental disabilities — but aren’t diagnosed with an intellectual disability. She proposed language that Mitchell and other sponsors could include in the law, to ensure children with disabilities were not improperly arrested.

“No student who makes a threat that is determined to be a manifestation of the student’s disability shall be charged under this section,” one version of the amendment read.

The amendment was never taken up for a vote in the state legislature. Lawmakers passed the narrower version instead.

“I think it demonstrates a lack of understanding of disability,” Jamail said.

Sexton, the Republican House speaker, said kids with disabilities were capable of carrying out acts of mass violence and should be punished under the law. “I think you can make a lot of excuses for a lot of people,” he said.

Ty still doesn’t fully grasp what happened to him, and why.

On a recent morning in October, Ty turned the stuffed bunny toward his mom and asked, “Is he the reason why I can’t bring plushies anymore?”

Ty’s mom told him the reason is because he didn’t ask first. “You can’t just sneak stuff out of the house,” she said.

“Will I get in trouble for that?” he asked her.

“Yeah, absolutely,” she said. “You want them to possibly think it’s another bomb and take you back down to kiddie jail?”

“No,” he said, emphatically.

After the incident, Ty’s middle school suspended him for a few days. His case was dismissed in juvenile court soon after.

The principal told Ty’s mom in an email that if Ty said something similar again, the school would follow the same protocol. She decided to transfer him out of Ooltewah Middle School as soon as she could.

“Whenever we go past that school, Ty’s like: ‘Am I going back to jail, mom? Are you taking me back over there?’ He’s for real traumatized,” she said. “I felt like nobody at that school was really fighting for him. They were too busy trying to justify what they did.”

Mitchell, the Democratic representative, said he was “heartbroken” to hear that Ty was handcuffed and traumatized. But, he added, “we’re trying to stop the people who should know better from doing this, and if they do it, they should have more than a slap on the wrist.” He said he would be open to considering a carve-out in the law in the upcoming legislative session for kids with a broader range of disabilities.

But, he said, he believes that the law as it stands is making all children in Tennessee, with or without disabilities, safer.

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