ProPublica

by B. “Toastie” Oaster, High Country News

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

In the autumn of 2021, an 800-page report crossed the desk of Washington state lands archaeologist Sara Palmer. It came from an energy developer called Avangrid Renewables, which was proposing to build a solar facility partly on a parcel of public land managed by the state. Palmer was in charge of reviewing reports like these, which are based on land surveys intended to identify archaeologically and culturally significant resources.

Developers have proposed dozens of similar solar and wind projects across the state — a “green rush” of sorts amid rising fears of climate change. With the projects came more reports.

Often, Palmer, who worked for the Washington State Department of Natural Resources, read the reports and signed off; sometimes she shared notes on any concerns or told the developer to have the archaeologists they’d contracted with do additional fieldwork. This time, as she looked at the report, she grew concerned. The consulting company that Avangrid had hired, Tetra Tech, had included a lot of boilerplate language about human history on the Columbia Plateau, but fewer details than Palmer expected about what was actually found on the land.

Palmer knew that the parcel, located on a ridge called Badger Mountain, near the confluence of the Wenatchee and Columbia rivers, was historically a high-traffic corridor for the škwáxčənəxʷ and šnp̍əšqʷáw̉šəxʷ peoples (also known as the Moses Columbia and Wenatchi tribes). The area would likely be rich in cultural resources, including historic stone structures and first foods, the ingredients that make up traditional Indigenous diets.

Palmer was used to helping developers improve their technical reports to meet state standards. So, as soon as the snow melted, she drove out to Badger Mountain to look at the land herself.

As she walked the sagebrush overlook, Palmer quickly found signs of current-day Indigenous ceremonial activity, as well as ancient sites such as stone structures that can look like natural formations to the untrained eye but serve a variety of functions, including hunting and storage.

Most of the proposed development is on private lands, which Palmer lacked the authority to access. But in about 20 hours of fieldwork on the state-owned parcel, over the course of several days, Palmer said she found at least 17 sites of probable archaeological or cultural importance not listed in Tetra Tech’s survey. She would find more on subsequent visits.

Over the next year, Palmer’s findings — and how she shared them — would pit her against corporate and political forces that seemed determined to push the project through.

As soon as she returned from her initial trip, Palmer emailed her findings of “serious deficiencies” in Avangrid’s report to her colleagues at the Department of Natural Resources, which manages lands like the Badger Mountain parcel for the purpose of generating revenue for public services. Palmer called the situation “extraordinary,” noting that she had found a significant network of interconnected archaeological sites from before the arrival of white settlers.

Palmer also forwarded her findings to two tribal nations whose resources would be impacted: the Confederated Tribes of the Colville Reservation and the Confederated Tribes and Bands of the Yakama Nation, where the škwáxčənəxʷ and šnp̍əšqʷáw̉šəxʷ people are enrolled today. The tribal nations retain the right, via treaty and other legal mechanisms, to continue cultural practices like harvesting on any public lands in their ancestral territory. Treaties are considered the “supreme Law of the Land,” according to the U.S. Constitution, and the courts are supposed to view them as “equivalent to an act of the legislature,” according to U.S. Supreme Court Chief Justice John Marshall.

States play a role in upholding treaties, which require them to protect cultural resources on public lands. To do that, the state needs to know what resources are out there. For energy projects in Washington, state officials like Palmer generally rely on developers to conduct the surveys to find out.

Developer-conducted surveys have caused issues elsewhere: Officials in Mecklenburg County, Virginia, for example, pressured their consulting archaeologists to change a report that concluded a Black cemetery was eligible for historical designation, while in Louisiana, an archaeological firm, under pressure from its clients, edited a report to downplay evidence that a grain facility threatened notable Black historic sites.

Joe Sexton, an Indigenous rights attorney with the Washington law firm Galanda Broadman, said developer-funded archaeologists are a chronic problem in the state. Their reviews “are at best deficient and at worst deliberately negligent in overlooking tribal interests, overlooking clear potential for, for example, human burials, not considering sacred sites, not discussing with tribal elders and considering oral histories in particular,” he said.

Tetra Tech did not respond to repeated requests for comment.

In an emailed statement, an Avangrid spokesperson said the company has followed “all relevant law and regulation” with regard to the Badger Mountain solar project. The company “has taken additional steps to accommodate stakeholder feedback where possible,” the spokesperson wrote. “We will continue to do so as the project moves forward.”

In late May and early July of 2023, the Colville Tribes and the Yakama Nation officially registered their disapproval of the survey for Badger Mountain with the state agency in charge of permitting the solar project. Last fall, the agency took the rare step of requiring Avangrid to pay for a second, independent survey.

But even a perfect cultural survey only tells the state where cultural resources are; it doesn’t necessarily prevent them from being damaged, removed or destroyed.

In June, at a tribal summit with state agencies and developers in Tacoma, Washington, Yakama Nation archaeologist Noah Oliver criticized the state’s green rush. “It’s a land grab,” he said, pointing to the entire method of siting, permitting and consultation for renewable energy projects. “The system we work under is broken.”

The Yakama Nation considers all of Badger Mountain to be a traditional cultural property — government parlance for a place the tribes have identified as significant and eligible for federal protections. It is also an important harvesting site for the heirloom foods that make up much of Colville people’s diets. Andy Joseph Jr., an elected member of the Colville Tribal Business Council, estimated that the Badger Mountain project would destroy roughly half the root vegetable harvest in the area.

Joseph said the destruction of tribal food systems began when white settlers arrived, eroding community health and forcing assimilation. The building of Columbia Basin hydroelectric dams in the mid-20th century extirpated salmon from much of the upper Columbia River. The impacts were so severe that the Yakama Nation called the construction of one dam “cultural genocide,” committed to develop renewable energy, and Joseph said the new development plans continue that practice.

Joseph, who has also served on the National Indian Health Board, said protecting the healthy foods on Badger Mountain is vital to the well-being of Native people, who experience some of the nation’s worst health disparities. Tribal leaders have declined to describe or identify their heirloom crops out of concern that the non-Native public might overharvest or commercially exploit them.

“This is one of the last places where our roots aren’t being sprayed by anybody or they’re not grazed over by animals,” Joseph said. “It’s our food cache, and we don’t want it ruined.”

This is one of the last places where our roots aren’t being sprayed by anybody or they’re not grazed over by animals. It’s our food cache, and we don’t want it ruined.

—Andy Joseph Jr. of the Colville Tribal Business Council

As well as being a source for foods, Badger Mountain is culturally critical as an active ceremonial ground, and some of the rock features crafted by tribal ancestors are spiritual in nature. As they do with root vegetables, the tribal nations keep ceremonial information private to protect it from appropriation or commodification by non-Natives. But Joseph said root harvesting begins with a prayer ceremony, which tribal elders teach to the youth, feeding both the body and spirit.

Political pressure to advance the Badger Mountain project has been growing for years. In 2018, DNR developed a plan to lease out state lands for solar and wind projects. Three years later, Gov. Jay Inslee signed his blockbuster Climate Commitment Act, formalizing a statewide goal of reducing net climate pollution to zero by 2050 and opening the doors to a sweeping array of development opportunities. As of early 2023, developers had proposed 50 new solar and 12 new wind projects across the state, according to government data. Most are in eastern Washington where the ancestral lands of the Colville Tribes and the Yakama Nation are.

By March 2019, DNR was discussing developing Badger Mountain with Avangrid, which had become a powerful player in the Northwest’s push for green energy. The company built Washington’s largest solar facility, the Lund Hill solar project, south of Badger Mountain in Klickitat County, and it also operates the largest solar facility in Oregon.

Avangrid, its subsidiaries and its parent company, Iberdrola, have faced legal and economic tumult in recent years, including millions of dollars in fines related to service issues with its subsidiary Central Maine Power and opposition to a now-canceled merger agreement with New Mexico’s public utility. In a statement, a company spokesperson said that Central Maine Power had improved its standing and “met or exceeded service quality benchmarks for more than three consecutive years.” Concerns regarding the merger were not relevant to Badger Mountain, the statement reads, and the merger “had wide support.” The company is “dedicated to being a socially responsible business and corporate citizen,” the spokesperson said.

In Washington, as Avangrid was in talks with DNR about Badger Mountain, the company was also negotiating leases for private lands around the state’s parcel and was ready to move ahead.

Before Avangrid could build, however, it would have to satisfy the State Environmental Policy Act, in part by documenting potential cultural resources. That’s where the developer-conducted surveys come in.

To conduct its survey of Badger Mountain, Avangrid hired Tetra Tech, a Pasadena-based company that has previously faced criticism for insufficient scientific work. In 2018, two Tetra Tech supervisors pleaded guilty to falsifying records on a shipyard cleanup project in San Francisco, part of an ongoing legal battle over the allegedly inadequate cleanup of a Superfund site. The U.S. Department of Justice joined three whistleblower lawsuits against Tetra Tech. In response, Tetra Tech sued the companies that the Navy hired to look into the cleanup work. Last year, a group of homeowners sought class status against Tetra Tech, alleging the company had falsified work that stunted property values; Tetra Tech challenged a separate class action lawsuit about the same site, filing a motion to dismiss and arguing the case was based on “unsupported speculation about alleged widespread data falsification.”

Given the issues she found with the survey, Palmer said, “it always seemed like the simplest thing to do would have been to tell Avangrid, ‘Look, we're going to need you to hire a different consultant.’”

But the Department of Natural Resources didn’t do that.

Critics say DNR’s dual responsibility for both protecting and monetizing state lands has sometimes worked against the interests of tribal nations. “We've seen prioritization of monetary interest, certainly over tribal resources and resources important to Indigenous people,” said Sexton, who has represented the Yakama Nation against city and county governments, as well as federal agencies, to protect tribal rights on treaty lands.

DNR “is committed to engaging Washington’s Tribes when it comes to safeguarding lands and resources,” agency spokesperson Courtney James wrote in an emailed statement. “While we are committed to using state lands to build the clean energy future we need, we understand the care we must take to ensure projects don’t impact critical cultural resources.”

In an interview, Michael Kearney, head of product sales and leasing at DNR, said, “I do understand the concerns with the project proponent hiring their own specialists,” adding that “there are potential pitfalls with that.” But he said the agency doesn’t regulate renewable energy developers and can’t force developers to edit their cultural survey reports.

“We generally consider that to be a proprietary or business relationship,” Kearney told High Country News and ProPublica. “We’re not really playing that regulatory function.”

(Illustration by J.D. Reeves, special to ProPublica and High Country News. Source images: Sara Palmer, United States Geological Survey, Washington State Department of Natural Resources.)

Palmer, however, felt compelled to step in.

After conducting her field work, Palmer emailed her colleagues: “I consider it unlikely that Tetra Tech will be able to produce a legally defensible technical document.”

Palmer said her findings quickly escalated tensions. “What I had seen was very inconvenient to the development plans out there, and it was clearly something that the project proponents did not like,” Palmer told HCN and ProPublica. She believed that it put DNR leadership in a “very uncomfortable situation where they had an unhappy, politically connected developer.” Neither Avangrid nor DNR would comment on this characterization.

Avangrid itself pushed back.

On May 5, 2022, about two weeks after Palmer emailed her findings to DNR colleagues, Avangrid’s director of business development, Brian Walsh, sent her a string of urgent text messages, which HCN and ProPublica obtained through a public records request. After Palmer said she wasn’t available to talk, Walsh insisted that she keep her findings private and not share them with the tribes.

“I wanted to make sure any comments or concerns based on your field visit to Badger Mtn remain internal until we have had a time to discuss w peer professionals,” Walsh wrote. “We would like the opportunity to discuss any of your concerns before they are communicated externally, especially w the tribes.”

In fact, Palmer was at Badger Mountain that day — showing her findings to a Colville tribal archaeologist. DNR shares cultural surveys with the tribes, and Palmer regularly communicated with tribal archaeologists.

“Can you respond to my question on any external communications that you have made on Badger cultural?” Walsh persisted. “Specifically the tribes.” Palmer did not respond.

On May 12, 2022, after Palmer told the Yakama Nation about her findings on Badger Mountain, tribal leaders sent a letter to the state, saying the deficiencies in Tetra Tech’s report had far-reaching implications, since the company was doing other work on Yakama lands as well. “At this time we will not accept cultural resources work conducted by this contractor,” wrote Casey Barney, manager of Yakama Nation’s cultural resources program.

In response, DNR held a series of meetings with other agencies, Avangrid and tribal representatives. Handwritten DNR meeting notes obtained through a public records request show that Walsh told DNR officials that Palmer had gone “rogue.” DNR confirmed that this was Walsh’s characterization of Palmer.

According to Palmer, DNR leadership stopped including her in meetings with Avangrid and appointed the agency’s clean energy program manager, Dever Haffner-Ratliffe, as the sole point of communication with Walsh.

Agency group chats show that Tetra Tech instructed its staff not to speak with Palmer, even regarding other projects, for “political” reasons.

We would like the opportunity to discuss any of your concerns before they are communicated externally, especially w the tribes.

—Brian Walsh, Avangrid’s director of business development, in a text message to Sara Palmer

Emails from June 10, 2022, show that Walsh asked for the power to vet external agency communications before they went out to the tribes or other agencies and threatened to pull Avangrid’s business — by moving the project forward on private lands only, depriving the state of any potential revenues — if the agency didn’t comply. He also asked DNR to issue Avangrid a lease before the state’s environmental review process was complete; DNR and Walsh acknowledged this was something the agency had done for him before under other circumstances. Haffner-Ratliffe told Walsh that neither would be possible.

But DNR had been sending Walsh mixed signals. Before his exchanges with Haffner-Ratliffe, the agency had already given Avangrid a letter of intent to lease once the review process was complete, for Walsh to show to his superiors. And the agency had allowed Walsh to vet a draft of the letter before sending it out.

Emails show that DNR intended the letter to assure Avangrid that Walsh was making progress securing the land, even while the environmental review process was pending. And the agency knew it had to be careful, because the letter could give the impression externally that it had made the decision to lease before the environmental review was complete.

Even after Haffner-Ratliffe denied Walsh’s requests for a lease and approval to vet communications, he kept pushing. He kept repeating these requests and asked her to cite state laws supporting her denial of them; he also asked her to loop in a supervisor who could authorize her reply.

By the end of the year, another state lands archaeologist besides Palmer had emailed Haffner-Ratliffe regarding Walsh’s behavior in meetings, saying he had been “combative and provocative to me in particular,” and tried to “bully me into giving him the answers he wanted.” The interactions, she wrote, left her shaking and in a cold sweat.

On Dec. 21, 2022, Haffner-Ratliffe emailed DNR leadership asking them to address Walsh’s behavior toward at least three women within the agency. “I’ve experienced him yelling at me in meetings,” she wrote, adding that he had demanded preferential treatment and asked staff to violate state laws. “So far, the direction I’ve received has primarily been that I should listen, be cooperative, and communicative.” Avangrid and Walsh, who has since left his position at the company, denied asking DNR to violate any state laws.

DNR spokespeople said the agency addressed some of Haffner-Ratliffe’s specific concerns, like making sure managers were present in meetings with Walsh and giving staff the authority to end meetings or phone calls if they became uncomfortable. Nevertheless, Haffner-Ratliffe left the agency in January 2023. In her resignation letter, she said she was leaving because of a “lack of support” and “unprofessional behavior by clients and peers going unaddressed.”

Haffner-Ratliffe declined a request to comment for this story.

Walsh told HCN and ProPublica that Avangrid conducted an internal investigation into his conduct and cleared him of any wrongdoing. Avangrid declined to comment on Walsh’s claim.

Palmer continued to advocate for accurate documentation of cultural resources. On Oct. 31, 2022, Tetra Tech updated its cultural survey to reflect some of Palmer’s findings, listing more stone structures.

But Palmer told DNR colleagues that the updates were inadequate. “A number of resources that I have observed in the field are not included in this documentation or in previous documentation I have seen from Tetra Tech,” she wrote in an email obtained through a public records request.

Palmer added that date estimates were also off, and some stone features were mischaracterized as natural formations, while others were missing entirely.

Still, in May 2023, Avangrid submitted Tetra Tech’s updated survey, which then became available to the Colville Tribes and Yakama Nation for feedback.

Avangrid representatives said they were unaware of the issues with the initial survey and, when they became aware of them, modified their project plans to accommodate the tribally significant sites. They acknowledged that the state concluded that the updates were inadequate.

(Illustration by J.D. Reeves, special to ProPublica and High Country News. Source images: Andy Joseph, United States Geological Survey, Washington State Department of Natural Resources.)

A number of tribal officials and sources in state agencies told HCN and ProPublica that tribal opposition to a cultural survey rarely, if ever, makes a difference. But this time it did.

The permitting authority for the Badger Mountain project is a state agency called the Energy Facility Site Evaluation Council. The agency has the power to recommend proposed renewable energy developments to the governor for project permits. Additionally, it will produce the environmental impact statement and oversee the process of satisfying state environmental regulations.

The Colville Tribes and Yakama Nation both filed official comments with EFSEC stating that Tetra Tech’s updates failed to address their concerns. According to the Colville Tribes’ comments, the survey included only four of the archaeological sites that Palmer had found and missed additional sites recorded by a Colville tribal archaeologist. The Yakama Nation requested a full redo of Tetra Tech’s cultural survey by an independent third party. And this time, tribal concerns were echoed by comments from DNR and the Washington State Department of Archaeology and Historic Preservation.

By October 2023, EFSEC commissioned an independent cultural survey. Karl Holappa, EFSEC’s public information officer, told HCN and ProPublica that agency leaders do not recall ever previously commissioning an independent cultural survey, and a public records request shows that there’s no record of one at least in the past decade.

Holappa said in an email that EFSEC took this step to “ensure confidence in the outcome of the Survey by all parties.” He added that the new cultural survey will replace Avangrid’s and that the date of completion will partly depend on when the snow melts, making the ground visible again.

The new cultural survey doesn’t necessarily mean that EFSEC will recommend against issuing a permit for the Badger Mountain project. “I’ve never had EFSEC stop a project on cultural resources — not that I’m aware of,” said Allyson Brooks, the historic preservation officer in charge of the Department of Archaeology and Historic Preservation. Holappa said EFSEC doesn’t have the authority to stop a project during the site evaluation process. DNR and the Department of Archaeology and Historic Preservation also said they lack the power to approve or deny a project.

Still, EFSEC can advise the governor not to permit the project, and DNR could also withhold a lease. State law does authorize agencies to deny a proposed project if it would have significant impacts and insufficient mitigations.

In an email to HCN and ProPublica, Holappa said EFSEC thoroughly examines impacts on cultural resources and tribal concerns during the site evaluation process. “EFSEC will complete its review before making any recommendation to the Governor either to reject this project, to approve it as proposed, or to approve it with additional conditions,” he wrote.

Oliver, the Yakama Nation archaeologist, said having tribal nations take the lead on renewable energy development would be one way to solve the bigger problem. “They’re the ones who have the knowledge” to avoid sensitive sites, he said. The developers themselves can also include tribes: For the Lund Hill renewable project, Avangrid contracted directly with the Yakama Nation to survey the land. Oliver also recommended the state survey public lands and catalog cultural resources before any developers propose projects.

Brooks, the state historic preservation officer, has been working with the governor’s office on a pilot project to do that, allocating about half a million dollars for the Department of Archaeology and Historic Preservation to inventory cultural resources on some state lands.

Some critics say that plan still overlooks the core issue: Federal and state governments don’t recognize tribal nations’ authority to stop or alter development projects that threaten cultural resources on off-reservation lands where they hold legal rights.

“It's incredibly important for tribal nations to have a decisive say over their land, territories, resources and people,” said Fawn Sharp, vice president of the Quinault Indian Nation and former president of the National Congress of American Indians. “For us to fully engage and fully exercise the broad spectrum of authorities that are inherent to our sovereign interests, we absolutely must have free prior and informed consent as a recognized policy.”

Meanwhile, the Yakama Nation is using federal funds to build solar panels of its own, in a way that it says supports tribal communities. “Non-carbon emitting energy projects are positive advancements our state and country needs, but not at the cost of our traditional grounds and resources,” Yakama Nation officials wrote in an emailed statement to HCN and ProPublica. “Yakama Nation supports responsible energy development efforts. The Badger Mountain project, and the developer’s approach to advancing the project, fall far short of responsible energy development.”

In early 2023, Palmer left DNR, in part due to her frustration with the Badger Mountain project. “I would like to think that we can model a better way to do rural economic development,” she told HCN and ProPublica. “I would like to think there are alternative ways of operating that aren't just corporations preying on people, and no regulation.”

Mariam Elba contributed research.

by Patrick Lohmann, Source New Mexico

This article was produced in partnership with Source New Mexico, which was a member of ProPublica’s Local Reporting Network in 2023. Sign up for Dispatches to get stories like this one as soon as they are published.

The director of a federal office overseeing a nearly $4 billion compensation fund for victims of a New Mexico wildfire that was accidentally triggered by the U.S. Forest Service is stepping down.

Angela Gladwell’s reassignment comes as the Federal Emergency Management Agency restructures its disaster response in the state amid sustained criticism of its handling of disaster aid and payments for damages, which Source New Mexico and ProPublica have reported on for the past year.

The largest wildfire in state history, the Hermits Peak-Calf Canyon Fire destroyed at least 430 homes and cost billions of dollars in firefighting services and damage. About 29,000 claimants, including residents, businesses and nonprofit organizations, could be eligible for payments, FEMA has said.

Many residents have been in limbo as they await checks to rebuild. The agency’s claims office didn’t make its first payment to a victim until April, seven months after the office was created. By midsummer, more than a year after the fire had ripped through the mountains of northern New Mexico, the claims office had paid less than 1% of the total allocated. It has now paid $311 million, about 8% of the total approved by Congress. Several lawsuits allege the claims office has missed payment deadlines.

FEMA also faces two lawsuits over its decision not to pay for intangible losses, like the stress of fleeing the fire and being displaced from home for weeks or months. FEMA has declined to respond to questions about its decision, citing the litigation.

Gladwell, a longtime FEMA official and the face of the recovery effort, has frequently faced angry questions at town hall meetings about these problems. In recent weeks, a coalition of fire victims and local elected officials has called for her to be replaced as head of the claims office.

In a news release announcing Gladwell’s departure, claims office spokesperson Deborah Martinez said she “successfully built a compensation program from the ground, assembling a team of locally hired staff with knowledge of New Mexico and the communities affected by the wildfires.”

Now, she said, Gladwell will “transition to a new role” as FEMA consolidates recovery programs in New Mexico, including the claims office, into a single operation.

Martinez did not answer questions about what that consolidation entails, except to say in an email that the office is “in the beginning stages” of the change.

In a statement posted to LinkedIn, Gladwell reflected on her “last day in New Mexico with an extraordinary team who is delivering on an extremely challenging mission.” She said she was “grateful for what we have learned that will continue to inform approaches to disaster recovery in the future, especially for wildfires and rural communities.”

Jennifer Carbajal, deputy director of the claims office and a resident of the area, spoke at a packed town hall meeting Wednesday night in Las Vegas, New Mexico. She said the agency had acted as quickly as it could to hire staff, open offices and establish procedures. The consolidation decision, which was “brand new,” will combine the claims office with FEMA’s short-term disaster aid programs, she said.

FEMA will soon hire a chief operating officer to lead “on-the-ground long-term” recovery efforts as the office focuses on making payments, Martinez said in the news release.

The office will soon publish a guide outlining the types of claims that are being paid and what documentation is needed, Martinez said. The agency recently acknowledged that the paperwork burden is too high for some claimants. It’s common among multigenerational families with long roots in the area not to have clear titles to their land or other documentation proving ownership.

The Coalition for Fire Fund Fairness, a group that includes local elected officials, and attorneys for thousands of victims have called for Gladwell to be replaced by someone who they said better understands New Mexico’s culture and laws, like a former judge. The group’s founder, Manny Crespín Jr., called FEMA’s announcement “welcomed news” and asked that the new leader not be “another FEMA bureaucrat.”

The federal law creating the claims office allows FEMA to appoint an independent administrator to oversee it. Instead, the office brought in Gladwell, a FEMA employee for more than 25 years in Washington, D.C. Martinez did not respond to a question about how FEMA will select the chief operating officer, including whether they will be from New Mexico or will be hired from within the claims office.

U.S. Sens. Ben Ray Luján and Martin Heinrich and Rep. Teresa Leger Fernández, Democratic members of New Mexico’s congressional delegation, said in a written statement that they hope the changes will speed up claims payments. Recently, the community of Las Vegas mourned a former police chief who died while awaiting a check to rebuild his home in Rociada, one of the hardest-hit areas.

The claims office faces several lawsuits accusing it of missing legally required deadlines to make payment offers and pushing victims to abandon their attorneys. FEMA has denied it puts such pressure on victims. It said it discovered a flaw in its reporting system that allowed some cases to languish, and it was addressing the issue.

Antonia Roybal-Mack, a local lawyer representing hundreds of clients, credited ongoing advocacy by lawyers and residents, and reporting by Source New Mexico and ProPublica, in bringing about the change. She said she’ll watch closely to see who takes over the new office.

“I think it’s a step in the right direction,” she said. “People in northern New Mexico — we need to now ask them to put a New Mexican in that position.”

by Lomi Kriel, ProPublica and The Texas Tribune, Alejandro Serrano, The Texas Tribune, and Lexi Churchill, ProPublica and The Texas Tribune

This article is co-published with The Texas Tribune, a nonprofit, nonpartisan local newsroom that informs and engages with Texans. Sign up for The Brief Weekly to get up to speed on their essential coverage of Texas issues.

UVALDE, Texas — Law enforcement agencies across the country should immediately prioritize active shooter training, U.S. Attorney General Merrick Garland said Thursday as he released a scathing report about the handling of the 2022 massacre in Uvalde, Texas, in which lives could have been saved if training protocols had been followed.

The Justice Department’s long-anticipated report about the shooting found that “cascading failures of leadership, decision-making, tactics, policy and training” led to the bungled response, which Garland said should never have happened. Nineteen children and two teachers were killed on May 24, 2022.

“Had law enforcement agencies followed generally accepted practices in an active shooter situation and gone right after the shooter to stop him, lives would have been saved and people would have survived,” Garland said during a news conference on Thursday.

The report’s findings about the failure to follow protocol and the lack of sufficient training to prepare officers for a mass shooting largely mirrored the flaws revealed in a Texas Tribune, ProPublica and FRONTLINE investigation published last month that found that states require students and teachers to receive far more training to prepare them for a mass shooting than they require for the police. At least 37 states require schools to conduct active-shooter-related drills, nearly all on an annual basis. But Texas is the only state that mandates that all of its police officers complete repeated training, at least 16 hours every two years. That requirement was implemented after the Uvalde shooting.

Garland said the report was produced in an effort to offer lessons that would hopefully better prepare law enforcement across the country to respond to future mass shootings. It offered recommendations that included requiring all agencies in a region to train together and providing officers across the country with at least eight hours of active shooter training annually.

The vast majority of at least 380 officers from about two dozen local, state and federal agencies who responded to the school had never trained together, “contributing to difficulties in coordination and communication,” the report stated.

“Our children deserve better than to grow up in a country where an 18-year-old has easy access to a weapon that belongs on the battlefield, not in a classroom,” Garland said. “And communities across the country, and the law enforcement officers who protect them, deserve better than to be forced to respond to one horrific mass shooting after another. But that is the terrible reality that we face. And so it is the reality that every law enforcement agency in every community across the country must be prepared for.”

Mo Canady, executive director of the National Association of School Resource Officers, said in an interview that he appreciates the emphasis the Department of Justice placed on widespread active-shooter training. Still, Canady said he is frustrated that leaders have not already learned that “25-year-old lesson” after the shootings at Columbine High, Sandy Hook Elementary and Marjory Stoneman Douglas High School.

Since the 1999 Columbine shooting, law enforcement officers have been trained to prioritize stopping the shooter. The report stated that everything else, including officer safety, should be secondary, adding that efforts to engage the shooter “must be undertaken regardless of the equipment and personnel available.”

“We’ve got to understand what the priorities are and, quite frankly, I see there are not a lot of priorities greater than keeping students safe at school,” Canady said.

Kimberly Mata-Rubio, whose 10-year-old daughter Lexi was killed in the shooting, said she hopes the report’s findings lead to action, that “the failures end today and that local officials do what wasn’t done that day, do right by the victims and survivors of Robb Elementary: terminations, criminal prosecutions and that our state and federal government enacts sensible gun laws.”

Kimberly Mata-Rubio, mother of Alexandria Rubio, one of the children killed in Uvalde, speaks to the media after DOJ officials detailed failures in the law enforcement response to the 2022 school shooting. (Chris Stokes for The Texas Tribune)

Garland directed questions about whether any officers who responded to the shooting would be criminally charged to the local district attorney, saying that was not within the jurisdiction of the federal government. Uvalde District Attorney Christina Mitchell initially planned to present her case to a grand jury in late 2023 but later told the Associated Press that her investigation would continue into this year. Mitchell said in a statement Wednesday that her office “will continue our independent review for any potential criminal charges.”

The district attorney and the Texas Department of Public Safety have fought the release of records related to the shooting, prompting news organizations, including ProPublica and the Tribune, to sue. A Travis County district judge ruled in the newsrooms’ favor last month, but DPS appealed. The agency did not respond to requests for comment about the Justice Department’s report.

Texas Gov. Greg Abbott, who initially praised the response and later said he was misled, released a statement thanking the Justice Department. He said the state has already adopted some of the recommended measures and would review others.

The report, which offers the most comprehensive account to date from authorities about the shooting, echoes many findings from a probe released by a state House committee two months after the shooting.

In presenting the new report’s findings, Associate Attorney General Vanita Gupta criticized initial misinformation and conflicting accounts provided by officials, including Abbott and DPS.

The report noted that the “misguided and misleading narratives, leaks, and lack of communication about what happened on May 24 is unprecedented and has had an extensive, negative impact on the mental health and recovery of the family members and other victims, as well as the entire community of Uvalde.”

The previous mayor of Uvalde requested the federal review days after the shooting when it became clear that the response was flawed. The review was led in part by Sheriff John Mina of Orange County, Florida, who was the incident commander during the 2016 Pulse Nightclub massacre in Orlando.

An outside review of that incident found that Florida officers, who waited three hours to take down the shooter, mostly followed best practices, although it stated that the law enforcement agencies in Orlando should update their training and policies.

In multiple after-action reviews, including the Pulse report, authors opted not to criticize significant law enforcement delays during mass shootings, according to an analysis of more than three dozen of these reports by ProPublica, the Tribune and FRONTLINE.

Associate Attorney General Vanita Gupta criticized the conflicting reports given by officials in her remarks at a press conference discussing the DOJ report on the law enforcement response to the 2022 school shooting in Uvalde. (Chris Stokes for The Texas Tribune)

The Uvalde report was far more critical, finding failures in leadership, command and coordination.

It stated that officers wrongly treated the situation as a barricaded suspect incident instead of one in which a shooter was an active threat to children and teachers. Officers should “never” treat an active shooter with access to victims as a barricaded suspect — especially in a school, where there is a “high probability” of potential victims and innocent civilians being present, the report stated.

Officers had multiple indicators that should have made it clear they were facing an active shooter, including 911 calls from children and teachers pleading for help, a dispatcher’s announcement minutes after officers arrived that students were likely in the classroom with the shooter, and an Uvalde school police officer announcing that his wife had called to tell him she had been shot, according to the report.

Gupta condemned the medical response, saying that after police breached the classroom and killed the gunman, dead victims were placed in ambulances while children with bullet wounds were put on school buses. Many of those findings were revealed in a 2022 investigation by the Tribune, ProPublica and The Washington Post that determined medical responders did not know who was in charge and that two students and a teacher who later died still had a pulse when they were rescued from the school.

In its blistering criticism of responding officers, the report said that supervisors from various law enforcement agencies “demonstrated no urgency” in taking control of the incident, which exacerbated communication problems and added to overall confusion.

Uvalde school district Police Chief Pete Arredondo, who was listed as the incident commander in the district’s active-shooter plan, had the “necessary authority, training and tools” to lead the response but did not provide “appropriate leadership, command and control,” the report found. Arredondo could not be reached for comment Thursday through his attorney. He has previously defended his actions and those of others involved in the response.

Beyond that, no leader from any of the other responding agencies “effectively questioned the decisions and lack of urgency” demonstrated by Arredondo and Uvalde Police Department Acting Chief Mariano Pargas, who both arrived at the school within minutes of the first round of gunfire. The report listed Uvalde County Sheriff Ruben Nolasco, Uvalde County Constables Emmanuel Zamora and Johnny Field, and an unidentified Texas Ranger as examples of such leaders.

“Responding officers here in Uvalde, who also lost loved ones and who still bear the emotional scars of that day, deserved the kind of leadership and training that would have prepared them to do the work that was required,” Garland said.

The report also found that key officers, including Pargas, had no active shooter or incident command training despite, in some instances, having decades of law enforcement experience. Nolasco, the sheriff, also had no active shooter training and “minimal” incident command training.

Law enforcement training academies must ensure that active shooter training instructs officers on how to distinguish between active threats and barricaded or hostage situations, the report said. Officers should be prepared to approach the threat using the tools they have with them, which are often standard firearms. They should not wait for specialized equipment or tactical teams if they know that people are injured, the report stated.

The Tribune reported early last year that some officers were afraid to confront the gunman because he had an AR-15 rifle.

“No law enforcement agency or community can assume that what happened here — or in Newtown or in Parkland or in Columbine — can’t happen in their community,” Gupta said. “That is our reality.”

Texas Tribune reporters William Melhado and Pooja Salhotra contributed reporting.

by Stephannie Stokes, WABE; Data analysis by Agnel Philip, ProPublica

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

Brittany Wise ran through the options in her head.

It was a sunny April morning in Cobb County, Georgia, a suburban area northwest of Atlanta. Wise was heading back to the cul-de-sac of budget motels where her family was staying after receiving an eviction notice from her landlord in January when the blue lights appeared in her Chevy Tahoe’s rearview mirror.

The police officer had stopped Wise for an expired tag. But when he looked up her name, he discovered a bench warrant for a traffic ticket she hadn’t paid. She remembers that the officer was kind and gave her a warning about her tag. For her warrant, however, he told her that she had to go to jail.

Wise’s mind went to her children. Six of them were there in the SUV. The other two were walking up to the motel parking lot. In all, they ranged in age from 4 to 18. Wise, a 35-year-old single mother, had to figure out where they all would go.

Wise didn’t have any other family members nearby. She knew she could leave her children in the care of her oldest daughter. But one has autism and another has severe behavioral issues, which would be too much to put on a teenager, she thought.

So Wise asked the officer to contact the Georgia Division of Family and Children Services. She hoped that the agency could care for her children just for as long as she had to be in jail — which turned out to be three days.

When Wise got out of jail, however, DFCS didn’t return her children. The reason, according to court documents and the case plan the agency gave her, was that she lacked stable housing and income for her kids.

In recent years, child welfare advocates and policymakers across the country have been working to prevent situations like this, arguing that no parent should ever lose their children just because they can’t afford housing. A handful of states now have laws and policies prohibiting government agencies from taking children into foster care because of homelessness. Georgia has not adopted such a rule, but the state Court of Appeals has ruled a number of times that unstable housing and employment “in no way constitutes intentional or unintentional misconduct resulting in abuse or neglect” that would justify child removals.

But Wise’s experience illustrates how an inability to afford housing still stands between parents and their children in many child welfare cases in Georgia.

Between fiscal years 2018 and 2022, DFCS reported “inadequate housing” as the sole reason for removing a child in more than 700 cases, according to an analysis by WABE and ProPublica.

The analysis, using data from the federal Adoption and Foster Care Analysis and Reporting System, which tracks child removal cases in each state, also shows that in thousands of additional cases — about 20% of Georgia’s nearly 31,000 child removals during the five-year period — DFCS reported housing as one of multiple reasons. Housing was the third most reported reason after substance use and neglect.

Wise’s case is not included in the analysis because it began in April 2023.

When Georgia removes children for housing — either as the sole reason or in conjunction with other issues — it becomes something that parents must fix in order to regain custody of their children. Child welfare advocates and attorneys say that’s a uniquely difficult barrier to overcome. When families are facing other issues, such as a parent’s drug addiction or untreated mental health condition, DFCS often steps in and provides remedial services. But the agency rarely provides families with housing assistance.

According to a review of agency spending records for the same five-year period, DFCS spent more than $450 million on programs that can be used to keep families together. But the agency directed only a tiny portion — less than half of 1% — of the money toward housing assistance.

DFCS’ spending on housing assistance is noticeably smaller than in some other states. Several child welfare agencies, even in states with smaller populations than Georgia, dedicate millions of dollars more each year toward housing assistance.

Child welfare advocates say it doesn’t make sense for DFCS to do so little to help families with housing, given that the agency can end up spending just as much or more after taking children into foster care.

DFCS spends a minimum of $830 to $980 a month to house a child in foster care, according to the state’s published daily rates for foster parents. That’s roughly equivalent to the monthly fair market rate to rent a one-bedroom apartment in most of Georgia outside of metro Atlanta, according to the U.S. Department of Housing and Urban Development’s estimates.

The cost for foster care can be significantly higher if a child has complex mental health or behavioral needs, as some of Wise’s kids do. Under the state’s current rates, specialized foster care for a single child in an institution or group home can reach $6,390 a month.

Josh Gupta-Kagan, who directs the Family Defense Clinic at Columbia Law School, said it’s baffling that DFCS would not provide housing assistance instead of removing children. “Why do we allow kids to be separated from their parents who we won’t help with housing — only to place them with strangers who we will help with housing?” he asked.

DFCS spokesperson Kylie Winton said the agency does refer families to outside resources provided by local nonprofits or other state agencies, in addition to the small amount of assistance DFCS offers directly.

But according to Winton, more housing assistance would not change the outcome for many families. When the state takes children into foster care, she said, housing often is not the sole — or even primary — reason. Most of the time, she said, another issue is driving the intervention.

“If a family is chronically unhoused and a connection to a community resource doesn’t resolve it, we typically find that there is a root cause issue, such as untreated mental health concerns or substance abuse,” Winton said in an email.

Citing confidentiality laws, Winton declined to comment on Wise’s case, even after WABE and ProPublica provided a waiver, signed by Wise, giving permission to the agency to discuss it. In Wise’s case plan, however, it did not list any serious underlying issues, beyond unstable housing and income, that explained why the court didn’t return her children.

Wise couldn’t understand how housing could be a justification in any case — but especially hers. That’s because the day of the traffic stop was not the first time she called DFCS. Months earlier, while she was trying to stave off her family’s eviction, she had reached out to the agency for housing assistance to maintain their stability — with no success.

As she confronted the loss of her children, Wise sat, with a scrunched-up tissue in her hand, alongside the advocate she met through that process, Sarah Winograd, who works to help parents avoid the foster care system, and explained what took place.

“I cried, I yelled, I prayed, I screamed,” Wise said. “Like, how did we get here?”

Wise shows a photo of her children. (Matthew Pearson/WABE)

As a single mother of a large family, Wise had faced financial challenges before. In North Carolina, where she’s from, she occasionally had to call assistance programs or relatives when she couldn’t work or when bills left her without enough money for food. Still, she always had the necessities covered for her close-knit family, according to her oldest daughter, Halle Mickel, who’s now 19. “She did that and more,” Mickel said.

As for their housing, Wise rarely had to worry because for several years she’d received a federal housing voucher through a North Carolina agency.

It was only when Wise left the state in 2021, to get away from an abusive relationship, that housing became a serious issue for her family. She didn’t realize how hard it would be for her to find a place that would accept a family the size of hers in Georgia. Her voucher program gave her a limited amount of time to locate housing in the new state, and she exceeded that, causing her to lose her long-term assistance.

When Wise finally did find a four-bedroom townhome in Cobb County, it wasn’t cheap.

Wise paid the $2,200 a month at first with rental assistance through a local nonprofit. When that ran out, she tried to manage the amount on her own. She received roughly $1,800 in disability payments for her daughter with autism and for Mickel, who had survived cancer as a teenager, and supplemented that by working at a fast food restaurant and selling home-baked desserts at car washes and barber shops. “I did the best I could,” she said.

But Wise couldn’t keep it up. The school suspended her daughter with autism and her son with behavioral issues multiple times, and Wise lost work to watch them. Her rent payments became out of reach.

When the eviction notice came in January, Wise had already contacted all of the assistance programs she could find. All of them told her they were out of funds. So she turned to her last resort. “I picked up the phone and called DFCS because I thought they would be a resource for my family,” she said.

To Wise’s surprise, DFCS responded by opening an investigation. A caseworker came to the apartment, looked in her fridge, interviewed her kids and took samples of Wise’s hair and urine for a drug test. Wise didn’t have her case files from DFCS at the time, but, according to texts from her caseworker that Wise shared with WABE and ProPublica, the agency didn’t find anything worth pursuing. “There’s no concerns on our end,” the caseworker wrote to Wise in February.

As for Wise’s need for housing assistance — the reason she called DFCS in the first place — the caseworker said there wasn’t much that she could offer. She texted Wise information about different nonprofits, along with the number for Winograd, who’s now co-founded a nonprofit called Together With Families. But as far as what DFCS could do, she was clear: “The issue is funding. DFCS isn’t provided with government funding to house families,” the caseworker told Wise in a text.

Only one of DFCS’ family preservation programs, called Prevention of Unnecessary Placement, describes an option to help families with their rent, utilities or mortgage. The analysis of agency spending records shows that DFCS spent just $278,000 on housing assistance under this program in 2022. No other state agency in Georgia offers housing assistance specifically to families in the child welfare system.

By contrast, child welfare agencies in several states have spent significantly more on programs aimed at preserving families whose children are at risk of being removed or who are having trouble getting reunited because of housing. In 2022, New Jersey, which has a population similar in size to Georgia’s, dedicated more than $17 million for its program. Connecticut, with less than half the population, spent close to $20 million. California, which has four times greater population than Georgia, allocated exponentially more: nearly $100 million.

The New Jersey Department of Children and Families effort has served around 1,000 families, according to Assistant Director of Housing Kerry-Anne Henry. The agency has seen 90% of the families in its program stay housed after two years, she said.

“If we are really taking our charge seriously, as a child and family serving system,” Henry said, “we have to be responsive to their needs.”

Some child welfare agencies have also partnered with their states’ housing agencies to provide federal vouchers to families in their systems. The Family Unification Program from HUD offers vouchers for this purpose. According to HUD's data, Washington state, which has a population smaller than Georgia’s, has claimed around 2,000 vouchers. Ohio and neighboring North Carolina, which have populations similar in size to Georgia’s, have more than 900 each.

Georgia, on the other hand, has received 530. Only a handful of city and county housing authorities have claimed the vouchers — but Cobb County, where Wise lived, is not among them. DFCS has not worked with the state housing agency, called the Department of Community Affairs, to apply for the vouchers.

Philip Gilman, deputy commissioner for housing assistance and development, said in a statement that the department didn’t have staff capacity to handle these vouchers. For her part, Winton, the DFCS spokesperson, said the agency is reviewing the possibility of applying in the future.

Meanwhile, Winton said DFCS is working on a housing-focused effort of its own. As part of a pilot program in Fulton County, which includes Atlanta, the state awarded a nonprofit $1 million to house 50 families over the course of the next year so parents can reunite with their children or remain with their children who may be at risk of entering foster care.

But child welfare advocates, like Ruth White of the Maryland-based National Center for Housing and Child Welfare, said DFCS shouldn’t be limiting housing assistance to a few dozen families. If the state is ever intervening because of housing, she said, the agency has a duty to help. “They should be serving every family that needs to be housed,” she said.

For Wise’s family, in the weeks leading up to the traffic stop in April, there were no other housing options. By the time she reached Winograd, Wise owed around $10,000 in rent and utility bills. The only plan Winograd could propose was for her organization to pay to relocate her family to Florida, where Wise’s grandmother lived — an arrangement DFCS accepted.

While Wise also agreed, she knew it couldn’t be a long-term solution. Her grandmother was in her 70s. Wise knew she couldn’t bring a family of nine into her home permanently.

Believing she could find a more sustainable solution on her own, Wise brought her family back to Cobb County a couple of weeks later. They paid daily for a hotel as she continued her search for housing assistance. She didn’t imagine that in another couple weeks she would have to call DFCS again — this time, because of a traffic stop — to get her kids.

Wise’s caseworker had told her that DFCS didn’t make housing assistance available to families, like hers, because that was not the agency’s job. “Technically,” the caseworker had texted her in March, “the DFCS agency is only responsible for the safety of children/housing children.”

Since the traffic stop that sent seven of Wise’s children to foster care, DFCS has paid for their housing. The cost of housing them has quickly exceeded the amount of her family’s overdue rent.

DFCS has been paying at least $6,200 a month. That estimate is based on the rates for foster parents set by the state and is the minimum possible amount required to cover seven children in their age range — not including any special subsidies for the two with additional behavioral needs.

The estimate doesn’t account for the administrative costs of paying case managers to visit the children in their foster homes, as they’re required to do in all cases. It also doesn’t cover the costs of transporters who take the children to and from court-ordered visitations, which could amount to hours of driving time.

While some of these expenses may be covered by federal funds, longtime parent attorney Amber Walden said she still has seen foster care costs add up to much more than the price of housing in many of the cases that she has handled over the years.

“How much money are we talking about with that — when you could just have them all in the same home with the parent?” Walden said.

As DFCS made these payments to foster care providers, the result has not only been that Wise was in a separate home from her children. They also have been in separate foster homes from one another.

Wise saw the effects of these disruptions on her children. One afternoon, as she was about to leave the county DFCS office after a meeting with staff, Wise learned her two sons were in the building. Although she was able to have an impromptu visit, that wasn’t the reason her sons were there — they had been fighting with their foster parents, Wise said the caseworker told her.

The caseworker brought the boys into the office while she figured out their next placement, Wise said. One was the son who already had behavioral issues. He had turned 9 in the month since he and her other children entered foster care. She had already told him that they’d have a celebration when they were all back home. As he played with toys in the DFCS office, she said he reminded her: “Mom, are we still gonna have my birthday? Are we still gonna get a cake?”

Wise reacts to the news that her two sons were being moved into a new foster placement after fighting with their foster parents. (Stephannie Stokes/WABE)

Wise hung her head and rubbed the tears in her eyes as she walked out of the office. “It just makes me sad because I didn’t mean for them to go and be tossed around,” she said, “to go through all of this.”

Wise said she later learned from her caseworker that her sons had to spend that night in the DFCS office because the agency still could not identify a new placement for them.

In recent years, DFCS has frequently resorted to placing children in need of specialized care in offices and hotels — at an average cost of $1,500 a night, according to January 2023 testimony to the state legislature by DFCS Director Candice Broce. The costs, totaling more than $77 million between 2018 and 2022, have sparked hearings at the state Capitol. But state legislators charged with reviewing Georgia’s system have not proposed new prevention funding for families, including for their housing.

The need is clear to people who have worked for the agency, like Nikita Raper, who resigned this past summer after two years with Cobb County DFCS.

Raper said so much of her job as a child abuse investigator was scrambling to find housing resources for families, who were sleeping in their cars, staying in homeless encampments or getting kicked out of their hotels. All the time spent on these cases distracted caseworkers, like her, from instances of actual abuse, she said.

“More funding for the housing cases would offer relief to families and take them off the radar of DFCS so that we could focus on the bigger cases,” she said.

When she was with DFCS, Raper could access the Prevention of Unnecessary Placement program funds only if she could demonstrate the family wouldn’t need help again. “It’s really difficult to show that,” she said.

According to WABE and ProPublica’s spending analysis, Cobb County did not approve this funding for housing even once in the fiscal years 2021 and 2022. Wise said she never even heard about the program from her caseworker.

Living on her own, Wise has struggled even more to secure housing and employment that would comply with the requirements of DFCS and the judge in her case. When she was in contact with the agency in January, her caseworker referred her to any resources that would provide her family with basic shelter. But once her children were in foster care and her case was before the court, DFCS and the judge wanted her to show housing and income that were “stable.”

“The court finds these children have lived in unstable living environments long enough,” the order from late April said.

But DFCS has no statewide definition of stable housing. The agency said that’s because the meaning depends on the details of each individual case. Attorneys who work on Georgia child welfare cases in half a dozen counties said DFCS regularly requests that parents maintain a lease for six months before returning their kids.

This standard shows up even in cases where housing wasn’t initially a driving factor, said Darice Good, who has represented parents in Georgia for 20 years. “They won’t send the children home if there’s not stable housing,” she said.

Wise tried to fight the court’s requirement in her case. Right after she got out of jail in mid-April, she managed to obtain a spot at a homeless shelter for families, along with her daughter, Mickel, and she believed DFCS had no reason to not return her children there.

“I have no history of drugs & alcohol abuse, endangerment, physical, mental or emotional abuse I have caused on my family,” Wise wrote in her notebook to prepare for a virtual call with DFCS at the beginning of May. “I kept us safe!”

But Wise’s effort didn’t get her very far. In the call, which she recorded and shared with WABE and ProPublica, the facilitator said it was the judge’s decision to keep her children in foster care. Wise pushed back, asserting that the judge was acting on DFCS’ recommendation. The two were soon talking over each other for several minutes until the facilitator hung up.

Throughout this time, Wise was also working to get permanent housing. Winograd could finally identify a nonprofit that could pay back the rent at Wise’s old townhome. Wise was even able to move back in — but only temporarily. Right when the nonprofit was supposed to cut the check, it told Wise that it was reversing its decision: Upon further review, an email said, she didn’t meet the criteria for the funding program — including the ability to show that she could maintain her rent after she was caught up.

So, in mid-summer, Wise stayed with Mickel, who managed to get housing through a program for young adults. Wise found jobs, but they only paid around $10 to $15 an hour, and a couple of times she had to call out as soon as she was hired in order to make court hearings and visitations with her kids. She also found herself so concerned about her children that it was hard to work.

Wise soon found it was difficult to hold a job because she was so concerned about her children in foster care. (Stephannie Stokes/WABE)

“Who can really function or focus in a situation where everything around you is on fire?” Wise said.

Winograd, who volunteered as an advocate for foster children before she started her work preserving families, said this is common among parents who have to prove stability to the child welfare system. “People might think, ‘OK, now, they don’t have the responsibility of their children, they don’t have to worry about child care, they don’t have to worry about doctors’ appointments,’” she said.

In reality, Winograd said, many parents struggle even more. “The mental health piece becomes a huge issue for them to be able to go and get stable because they’re so worried about their child,” she said.

Wise has since located transitional housing in North Georgia. She has also found the support of another nonprofit, which has offered rental assistance to help her obtain housing and stabilize her family. But the nonprofit will provide the rental assistance only if the court first agrees to return her kids — and the court has not made such an agreement.

Meanwhile, Wise’s children have now spent nine months in foster care. She still finds herself trying to make sense of the reason.

How is it “that we had to endure all of this catastrophe and chaos and trial and trauma, just because I couldn’t pay a couple of months of rent?” she said.

How We Analyzed the Effect Housing Has on Children Being Placed in Foster Care

We analyzed data from the Adoption and Foster Care Analysis and Reporting System to examine the reasons Georgia’s child welfare agency reported for taking children into foster care.

The AFCARS data, obtained from the U.S. Department of Health and Human Services’ National Data Archive on Child Abuse and Neglect, required steps to clean and deduplicate before we could analyze it. We used unique identifiers for children called AFCARS IDs and dates when a child was last taken into foster care to remove duplicates. We then filtered the dataset to removals that occurred from July 1, 2017, to June 30, 2022, corresponding to Georgia’s 2018 to 2022 fiscal years. We then grouped by removal reason and counted the number of removals in which housing was reported, both alone and in combination with other removal reasons, and compared that to the total number of removals during the same period.

We chose not to compare the percentage of housing-related removals with other states because there are wide variations in how states report the reasons for taking children into foster care. In limiting the analysis to Georgia, our analysis was not affected by those differences.

The data used in this story was obtained from NDACAN via Cornell University and used in accordance with a terms of use agreement license. The Administration on Children, Youth and Families; the Children’s Bureau; the original dataset collection personnel or funding source; NDACAN; Cornell University; and their agents or employees bear no responsibility for the analyses or interpretations presented here.

by Marilyn W. Thompson

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Washington state’s mapmakers had been working for almost a year to draw the lines that would shape the state’s elections for the next decade. Now they had five hours until the midnight deadline and they’d made little progress.

Promptly at 7 p.m. on Nov. 15, 2021, the five members of the state’s Redistricting Commission appeared in a public Zoom meeting. Chair Sarah Augustine, a nonvoting member, sat near an ice machine in front of a backdrop with the commission’s new logo, “Draw Your WA.” She called the roll and ratified the minutes. The commissioners appeared on screens, seemingly calling in from different locations. Augustine immediately announced that they wanted to caucus privately. She promised that staff would reappear about every 30 minutes to give updates. A sign announcing “Meeting on Break” flashed up.

In most states, lawmakers draw new districts every 10 years to accommodate changes in population and ethnic makeup. They’re usually exercises of raw political power allowing lawmakers to, in essence, choose their voters instead of the other way around. But in Washington, an independent panel of commissioners has long revised the maps to avoid the common pitfalls of such redistricting, which often disenfranchises people of color or results in gerrymandering.

This year, Augustine’s master’s degree in conflict resolution was failing her. The commission’s work had devolved into a partisan mess, the very thing it had been created to avoid. The two Democratic commissioners and their two Republican counterparts had fought over how to address complaints from the state’s growing Latino population that it didn’t have representation. As they tried to work out a deal, they were repeatedly distracted by lawmakers and at least one lobbyist who had gotten wind of the final meeting and wanted to weigh in.

In a desperate move, the commission opted for a charade, with the public Zoom as its cover. In reality, the four voting commissioners were secretly hashing out the maps in person at a Hampton Inn a healthy 40 miles outside the capital, Olympia. It was a violation of the rules for more than two members to negotiate in private. One commissioner balked and rented a room in a Marriott a short distance away.

Throughout the process, the members of this ostensibly independent body were consulting with their party leaders and state and national political operatives, and were relying on partisan funding. Throughout the night, a cadre of lawmakers continued to pepper the commissioners with requests as picayune as moving one constituent’s house into a different district.

Every half-hour, a staffer briefly came on camera to inform viewers that caucuses continued. An interpreter even signed for deaf viewers. No member of the public ever saw any maps they could comment on, however. Then the break notice would go up again. As one commissioner later joked to another, the spectacle was “the screenplay to a movie no one would want to watch.”

The commissioners blew past their midnight deadline as they scrambled to reach deals and haggled over the “price” of Latino representation. The two Democrats finally capitulated to Republican demands, allowing a map that they felt didn’t give Latinos enough representation. They hadn’t been able to finish the job but hoped the courts would resolve the issue.

The independent commission’s work had been a disaster. A federal judge threw out the map in August 2023 after determining it had discriminated against Latinos. The commissioners were fined for their public meeting deception.

It was an ignominious referendum on Washington’s redistricting model. As the nation grapples with ever-more-aggressive battles over access to voting, a review of what unfolded in Washington shows that independent commissions — still reformers’ best hope for fixing this problem nationwide — have not always succeeded in taking this central democratic function out of politicians’ hands.

While independent commissions usually make fairer maps than their legislative counterparts, all over the country some, like Washington, have stumbled. Several were not the bulwark against discrimination that supporters had hoped. In 2021, five states with independent commissions faced lawsuits over their maps. In New York, an independent commission bungled the job so badly that the state legislature stepped in to create new maps. Then a judge threw those maps out. The independent commission has been reconvened to create new congressional maps. Michigan’s new independent commission lost a federal lawsuit brought by Black voters in Detroit. A judicial panel has ordered the commission to redraw maps and the case is being appealed to the U.S. Supreme Court.

In Washington state, criticism of the commission’s work has been so intense that lawmakers decided not to reconvene the group to draw the new maps. Even good-government types have been aghast. Simone Leeper, a legal counsel for the nonpartisan Campaign Legal Center, which handles voting-rights cases and represented Latino plaintiffs in Washington, says, “Going about this in this secretive way to trade away the rights of individuals is abhorrent to the concept of these commissions and what they're intended to do.”

A Pioneering Reform

Washington was the third state in the nation to set up an independent commission. State voters approved it by constitutional amendment in 1983 after the Legislature, then led by Republicans, passed a redistricting plan that was found to be discriminatory by a federal court, which ordered new maps to be drawn.

Through several redistricting cycles, Washington’s commission worked smoothly, praised as a national model for how to fix the process of drawing lines for congressional and state legislative districts. The commission’s enabling legislation prohibited gerrymandering, or drawing lines to favor one party or undermine the voting power of a demographic group. Commission members could meet with lawmakers individually to hear specific requests, but public input was paramount since every voter had a stake in how the lines were drawn.

Today, 22 states have some type of independent commission to handle map-drawing, according to the Brennan Center for Justice at New York University School of Law.

Washington’s model is known as a bipartisan commission, which purports to be independent. But legislators still play a significant role. House and Senate majority and minority leaders choose four commission members by political affiliation, with one nonvoting member put in place to mediate. Liaisons for both political parties are assigned to monitor the commission and report back to caucuses. The commission gets around $2 million for staffing and expenses, but state political parties sometimes step in to cover expenses for studies or other activities that have a partisan slant.

The start of this redistricting cycle was dogged by controversy. Members chosen for the 2021 Washington commission had strong legislative ties. Republicans Joe Fain and Paul Graves and Democrat Brady Piñero Walkinshaw were former lawmakers. Democrat April Sims was an executive with the Washington State Labor Council, chosen by House Speaker Laurie Jinkins to represent the House Democratic caucus. Augustine, the nonvoting member, was chosen by the other members.

This commission began in rancor. Fain, a former senator from King County, had lost his 2018 reelection bid after a former Seattle city official publicly accused him of sexual assault. Fain denied the allegation, and the woman declined to press charges. But Walkinshaw and Sims sided with protestors and called, unsuccessfully, for Fain to resign. Fain did not respond to repeated requests for comment.

From the start, the commissioners faced pressure from the surging Latino population, which had grown by 14% since 2010 but still struggled to elect members of the House of Representatives. The growth had been particularly intense in the Yakima Valley agricultural region east of the Cascade Mountains, where the population includes many immigrant laborers from Mexico and South Texas.

The Yakima Valley farming region stretches for 80 miles and includes five counties, with three reporting majority Latino populations. Some small farming towns reported that as much as 80% of the population is Hispanic, according to UCLA Voting Rights Project founder Matt Barreto, who conducted an analysis of voting in the area.

Yet white Republicans for years had dominated political offices in the area, and Latinos complained they had been penalized by decades of “cracking,” a redistricting term that means splitting up communities to diminish their power. The valley’s Latino population was carved into three House districts that Latinos had little chance of winning.

Spanish-speaking voters won lawsuits against local governments to force changes, but little was done. “Time and time again, there have been findings and consent decrees, and other outcomes, that make clear that this community has persistently faced discrimination in voting,” said Campaign Legal Center’s Leeper.

In 2021, as the independent commission began its work, Latino activists were hopeful. Supporters of more representation testified at virtual public meetings. “There were so many voices,” said Susan Soto Palmer, an advocate and unsuccessful candidate for state and county office. At the public meetings, she described taunts she faced in Yakima from white voters when campaigning and the inadequate services for her community.

Susan Soto Palmer advocates for Latino voters in Washington state, who have been split up into multiple voting districts. (Amanda Lucier for ProPublica)

The commission had been briefed by the attorney general’s office about the federal Voting Rights Act, which required that it draw election maps that give Latino populations the opportunity to elect candidates of their choice.

Commission Democrats advised getting an expert analysis of the area’s voting patterns. But the two Republicans protested the hiring of UCLA expert Barreto because he had strong ties to national Democratic Party entities.

Senate Democrats paid for Barreto’s analysis. He concluded that the state must create at least one, possibly two, districts in the Yakima Valley with substantial Latino populations. The VRA requires that when a racial or ethnic group makes up a significant percentage of the electorate, the group should be able to elect candidates of its choice. Such a district is called a “performing” one. While that doesn’t always mean that the group needs to be a majority in a district, in this case, Barreto determined that a new district needed to have a Latino voting-age population of around 60%. Both Democratic commissioners proposed maps with a Yakima Valley district that had a greater than 60% Latino voting-age population.

The Republicans resisted such a proposal. They offered maps that were bare-majority Latino, giving the GOP a greater chance of winning the seat. Barreto said these proposals still cracked Hispanic voters.

Fain and Graves turned to the state GOP to pay a Seattle law firm, which produced a legal brief justifying a more conservative-friendly map. The lawyers urged them to avoid drawing a new district solely on the basis of race. In recent years, conservative legal experts have begun to argue that the 14th Amendment’s equal protection clause means that mapmakers cannot take race into account when drawing districts. The amendment supersedes the Voting Rights Act, they argue. The firm warned that the commission could face a lawsuit that claimed the map discriminated against non-Latino voters.

Jinkins, the House speaker, told ProPublica, “While the Washington approach has generally worked well for us, I’m always interested to understand what other states have learned and consider incorporating changes that make sense for Washington.” One model is California, which has been praised for creating a large commission with so many guardrails against legislative influence that it is now considered the gold standard.

“Meeting on Break”

The commission’s November Zoom call made for excruciating video. The “Meeting on Break” sign stayed up for hours. Every so often, Augustine came on camera to report that private discussions continued. Staffers killed time with card games. Occasionally, a commissioner surfaced to cryptically describe what was happening behind closed doors.

Graves, one of the Republicans, looked bleary-eyed on camera, later revealing in a deposition that he had a three-month old at home and hadn’t slept for days. “I know it’s frustrating,” he told viewers.

In the days leading up to the Zoom, Graves had been driving a hard bargain behind the scenes, according to text messages and emails that surfaced later.

Graves and Fain texted on Nov. 7 about how they could extract a price from Democrats if the GOP agreed to their version of a 14th district. “If you had notes on the price for their 14, can you please send them to me?” Graves wrote Fain.

On Nov. 11, Graves emailed Democrat Sims to outline his latest “ever so slightly more Republican proposal” and to offer a brazen political trade. Republicans would give up some of their strength in the Yakima Valley, but only if Democrats would give them a more competitive district elsewhere.

“I will be interested to hear from you what you think is a fair price for this 14th,” Graves wrote Sims. Graves described to ProPublica his logic: He acknowledged his offer to Sims was “purely partisan,” but he said he and Sims had already agreed to draw a majority-Latino district and were fine-tuning.

“One of the requirements in our statute is that the plan cannot be drawn to purposely favor or discriminate against any political party. I was trying to avoid the kind of gerrymandering where one party gets substantially more representation than its pure votes would suggest,” he said.

He says he strongly supports independent commissions.

As they struggled to resolve the Yakima issue, commissioners kept getting distracted by lawmakers and lobbyists pushing their own agendas. Texts and emails from that evening and the days leading up to it, which were later produced in lawsuits, documented exchanges among commissioners and with legislators and special interests who were closely following the action.

The commission had no rules to limit ex parte communications. Attorneys in the lawsuits found that some records were never turned over. Sims, for example, acknowledged deleting some Nov. 15 texts that she considered personal.

That night, then-House Republican leader J.T. Wilcox texted with Graves, whom he had appointed. Graves said in a deposition that Wilcox had earlier passed along thoughts about how to shape his own district and “keep places … I have great affection for.”

That night, the two discussed a logjam that had developed between Fain and Walkinshaw, who were negotiating on congressional maps.

Graves told Wilcox that Walkinshaw was resisting a deal, but he still thought one was possible with a little strong-arming. Fain had “a lot of good contacts who can make Brady’s life very hard who want a deal.”

House Republican leader J.T. Wilcox texted with Paul Graves, a redistricting commissioner who Wilcox had appointed, throughout a last-minute meeting to try to finalize a deal. (Obtained by ProPublica)

Walkinshaw told ProPublica he found the messages puzzling since he and Fain shared no political connections. Wilcox and Graves described it in interviews as a flippant comment, fired off in the heat of the moment.

Graves exchanged messages with state Rep. Andrew Stokesbary, a rising leader in the House GOP.

Commission staffers had been told to avoid last-minute lawmaker requests for mapping changes. But House and Senate leaders could get around this by sending messages through their party liaisons, who were on standby at the Hampton Inn.

House Speaker Jinkins texted her liaison, requesting a mapping tweak desired by two local Democratic officials, who shared a home in Tacoma.

“Not the biggest deal,” Jinkins wrote, asking to get the specific Tacoma street address into another district. “Right now, it’s just on the other side of the line.”

Jinkins said constituents had asked her if they could remain in their previous district.“I told them I would ask staff to see if that was possible but that I could make no promises.”

In the end, she said, her request was denied by “the independent, bipartisan commission.”

House Speaker Laurie Jinkins, a Democrat, texted her liaison, asking for a change that had been requested by two local Democratic officials, who shared a home in Tacoma. (Obtained and redacted by ProPublica)

Jamie Nixon, a former commission staffer, said Jinkins’ request violated protocol and was “a vulgar attempt to wield her power to modify a map for her own political benefit.”

Fain, who had recently moved from Bellingham to Normandy Park, didn’t like the district assigned to his new residence. He asked Walkinshaw if they could tweak the congressional lines to move his house.

Walkinshaw rejected the idea.

State government lobbyists were supposed to report any contact with the commission, but a lobbyist for the Service Employees International Union did not disclose texts she sent to Sims on the final night offering assistance finishing up the work. The lobbyist, who was in a relationship with a state Democratic leader, later got a warning letter from the state public records commission. Neither the lobbyist nor Sims responded to ProPublica’s request for comment. The lobbyist’s attorney said in a filing that her texts were not an attempt to influence Sims.

Though commissioners resisted these entreaties, upholding their independence, they had spent precious time fending them off. “There were text messages being exchanged as well as commissioners meeting in the hallway or in the hotel lobby,” Democratic liaison Ali O’Neil wrote on Nov. 21, 2021. “We were forced to compromise on our stated priorities and at times disregard what was shared with the commission during months of gathering public input.”

Lobbying had been going on for months, mostly by persistent citizen groups and Native American tribes. National political operatives were involved in the state’s process too, records revealed. Kurt Fritts, a former national political director for the Democratic Legislative Campaign Committee who now runs a state consulting firm, attended commission meetings and was briefed by Democrats throughout the process. He did not respond to emails or phone calls.

The National Democratic Redistricting PAC made a small contribution to pay for “proprietary redistricting software,” according to Adam Bartz, director of a fundraising arm of the Senate Democrats.

Graves said he consulted the Virginia-based National Republican Redistricting Trust, which coordinates national GOP redistricting strategy. In a deposition, Graves described meeting with NRRT executive director Adam Kincaid while he was in Washington, DC., conferring with GOP members of his state’s congressional delegation. Kincaid said he described to Graves the assistance the NRRT could offer with data and litigation.

Commissioners finally compromised on the Yakima Valley, but only after Democrats conceded. They approved a plan almost guaranteed to bring a federal lawsuit, with a district that had only a 51.5% Latino voting-age population, which was close to what Republicans had wanted.

Source: Washington State Redistricting Commission (Lucas Waldron/ProPublica)

As the meeting wore on, Walkinshaw said it was clear the deal “was the best result that could be achieved through bipartisan negotiation.”

Graves emailed his party leadership just before 6 a.m. to alert them a deal had been reached.

“Get Out of the Way”

Commissioners finally stumbled out of the Hampton Inn just before sunrise and reconvened the next afternoon to get their mapping recommendations drawn. Even though the commission had blown its deadline, the state Supreme Court reviewed its work and decided in late 2021 to let the mapping recommendations stand so that 2022 elections could proceed without interruption.

Angry that they were once again forced to vote under maps they considered discriminatory, Soto Palmer and other plaintiffs sued in federal court, alleging the commission created a Latino district that was a “facade.”

U.S. District Judge Robert Lasnik sided with the plaintiffs in August 2023, finding “inequality in the electoral opportunities enjoyed by white and Latino voters.” He ordered the state to correct the maps.

But Republicans countered, using the Seattle law firm’s tack. A Latino Republican filed a federal lawsuit in March 2022, arguing that the new Latino-dominated legislative district was an illegal racial gerrymander. The plaintiff claimed that Latino voters did not need a 60% opportunity district because the maps drawn by the commission allowed the Yakima Valley to elect its first Latino Republican state senator in 2022. Progress was underway, the plaintiff maintained.

A judicial panel declared the case moot after Lasnik decided the Soto Palmer case, but it is now on appeal to the U.S. Supreme Court.

Jinkins and other legislative leaders decided not to reconvene the 2021 commission to draw new maps that can be used in 2024 elections. Instead, lawmakers asked the court to handle it. A special master is expected to decide soon among five proposed maps that could cost several Republicans their seats.

The commission was forced to acknowledge that its November Hampton Inn meeting violated the state’s Open Public Meetings Act and its own transparency rules. It settled a lawsuit brought by the Washington Coalition for Open Government and agreed to pay about $130,000 in legal fees. Individual commissioners were fined $500 each.

With the next redistricting nearly a decade away, Mike Fancher, the coalition’s president, said the Legislature should decide to “appoint a commission and then get out of the way. Don’t be involved in the staffing of it, don’t be involved in the direction of it. Let this commission do its work. We want to make sure this never happens again.”

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Ryann Grochowski Jones contributed research.

Correction

Jan. 22, 2024: This story originally reported incorrectly to the timing of a lawsuit filed by a Latino Republican. It was filed in March 2022, not March 2023. It also referred imprecisely to New York’s recent redistricting process. A state judge threw out the maps that the legislature had made after an independent commission had failed to finish the redistricting; the judge did not toss the independent commission’s work.

by Haajrah Gilani, Emma McNamee, Phillip Powell and Juliann Ventura, Northwestern University; and Jonathan D. Salant, Pittsburgh Post-Gazette

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

Congressional investigators are launching an inquiry into the Food and Drug Administration’s oversight of medical device recalls for the first time in years following reports that the agency failed to issue warnings about breathing machines capable of sending hazardous particles and fumes into the lungs of patients.

U.S. Sens. Dick Durbin, D-Ill., and Richard Blumenthal, D-Conn., urged the Government Accountability Office to investigate, citing reports by ProPublica and the Pittsburgh Post-Gazette that detailed the role of the FDA in an ongoing health crisis that has threatened millions of people in the United States and around the world.

The news organizations revealed that the agency had received hundreds of complaints about breathing machines manufactured by Philips Respironics long before the company announced a massive recall in 2021, but took no action to alert patients or doctors.

Philips withheld thousands of additional complaints over the course of 11 years while customers who relied on the machines to breathe reported respiratory problems, kidney and liver conditions, and cancer, the news organizations found.

“It’s clear from the Philips case that information about patient harm was known for years and not properly shared or addressed,” Durbin, who chairs the Senate Judiciary Committee, said in a statement. “We must ensure there is adequate oversight on medical device manufacturers so that Americans know the potential risks and can make informed decisions with their health care providers.”

In their request to the GAO, the watchdog arm of Congress, Durbin and Blumenthal said they needed far more information about the FDA’s oversight of the medical device industry, including how the agency ensures that companies initiate recalls and what happens when manufacturers fail to comply.

In an email, the GAO said it accepted the lawmakers’ request to conduct an inquiry.

Philips has said that it evaluated the early complaints about its sleep apnea machines and ventilators on a case-by-case basis and launched the recall after the company became aware that an industrial foam fitted inside the devices could break down and release potentially “toxic and carcinogenic” material.

The FDA has defended its handling of the crisis, saying it received complaints about “general contamination issues” before the recall but that the debris could have been caused by external sources unrelated to foam. At least 30 of the complaints described foam degradation, but the FDA said the reports did not indicate that any patients had been harmed.

“The FDA welcomes the opportunity for GAO review of the agency’s oversight of medical device recalls,” the agency said in a statement last week.

Durbin and Blumenthal said the GAO inquiry would follow up on a similar probe in 2011 that called for changes to better protect patients. Safety advocates said a new investigation is badly needed and long overdue.

In 2022, the FDA received 3 million reports about malfunctioning devices — nearly 30 times more than in 2005, government records show. Nearly one-third described injuries and deaths.

“At the end of the day, the public should have confidence in the products that are regulated by the FDA,” said Kushal Kadakia, a public health researcher at Harvard Medical School who has written about the Philips recall.

Device safety advocates said the GAO should review whether the FDA is regularly using information in health records, insurance claims, medical device registries and other sources — data they said would greatly improve the agency’s ability to track dangerous products. The FDA moved to create a center to bring together that data years ago, but a comprehensive new system is still not in place, records and interviews show.

Former FDA analyst Madris Kinard also said the FDA should do more to ensure the safety of devices before they are marketed and sold. A controversial process at the agency allows device makers to gain clearance for a new product by showing that it is substantially equivalent to one already on the market.

Kinard said the FDA should investigate whether those older models had any safety issues before newer versions are cleared.

“Simply getting a new device to market to me isn’t innovation,” she said. “Innovation is only good if it’s helping the patient.”

Durbin and U.S. Rep. Jan Schakowsky, D-Ill., have proposed legislation aimed at ensuring that doctors and patients receive vital information about recalls by requiring the FDA to create an electronic system of communication for the agency, device makers, hospitals and other providers. The bill would also require device makers to disclose more information about health risks and instruct hospitals and health care workers to pass the information to patients.

The proposal “will create an efficient, accountable system for ensuring patients are routinely notified about safety recalls for medical devices,” Chuck Bell, advocacy programs director at Consumer Reports, said in a statement. “As our health system operates today, consumers and providers may never receive any information ... or may receive it too late to avoid adverse consequences.”

Medicare claim forms should also include identifying information for devices — model numbers and names of manufacturers — to make it easier to detect troubled devices and contact patients in the event of a recall, Kadakia and others said.

“Right now, we rarely know what device has been used in what patient and when,” said Dr. Sanket Dhruva, a cardiologist and assistant professor at the University of California, San Francisco who has studied medical device safety and regulation. “Without this basic, really fundamental information about the device a patient has received, we can’t track the device.”

The GAO inquiry comes as a growing number of federal lawmakers call for investigations into Philips.

Schakowsky, the ranking member of the House Energy and Commerce subcommittee that oversees consumer product safety, said earlier this month that the company must be “fully held accountable and stopped from any future wrongdoing” if investigators determine that Philips failed to warn consumers in the years before the recall.

Schakowsky also cited new revelations, reported last month by ProPublica and the Post-Gazette, that a different foam placed inside replacement devices sent out by Philips after the recall was also found to emit hazardous chemicals, including formaldehyde, a known carcinogen.

“Americans should not be kept in the dark when it comes to the safety of their medical devices, and they certainly should not be forced to choose between a dangerous product and getting the care they need,” Schakowsky said in a statement.

Philips has said the new foam is safe and does not emit chemicals at dangerous levels. The FDA, which first reported that the foam failed emissions testing in 2021, said more tests are needed.

Philips said it regrets any “distress and concern” caused by the recall and is cooperating with authorities. The company also said testing on the original foam in the months after the recall found that the chemical emissions are not at levels that can cause “appreciable harm” to patients. The FDA has challenged Philips, saying in a statement in October that the studies were not adequate and that the company had agreed to conduct additional tests.

Debbie Cenziper with ProPublica and Michael D. Sallah with the Post-Gazette contributed reporting.

by Craig Silverman and 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.

Christy Browne was in a panic. The man on the phone said he was from the FBI. He warned her that drug traffickers had obtained her Social Security number and were using it to launder money. He said the FBI needed money to catch them.

“They told me not to go to local law enforcement,” Browne testified in court recently about the February 2020 call. The police were watching her and considered her a suspect, the man said.

At his direction, Browne, a retired elementary school teacher who lives in upstate New York, bought four $500 Walmart gift cards at her local Walmart. It was 3:15 pm. She took photos of the serial numbers and PINs on the back and texted them to the man on the phone. With that information, the fraudster had access to $2,000.

That was only the first step. The gift card numbers were then sold to Qinbin Chen, a Chinese national living in Virginia. At 5:47 pm, Chen passed the numbers to a co-conspirator waiting near a Walmart in Sterling, Virginia.

Just eight minutes later, at 5:55, the accomplice did something that an ordinary consumer would rarely do, but which is routine for fraudsters: use one gift card to buy another. With the numbers from Browne’s Walmart cards, he purchased Apple, Google Play and other gift cards at the store’s self-checkout kiosk. He sent the serial numbers and PINs for those cards to Chen, who then sold them to a buyer in China. Transferring the money to other companies’ gift cards for use in another country made it impossible for Walmart to figure out where the funds ended up. Browne had no way to recover her $2,000.

She was far from the only victim. Chen oversaw the laundering of some $7 million in fraudulently obtained gift cards, according to the Department of Justice. It was a complex international operation involving hundreds of victims, thousands of gift cards and multiple co-conspirators in the U.S. and China.

Federal prosecutors would give it a simple name: “The Walmart scheme.”

America’s largest retailer has long been a facilitator of fraud on a mass scale, a ProPublica investigation has found. For roughly a decade, Walmart has resisted tougher enforcement while breaking promises to regulators and skimping on employee training, according to more than 50 interviews, internal documents supplied by former industry executives, court filings and other public records.

Scammers dupe a victim, as they did with Browne, and then they exploit Walmart’s lax systems to get paid quickly and easily. That’s been true whether the fraudsters use Walmart gift cards or instruct customers to send funds by electronic money transfer. The company, in the latter instance, is supposed to be on the lookout for fraud and asking questions: Do you know the person you’re sending money to? Is the money transfer related to a telemarketing offer?

Too often, Walmart has failed. More than $1 billion in fraud losses were routed through the company’s financial systems between 2013 and 2022, according to filings by the Federal Trade Commission and court cases analyzed by ProPublica. That has helped fuel a boom in financial chicanery. Americans, many of them elderly, were swindled out of $27 billion between 2013 and 2022, according to the FTC.

Walmart has a financial incentive to avoid cracking down. It makes money each time a Walmart gift card is used and earns a fee when another brand of card is bought. And it receives one commission when a person sends a money transfer and a second when the recipient picks it up. The company’s financial services business generates hundreds of millions in annual profits. (Its filings do not provide specific figures for gift cards and money transfers.)

“They were concerned about the bucks. That’s all,” Nick Alicea, a former fraud team leader for the U.S. Postal Inspection Service who investigated Walmart for years, told ProPublica.

Walmart’s deficiencies have repeatedly attracted government scrutiny. In 2017, the attorneys general of New York and Pennsylvania investigated Walmart over concerns that it was “reaping the benefits” of gift card fraud. The investigation concluded a year later with Walmart promising to restrict or eliminate the use of its gift cards to purchase other gift cards, a favored tactic of fraudsters such as Chen. Instead, the company let the practice continue until 2022 — even after it knew that millions of dollars were being laundered through its stores.

The FTC sued Walmart in 2022, alleging it “turned a blind eye” as criminals took advantage of its money transfer service. Walmart, the FTC claimed, pocketed millions in fees while “letting fraudsters fleece its customers.” Summarizing the FTC’s evidence, a federal judge in the case wrote that “Walmart knew that its services were used by fraudsters” and that the company was repeatedly warned about certain stores where “twenty-five, fifty, or even seventy-five percent of money transfer activity was fraudulent.” Separately, a federal grand jury in Pennsylvania is hearing evidence of possible criminal conduct in Walmart’s money transfer business, according to corporate filings that did not detail the allegations.

None of this appears to have slowed Walmart’s ambitions to grab an ever-bigger portion of the financial services market. After years of offering gift cards and prepaid cards, money transfers and check cashing, in 2022 Walmart acquired an online banking platform called One, broadening its financial offerings even further.

But as the company seeks to grow, there is reason for caution. Not only is Walmart continuing practices that ease the way for fraudsters, its previous failings go deeper than the government has alleged, ProPublica found. Its long record of spotty training and compliance, and its refusal to take responsibility for the fraud perpetrated using its systems, cast doubt on its ability to run a sprawling financial business, experts and current and former Walmart employees said.

Walmart strenuously defends its anti-fraud efforts. In a statement, the company said its push into financial services has saved customers without traditional bank accounts $6 billion in fees. The company asserted that it has blocked more than $700 million in suspicious money transfers and refunded $4 million to victims of gift card fraud. “Walmart offers these financial services while working hard to keep our customers safe from third-party fraudsters,” it said. “We have a robust anti-fraud program and other controls to help stop scammers and other criminals who may use the financial services we offer to harm our customers.”

The company’s legal filings in the FTC case struck a different tone. Walmart is seeking to dismiss the suit, partly on the grounds that it has “no responsibility to protect against the criminal conduct of third parties.” Though fraud is “deeply unfortunate,” Walmart argues, such schemes are “reasonably avoidable by consumers.” The company also asserts that the FTC is exceeding its authority in bringing the action. (The judge upheld the FTC’s authority and allowed the suit to continue. He dismissed a second count, which accused Walmart of violating a rule relating to telemarketing fraud, but permitted the FTC to re-file the claim and address his objections.)

Walmart’s weaknesses provided an opportunity for Chen, whose operation is the largest gift card laundering scheme ever prosecuted by U.S. law enforcement, based on a ProPublica analysis of court records. Including Chen, at least 28 state and federal defendants — almost all from China — have been convicted of using gift cards obtained from fraud victims to transfer tens of millions of dollars through Walmart. It’s likely that many more have avoided detection. One prosecutor called gift card schemes a “worldwide effort to empty the United States of its retirement funds.”

Chen spent five years laundering Walmart gift cards before he was arrested in 2021, according to evidence that would emerge in court. Earlier that year, he complained to an associate that more and more people were competing to resell cards in China, eating into his profits.

So many scammers were flocking to Walmart that he and his team regularly encountered them at self-checkout counters. “All of a sudden, a lot more people started to do it in the past couple of years,” Chen wrote in an online message. “We ran into quite a few at the store, and we even started chatting.”

Store #2038, in the Washington, D.C., suburb of Sterling, Virginia, has much in common with the 4,621 other Walmarts across America. A giant U.S. flag stands out front. Walmart’s yellow “spark” logo marks the hangar-like building. And on a sunny midweek afternoon in late November, the massive parking lot is nearly full, but for a pair of close-in spots reserved for “our law enforcement partners.”

Inside, Walmart shoppers are buffeted by financial promotions. Hundreds of gift cards hang on unattended kiosks near the customer-service counter, where people queue to return broken toasters or exchange pajamas. At the money services desk, where three signs tout Walmart’s recently acquired banking app, you can cash a check, pay a bill, or send and receive money to or from just about anyplace in the world.

It doesn’t look like a hub for fraud. But this was one of the stores frequented by Chen’s crew. Born in Fujian province in southeastern China, Chen dropped out of high school and began working in restaurants at the age of 15. In 2014, when he was 21, he came to the U.S. with his father. In America, he often went by the name Ben Chen and worked in Chinese and sushi restaurants until he found a new way to make money in 2016: gift cards.

How Gift Card Laundering Schemes Typically Work A person receives an email, call or text that falsely claims there’s an emergency (say, they owe the IRS money, or a relative was arrested and needs bail). They talk to the fraudster, typically located abroad, who says the only recourse is to spend a large sum on Walmart gift cards and send photos of the numbers on the backs of the cards. The fraudster in turn resells the gift card numbers. They’re bought by a middleman, who then sends them to a “runner” waiting in a Walmart parking lot in the U.S. The runner immediately loads the gift card numbers into the Walmart mobile app or an app used to manage and spend gift cards. The runner heads to a Walmart self-checkout kiosk and uses the card numbers on the app to buy new gift cards for services like Google Play, Steam and Apple iTunes. This launders the money and prevents the victim from getting a refund. The runner sends the new gift card numbers back to the middleman. They are resold on online marketplaces, frequently before the victim even realizes what has happened.

In China, gift card trading is a lucrative business. Gamers crave American Google Play, Apple and Steam gift cards because they can use them to purchase credits for games without needing a U.S. credit card. Gift card trading can create “small gold mines” that generate “long-term, stable profits,” according to a post on a Chinese message board.

The lightning-fast model Chen used to launder the money extracted from Browne was typical of such scams. Chen made his profit by purchasing Walmart gift card numbers at a discount from contacts in China. A $100 Walmart gift card obtained from a victim might cost him only $70. He could then use that Walmart card to buy a $100 Apple card, then resell the Apple card at close to its face value, pocketing the difference.

For years, the scam paid off. At the time of his arrest, Chen had $304,033.99 in one bank account and $278,602.69 in another, according to one court filing.

Chen seemed to enjoy taking chances. “Let me say it plainly,” he messaged one associate. “Buying this stuff has the risk of being arrested.” Chen lied to his then-girlfriend to convince her to let him move money through her U.S. bank account, she later testified. He instructed one of his runners to give police a fake phone number, and furnished another with receipts to deceive officers who might request proof of a gift card purchase, according to court exhibits.

And he could be threatening. Once, a former runner used Chen’s name to set up a Sam’s Club membership. Chen was incensed, court records show. He told the man over WeChat to meet him at a Chinese restaurant in Virginia. Noting that he knew the man’s license plate number, he said, “You will die very painfully.”

Starting in 1999, Walmart made four unsuccessful bids to enter the banking business. Such services would give customers yet another reason to visit Walmart stores, and owning its own bank would save Walmart millions in transaction fees. But Walmart faced resistance from regulators, protests from lawmakers and an outcry from community banks fearful that Walmart would wipe them out.

The company responded to these setbacks by launching a variety of financial offerings that didn’t require a bank charter, including check cashing, electronic bill payments, money orders, and branded debit and credit cards. In each case, Walmart undercut typical industry fees, saving its customers money.

Its largest financial venture, launched in 2002, was in money transfers. The company partnered with MoneyGram, which, like Western Union, has long been in the business of transferring funds. Walmart employees would serve customers, then transmit the money through MoneyGram’s electronic network.

The money transfer industry was, and is, massive, running into the hundreds of billions of dollars globally. It was also awash in swindles. Scammers had long loved money transfers for the same reason customers did: They made it easy to move cash rapidly across the world. Plus, they were hard to trace. The problems were so pervasive that a federal fraud investigation would force MoneyGram to terminate its partnerships with hundreds of non-Walmart retail outlets in the U.S. and Canada in 2009.

In the aftermath of this crackdown, federal officials warned Walmart that fraudsters were using its stores to send and receive money transfers. Walmart assured the officials that it already had a “comprehensive” anti-fraud program and would bolster its efforts by training employees to identify suspicious transactions and providing warning signs and brochures in its stores. But those claims, according to the FTC, “turned out to be false.”

Fraud soared. Walmart outlets at one point accounted for the top 20 locations for fraud nationally among chains that partnered with MoneyGram, according to internal documents. In a single week in March 2017, consumers claiming they’d been duped into a money transfer filed 610 complaints about Walmart, according to documents obtained by ProPublica. CVS ranked second, with 47. Site inspections routinely found that Walmart staff lacked anti-fraud training and that employees failed to ask screening questions.

At the time, MoneyGram was bound by agreements with the FTC and Department of Justice that required it to police any lapses it detected among its partners. An independent monitor appointed as part of one of those agreements wrote that “Walmart has weaknesses in its compliance program.”

But Walmart resisted MoneyGram’s attempts to fight fraud. “Walmart pushed back more than any [outlet] I’ve ever seen,” said Alicea, the former fraud team leader for the postal inspector’s office in Harrisburg, Pennsylvania, who investigated MoneyGram and Walmart.

MoneyGram’s agreements with the government also required that it quickly suspend or terminate transfers at any partner that exceeded fraud-complaint limits. Yet until May 2017, 15 years into their partnership, MoneyGram hadn’t suspended a single Walmart store, according to the FTC. MoneyGram’s inaction helped prompt additional penalties from the FTC and the Justice Department.

Walmart officials insisted that shutting down transfers wasn’t “customer-friendly,” Alicea said. The company said it could address the problem with training. Walmart also routinely blamed MoneyGram, even though Walmart shared responsibility for compliance and its employees processed the transfers, Alicea said. “They have the face-to-face contact with the customer. MoneyGram doesn’t,” he said. “Someone’s going in there with a walker and $5,000 and sending the money to Nigeria? Come on.”

MoneyGram was afraid to alienate Walmart, three former MoneyGram officials said. “You don’t shut down one store and make Walmart angry,” said Mark Shaffer, who worked at Walmart for 27 years before joining MoneyGram to help manage its relationship with the retailer. “They [might] say, ‘Fine, you’re out of all 3,000!’” (MoneyGram was released from its FTC and Justice Department compliance agreements in 2021. A spokesperson for the company said it has “invested more than $800 million to enhance its compliance program and doubled the size of its compliance team,” and now has “record-low consumer fraud complaints.”)

A Walmart MoneyCenter in 2011. After failed attempts to set up its own bank, the company began expanding into money transfers, check cashing and other financial services. (Laura Pedrick/The New York Times/Redux)

Even as Walmart dragged its heels on combating fraud in its partnership with MoneyGram, the company took a major step that effectively loosened security. Walmart launched a second money-transfer service, Walmart2Walmart, a discount operation that allowed people to send money between Walmart stores. If fraudsters seeking to transfer money through MoneyGram at a Walmart store were stymied by security, they could simply try again using Walmart2Walmart, or vice versa.

Scammers immediately abused the popular service, causing an explosion in money transfers by victims of fraud, according to former executives and testimony from law enforcement. “There were a whole bunch of transactions that should have been looked into that weren’t,” former Walmart business development director Axel Wulff, who helped create Walmart2Walmart, said in an interview. “We simply didn’t have the resources to follow up on everything.”

Ria, the company that provides the electronic backbone of Walmart2Walmart, acknowledged the service’s struggles. “Unfortunately,” Ria noted in a statement, Walmart2Walmart was “exploited by fraudsters, who are always looking for new alternatives to facilitate their fraud schemes.” In response, Ria restricted or suspended transactions at high-fraud Walmart stores and worked with Walmart to establish systemwide controls. Ria “prevented significantly more fraud attempts than those that were completed,” it said.

In its own statement to ProPublica, Walmart asserted that it has stopped “hundreds of thousands of suspicious money transfer transactions” and that “fewer than 2 out of every 10,000 money transfers at Walmart were reported as even possibly fraudulent in 2021.”

Walmart was more combative in its pleadings in the FTC case, denying any obligation to act on “alleged” red flags. “No law prohibits consumers from sending multiple money transfers or from using out-of-state IDs, and Walmart has no grounds to scrutinize customers who do so,” it wrote. The company rejected the idea that it should “interrogate” customers sending money to “certain countries” based on “stereotypes that an entire ‘countr[y]’ presents a ‘high-risk’ of ‘fraud.’”

It was unfair, Walmart said, to punish the company for “not second-guessing customers and blocking transfers they have freely chosen to undertake.” But standard industry agreements and federal regulations require precisely that.

As the FTC and DOJ began cracking down on money transfers and MoneyGram responded in 2017 by suspending transfers at some Walmarts, scammers started favoring another tactic: telling victims to buy gift cards.

Complaints about gift card purchases at Walmart flooded the offices of state attorneys general. As part of the joint investigation launched in 2017 with New York’s attorney general, Pennsylvania officials pressed Walmart to compensate “victims who were never questioned or warned of the potential for a scam by Walmart clerks or managers.” The attorneys general also looked at Target and Best Buy.

Walmart representatives met with lawyers from the two states. According to meeting notes obtained through a records request, Walmart again invoked its customer-service argument: “Walmart not sure they want employees to refuse transactions … against the ethos of making customers happy,” the notes said.

On Nov. 20, 2018, New York and Pennsylvania announced that Walmart, Target and Best Buy agreed to make “significant” changes to their gift card policies. They included lowering the amount of money that could be loaded onto a card to $500, limiting the number and total value of gift cards that could be purchased at one time, and improving employee training.

The retailers also said they would restrict or eliminate the use of a gift card to purchase other gift cards. That should have been the death knell for the laundering method used by Chen and others. Best Buy and Target soon implemented a ban on gift-card-for-gift-card purchases.

Walmart said it would do the same, but then let the laundering continue for nearly four more years.

The company decided against imposing a ban, according to Fred Helm, who worked for Walmart’s global investigations unit. “That was a big conversation,” Helm told ProPublica. “The Walmart business side makes that call, not the legal side. I think it was probably just a case of ‘business wins the day.’”

Walmart’s statement to ProPublica did not address questions about its agreement with New York and Pennsylvania. The company pointed to an FTC report that showed fraud losses were considerably higher for Target cards than Walmart cards in the first nine months of 2021. (The FTC’s method didn’t take into account gift-card-for-gift-card purchases, which Target had banned, but which were still allowed at Walmart. The FTC has not run a similar calculation for other years.)

Chen had already made Walmart his focus before the 2018 agreement. The company’s decision not to bar card-for-card purchasing enabled him to expand his business. He recruited runners by placing ads on WeChat, a Chinese social network, and on a Chinese-language site focused on the D.C. area, according to trial evidence.

In 2019, Chen connected with Jin Hong, a Virginia native, and offered him a 3% commission on the dollar amount of Walmart gift cards he laundered. He could earn $300 a day by moving $10,000 in cards.

“Easy to do [USD] 2,000 in a single store,” Chen said, according to WeChat messages translated by the FBI. He added: “Working hours are from 11 to 6. [You] may leave early if there is no order.”

“I don’t mind giving it a shot!” Hong said.

Chen sent him a list of Walmarts and Sam’s Clubs. “These are the ones where are relatively easy to make the purchase,” Chen said. Hong started the next day and worked for Chen for six months. Hong would later plead guilty to one count of conspiracy to commit wire fraud and agreed to cooperate with the government.

“You would sit in a Walmart parking lot from 11:00 to 6:00, five days a week, redeeming gift cards, correct?” a prosecutor asked.

“Correct,” Hong said. It was Hong who waited in the Walmart parking lot before converting the gift cards that Christy Browne was tricked into buying.

Reached by phone, he declined to comment.

Chen had two rules for his runners: Move fast and use the self-checkout kiosk. Speed ensured a victim couldn’t reclaim their funds before a runner could launder the Walmart gift card. Self-checkouts were key because they operate with little oversight.

But even if Walmart employees had noticed Chen or one of his minions, they weren’t properly trained to identify and stop financial misbehavior. With Walmart’s high turnover, many workers lacked experience, and they were under pressure to make quick sales to keep checkout lines short. A former manager who spent a decade working at Walmart said it was “very rare” for associates to ask questions to determine whether customers might be involved in, or a victim of, fraud. Federal regulations require such questions for money transfers but not gift cards.

Today, Walmart cashiers handling gift cards, prepaid cards and money transfers are supposed to complete anti-money-laundering and anti-fraud training through computer-based courses. They consist of videos and multiple-choice quizzes. Associates must score 100% before being allowed to work the register.

A current Walmart employee with six years’ experience in the MoneyCenter, a financial services section offered in some Walmart stores, said that the training videos include obsolete technology and don’t cover all of Walmart’s financial products. “I think the training could be a heck of a lot better than it is. They’re not current to what we’re doing.”

Walmart said that associates “are part of a large team dedicated to fighting fraud. Walmart trains hundreds of thousands of associates annually.” It said employees handling money transfers receive additional training, including “job aids, manuals and infographics” and “daily knowledge checks at the register.”

ProPublica readily found copies of Walmart’s current “advanced” anti-money-laundering and anti-fraud quiz online, complete with answers. They were posted by Walmart associates who said they shared them to help colleagues pass the quiz.

ProPublica showed a copy to Christian Hunt, a former head of compliance at UBS Asset Management and the author of “Humanizing Rules: Bringing Behavioural Science to Ethics and Compliance.” Hunt said Walmart’s test is riddled with “lazy, pointless” questions that don’t help employees identify or prevent fraud. “It allows you to say you have tested them,” he said. “It does not allow you to say they genuinely understand this.”

The test’s first question is, “Which of the following is the process of collecting basic information about a customer regarding their identity?” The answer is “Know Your Customer.” Hunt said Walmart cashiers don’t need to know the phrase; they need to understand what information to collect and why.

Walmart cashiers and managers said they are responsible for enforcing a limit of four $500 gift cards per purchase (as laid out in the agreement with New York and Pennsylvania). But, according to police reports and a current Walmart associate, employees often ignore the limit.

Walmart seems to have had more success in staving off fraud when it relies on technology. The company employs analytics and artificial intelligence, and Helm’s team developed a system called Redemption that can automatically freeze the balance of a gift card if it exhibits activity consistent with fraud.

In 2022, Walmart turned over to the Secret Service roughly $4 million that it had frozen using the Redemption system. The funds, which were seized from gift cards loaded in July 2017, are being refunded to people who purchased the original gift cards.

“The secret sauce is miles per hour — the speed that the money is moving between the reload [of a gift card] and redemption,” Helm said. The system could, for example, detect if someone had bought gift cards in Pennsylvania and the same cards were being redeemed in Texas soon after. “We may have the disease of being so large, and things fall through the cracks, but this was one hell of an effort,” Helm said.

Still, Redemption captures only a small fraction of the fraud. And Walmart has not returned any money that was frozen on cards since 2017. Walmart declined to comment on the lag or to reveal how much money it has seized in total.

The flimflams continue, even in Walmart’s home state of Arkansas. In March 2022, a 39-year-old man with autism and what his mother described as “a mental impairment” began an online romance with someone he believed was WWE wrestling star Bianca Belair. Following the impersonator’s instructions, he used a credit card he’d obtained at the direction of the scammer to purchase $7,500 in Apple gift cards at a Walmart in Hot Springs, Arkansas. His mother filed a complaint with the Arkansas attorney general, asking how Walmart could permit such a suspicious transaction without asking questions. As she put it, “I’m a pissed off angry mom.”

A few months later, an 82-year-old woman ensnared in a fraud scheme purchased $14,000 worth of Walmart gift cards at two stores in Rogers, Arkansas. According to her son, employees didn’t ask anti-fraud questions and failed to enforce the gift card limits. She never got her money back. The woman had worked for many years in a warehouse — at Walmart.

Gift card fraud is increasingly taking a different form: balance theft. A scammer grabs Walmart gift cards and takes them to a private spot, such as a bathroom stall. The criminal peels off the protective tape covering the PIN and photographs it and the card’s serial number. They reapply security tape and put the cards back on display, hoping a customer will pick one up.

As soon as a customer activates a card and loads money onto it, the crook (who uses the PIN and serial number to monitor the card’s balance on Walmart’s website) spends the money. When people go to use the card, they discover it has a balance of zero.

Walmart could thwart balance theft by wrapping its gift cards in secure packaging, as other retailers do, and by keeping them in a secure location. Walmart already puts items such as video games, nicotine gum and replacement bulbs for car headlights behind lock and key.

Walmart gift cards are “just sitting on the shelf like an open deck of cards,” noted Craig Heidemann, an attorney who filed a class-action against Walmart in 2018 over its alleged failure to protect gift card buyers. (Heidemann’s suit was dismissed in 2022 and he wouldn’t comment on whether he’d reached a settlement.)

The difference between Walmart and other brands was evident in November at the Virginia store formerly targeted by Chen. Among dozens of varieties of gift cards, only the Walmart-branded ones lacked protective packaging.

In September, Qinbin Chen went on trial. Six of his confederates had already pleaded guilty to criminal charges. Now the diminutive Chen sat at the defense table, with a Mandarin translator, to answer to eight counts of money laundering, conspiracy, access device fraud and aggravated identity theft.

The pretrial period had been contentious. Chen was chronically dissatisfied with his lawyers, most of whom were court-appointed. As the trial began, he was on his sixth attorney.

The trial lasted three days. Prosecutors used testimony from co-conspirators and messages obtained from Chen’s phone to portray him as a driven criminal. The government called him the “quarterback for a criminal organization that obtained, used, transferred, and laundered” Walmart gift cards with millions of dollars of value. Chen’s lawyer countered that his client ran a legitimate gift card business and that the government failed to show Chen knew the Walmart cards came from fraud victims.

On Sept. 14, after less than three hours of deliberation, the jury convicted Chen on all eight charges. He faces between two and 20 years in prison and is expected to be sentenced in February.

In late November, Chen sent a letter to the trial judge, outlining multiple grievances. Printing by hand on yellow lined paper, Chen complained that he was “treated in an Incorrect and careless way. It’s led me lose my trial. … I really need my retrial with different lawyer.” (By Dec. 13, a seventh attorney was representing him. That lawyer did not respond to requests for comment.)

For her part, Browne, the retired teacher who lost $2,000, is still grappling with what happened to her. Even before being defrauded, she didn’t use credit cards or digital payments due to security and privacy concerns. Now she’s scared to answer her phone.

She told ProPublica: “There isn’t anything I trust any more.”

Doris Burke contributed research.

by Isabelle Taft, Mississippi Today

This article was produced in partnership with Mississippi Today, which was a member of ProPublica’s Local Reporting Network in 2023. Sign up for Dispatches to get stories like this one as soon as they are published.

For many people in Mississippi, the path to treatment for a serious mental illness may run through the local jail — even though they haven’t been charged with a crime.

In 2023, Mississippi Today and ProPublica investigated the practice of jailing people solely because they were waiting for mental health treatment provided through a legal process called civil commitment.

We found that people awaiting treatment were jailed without criminal charges at least 2,000 times from 2019 to 2022 in just 19 counties, meaning the statewide figure is almost certainly higher. Most of the jail stays we tallied lasted longer than three days, and about 130 were longer than 30 days.

Some people have died after being jailed purportedly for their own safety.

Every state has a civil commitment process in which a court can order someone to be hospitalized for psychiatric treatment, generally if they are deemed dangerous to themselves or others. But it is rare for people going through that process to be held in jail without criminal charges for days or weeks — except in Mississippi.

If you’d like to share your experiences or perspective, contact Isabelle Taft at itaft@mississippitoday.org or 601-691-4756.

In Mississippi, the process starts when someone files paperwork with a county office alleging that another person’s mental illness or substance abuse is so serious that they are a danger to themselves or others. That person is taken into custody by sheriff’s deputies until they can be evaluated and go before a judge. Although people may wait at a medical facility, if no publicly funded bed is available, they can sit in a jail cell until a treatment bed opens up.

We have spoken with people who were jailed solely on the basis of mental illness, family members of people who went through the commitment process, sheriffs and jail administrators, county officials, lawmakers, the head of the state Department of Mental Health, and experts in mental health and disability law. We have filed more than 100 public records requests and reviewed lawsuits and Mississippi Bureau of Investigation reports on jail deaths.

Here are five key findings from our reporting so far.

People Jailed While Awaiting Mental Health Treatment Are Generally Treated the Same as People Accused of Crimes

We spoke to more than a dozen Mississippians who were jailed without criminal charges as they went through the civil commitment process. They wore jail scrubs and were often shackled as they moved through the jail. They were frequently unable to access prescribed psychiatric medications, much less therapy or other treatment. They had no idea how long they would be jailed, because they could get out only when a treatment bed became available. They were often housed alongside people facing criminal charges. One jail doctor told us that people going through the commitment process were vulnerable to assault and theft of their snacks and personal items.

“They become a prisoner just like the average person coming in that’s charged with a crime,” said Ed Hargett, a former superintendent of Parchman state penitentiary and a corrections consultant who has worked with about 20 Mississippi county jails. “Some of the staff that works in the jail, they don’t really know why they’re there. … Then when they start acting out, naturally they deal with them just like they would with a violent offender.”

A woman going through the civil commitment process, wearing a shirt labeling her a “convict,” is transported from her commitment hearing back to a county jail to await transportation to a state hospital in north Mississippi. (Eric J. Shelton/Mississippi Today) Jails Can Be Deadly for People in Crisis

At least 14 people have died after being jailed during the commitment process since 2006, according to our review of lawsuits and records from the Mississippi Bureau of Investigation. Nine died by suicide, and three died after receiving medical care that experts called substandard. Most recently, 37-year-old Lacey Handjis, a Natchez hospice-care consultant and mother of two, died in a padded cell in the Adams County jail in late August. Her death was not a suicide and is still under investigation.

Brandon Raymond died in the Quitman County Jail in 2007 while awaiting a rehab bed. His sister, Stacy Raymond, has few pictures of her brother; she got this one from a Facebook memorial post. She said if she had known he would die so young, she would’ve taken more photos. She described him as big-hearted, always happy and a devoted father to his son. (Courtesy of Stacy Raymond)

Adams County Sheriff Travis Patten said he asked the state Bureau of Investigation to review Handjis’ death. “It just hurt me because I just know that people who are suffering from those type of conditions shouldn’t be in jail,” he said in September.

Mental health providers we spoke with said jail can exacerbate symptoms when someone is in crisis, increasing their risk of suicide. Jail staff with limited medical training may interpret signs of medical distress as manifestations of mental illness and fail to call for additional care.

After three men awaiting treatment died by suicide in the Quitman County jail in 2006, 2007 and 2019, chancery clerk Butch Scipper no longer jails people going through the commitment process. His advice to other county officials: “Do not put them in your jail. Jails are not safe places. We think they are, but they’re definitely not” for people who are mentally ill.

Mississippi Is a Stark Outlier in the U.S.

Mississippi Today and ProPublica surveyed disability rights advocates and state behavioral health agencies in all 50 states and the District of Columbia. Nowhere else did respondents say people are routinely jailed for days or weeks without criminal charges while going through the involuntary commitment process. In three states where respondents said people are sometimes jailed to await psychiatric evaluations, it happens to fewer people and for shorter periods. At least a dozen states ban the practice altogether; Mississippi law allows it when there is “no reasonable alternative.” In Alabama, a federal judge ruled it unconstitutional in 1984.

Disability rights advocates in other states and experts on civil commitment or mental health care used words like “horrifying,” “breaks my heart” and “speechless” when they learned how many Mississippians are jailed without criminal charges while they wait for mental health care every year.

Wendy Bailey, head of the Mississippi Department of Mental Health, has said it’s “unacceptable” to jail people simply because they may need behavioral health treatment, and staff have encouraged chancery clerks to steer families toward outpatient treatment instead of the civil commitment process when appropriate.

The Department of Mental Health says it prioritizes people waiting in jail when making admissions to state hospitals, and the average wait time in jail after a hearing has dropped. The state has expanded the number of crisis unit beds and plans to add more. And it has increased funding for local services in recent years in an effort to reduce commitments.

In early January, Bailey said the agency has been reviewing commitment statutes in other states that restrict jailing people during the process. During the current legislative session, she said, the agency will support “changes to the commitment process that we hope will divert Mississippians from unnecessary commitments.”

Cassandra McNeese, left, and her mother, Yvonne A. McNeese, in Shuqualak, Mississippi. Cassandra’s brother, Willie McNeese, has been held in jail during civil commitment proceedings at least eight times since 2008. Cassandra McNeese said Noxubee County officials told her jail was the only place available for him to wait. “This is who you trust to take care of things,” she said. “That’s all you have to rely on.” (Eric J. Shelton/Mississippi Today) Despite a State Law, There Has Been Almost No Oversight of Jails That Hold People Awaiting Treatment

In 2009, the Mississippi Legislature passed a law requiring any county facility that holds people awaiting psychiatric treatment through the commitment process to be certified by the Department of Mental Health. The department developed certification standards requiring suicide prevention training, access to medications and treatment, safe housing and more. But the law provides no funding to help counties comply and has no penalties if they don’t. Only a handful of counties got certified, and after 2013 the department’s efforts to enforce the law apparently petered out.

As of late last year, only one jail — out of 71 that had recently held people awaiting court-ordered treatment — was still certified. There is no statewide oversight or inspection of county jails.

After we asked about the law, the Department of Mental Health sought an opinion from the Mississippi Attorney General’s Office, which opined that it is a “mandatory requirement” that the agency certify the county facilities, including jails, where people wait for treatment. In October, the department sent letters to counties informing them of the attorney general’s opinion and encouraging them to get certified. Department officials are waiting for counties to initiate the certification process, though they know which jails have held people after their hearings. Department leaders, including Bailey, have emphasized that they have limited authority over counties and can’t force them to do anything.

A padded cell used to hold people awaiting psychiatric evaluation and court-ordered treatment at the Adams County jail in Natchez, Mississippi. Lacey Robinette Handjis, a 37-year-old hospice care consultant and mother of two, was found dead in one of the jail’s two padded cells in late August, less than 24 hours after she was booked with no criminal charges to await mental health treatment. (Eric J. Shelton/Mississippi Today) The Practice Is Not Limited to Small, Rural Counties

According to data from the Mississippi Department of Mental Health, 71 of the state’s 82 counties held a total of 812 people prior to their admission to a state hospital during the fiscal year ending in June. According to state data and our analysis of jail dockets, the two counties that jail the most people during the commitment process are DeSoto and Lauderdale — together home to three of the state’s 10 largest cities. DeSoto has one of the highest per capita incomes in the state, and Lauderdale’s is above average. (Those counties’ chancery clerks, who handle the civil commitment process, and officials with the boards of supervisors, which handle county finances, haven’t responded to questions about why they jail so many people going through the commitment process.)

Meanwhile, some smaller, rural counties don’t jail people or do so rarely. Guy Nowell, who served as chancery clerk of Neshoba County until the end of 2023, said the county arranged each person’s commitment evaluations and hearing to take place on the same day to eliminate waits between appointments. If no publicly funded bed is available after the hearing, the county pays for people to receive treatment at a private psychiatric hospital.

by Mike Spies, The Trace

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

This story was published in partnership with The Trace, a nonprofit news organization covering guns in America.

At a meeting in June 2009, the treasurer of the National Rifle Association worked out a plan to conceal luxury expenses involving its chief executive, Wayne LaPierre, according to audio of the meeting obtained by The Trace and ProPublica. The recording was unknown to New York’s attorney general, who is pursuing the NRA and LaPierre over a range of alleged financial misdeeds. It shows, in real time, the NRA’s treasurer enlisting the group’s longtime public relations firm to obfuscate the extravagant costs.

Captured on tape is talk of LaPierre’s desire to avoid public disclosure of his use of private jets as well as concern about persistent spending at the Beverly Hills Hotel by a PR executive and close LaPierre adviser.

During the meeting, which took place in the Alexandria, Virginia, office of PR firm Ackerman McQueen, executives agreed that Ackerman would issue a Platinum American Express card to Tyler Schropp, the new head of the NRA’s nascent advancement division, which was responsible for bringing in high-dollar contributions from wealthy donors. Ackerman would then cover the card’s charges and bill them back to the NRA under nondescript invoices.

“It’s really the limo services and the hotels that I worry about,” William Winkler, Ackerman’s chief financial officer, said. “He’s going to need it for the hotels especially.”

The use of the Ackerman American Express card, according to a report by New York Attorney General Letitia James’ expert witness on nonprofits, skirted internal controls that existed to ensure proper disclosure and regulatory compliance and to prevent “fraud and abuse” at the nonprofit. As a result, outside of a tiny group of NRA insiders, everyone was in the dark about years of charges by Schropp — who is still the head of the nonprofit’s advancement division — for luxury accommodations, including regular sojourns to the Four Seasons and the Ritz-Carlton. The NRA, in response, said the report was “rife with inadmissible factual narratives, impermissible interpretations and inferences, and improper factual and legal conclusions.”

James’ investigation into the NRA began in 2019, after The Trace, in partnership with The New Yorker, and later with ProPublica, reported on internal accounting documents that indicated a culture of self-dealing at the gun-rights group. In 2020, James sued the NRA and LaPierre, who presided over the organization for three decades, over claims of using nonprofit resources for personal enrichment, luxury travel and bloated contracts for insiders, allegations that the parties deny. The attorney general is seeking financial restitution from the defendants and was until last week petitioning for LaPierre’s removal, which was preempted on Friday when LaPierre announced he would resign at the end of January.

The attorney general’s office was unaware of the audio until it was contacted by The Trace and ProPublica and did not respond to a request for comment.

Ackerman McQueen and Winkler declined to comment. None of the other individuals mentioned in this story responded to requests for comment. The gun-rights group’s attorney, William A. Brewer III, said in an email: “The tape has not been authenticated by the NRA but, if real, we are shocked by its content. The suggested contents would confirm what the NRA has said all along: there were certain ‘insiders’ and vendors who took advantage of the Association. If true, it is an example of a shadowy business arrangement — one that was not brought to the attention of the NRA board.”

In the recording, Woody Phillips, who was the NRA’s top financial official from 1993 to 2018 and is also a defendant in James’ suit, did not say why the unusual credit card arrangement was necessary. But at one point, he indicated that LaPierre — whose public persona was that of a populist firebrand — had concerns about the optics of using NRA funds for travel on a private jet.

“We just have to be careful because Wayne wants to get through this whole year saying he hasn’t used private aircraft,” Phillips said. In that year’s tax filings, he explained, nonprofits, for the first time, would be required to disclose whether they paid for chartered flights for any of the numerous executives and officials listed in the documents. LaPierre, Phillips explained, “just doesn’t want to be seen getting off the plane — anywhere.”

“He Just Doesn’t Want to Be Seen Getting Off the Plane — Anywhere” Woody Phillips, the NRA’s top financial official for nearly a decade, discusses Wayne LaPierre’s concerns about wanting to avoid disclosing the use of private jets. (Obtained by The Trace and ProPublica)

In the opening statement by Phillips’ attorney on Jan. 9, he said that the NRA’s political activities caused “real and serious” security concerns. To that end, his client always “acted in good faith,” he said, and the questionable arrangements Phillips helped devise were not due to “a desire for secrecy” or “to keep information from the NRA and its board. But for confidentiality.”

LaPierre’s attorney spoke of his client’s unflagging devotion to the NRA and dedication to his job. “Was his thinking always right?” he asked. “No. Is perfection a standard for leading a not-for-profit? No.”

James’ complaint states that LaPierre “spent millions of dollars of the NRA’s charitable assets for private plane trips for himself and his family.” In a 2021 deposition, LaPierre said that “NRA security has a policy against me flying commercial because of threats,” and that the requirement had been in place for a decade or more.

In 2009, the NRA did indeed check the box on its tax filing indicating it had used “first-class or chartered travel.” The NRA’s explanation, which the Internal Revenue Service requires nonprofits to provide, was that “charter travel was used on occasions involving multiple events when reduced airline schedules precluded other options.” The description became the NRA’s standard template going forward. Other nonprofits, such as the U.S. Chamber of Commerce, disclose the names of executives who use the luxury service.

At the meeting, according to a source who asked not to be named for fear of professional retribution, Phillips, the NRA’s sole representative in attendance, was joined by Melanie Montgomery, an executive vice president at Ackerman McQueen, and Hillary Farrell, then the company’s chief operating officer. Winkler, from Ackerman, attended via videoconference.

The recording shows how the NRA used Ackerman, which devised the nonprofit’s most prominent messaging campaigns, as an extension of itself. The decadeslong relationship ended in acrimony and lawsuits. After evidence of the NRA’s self-dealing became public in 2019, the NRA and Ackerman accused each other of financial misconduct, with the gun-rights group claiming that the firm filed fraudulent invoices. In 2022, the two entities reached a settlement in which the NRA paid Ackerman $12 million.

In the recording of the 2009 meeting, Winkler said he was told that Phillips wanted to route Schropp’s pricey expenses through Ackerman McQueen, filing them as a “travel job,” which was billed to clients with an invoice that was devoid of detail.

“Well that’s easy,” Winkler announced. “As far as I’m concerned, we can give Tyler an Ackerman Amex. And do it that way.”

“Oh well that’s the way to do it then,” Montgomery replied.

“Yeah,” Phillips agreed. “That’s the easiest way to do it, and for the most part, it’s going to be stuff that Gayle books because it’s stuff with Wayne.” (Gayle Stanford was a consultant who handled LaPierre’s travel.)

“That aspect of it’s very easy,” Winkler said.

“That Aspect of It’s Very Easy”

Melanie Montgomery, a vice president at the NRA’s PR firm, describes how Phillips would like to route high-end expenses involving LaPierre through the company in order to obfuscate them.

(Obtained by The Trace and ProPublica)

Phillips later said of Schropp, “Most of what he’ll do, he’ll do like he does here, where it’ll just be he’ll fill out an expense report for us, he’ll have cards for that too.”

Montgomery responded: “Woody just asked him, ‘Can you do some, you know, that goes through the NRA system, then just your high, well, the stuff you do with Wayne, do through Ackerman.’”

Before Schropp took over the NRA’s advancement division in 2009, he was a vice president at Ackerman, where he worked directly with LaPierre, who recruited him to the NRA. “We were great, great friends and spent a lot of time together,” Schropp later said in a deposition. “And I think we had a mutual respect for each other.”

At the meeting, there was some confusion about whether Schropp already had an Ackerman American Express card. Winkler settled the matter by calling a colleague.

“Does Tyler Schropp have an Amex?” Winkler asked. “Get him one.” He added that it should be a “Platinum.”

Schropp would use the card extensively in the years to come. The lawsuit alleges, “He routinely stayed in suites costing over $1,500 a night.” In addition to the Four Seasons and the Ritz-Carlton, he was partial to the Beverly Hills Hotel and the St. Regis.

In a 2021 deposition, Schropp said that he had the card for “donor privacy reasons, and Wayne LaPierre privacy and security reasons.” Phillips has not addressed the matter in unsealed testimony, while LaPierre, for his part, said in a 2019 deposition, “I was aware that — from our treasurer’s office that the advancement expenses, some of them, were — were under Ackerman McQueen,” a practice that was stopped a decade later, when, he said, the NRA “self-corrected under New York state law.”

At another point during the 2009 meeting, Phillips brought up Tony Makris, an Ackerman executive who worked closely with LaPierre as an adviser. The two were good friends. Makris had served as the actor Charlton Heston’s personal and political adviser while Heston was president of the NRA in the late ’90s and early 2000s.

“In the case of Tony, now that he’s married, does anyone know what he’s doing about the Beverly Hills Hotel?” asked Phillips, who was looking for ways to save cash. “Because that would cut out a lot of this cost if he’s not doing that. I think without it being a special occasion, we’d have a hard time paying for that.”

“Does Anyone Know What He’s Doing About the Beverly Hills Hotel?” Phillips inquires about LaPierre adviser Tony Makris’ stays at the Beverly Hills Hotel on the gun-rights group’s dime. (Obtained by The Trace and ProPublica)

Makris was responsible for recruiting conservative celebrities, like Tom Selleck, into the NRA’s fold.

Phillips then mentioned Rick Tedrick, the NRA’s managing director of finance, a job he still holds.

“And I know Rick’s going to be watching that,” Phillips continued, “not that he’d say anything or do anything.”

Winkler chimed in: “What you guys need to do is give me the guidance with Tony. Because you know what will happen. It will go full circle, right back to Wayne.”

Listen to the Full Meeting Audio Here The 2009 NRA finance meeting with officials from its PR firm (Obtained by The Trace and ProPublica)

Will Van Sant contributed reporting.

by Jennifer Berry Hawes

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.

London Lamar rose from her chair in the Tennessee Senate last spring, stomach churning with anxiety as she prepared to address the sea of men sitting at creaky wooden desks around her. She wore a hot pink dress as a nod to the health needs of women, including the very few of them elected to this chamber, none of whom were, like her, obviously pregnant. She set her hands onto her growing belly.

The Senate clerk, a man, called out an amendment Lamar had filed. The Senate speaker, also a man, opened the floor for her to speak. The bill’s sponsor, another man, stood near her as she grasped a microphone to discuss the matter at hand: a tweak to the state’s near-total ban on abortion access for women.

Lamar glanced around at her fellow senators, three quarters of them men. The imbalance was even more stark in the state’s House of Representatives, where almost 9 in 10 members were men. And Tennessee is no anomaly. Across much of the Southeast, state legislatures are more than 80% male.

On this day, the Tennessee Senate was poised to take a final vote on a bill that would allow abortions to prevent a woman’s death or “serious risk of the substantial and irreversible impairment of a major bodily function.” Lamar stood to pitch a broader health exception.

A Democrat in the substantial minority, she could have appealed to her female Republican colleagues. Although they oppose abortion, they bring to the debate their personal knowledge of women’s bodies and experiences. But there were only three of them in the 33-member Senate. Instead, Lamar turned to the two dozen Republican men.

She reminded them that four years earlier, she was 32 weeks pregnant and serving in the House when her blood pressure suddenly spiked. Her placenta ruptured. Her son died in utero, and she faced a terrifying risk of a stroke. “It’s personally one of my biggest fears that this thing would happen again to me,” she told them. If it did, she feared the proposed law would prevent her doctor from protecting her health.

She implored the men to see her as a family member: “I’m telling you as your own colleague, as your niece, baby girl. I love you all. It is real, not only for me but for women all across the state.”

Scenes like this play out across the Southeast, even as the U.S. as a whole saw a record number of women elected to statehouses last year. Nationally, one-third of legislators are women, the most in history. In recent years, three states — Nevada, Arizona and Colorado — achieved parity.

But much of the Southeast lags far behind.

Seven States, Almost All in the Southeast, Had Legislatures That Were Less Than 20% Women in 2023

Women made up less than half of the state legislatures in nearly every state.

State legislature data provided by Reflective Democracy Campaign and current as of July 27, 2023. (Lucas Waldron/ProPublica)

More than a century after the 19th Amendment gave women the right to vote, women constitute fewer than 1 in 5 state legislators across much of the region: in Alabama, Mississippi, South Carolina and Tennessee, according to the Center for American Women and Politics at Rutgers University, which studies women’s political participation. West Virginia has the lowest percentage of any state; less than 13% of its state lawmakers are women.

As Lamar spoke, 14% of Tennessee’s legislators were women. The Republicans, including two of the three GOP women in the Senate, swiftly rejected her amendment. She sank into her chair and pressed one palm over her heart, the other onto her belly, and practiced deep breathing exercises to help keep her blood pressure from soaring again.

Men Made Up Half of Tennessee’s Population but 86% of the State’s 2023 General Assembly State legislature data provided by Reflective Democracy Campaign and current as of July 27, 2023. (Lucas Waldron/ProPublica)

Soon after, another Black woman in the chamber stood to speak. Holding the microphone, Sen. Charlane Oliver read prepared remarks calling for an exception in cases of rape. Then, she paused. She glanced to her right and bit her cheek. She cleared her throat.

Fighting tears, she began again: “I rise before this body as a sexual assault survivor.”

Sitting nearby, Lamar listened intently. She hadn’t known this about her fellow senator, yet Oliver felt compelled to share her trauma so publicly to try and sway the men around them. Tears welled in Lamar’s eyes as well. She passed her colleague a tissue.

Waiting to Run

Three decades have passed since a U.S. Senate Judiciary Committee composed entirely of men grilled Anita Hill on live TV. Some of the men were dismissive, others downright hostile toward her testimony that Clarence Thomas, her former boss, had sexually harassed her. Millions watched it on live TV, and the Senate later confirmed Thomas to the U.S. Supreme Court.

The following year, voters elected a record number of women to Congress in what became known as the “The Year of the Woman.” Yet while Congress and many states have seen steady growth in numbers of female lawmakers over the years since then, much of the Southeast has stagnated or barely inched forward.

Tennessee has fewer female legislators than it had 20 years ago. Mississippi improved less than 3 percentage points since then; South Carolina fared only slightly better. Louisiana gained 6 percentage points, and Alabama gained 7.

This leaves large majorities of men controlling policy — including laws that most impact women — at a time when the U.S. Supreme Court is sending more power to statehouse doorsteps. Abortion, a key issue of the day, provides one window: A ProPublica analysis of comprehensive legislative data kept by the Reflective Democracy Campaign found that with few exceptions, the states with legislatures most dominated by men as of July have some of the nation’s strictest abortion bans.

Of the 10 states where men made up the biggest share of the legislatures, eight have strict abortion bans, and one outlaws it at around six weeks, before many women know they are pregnant. Five don’t allow exceptions for women who are raped.

Seven of the 10 states have trigger laws in place that went into effect after Roe v. Wade was overturned. Those were adopted by legislatures years earlier. But the passage of time hasn’t always resulted in more women at the table. Four of the seven legislatures have more female lawmakers today, albeit barely, than when they passed their trigger laws. One state has remained stagnant. And two have fewer female lawmakers than when they passed their trigger laws.

These are all conservative states, so it doesn’t mean women who oppose abortion rights would have voted differently. But their voices were hardly at the table.

Men’s numeric dominance means they also control what issues get debated in the first place — and which do not. Female lawmakers have been more likely to champion issues like maternal health, children’s welfare and education, said Jean Sinzdak, associate director for the Center for American Women and Politics.

“Women’s presence is correlated with more conversation and more issues on the agenda that are related to women,” said Anna Mahoney, executive director of the Rockefeller Center for Public Policy and the Social Sciences at Dartmouth College who wrote the book “Women Take Their Place in State Legislatures.”

Women haven’t run for legislative seats as often as men for many reasons: money, history, incumbency. But no factor plays a bigger role in the Deep South than its entrenched patriarchal culture and gender norms, female legislators and experts say.

“Traditional gender roles are more deeply enforced in Southern states,” Sinzdak said. “There’s more of a paternalistic streak that runs through them culturally.”

For instance, across party lines, virtually every Southern female legislator ProPublica interviewed for this story said voters had asked her who would care for her family if she won. Carla Litrenta, a South Carolina attorney, was breastfeeding when she filed to campaign for a House race that she ultimately lost in 2022. Voters often looked at the Democrat’s two young children and asked how she would find time to serve in office. “It was ironic because the male candidates had full-time jobs,” she said, “and I was working part time.”

Statehouse gender disparities are more acute among Republicans. Across the country, two-thirds of female state legislators are Democrats. The 20 states with the lowest percentages of women in their legislatures are almost all led by Republicans.

Republican organizations “are not recruiting as many women to run and not giving as much support to run and be successful candidates,” Sinzdak said. “You reap what you sow.” South Carolina state Rep. Sylleste Davis, a Republican, agreed that the GOP needs to seek out more female candidates but added, “I don’t get the sense that they are.”

ProPublica reached out to Republican Party leaders in Southeastern states with the fewest female lawmakers asking why more women weren’t running and what they could do to recruit more female candidates. Only one responded.

Scott Golden has worked as chair of Tennessee’s Republican Party for seven years. He said the party doesn’t target recruitment based on gender. During his tenure, including working for a prominent female lawmaker, the barriers he has seen for women are primarily structural ones. The state’s legislature operates part time but requires substantial attendance during those months, and the capital of Nashville sits a four-hour drive from some districts. Both make legislative seats less appealing for women with young children who want to stick closer to home.

“Families with volleyball and softball and senior dances and homecoming parades, it’s difficult for anybody to do it — much less women to do it — during those years,” Golden said. Instead, he sees far more Republican women running for local elected offices where they can earn full-time salaries and travel less. “It’s time, money and proximity,” he said.

Indeed, like other female Republicans ProPublica interviewed, Davis did not seek a legislative seat until her children were older. Yet that decadeslong wait for women like her to run means that legislatures have fewer members who bring current firsthand experience with pregnancy, birth and child care — knowledge critical to crafting the policies that govern these issues.

Women also are also less likely to consider running unless they are asked. Rep. Anne Thayer, a Republican who hails from a particularly religious and conservative area of South Carolina, said she didn’t consider seeking public office until people approached her. Even then she demurred.

“I gave that good Southern Christian girl response in that I’ll pray about it,” she recalled. A small-business owner and mother, she had worked behind the political scenes but “never wanted to be the one driving the bus.”

Supporters kept asking, however, and today she and Davis are two of four female committee chairpeople out of 28 standing committees in a statehouse whose rolling grounds are adorned with a dozen monuments to white men. Only one specifically celebrates female South Carolinians — and it stands behind the domed building to honor Confederate women “reared by the men of their state,” as the inscription reads.

When Republican Katrina Shealy was elected to the South Carolina Senate a decade ago, she was the only woman in the chamber. A few years later, she made national news for rebuking a male colleague who had called women “a lesser cut of meat,” referencing the biblical story of God creating Eve from Adam’s rib.

Shealy made national news again last spring. By then, she had four female colleagues in the 46-member Senate. All five women united across racial and party lines to help thwart a near-total abortion ban. (A sixth woman, a Democrat, was elected to the Senate on Jan. 2.)

Whatever their views on abortion, Shealy noted, women bring to the debate personal experience with menstrual cycles, pregnancy complications and motherhood. Male lawmakers around her simply don’t have that. “When they get up and talk about women’s issues,” she said, “it is just so frustrating because they don’t know what they’re talking about.”

After she joined her female colleagues to filibuster the strict abortion ban, they called themselves the Sister Senators and later received the JFK Profile in Courage Award. But they couldn’t defeat a bill that outlawed abortion after around six weeks of pregnancy.

Months earlier, South Carolina’s legislature — one of the most male-dominated in the country — had replaced the state Supreme Court’s lone female justice with a man. (Two of the three nominees for the seat were women.) The female justice had penned the lead opinion rejecting a similar six-week ban the previous month. The newly all-male court, now the country’s only state supreme court without a female justice, promptly upheld the six-week ban.

The Backdrop of History

The case that overturned national abortion rights, Dobbs v. Jackson Women’s Health Organization, originated in Mississippi, the state where white men in particular are most overrepresented in the Legislature. They hold more than 60% of the seats even though they account for only 28% of the state’s population. That means every white man is represented more than two times over in the body, according to a ProPublica analysis of comprehensive legislative and census data tracked by the Reflective Democracy Campaign.

Women, however, are underrepresented by more than a factor of three. It’s about the same for Black women and white women.

Yet when it comes to the impact of abortion restrictions the Legislature passed, Black women are disproportionately affected. They are four times more likely to die of pregnancy-related causes than white women. They also are more likely to experience unintended pregnancies. And in 2021, 80% of abortions reported in Mississippi were performed on them, the highest percentage of any state in the nation.

This is happening against history’s disturbing backdrop: centuries of white men controlling Black women’s reproduction. Enslaved women’s health once was only as important as the human property their bodies could produce. Black women had to birth the children of white men who raped them. They were forced to breastfeed white babies.

Michelle Colon, co-founder of a reproductive justice organization in Mississippi called SHERo, said this history has created a culture of devaluing Black women that persists today. Many state lawmakers “are the descendants of white men who basically controlled Black women’s bodies,” she said.

Black women in Mississippi aren’t alone. Across most of the Southeast, a region of former slave states, the more white men are overrepresented, the more Black women are underrepresented. This relationship doesn’t exist in other states that also have at least 5.6% Black women, the national average.

States with the Lowest Representation of Black Women in Their Legislatures Also Had the Highest Representation of White Men

In most Southeastern states, white men are overrepresented at the expense of other groups, especially Black women.

The chart shows representation ratios between the proportion of a demographic group in the state legislature and the proportion of that group in the state population. A ratio of 1 implies equal representation. This chart includes only states where Black women are at least as prevalent in the state’s population as the national average. State legislature data provided by Reflective Democracy Campaign and current as of July 27, 2023. (Lucas Waldron and Irena Hwang/ProPublica)

This imbalance is most pronounced in Mississippi, the state with the nation’s largest percentage of Black residents. “It’s not the year of the woman here,” said Tracy DeVries, executive director of the Women’s Foundation of Mississippi. “There’s no priority for women’s health. None. It’s just not important.”

Democratic Rep. Omeria Scott, a Black woman, has served in the Mississippi House of Representatives for three decades and sits on its public health committee, made up of 24 men and five women. The chair is a white man. As long as she could remember, it has always been a white man.

Scott also serves on the House’s Medicaid committee. Its chair also is a white man. He and the House speaker, another white man, stymied efforts in 2022 to extend Medicaid coverage, which pays for almost 60% of births in the state.

“White men handle those appropriations,” Scott said. “They handle the policy and the money in Mississippi.”

Black and White Women in Mississippi Were Dramatically Underrepresented in the State Legislature Compared with White Men Mississippi Legislature data provided by Reflective Democracy Campaign and current as of July 27, 2023. (Lucas Waldron/ProPublica)

In 2022, House Speaker Philip Gunn spoke to The Associated Press after blocking a Senate-backed effort to extend Medicaid for the state’s poorest new mothers from the federally required two months to a year postpartum. Gunn said that he was aware of the state’s high maternal mortality rate, but he had not seen evidence that extending coverage would save money. When asked if the move could save lives, he told the AP, “That has not been part of the discussions that I’ve heard.”

Only after the state’s strict abortion ban went into effect did Gunn agree to stop blocking the extension.

Republican Gov. Tate Reeves posted on social media, “In a post-Dobbs world — we may even have to be willing to do things that make us ‘philosophically uncomfortable.’” He would support the Medicaid extension as part of a pro-life agenda. “As I’ve said many times, it will not be easy and it will not be free. But it will be worth it, as more children of God are brought into the world!”

Neither Reeves nor Gunn responded to ProPublica’s requests for comment. Scott was pleased that the men finally stopped thwarting the extension of coverage for mothers. But it also felt like a consolation prize.

Triggering Confusion

Not quite a year had passed since the Dobbs decision when a Black woman named Nancy Davis sat before a Louisiana House committee. She urged the panel, chaired by a white man, not to punish women’s doctors if they abort nonviable fetuses.

“Step out of yourself for one minute, and try to envision what it’s been like for women in Louisiana,” she said.

During her visit to the capitol, Davis wondered: Where were the lawmakers who looked like her? Only nine Black women served in the entire Louisiana State Legislature — 6% in a state where they constitute 17% of residents. Yet Davis had just experienced very personally how a policy the Legislature passed directly affected women like her.

About a month after the Dobbs decision’s release, the 36-year-old mother arrived at a hospital for a routine check up. She was 10 weeks pregnant and thrilled. When an ultrasound technician slid a wand across her belly, Davis peered eagerly at the gossamer image emerging into view on the monitor beside her.

Then, she felt everything pause.

“Why does my baby look that way?” she asked. The top of his head looked amorphous, like mist fading into the dark.

The technician slipped from the room.

Davis burst into sobs. Leaping up, she tugged on her clothes and stared at the image through tears. A physician soon explained that it appeared the top of the skull had not formed, a fatal anomaly. Davis recalled her also assuring, “This is one of the reasons for an abortion.” The doctor was referring to a narrow exception in Louisiana’s trigger ban, which had just gone into effect.

But Davis was enrolled in Medicaid, which did not cover abortions. The procedure would cost $6,000 out of pocket at the hospital, she said, so the doctor sent her to an abortion clinic. Davis found it shuttered.

When she returned to the hospital, a woman explained that the doctor could no longer provide her an abortion. “The director of the hospital shut it down because of the Louisiana abortion law and the fetus still having a heartbeat,” Davis recalled her saying. (Debate later ensued over whether the state’s abortion laws would have allowed her to get an abortion.)

For a month, Davis carried a fetus she knew would die. Some nights, she slipped outside and clutched her stomach, crying alone in the darkness so she didn’t wake her fiance, Shedric Cole, or their other three children. But what could she do?

Desperate, she emailed local news outlets. A TV reporter came to interview her, and the video went viral. She wound up in touch with Planned Parenthood of Greater New York and The Brigid Alliance, which helped her book flights to New York and pay for a hotel, child care and meals.

On Sept. 1, Davis and Cole arrived at a Manhattan clinic 1,400 miles from home. An abortion wasn’t something she could imagine a woman wanting. But she did want their nightmare over.

After they returned home to Baton Rouge, Davis became determined to give more of a voice to women. She wants to run for office.

Feeling Overwhelmed

After Lamar, the Tennessee senator, pleaded for broader abortion exceptions to protect women’s health, she drove home to Memphis, a majority-Black city in a county with the state’s highest ratio of pregnancy-associated deaths. She felt exhausted and disregarded.

“Black women are telling you, basically you’re killing me, and it’s like you don’t give a damn,” Lamar said. “My life is less valuable than theirs, and that is what hurts the most.”

Tennessee Democratic state Sen. London Lamar at the state Capitol in Nashville. (Diana King, special to ProPublica)

Four months later, in August, she gave birth to a baby boy. Although she developed postpartum preeclampsia, she recovered and celebrated her healthy son with round brown eyes and chubby cheeks.

Yet, despite much-appreciated help from her own mother, the 33-year-old single mom quickly learned why many women with young children often don’t run for office. One day shortly after her maternity leave ended, she handled a phone call while greeting her mother, saying goodbye to her baby, saying goodbye to her mother and then rushing to her car to head to an assignment for her job overseeing a program that develops the Black teacher pipeline, stopping to fill the air in her car tires on the way.

“It’s overwhelming,” she said. “You feel like no one understands or cares, but also you know that you represent the masses of women dependent on you to be their voice.”

With January’s arrival, the Tennessee General Assembly is among legislatures across the Southeast getting back to work. Behind the door of her Senate office, Lamar hung a white board to track the bills she cares about most. It lists abortion, maternal mental health, doula certification and timely processing of rape kits.

She mustered hope for the months to come. Last year, she discovered a tactic that helped her pass a bill to study the expansion of doula services in Tennessee. She planned to employ the strategy again. To gain support from her male Republican colleagues, she had learned to present her bills as “pro-life” rather than pro-woman.

About the Data: How We Analyzed Representation in State Legislatures

ProPublica obtained a database detailing the demographic makeup of state populations and legislatures from the Reflective Democracy Campaign. The database includes race and gender information for all state legislators and was last updated in July, prior to the 2023 state elections. The state demographic data is from the 2020 census, with additional information from 2022 annual population estimates.

To assess representation of demographic groups, ProPublica calculated the ratio of percent representation of the group in the state legislature to percent representation in the state as a whole. A ratio of 1 can be interpreted as the proportion of a demographic in the state legislature equaling the proportion of that demographic among the state’s general population. A ratio larger than 1 means that the demographic is more present in the legislature than in the state population, and a ratio less than 1 means that the demographic is less present in the legislature than expected, given their prevalence in the state population. For instance, a ratio of 2 should be interpreted as there being twice the proportion of a demographic group in the state legislature as in the state population, and is described as overrepresentation by a factor of 2.

To be sure, an individual is not solely represented by the politicians who share their identity, nor does an individual politician work only towards the interests of constituents of the same identity. However, the expectation that a demographic group should be proportionally represented among politicians as in the population as a whole is intuitive and widely used as a proxy for representation in news reports.

When assessing the representation of Black women and white men, we limited our analysis to states with a meaningful proportion of Black women. Black women make up between 0.2% to nearly one-fifth of state populations. As a result, we used the average proportion of Black women in state populations, 5.6%, as a threshold and focused on the 21 states with a higher-than-average proportion of Black women. We used the U.S. Fish and Wildlife Service’s definition of the Southeast and used linear regression to assess trends in representation within and outside of the Southeast.

Irena Hwang contributed data analysis.

by Duaa Eldeib

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

The stillbirth of her daughter in 1999 cleaved Kristina Keneally’s life into a before and an after. It later became a catalyst for transforming how an entire country approaches stillbirths.

In a world where preventing stillbirths is typically far down the list of health care priorities, Australia — where Keneally was elected as a senator — has emerged as a global leader in the effort to lower the number of babies that die before taking their first breaths. Stillbirth prevention is embedded in the nation’s health care system, supported by its doctors, midwives and nurses, and touted by its politicians.

In 2017, funding from the Australian government established a groundbreaking center for research into stillbirths. The next year, its Senate established a committee on stillbirth research and education. By 2020, the country had adopted a national stillbirth plan, which combines the efforts of health care providers and researchers, bereaved families and advocacy groups, and lawmakers and government officials, all in the name of reducing stillbirths and supporting families. As part of that plan, researchers and advocates teamed up to launch a public awareness campaign. All told, the government has invested more than $40 million.

Meanwhile, the United States, which has a far larger population, has no national stillbirth plan, no public awareness campaign and no government-funded stillbirth research center. Indeed, the U.S. has long lagged behind Australia and other wealthy countries in a crucial measure: how fast the stillbirth rate drops each year.

According to the latest UNICEF report, the U.S. was worse than 151 countries in reducing its stillbirth rate between 2000 and 2021, cutting it by just 0.9%. That figure lands the U.S. in the company of South Sudan in Africa and doing slightly better than Turkmenistan in central Asia. During that period, Australia’s reduction rate was more than double that.

Definitions of stillbirth vary by country, and though both Australia and the U.S. mark stillbirths as the death of a fetus at 20 weeks or more of pregnancy, to fairly compare countries globally, international standards call for the use of the World Health Organization definition that defines stillbirth as a loss after 28 weeks. That puts the U.S. stillbirth rate in 2021 at 2.7 per 1,000 total births, compared with 2.4 in Australia the same year.

Every year in the United States, more than 20,000 pregnancies end in a stillbirth. Each day, roughly 60 babies are stillborn. Australia experiences six stillbirths a day.

Over the past two years, ProPublica has revealed systemic failures at the federal and local levels, including not prioritizing research, awareness and data collection, conducting too few autopsies after stillbirths and doing little to combat stark racial disparities. And while efforts are starting to surface in the U.S. — including two stillbirth-prevention bills that are pending in Congress — they lack the scope and urgency seen in Australia.

“If you ask which parts of the work in Australia can be done in or should be done in the U.S., the answer is all of it,” said Susannah Hopkins Leisher, a stillbirth parent, epidemiologist and assistant professor in the stillbirth research program at the University of Utah Health. “There’s no physical reason why we cannot do exactly what Australia has done.”

Susannah Hopkins Leisher pairs a photo of her stillborn son, Wilder Daniel, with one of herself when she was pregnant with him. Leisher is working with others to create a center for stillbirth research and prevention in the U.S. (Natalie Keyssar, special to ProPublica)

Australia’s goal, which has been complicated by the pandemic, is to, by 2025, reduce the country’s rate of stillbirths after 28 weeks by 20% from its 2020 rate. The national plan laid out the target, and it is up to each jurisdiction to determine how to implement it based on their local needs.

The most significant development came in 2019, when the Stillbirth Centre of Research Excellence — the headquarters for Australia’s stillbirth-prevention efforts — launched the core of its strategy, a checklist of five evidence-based priorities known as the Safer Baby Bundle. They include supporting pregnant patients to stop smoking; regular monitoring for signs that the fetus is not growing as expected, which is known as fetal growth restriction; explaining the importance of acting quickly if fetal movement changes or decreases; advising pregnant patients to go to sleep on their side after 28 weeks; and encouraging patients to talk to their doctors about when to deliver because in some cases that may be before their due date.

Officials estimate that at least half of all births in the country are covered by maternity services that have adopted the bundle, which focuses on preventing stillbirths after 28 weeks.

“These are babies whose lives you would expect to save because they would survive if they were born alive,” said Dr. David Ellwood, a professor of obstetrics and gynecology at Griffith University, director of maternal-fetal medicine at Gold Coast University Hospital and a co-director of the Stillbirth Centre of Research Excellence.

Australia wasn’t always a leader in stillbirth prevention.

In 2000, when the stillbirth rate in the U.S. was 3.3 per 1,000 total births, Australia’s was 3.7. A group of doctors, midwives and parents recognized the need to do more and began working on improving their data classification and collection to better understand the problem areas. By 2014, Australia published its first in-depth national report on stillbirth. Two years later, the medical journal The Lancet published the second report in a landmark series on stillbirths, and Australian researchers applied for the first grant from the government to create the stillbirth research center.

But full federal buy-in remained elusive.

As parent advocates, researchers, doctors and midwives worked to gain national support, they didn’t yet know they would find a champion in Keneally.

Keneally’s improbable journey began when she was born in Nevada to an American father and Australian mother. She grew up in Ohio, graduating from the University of Dayton before meeting the man who would become her husband and moving to Australia.

I’m smart. I’m educated. How did I let this happen? And why did nobody tell me this was a possible outcome?

—Kristina Keneally, former premier of the Australian state of New South Wales and stillbirth parent

When she learned that her daughter, who she named Caroline, would be stillborn, she remembers thinking, “I’m smart. I’m educated. How did I let this happen? And why did nobody tell me this was a possible outcome?”

A few years later, in 2003, Keneally decided to enter politics. She was elected to the lower house of state parliament in New South Wales, of which Sydney is the capital. In Australia, newly elected members are expected to give a “first speech.” She was able to get through just one sentence about Caroline before starting to tear up.

As a legislator, Keneally didn’t think of tackling stillbirth as part of her job. There wasn’t any public discourse about preventing stillbirths or supporting families who’d had one. When Caroline was born still, all Keneally got was a book titled “When a Baby Dies.”

In 2009, Keneally became New South Wales’ first woman premier, a role similar to that of an American governor. Another woman who had suffered her own stillbirth and was starting a stillbirth foundation learned of Keneally’s experience. She wrote to Keneally and asked the premier to be the foundation’s patron.

What’s the point of being the first female premier, Keneally thought, if I can’t support this group?

Like the U.S., Australia had previously launched an awareness campaign that contributed to a staggering reduction in sudden infant death syndrome, or SIDS. But there was no similar push for stillbirths.

“If we can figure out ways to reduce SIDS,” Keneally said, “surely it’s not beyond us to figure out ways to reduce stillbirth.”

She lost her seat after two years and took a break from politics, only to return six years later. In 2018, she was selected to serve as a senator at Australia’s federal level.

Keneally saw this as her second chance to fight for stillbirth prevention. In the short period between her election and her inaugural speech, she had put everything in place for a Senate inquiry into stillbirth.

In her address, Keneally declared stillbirth a national public health crisis. This time, she spoke at length about Caroline.

“When it comes to stillbirth prevention,” she said, “there are things that we know that we’re not telling parents, and there are things we don’t know, but we could, if we changed how we collected data and how we funded research.”

Keneally declared stillbirth a public health crisis in her first speech in the Australian Senate. (Michael Masters/Getty Images)

The day of her speech, March 27, 2018, she and her fellow senators established the Select Committee on Stillbirth Research and Education.

Things moved quickly over the next nine months. Keneally and other lawmakers traveled the country holding hearings, listening to testimony from grieving parents and writing up their findings in a report released that December.

“The culture of silence around stillbirth means that parents and families who experience it are less likely to be prepared to deal with the personal, social and financial consequences,” the report said. “This failure to regard stillbirth as a public health issue also has significant consequences for the level of funding available for research and education, and for public awareness of the social and economic costs to the community as a whole.”

It would be easy to swap the U.S. for Australia in many places throughout the report. Women of Aboriginal and Torres Strait Islander backgrounds experienced double the rate of stillbirth of other Australian women; Black women in America are more than twice as likely as white women to have a stillbirth. Both countries faced a lack of coordinated research and corresponding funding, low autopsy rates following a stillbirth and poor public awareness of the problem.

The day after the report’s release, the Australian government announced that it would develop a national plan and pledged $7.2 million in funding for prevention. Nearly half was to go to education and awareness programs for women and their health care providers.

In the following months, government officials rolled out the Safer Baby Bundle and pledged another $26 million to support parents’ mental health after a loss.

Many in Australia see Keneally’s first speech as senator, in 2018, as the turning point for the country’s fight for stillbirth prevention. Her words forced the federal government to acknowledge the stillbirth crisis and launch the national action plan with bipartisan support.

Australia’s assistant minister for health and aged care, Ged Kearney, cited Keneally’s speech in an email to ProPublica where she noted that Australia has become a world leader in stillbirth awareness, prevention and supporting families after a loss.

“Kristina highlighted the power of women telling their story for positive change,” Kearney said, adding, “As a Labor Senator Kristina Keneally bravely shared her deeply personal story of her daughter Caroline who was stillborn in 1999. Like so many mothers, she helped pave the way for creating a more compassionate and inclusive society.”

Keneally, who is now CEO of Sydney Children’s Hospitals Foundation, said the number of stillbirths a day in Australia spurred the movement for change.

“Six babies a day,” Keneally said. “Once you hear that fact, you can’t unhear it.”

Australia’s leading stillbirth experts watched closely as the country moved closer to a unified effort. This was the moment for which they had been waiting.

“We had all the information needed, but that’s really what made it happen.” said Vicki Flenady, a perinatal epidemiologist, co-director of the Stillbirth Centre of Research Excellence based at the Mater Research Institute at the University of Queensland, and a lead author on The Lancet’s stillbirth series. “I don’t think there’s a person who could dispute that.”

Flenady and her co-director Ellwood had spent more than two decades focused on stillbirths. After establishing the center in 2017, they were now able to expand their team. As part of their work with the International Stillbirth Alliance, they reached out to other countries with a track record of innovation and evidence-based research: the United Kingdom, the Netherlands, Ireland. They modeled the Safer Baby Bundle after a similar one in the U.K., though they added some elements.

Vicki Flenady (first image) and Dr. David Ellwood lead an Australian research center that aims to reduce the number of stillbirths. (Natalie Grono for ProPublica)

In 2019, the state of Victoria, home to Melbourne, was the first to implement the Safer Baby Bundle. But 10 months into the program, the effort had to be paused for several months because of the pandemic, which forced other states to cancel their launches altogether.

“COVID was a major disruption. We stopped and started,” Flenady said.

Still, between 2019 and 2021, participating hospitals across Victoria were able to reduce their stillbirth rate by 21%. That improvement has yet to be seen at the national level.

A number of areas are still working on implementing the bundle. Westmead Hospital, one of Australia’s largest hospitals, planned to wrap that phase up last month. Like many hospitals, Westmead prominently displays the bundle’s key messages in the colorful posters and flyers hanging in patient rooms and in the hallways. They include easy-to-understand slogans such as, “Big or small. Your baby’s growth matters,” and, “Sleep on your side when baby’s inside.”

In many Australian hospitals, pregnant patients are given stillbirth prevention materials. (Peter DiCampo/ProPublica)

As patients at Westmead wait for their names to be called, a TV in the waiting room plays a video on stillbirth prevention, highlighting the importance of fetal movement. If a patient is concerned their baby’s movements have slowed down, they are instructed to come in to be seen within two hours. The patient’s chart gets a colorful sticker with a 16-point checklist of stillbirth risk factors.

Susan Heath, a senior clinical midwife at Westmead, came up with the idea for the stickers. Her office is tucked inside the hospital’s maternity wing, down a maze of hallways. As she makes the familiar walk to her desk, with her faded hospital badge bouncing against her navy blue scrubs, it’s clear she is a woman on a mission. The bundle gives doctors and midwives structure and uniform guidance, she said, and takes stillbirth out of the shadows. She reminds her staff of how making the practices a routine part of their job has the power to change their patients’ lives.

“You're trying,” she said, “to help them prevent having the worst day of their life.”

Christine Andrews, a senior researcher at the Stillbirth Centre who is leading an evaluation of the program’s effectiveness, said the national stillbirth rate beyond 28 weeks has continued to slowly improve.

“It is going to take a while until we see the stillbirth rate across the whole entire country go down,” Andrews said. “We are anticipating that we’re going to start to see a shift in that rate soon.”

As officials wait to receive and standardize the data from hospitals and states, they are encouraged by a number of indicators.

For example, several states are reporting increases in the detection of babies that aren’t growing as they should, a major factor in many late-gestation stillbirths. Many also have seen an increase in the number of pregnant patients who stopped smoking. Health care providers also are more consistently offering post-stillbirth investigations, such as autopsies.

In addition to the Safer Baby Bundle, the national plan also calls for raising awareness and reducing racial disparities. The improvements it recommends for bereavement care are already gaining global attention.

To fulfill those directives, Australia has launched a “Still Six Lives” public awareness campaign, has implemented a national stillbirth clinical care standard and has spent two years developing a culturally inclusive version of the Safer Baby Bundle for First Nations, migrant and refugee communities. Those resources, which were recently released, incorporated cultural traditions and used terms like Stronger Bubba Born for the bundle and “sorry business babies,” which is how some Aboriginal and Torres Strait Islander women refer to stillbirth. There are also audio versions for those who can’t or prefer not to read the information.

The U.S. is not pulling its weight in relation either to our burden or to the resources that we have at our disposal.

—Susannah Hopkins Leisher, an epidemiologist, stillbirth researcher and stillbirth parent

In May, nearly 50 people from the state of Queensland met in a large hotel conference room. Midwives, doctors and nurses sat at round tables with government officials, hospital administrators and maternal and infant health advocates. Some even wore their bright blue Safer Baby T-shirts.

One by one, they discussed their experiences implementing the Safer Baby Bundle. One midwifery group was able to get more than a third of its patients to stop smoking between their first visit and giving birth.

Officials from a hospital in one of the fastest-growing areas in the state discussed how they carefully monitored for fetal growth restriction.

And staff from another hospital, which serves many low-income and immigrant patients, described how 97% of pregnant patients who said their baby’s movements had decreased were seen for additional monitoring within two hours of voicing their concern.

As the midwives, nurses and doctors ticked off the progress they were seeing, they also discussed the fear of unintended consequences: higher rates of premature births or increased admissions to neonatal intensive care units. But neither, they said, has materialized.

“The bundle isn’t causing any harm and may be improving other outcomes, like reducing early-term birth,” Flenady said. “I think it really shows a lot of positive impact.”

As far behind as the U.S. is in prioritizing stillbirth prevention, there is still hope.

Dr. Bob Silver, who co-authored a study that estimated that nearly 1 in 4 stillbirths are potentially preventable, has looked to the international community as a model. Now, he and Leisher — the University of Utah epidemiologist and stillbirth parent — are working to create one of the first stillbirth research and prevention centers in the U.S. in partnership with stillbirth leaders from Australia and other countries. They hope to launch next year.

“There’s no question that Australia has done a better job than we have,” said Silver, who is also chair of the University of Utah Health obstetrics and gynecology department. “Part of it is just highlighting it and paying attention to it.”

Dr. Bob Silver, a leading stillbirth researcher, is working to help create a center for investigating and preventing stillbirths in the U.S. (Kim Raff for ProPublica)

It’s hard to know what parts of Australia’s strategy are making a difference — the bundle as a whole, just certain elements of it, the increased stillbirth awareness across the country, or some combination of those things. Not every component has been proven to decrease stillbirth.

The lack of U.S. research on the issue has made some cautious to adopt the bundle, Silver said, but it is clear the U.S. can and should do more.

There comes a point when an issue is so critical, Silver said, that people have to do the best they can with the information that they have. The U.S. has done that with other problems, such as maternal mortality, he said, though many of the tactics used to combat that problem have not been proven scientifically.

“But we’ve decided this problem is so bad, we’re going to try the things that we think are most likely to be helpful,” Silver said.

After more than 30 years of working on stillbirth prevention, Silver said the U.S. may be at a turning point. Parents’ voices are getting louder and starting to reach lawmakers. More doctors are affirming that stillbirths are not inevitable. And pressure is mounting on federal institutions to do more.

Of the two stillbirth prevention bills in Congress, one already sailed through the Senate. The second bill, the Stillbirth Health Improvement and Education for Autumn Act, includes features that also appeared in Australia’s plan, such as improving data, increasing awareness and providing support for autopsies.

And after many years, the National Institutes of Health has turned its focus back to stillbirths. In March, it released a report with a series of recommendations to reduce the nation’s stillbirth rate that mirror ProPublica’s reporting about some of the causes of the crisis. Since then, it has launched additional groups to begin to tackle three critical angles: prevention, data and bereavement. Silver co-chairs the prevention group.

In November, more than 100 doctors, parents and advocates gathered for a symposium in New York City to discuss everything from improving bereavement care in the U.S to tackling racial disparities in stillbirth. In 2022, after taking a page out of the U.K.’s book, the city’s Mount Sinai Hospital opened the first Rainbow Clinic in the U.S., which employs specific protocols to care for people who have had a stillbirth.

But given the financial resources in the U.S. and the academic capacity at American universities and research institutions, Leisher and others said federal and state governments aren’t doing nearly enough.

“The U.S. is not pulling its weight in relation either to our burden or to the resources that we have at our disposal,” she said. “We’ve got a lot of babies dying, and we’ve got a really bad imbalance of who those babies are as well. And yet we look at a country with a much smaller number of stillbirths who is leading the world.”

“We can do more. Much more. We’re just not,” she added. “It’s unacceptable.”

by Becca Savransky, Idaho Statesman

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

Idaho Gov. Brad Little on Monday proposed spending $2 billion over 10 years to help school districts repair and replace their aging buildings. This would mark the largest investment in school facilities in state history, he said.

The proposal, announced during the governor’s annual State of the State address, follows an Idaho Statesman and ProPublica investigation, which showed how Idaho’s restrictive school funding policies and the Legislature’s reluctance to make significant investments in school facilities have impacted students and teachers. Hundreds of students, teachers and administrators shared photos, videos and stories with the publications about the conditions they deal with on a daily basis.

“We’ve all seen the pictures and the videos of some Idaho schools that are neglected — crumbling, leaking, falling apart,” Little said, standing before the Legislature in the Idaho Capitol. “In one school I visited, raw sewage is seeping into a space under the cafeteria. Folks, we can do better.”

Showing photos of fallen ceiling tiles, cracked paint and damaged drains published by the Statesman and ProPublica, he added, “Let’s make this priority No. 1.”

Idaho has long ranked last or near last among states in spending per pupil, and it spends the least on school infrastructure per student, according to the most recent state and national reports. Districts across the state struggle to pass bonds — one of the few ways they can get funds to repair and replace their buildings — because Idaho requires two-thirds of voters for a bond to pass. Most states require a simple majority or 60%. Many superintendents told the Statesman and ProPublica that reaching Idaho’s threshold has been nearly impossible in their communities, and some have given up trying altogether.

As a result, students have had to learn in freezing classrooms and overcrowded schools, with leaky ceilings, failing plumbing and discolored drinking water. These conditions have made it difficult to learn, students and educators said, and have, at times, caused districts to temporarily close schools.

“It’s just a continuous struggle,” Jan Bayer, superintendent of the Boundary County School District, told the Statesman and ProPublica. Boundary County, a rural district in North Idaho, has run two bond elections to try to replace one of its elementary schools plagued with disintegrating pipes, cracked walls and a roof that’s reaching the end of its lifespan. But while one bond had 54% of voter support, both elections failed to reach the two-thirds threshold.

“It would be such a relief to be able to go to our local taxpayers and say our state’s going to invest in us too now,” Bayer said. “It would be a pretty joyful and hopeful moment for our teachers and for our community.”

The governor said his proposal would help make schools more modern, address “unmet critical maintenance” and bring long-term property tax relief. The Legislature would need to determine how the money is distributed to school districts.

The State of the State address often sets the tone for the legislative session, which began Monday, with the governor outlining his priorities for the budget and the coming year.

Addressing Idaho’s school facilities is expected to be a key part of this year’s legislative session.

Legislators have been discussing a series of proposals that would make it easier for school districts to get the money needed to repair and replace their buildings, including one that would start the process of lowering the supermajority required to pass bonds.

“People are generally getting more and more dissatisfied with the fact that we’re not able to address our aging facilities in public education,” Sen. Dave Lent, the chairman of the Senate Education Committee, told the Statesman and ProPublica last month.

Reducing the threshold would require a constitutional amendment, which needs support from two-thirds of legislators and a majority of voters. In the past, that proposal has failed to gain traction, and some lawmakers have argued the threshold needs to remain in place as a protection for taxpayers.

Legislators have also talked about proposals to offer more state funding to reduce the burden that falls on property taxpayers.

Misty Swanson, the executive director of the Idaho School Boards Association, said school board members have been advocating for decades for a “more strategic and effective approach to address the ongoing school facilities crisis.”

“The governor’s approach is a huge step in ensuring Idaho students have access to safe school buildings for years to come,” she said in an email.

Following the speech, education groups and state officials applauded the governor’s proposal on school facilities. Board of Education President Linda Clark called it a “game changer.” Idaho Education Association President Layne McInelly said the group is excited to work with legislators to make sure “a child’s ZIP code doesn’t determine whether their classrooms are up-to-date or crumbling, supportive or overcrowded, kept warm or freezing.”

Superintendent of Public Instruction Debbie Critchfield said in a statement: “In recent years the state has focused on supporting educators by increasing salaries, improving their health insurance and adding money to school budgets for support staff. Now, the time is right to put that same emphasis on the buildings where our students learn. I appreciate that Governor Little recognizes the need and is making it a priority.”

by Robin Fields and Maya Miller

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This story is part of a partnership with Scripps News.

In a victory for many cancer patients in Michigan, the state’s top insurance regulator told health plans on Monday that they cannot deny coverage for clinically proven cancer treatments, and she made it clear for the first time that this includes cutting-edge genetic and biologic therapies.

The move follows weeks of questions from ProPublica and pressure from state lawmakers after the news organization reported in November that an insurer there refused to pay for the only treatment that could save the life of Forrest VanPatten, a 50-year-old father of two, even though a state law requires insurers to pay for proven cancer drugs.

Internal emails obtained by ProPublica showed that executives at Priority Health, the second-largest insurer in Michigan, had argued that the expensive treatment VanPatten needed was a gene therapy, not a drug, so the state’s mandate didn’t apply. VanPatten died in February 2020, still fighting for access to treatment. Priority Health’s associate chief medical officer had tried fruitlessly to convince his bosses that the company was required to cover the treatment, known as CAR T-cell therapy. He later told ProPublica: “We crossed the line.”

Forrest VanPatten’s widow, Betty, and their two adult children said they hoped the historic directive from Michigan’s insurance regulator would ensure that other families wouldn’t have to go through what theirs did.

“I’m literally sitting here in tears because Forrest would be so proud that something is going to happen and, you know, that they’re not going to get away with it again,” Betty VanPatten said.

More than 30 years ago, state legislators passed the law because they were fed up with insurers finding excuses to get out of covering treatments for cancer patients. Now, the Department of Insurance and Financial Services’ bulletin to insurers makes it clear that therapies that have been developed using technologies that didn’t exist when the law was originally written must be covered. The agency previously acknowledged to ProPublica that it hadn’t taken any actions to enforce the law since it was enacted in 1989.

In the press release announcing the step, the department’s director, Anita Fox, said her department was “committed to protecting Michiganders by ensuring that health insurers are following all state and federal laws and regulations.”

A Priority Health spokesperson said the company hadn’t yet seen the bulletin and couldn’t comment on it. In a written response to ProPublica questions on lawmakers’ outrage over the VanPatten case, the spokesperson wrote: “We welcome the opportunity to answer any questions from legislators about coverage decisions." He said the company had begun covering CAR T-cell therapy “several years ago” — after VanPatten died — based on clinical improvements. He added that Priority Health follows all state and federal coverage requirements and wrote: “The health and safety of our members is always our top priority.”

In earlier comments to ProPublica, Priority Health had said there was initially a lack of consensus in the medical community around the treatment VanPatten needed. But well before VanPatten’s doctors requested Priority Health’s approval for the medication, there was substantial consensus about the efficacy of the treatment, according to the National Comprehensive Cancer Network, an alliance of leading U.S. cancer treatment centers.

Not all Michigan health plans have to follow the state law. Some employers pay directly for the health care of their workers and hire insurers only to process claims. These plans are regulated by the federal government and are exempt from state coverage requirements, though some follow them voluntarily.

Michigan’s legislative session is set to open on Wednesday, and several members have been pushing the state insurance department to investigate Priority Health’s actions in the VanPatten case, calling out insurance regulators for failing to enforce the statute.

Sen. Michael Webber, a Republican who represents Rochester Hills, called the agency’s lack of action “a red flag” and said that “laws are only impactful if properly communicated and properly enforced.”

Rep. Julie Rogers, a Democrat from Kalamazoo, who chairs the House health policy committee, called what happened to the VanPatten family “horrifying” and said that “a thorough examination of this case and a review of the regulatory tools available to address this situation is warranted.”

Laura Hall, communications director for the state insurance department, said she couldn’t reveal whether the agency was investigating Priority Health unless a formal enforcement action is taken.

Even after the insurance department’s bulletin to health plans, Sen. Jeff Irwin, a Democrat from Ann Arbor, said he still supports writing a new bill to make it “painstakingly clear” that the new generation of cancer treatments are covered under Michigan law. He called Priority Health’s actions “unconscionable” and said in a written statement that he wants an investigation into “why and how this family was subjected to denial, delay, and death.”

Do You Have Insights Into Dental and Health Insurance Denials? Help Us Report on the System.

by Kathleen McGrory and Neil Bedi

This article contains descriptions of mental illness and suicide.

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A veteran with a known history of suicidal thoughts showed up at a St. Louis hospital before dawn one morning and was left unmonitored in an exam room for hours.

Another was deemed at risk of suicide by a hospital psychiatrist in Washington, D.C., then forcibly discharged, even as he tried to stay, by the same hospital’s emergency department.

Another still in Pittsburgh was assigned a behavioral health nurse who failed to complete thorough suicide screenings or review his suicide safety plan, and didn’t follow up when he said he wished he was dead.

In all three cases, independent inspectors documented serious failures by the Department of Veterans Affairs. And in all three cases, the veterans involved went on to kill themselves or other people.

The lapses were similar to ones examined by ProPublica last week in an investigation of the VA’s handling of two veterans with serious mental disorders. Both suffered for years with inadequate care from the same clinic in Northern California, they told reporters. Their stories ended in tragedy.

The problems appear to be systemic. Over and over, the hospitals and clinics in the VA’s sprawling health care network have fallen short when it comes to treating people with mental illness.

That conclusion emerges from a ProPublica review of all of the reports published by the VA’s inspector general since 2020. That includes 162 regular surveys of facilities and 151 investigations that were triggered by a complaint or call to the office on a wide variety of alleged health care problems.

If you or someone you know needs help:

• Call the National Suicide Prevention Lifeline: 988
• Text the Crisis Text Line from anywhere in the U.S. to reach a crisis counselor: 741741
• If you are a veteran, call the Veterans Crisis Line: 988, then press 1

Issues with mental health care surfaced in half of the routine inspections. Employees botched screenings meant to assess veterans’ risk of suicide or violence; sometimes they didn’t perform the screenings at all. They missed mandatory mental health training programs and failed to follow up with patients as required by VA protocol.

One in 4 of the reports stemming from calls or complaints detailed similar breakdowns. In the most extreme cases, facilities lost track of veterans or failed to prevent suicides under their own roofs.

Sixteen veterans who received the substandard care killed either themselves or other people, the review revealed. An additional five died for reasons related to the poor care, such as a bad drug interaction that the reports say could have been prevented. Twenty-one such deaths is a meaningful count even for a health care system that has more than 9 million people enrolled, in the view of Charles Figley, a Tulane University professor and expert in military mental health. The VA has struggled with mental health care for decades, he said. “It’s a national disgrace.”

For grieving family members, it is incomprehensible. “It was never my expectation that [the VA was] going to solve his problems,” said Colin Domek, the son of the veteran in Pittsburgh. “My expectations were that someone who was saying ‘help me’ would receive some kind of help.”

The inspector general reports reviewed by ProPublica have limitations. The individual investigations can be narrow. The reports offer only broad suggestions as to whether individuals should be held accountable for breakdowns and provide little sense of whether they actually were. Even together, they don’t capture the full reality of the VA’s 1,300 health care facilities. But they do start to assemble a meaningful picture of the system’s most chronic shortcomings when it comes to treating people with mental illness.

The VA declined requests for an interview for this story. In a statement to ProPublica, VA press secretary Terrence Hayes said “there is nothing more important to VA than providing high-quality mental health care to Veterans” and that the agency was “grateful” to the inspector general’s office for its oversight. He noted that last year, more than 80% of veterans who participated in VA surveys reported being satisfied with the mental health care they received through the agency.

In a separate statement, VA Inspector General Michael Missal said, “Our reports have repeatedly illustrated that it is critical that [Veterans Health Administration] leaders remain vigilant to problems, ensure care is coordinated, and take swift, responsive actions that address root causes and promote accountability.”

The VA’s health care system is the nation’s largest. The agency operates about 170 medical centers and 1,100 outpatient sites, and it provides counseling services at some 300 facilities known as vet centers. In the last fiscal year, the VA provided mental health services to about 2 million veterans, according to agency figures.

The system has notable strengths. The VA has played an important role in developing treatments for conditions such as post-traumatic stress disorder and traumatic brain injury, and provides critical training opportunities for psychiatrists, psychologists and social workers nationwide.

But the number of suicides among veterans has remained stubbornly high, ticking up to 6,392 in 2021, the most recent year in agency statistics. And acts of violence by veterans with mental illnesses have continued making news, including two mass shootings in Atlanta last year alone.

Experts told ProPublica the failures revealed in the inspector general reports point to broad problems, including inadequate mental health staffing, outdated policies and the inability to enforce high standards across a large, decentralized health care network.

“It’s a very sad thing,” said M. David Rudd, a psychology professor at the University of Memphis for whom the Rudd Institute for Veteran and Military Suicide Prevention is named. “You can sit here today and predict with great accuracy how many deaths there are going to be over the next five years. Yet there are unlikely to be any meaningful, significant changes.”

When there are allegations of patient care issues, mistakes or policy violations inside a VA health care facility, it is often up to the agency’s independent inspector general to investigate. The office can then write a report explaining what happened and offering recommendations for improvement. Facilities typically follow the recommendations.

The inspector general’s reports don’t name the veterans or any doctors or nurses — a deliberate choice intended to protect their privacy. They obscure gender and specific dates, too. In several cases, however, ProPublica was able to match details from the reports with information contained in news stories or lawsuits and interview the veteran’s relatives.

One of those cases involved Kenneth Hagans, a 60-year-old father of four who served as a private in the Army in the early 1980s.

In September 2021, Hagans showed up at the John Cochran Veterans Hospital in St. Louis complaining of bladder problems and depression, records show. By then, he had been receiving care at the facility for more than two decades and treated for substance abuse and suicidal thoughts.

The nurse who first saw Hagans that morning determined he was not at risk of self-harm. But instead of using the computer to call up a questionaire to assess his risk of suicide, the nurse recited the questions from memory, then left Hagans unmonitored in an exam room.

The nurse claimed to have notified the on-call physician, who was “resting” on a stretcher in another exam room when Hagans arrived, according to the inspector general report on the case. But video footage did not support that claim, the report said. A second nurse alerted the physician an hour after Hagans’ arrival. But the physician was feeling the effects of a vaccine and slow to respond, the physician told investigators.

An hour after that, Hagans was found dead in the exam room. He had used a cord to take his own life.

The inspector general report, which was published in June, found that the nurse had failed to monitor Hagans and that the nurse and physician were responsible for a delay in his care. It also raised questions about the quality of the suicide screening Hagans received. (Later, when asked by investigators to recall the questions on the assessment by memory, the nurse could not, records show.)

Additionally, the report drew attention to an email sent by an emergency department leader regarding the inspector general’s investigation into Hagans’ death. “Everybody needs to know this is NOT the opportunity to air grievances,” the leader wrote to a staff physician. “The [inspector general] will be trolling for evidence of leadership and administrative malfeasance that allowed a veteran to kill himself in our [emergency department]. Appropriate responses to direct questions are: yes, no, I don’t know, and I don’t remember. BOOM!”

The inspector general recommended that the medical center standardize its processes for suicide screenings and monitoring patients — and that local leaders in St. Louis investigate the possible interference in the inspection. In a written response to the report, facility director Candace Ifabiyi did not challenge any of the inspector general’s findings and said she agreed with the recommendations.

Kenneth Hagans and his son Graie (Courtesy of Graie Hagans)

Hagans grew up as one of eight siblings in Hammond, Louisiana. As a kid, he hopped onto trucks bound for New Orleans and hung out in the French Quarter. He saw an opportunity in the Army, his son Graie told ProPublica. But in the years that followed, he struggled with drug addiction and homelessness. He was in and out of his children’s lives.

Hagans never talked about any traumatic experiences he had while serving in the military, Graie said. But in 2017, he started getting help for post-traumatic stress disorder stemming from that period in his life. The treatment, which he got through the VA, was making a difference, Graie said. “He was learning about the impact of PTSD on his life,” he said. “Some things were making more sense about his behavior.”

Graie was stunned to learn the circumstances of his father’s death, he said. His call with a hospital official that day raised questions. Shouldn’t the VA hospital system that treated his father for psychiatric issues have been familiar with his mental health history? Shouldn’t the staff have kept an eye on him?

Hagans’ death could have and should have been prevented, Graie contended. “There’s an institutional and structural failure if what happened to my dad can happen inside a VA hospital,” he said.

In a statement to ProPublica, the VA St. Louis Health Care System expressed its “deepest condolences to Mr. Hagans’ family and friends.” The statement added that health system leaders had established standard policies for suicide screenings and monitoring patients, and initiated “appropriate personnel action” for individuals involved in the case. The health system declined to share specific details.

Hagans’ case was not an anomaly, ProPublica’s review of records found. Many of the breakdowns in care involved problems with screenings for the risk of suicide and violence.

Screenings are simple; they generally entail asking a patient a few questions about their thoughts and actions to assess their potential of self-harm or violence. But research has shown they can help save lives.

Screenings played a key role in the case of Nicholas Domek, a former Army engineer and demolition expert whose three decades in the military included serving overseas in Operation Desert Storm and in the Army Reserves.

In 2018, Domek attempted suicide and was admitted to the Pittsburgh VA’s inpatient mental health unit. He also attempted to kidnap his former domestic partner and, in early 2019, was readmitted to the mental health unit for homicidal thoughts.

The VA gave Domek a designated behavioral health nurse practitioner; the two met monthly after his second hospitalization. The nurse practitioner documented Domek’s thoughts of suicide after each of their four visits, according to the inspector general report. But there was no evidence the nurse practitioner did a thorough suicide risk assessment or reviewed Domek’s suicide safety plan as protocol dictates.

Two weeks after Domek’s last meeting with the nurse practitioner, Domek killed the former domestic partner, Mary Jo Kornick. He then killed himself.

The nurse practitioner could not remember why no risk assessment was done, the report said. The inspector general determined the nurse practitioner had copied and pasted information from prior visits throughout his records, making them difficult to follow and interpret.

Domek’s son Colin told ProPublica the nurse practitioner should have done more. He said the nurse practitioner knew about his dad’s plans; he had been in the room when his father told the nurse practitioner he intended to kill both himself and Kornick, he said.

Mary Jo Kornick (Courtesy of Sherry Kornick)

Colin Domek described his father as a hard worker who enjoyed fishing and geocaching, a recreational activity in which participants search for hidden objects outdoors. He loved being a soldier, Colin said, and the whole family took pride in his service. One year at Christmastime, they decorated their tree with tiny paratroopers. The family was on the local news when Domek deployed to Iraq.

More recently, though, Nicholas Domek had had his left leg amputated and struggled with depression, Colin said. He’d started seeing a mental health professional and trying medications. “In his mind, the VA was going to take care of him,” Colin said. “It was never a thought to see someone outside the VA. That was never on the table.”

The tragedy ravaged a second family. Kornick was a loving mother and grandmother who worked at a home for older people, her daughter Sherry Kornick told ProPublica. She loved to laugh and play pranks. She made up songs to make people smile.

She was killed the day before Mother’s Day. “I don’t even want to celebrate Mother’s Day” anymore, Sherry said, breaking down into tears. “And I realized it’s not fair to my kids who want to celebrate me.”

In its investigation, the inspector general determined the nurse practitioner had made similar missteps with at least seven other patients and had copied and pasted “significant sections of notes” from prior evaluations in 97% of the 143 patients’ health records it reviewed.

The report on the case recommended that the VA’s Pittsburgh health system consult with its human resources and legal teams to “determine whether personnel action [was] warranted.” The facility director agreed with the recommendation but noted the nurse practitioner retired in January 2022.

In a statement to ProPublica, the Pittsburgh health system said it was “devastated when [it] learned about the challenges Mr. Domek faced and took immediate action to prevent another Veteran from having a similar experience.” That included developing a refresher training program for suicide-risk evaluation and management as well as a new template for electronic health records.

Nicholas Domek (National Personnel Records Center)

Other VA facilities missed screens, too, ProPublica’s review found. At one Arizona hospital, a social worker didn’t screen a veteran who called to reestablish mental health care, instead referring the veteran for psychological diagnostic testing. The veteran wasn’t offered treatment for a month and later died by suicide. A South Carolina hospital didn’t do a suicide risk assessment on another veteran who was being released from its inpatient mental health unit as VA policy requires. That veteran also died by suicide.

There were other cases, too, in which veterans with serious behavioral health issues were overlooked or didn’t get the help they needed.

The VA Medical Center in Houston, for example, lost track of a veteran with chronic schizophrenia who sought treatment at the facility’s emergency room in 2020 for back pain. The veteran was found off-site four days later in cardiac arrest and died the next day, according to an inspector general report. In interviews with the investigators, hospital staff said the veteran had been shuttled between departments due to possible COVID-19 symptoms and then wandered off. In a statement to ProPublica, Houston health system leaders said the situation did not “represent the quality health care southeast Texas Veterans have come to expect from Houston VA” and that they had improved their COVID screening processes and trained employees on wandering patients.

At the VA Medical Center in Washington, D.C., a psychiatrist found a veteran with drug withdrawal symptoms to be at moderate risk of suicide and recommended in-patient treatment. The psychiatrist walked the veteran to the facility’s emergency room for follow-up. But doctors there didn’t read the psychiatrist’s notes and determined the veteran should be discharged. When the veteran refused to leave, an attending physician called the VA police and was heard saying the veteran could go shoot himself. The veteran died from a self-inflicted gunshot wound six days later.

Hospital leaders agreed with the findings in the inspector general report and noted that the physician who made the insensitive remark was replaced as a contract provider. They told ProPublica in a statement that a second physician on contract had resigned from the facility.

Experts say such missteps often stem from the fact that employees are overworked and undertrained.

Demand for mental health services within the VA has been surging, and the system has long endured mental health provider shortages. A survey published by the inspector general in August found that more than three quarters of the VA’s 139 networks of hospitals and associated clinics had reported “severe” shortages of psychiatrists, psychologists or both.

Separately, a report from the Government Accountability Office from 2022 concluded that one-fifth of all large VA health care facilities failed to meet requirements that mental health providers be available within primary care settings to help assess veterans and follow up with their care. The facilities said “persistent staffing challenges” were largely to blame.

The VA is far from the only health care organization that has had difficulty filling critical behavioral health positions amid a national shortage of providers in recent years. But Carl Castro, a professor at the University of Southern California and director of its Center for Innovation and Research on Veterans and Military, said the VA in particular has struggled to compete for providers.

“The system doesn’t pay them enough money,” he said. “It works them to the bone. That’s why it is hard to recruit people.”

Indeed, in exit interviews, VA psychologists cited insufficient pay, too much work and job stress as among the top five reasons they left their positions, according to data published by the VA in October.

The VA, for its part, has steadily increased its funding for mental health over time, federal budget data shows. In 2022, the figure surpassed $13 billion, up from about $6 billion a decade earlier. In 2022, mental health was about 13% of the total health care budget. In 2012, it was about 12%.

Agency leaders have acknowledged that growing the mental health workforce is a priority. They recently announced a targeted hiring initiative intended to bring 5,000 new mental health professionals into the system over the next five years. The agency also boosted the pay range available for staff psychiatrists last year and is offering more flexible schedules to employees to help battle burnout, it said.

“We are fully engaged in a multi-faceted strategy to attract qualified candidates, leverage all flexibilities and incentives to meet the workforce needs, and monitor staffing ratios and other data regularly to help inform facility staffing priorities and decisions,” the agency said in a statement to ProPublica.

Aside from staffing issues, experts said the VA struggles with consistency across its huge system, which is broken down into 18 regional networks and dozens of smaller hospital systems, each with its own leaders and policies. “If you’ve seen one VA facility,” said Alyssa Hundrup, a director on the Government Accountability Office’s health care team, “you’ve seen only one VA facility.”

The national policies alone have generated confusion, the reports showed. According to the inspector general’s office, two of the handbooks describing the mental health policies all VA facilities must follow had been outdated for years. One was missing the agency’s most recent guidance on managing patients at risk of suicide or suffering from PTSD or major depressive order.

Dr. Sandro Galea, dean of the Boston University School of Public Health who chaired a congressionally mandated committee on the treatment of PTSD in military and veteran populations a decade ago, said the individual tragedies highlight the need for a wholesale look at the VA’s mental health care system “to identify gaps and holes.”

“That needs to happen,” Galea said. “It’s clearly time.”

Emma Dash is sure something needs to be done. Her husband, a 33-year-old Army veteran named Brieux Dash, was struggling with PTSD when he was involuntarily committed to West Palm Beach VA Medical Center in 2019. He took his own life during his stay.

Brieux Dash and his family (Courtesy of Emma Dash)

Dash had been a wheeled vehicle mechanic in the Army from 2006 until 2015. He deployed to Iraq twice, his Army records show. When he returned home the second time, he was different, Emma said. He would scream in the middle of the night. Sometimes, he erupted into violence in his sleep.

Emma, who worked in the West Palm Beach VA medical center’s pharmacy department, had her husband committed to the medical center’s inpatient mental health unit once before, she said. “It got him back to being him,” Emma recalled. So when he attempted suicide at home in 2019, she followed a similar course of action.

The VA’s inspector general later found that a nursing assistant who had been assigned to do patient safety checks every 15 minutes the day Brieux Dash died had also carried out other tasks contrary to unit protocol. In addition, video cameras that were supposed to help monitor patients hadn’t worked in years.

The findings shocked Emma, who had believed the facility was the best equipped to help her husband. She sued the VA in 2022 and settled for $5.75 million last year, an amount her lawyer characterized as “historic.”

In a statement to ProPublica, the West Palm Beach VA Medical Center said it installed sensor alarms and new surveillance cameras after Dash’s death and added a new checklist to address environmental risks for patients on inpatient mental health units. “Anytime a Veteran in our care dies by suicide,” the statement said, “it is heartbreaking.”

Emma Dash had a simple message for the VA, she told ProPublica: “Do better!”

If you have information about mental health care services provided by the VA, email VAmentalhealth@propublica.org.

by Alec MacGillis

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

This story is exempt from our Creative Commons license until March 15.

On a cold, clear weekday morning in early December, Shepria Johnson pulled up to a small house in Ecorse, Michigan, in an SUV with a decal on the driver’s door that read “Student Wholeness Team.” She looked at an app on her phone. It was her third of 10 visits that morning, and she was there to check on a girl and a boy, 11 and 9, who had missed enough days of school to put them on a list of “chronically absent” students at Grandport Academy, in Ecorse, an industrial suburb of Detroit.

In case there was no one home, Johnson wrote the students’ names on a form letter and addressed the envelope to “the parent of Jisaiah and King.” She wrote “parent,” avoiding the plural as she had seen schools do. “If it’s a one-parent household, that might get touchy.”

There was someone home. Kuanticka Prude opened the door; behind her were some of her eight children. Cats darted up and down the front steps, which were garlanded with Christmas decorations. Johnson introduced herself and said that she was concerned about Jisaiah’s and King’s attendance and wanted to see if there was anything the family needed to help them get to school.

“This is King,” Prude said, gesturing to a slender boy with wary eyes, “and this is Jisaiah” — a girl with her hair in thick side buns. Prude, a friendly 32-year-old with multiple nose and lip studs, said she had woken the two up that morning, but they had gone back to bed, assuming she would be at her job, as a security guard at the Fillmore Detroit entertainment venue. By the time she discovered that they hadn’t left for school, it seemed too late to send them. She had set up a nanny cam to see what was going on at the house when she was away, she said, but the cats had chewed it up. She hadn’t been aware until recently how many days they had missed; she had noticed some attempted calls from their school but hadn’t realized what they were about.

“I tell them, ‘Y’all are going to get me in trouble for this,’” she told ­Johnson.

“This is not anything like truancy. We come from a place of support,” Johnson said, in her characteristically upbeat tone. “But, yes, it could lead to that, if they’re not in school, so we want to make sure they understand.”

Back in the SUV, Johnson’s composure briefly fell away. “Wow, they are too little to be skipping,” she said under her breath.

Johnson is part of an increasingly popular approach to combating truancy: She makes home visits to learn why children are missing school and then works with families and schools to get them back on track. She oversees a team of six people in southeastern Michigan who are employed by a Baltimore company called Concentric Educational Solutions, which has contracts with seven small school districts in the Detroit area. Since 2021, she has been driving back and forth across the Downriver towns southwest of the city, a vast expanse of dollar stores, pot dispensaries and manufacturing plants — some active, some abandoned. She passes the Marathon refinery, the Great Lakes Steel Works and the giant Ford Rouge Complex, where this fall she could see the picket line of the United Auto Workers strike.

The strike ended. The crisis that Johnson was dealing with, on the other hand, seemed never-ending. Absenteeism has long been a problem in the Detroit area, as in other places with high poverty rates, but since the coronavirus pandemic it has worsened dramatically. Nationwide, the rate of chronic absenteeism — defined as missing at least 10% of school days, or 18 in a year — nearly doubled between 2018-19 and 2021-22, to 28% of students, according to data compiled for The Associated Press by Thomas Dee, a professor of education at Stanford. Michigan’s rate was 39%, the third highest among states. States that have reported data for the most recent school year showed only minimal improvement; some cities have rates of more than 40%.

Absenteeism underlies much of what has beset young people in recent years, including falling school achievement, deteriorating mental health — exacerbated by social isolation — and elevated youth violence and car thefts, some occurring during school hours. But schools are using relatively little of the billions of dollars that they received in federal pandemic-recovery funds to address absenteeism. The issue has also attracted surprisingly little attention from leaders, elected or otherwise, and education coverage in the national media has focused heavily on culture-war fights.

This void created an opportunity for a fledgling company like Concentric. Founded in 2010, by David Heiber, a former school administrator, the company grew slowly. It had only about 20 employees before COVID-19 ignited the business. Concentric now has more than 100 employees, and it recently received a $5 million investment from a social-venture-capital firm to fuel expansion.

“Right place, right time, right pandemic,” Heiber told me sardonically.

It takes help to build the habit of going to school, said Johnson, seen at Wayne Memorial High School in the suburbs of Detroit. “I don’t think just one person can do it alone. (Brittany Greeson for ProPublica)

Kuanticka Prude had her first child when she was 13, so she finished her education at the city’s maternity academy. Before that, though, she’d liked going to school. “It was fun! Who wanted to be at home and listen to your mom complain all day?” she told me, when I spoke with her after Johnson’s visit. “But, then, we didn’t have COVID and cities being shut down.”

During the pandemic, Detroit’s public schools, where her kids were enrolled at the time, remained closed to in-­person instruction for nearly a year. “They did school online. I hated it,” she said. “They took it as a joke most of the time, playing in class, because they felt like they were at home and they could do that.” After the family moved to Ecorse, last summer, the mindset lingered. “They got too comfortable at home,” she said.

This is a dynamic that Johnson has repeatedly encountered. When classes were virtual, students would log on some days, and some days they wouldn’t. The world did not end. For parents, it might seem easier that way. No dragging kids out of bed before daybreak. No wrestling them into proper clothes. No getting them to the bus stop as one’s own work waited. “You were able to just do the things you needed to do,” Johnson said. “Everybody was comfortable. It was: ‘I can go to my computer, my baby is in my room on the computer. We’re good.’”

After that hiatus, relearning old behaviors was hard. “If I were a child, and I could stay at home on my computer, in my room, and play with my little toys on the side, pick up the game for your break or lunchtime, how hard is it to sit in a school building for seven hours?” she said. “It takes us to help build those habits, and I don’t think just one person can do it alone.”

Some parents, unimpressed by what instruction consisted of during remote learning, didn’t see missing school as that consequential. Some simply liked having their kids around. “You’re dealing with a different generation here. This is a parent generation that plays video games with their children,” Steven McGhee, the superintendent of the Harper Woods district, another Concentric client near Detroit, said. “When we were kids, we were out of the house and at school. There was no option. This became optional.”

Even before COVID, some students in the Detroit area had been able to choose online-only learning as an offering from public or charter schools. Since the pandemic, many schools have made it easier for students to try to catch up from missed days with online material.

The spectrum from in-person to virtual to nothing at all can get pretty fuzzy. One early afternoon, I saw an 8-year-old boy with headphones on standing outside a house in Ecorse, playing a video game on a tablet. His mother had died of a heroin overdose two years earlier, and his father said that he had enrolled his son in an online academy, because their housing situation was uncertain. Usually, there were three hours of instruction daily, he said, but the Wi-Fi hadn’t been working properly. “He’s done for the day,” his father said.

Families faced other hurdles as well. One student’s father had died a month earlier, and in the previous six months two of his grandparents had also died; his mother was suffering from heart disease that prevented her from working, and she could no longer afford school clothes. Johnson alerted the student’s principal, who had a special fund for such needs.

The mother of a middle school girl had been in a car crash; when a Concentric employee visited, the mother had trouble even coming to the door, and she explained that she couldn’t get her daughter to school anymore. A high school boy had moved in with his grandmother, but he was sleeping on the porch for lack of a bed; Concentric bought him one. A superintendent purchased a washer and dryer after hearing from Concentric that some students weren’t coming to school because they didn’t have any clean clothes. “Once you have these conversations, you know that there are real-­life events that happen, there are real-­life circumstances, where they’re just not able,” Johnson said.

Still, there were circumstances in which negligence did seem to be an issue. Johnson, who is 34 and has three kids, could feel her natural sympathy being tested: “I’ve had a parent tell me, ‘Well, hey, she wasn’t there because of my life problems.’ I get it, but you can’t just leave a student out of school because you have issues.”

Sometimes parents asked Johnson if she was a truant officer, and she would reply, “No, I’m a professional student advocate,” which was what Concentric called its outreach workers. “If you’re a truant officer, they’re defensive,” she told me. “They automatically assume you’re here to get them in trouble.”

Within the U.S., the concept of mandatory schooling can be traced to the 17th century, when the Puritans of Massachusetts positioned it as fundamental to Christian society, but this tenet was challenged by the Industrial Revolution, as children went to work in the mills. After Massachusetts instituted compulsory schooling policies in the 1840s and ’50s, enforcement was spotty. But, in 1873, the state passed a law requiring attendance between the ages of 8 and 12, for at least 20 weeks a year. The law was enforced by agents of the school committee — truant officers — with fines of up to $5 per week. Sixteen years later, the age range was expanded to 14, and a year after that the required term became 30 weeks a year. W.E.B. Du Bois, reflecting on his upbringing in western Massachusetts in the 1870s and ’80s, emphasized his school routine. “I was brought up from earliest years with the idea of regular attendance at school,” he wrote. “This was partly because the schools of Great Barrington were near at hand, simple but good, well-taught, and truant laws were enforced.”

By the 1890-91 school year, more than 200 of Massachusetts’s 351 towns had an average daily attendance of 90%, and only 11 were below 80%. During the following decades, mandatory schooling spread nationwide. William Reese, a professor of history at the University of Wisconsin, found that just 6% of adolescents were in high school in 1890 but that by 1930 half of them were. By 1950, attendance was so universal that those who weren’t in school were called dropouts. “By the early 20th century, the truth is that you’re supposed to be in school, and, in the long reach of history, that’s a remarkable fact,” Reese told me. “It became a universal norm. Other European nations sort of caught up eventually, but America was in the vanguard of this.”

Cities often employed truant officers, who roamed the streets searching for children to corral, and repeat offenders risked being brought to juvenile court. But in recent decades many areas have moved away from legal remedies, following a general shift toward less punitive juvenile justice. In addition, experts — citing psychology literature and evidence from states that still meted out consequences — argued that threats were unlikely to be effective. “Punitive rather than positive is not the best approach,” Michael Gottfried, an economist at the University of Pennsylva­nia Graduate School of Education, said.

Enforcement of state truancy laws has grown rarer. In August, Missouri’s highest court affirmed the sentencing of two parents to at least a week in jail for their young children’s absences, but most of the movement has been in the other direction. In 2019, for instance, New Mexico removed the role of district attorneys in enforcing attendance. (The state, which had some of the longest school closures, saw its chronic absenteeism rates more than double after the pandemic, to 40%, the second-highest rate among states, after Alaska.)

The case of Kamala Harris is instructive. As the San Francisco district attorney in the mid-2000s, she made headlines for prosecuting parents of extremely truant students. “I believe that a child going without an education is tantamount to a crime,” Harris said, during her run for state attorney general, in 2010. “So, I decided I was going to start prosecuting parents for truancy.” During that campaign, she pushed for a statewide law that made it a misdemeanor for parents if their kids were chronically absent, punishable by a fine of up to $2,000 or a year in jail. In 2013, the state amended the law, giving school principals more leeway to excuse absences.

When Harris ran for the 2020 Democratic nomination for president, she received heavy criticism for her efforts. She expressed contrition, saying that she had hoped the law would simply prod districts to offer more resources to aid truant students. “My regret is that I have now heard stories where, in some jurisdictions, DAs have criminalized the parents,” she said. “And I regret that that has happened.”

In recent years, however, efforts to fight absenteeism have tended to involve nudges, not threats. In 2015, Todd Rogers, a behavioral scientist at Harvard, co-founded EveryDay Labs, which sent letters and text messages to families with reminders about the importance of school, and statistics about how their children’s attendance compared with classmates’. Parents could also respond to a chatbot about challenges that they were facing in getting their kids to school. The company was hired by some 50 school districts, but its approach was most effective with milder cases of absenteeism, less so with more severe ones.

David Heiber, Concentric’s founder, is an advocate of direct intervention, perhaps because he wishes he had received it when he was young. Heiber, who is 47, was brought up in Delaware by his maternal grandparents. He had some contact with his mother, a white woman who suffered from alcoholism, but he did not know his father, who was Black, until he was an adult. His grandfather, whom he called Dad, was a truck driver, and he and Heiber’s grandmother — Mom — provided him with a stable middle-class upbringing. In high school, he was a track star who attracted scholarship offers.

In his senior year, his grandfather had a fatal heart attack while Christmas shopping. Heiber went back to school just two days later and, receiving no social-­work support — although a gym teacher let him play Ping-Pong for hours on end — he “spun out of control,” he told me. He was expelled from school, convicted of burglary and sentenced to some five years in prison. While he was incarcerated, his grandmother died of cancer. “I just decided, Something has to happen,” he said. “I got to do something.”

He earned his GED behind bars and a judge released him after 27 months, on the condition that he enroll in college. He attended Lincoln University, a historically Black institution in Pennsylvania, and got a job teaching high school in Baltimore, which he did for a year before taking an administrative position at a different local high school. But, in 2006, he faced one set of misdemeanor charges related to a breakup, which were later dropped, and another set, he told me, for his role interceding in a fight between students at a high school in Washington, D.C., which he had been visiting as an observer. That case resulted in four years of probation. “It was a rough period,” Heiber said. “Very few people go in a straight trajectory.”

In 2007, he moved to Washington, D.C., to become the director of student services for a small group of charter schools. One day, Heiber and some colleagues were wondering what to do about truant students, and it occurred to him that one lived just across the street from the school. He suggested going to the student’s home. There, his grandmother said that he was attending a different school. For Heiber, it was an epiphany: To get the right information, you needed to go to students’ homes, both to show families that the system cared about them and to gain a better understanding of what was keeping the students away — unreliable transportation, depression, lack of clothes or myriad other factors. “There was a list of maybe 200 or so, and we just thought, Ask them questions,” he said.

Heiber came to realize that there was an art to conducting visits in ways that didn’t make families feel judged. In one home, a cockroach fell onto his shoulder, and he managed to keep himself from recoiling, “because it would have made the whole conversation go different,” he said.

In 2010, he was approached by the NewSchools Venture Fund, a philanthropy looking to invest in Black entrepreneurs. He received $150,000 to help create Concentric, with the initial aim of advising districts on how to improve home visits by teachers. But it became apparent that many districts were having trouble getting teachers to do home visits at all and, instead, were interested in having Concentric do them.

Heiber embraced the new mission, becoming an evangelist for what he saw as an underappreciated aspect of the education system. Most school systems “pay the least amount of money for the most important job,” he said. “I’m not saying that teaching is not a very important job. But they got to be in school to be taught.”

His initial contracts were primarily in Detroit. He met several administrators in the school system there, mostly Black men roughly his own age, who then left to lead districts in the city’s working-class inner suburbs. They hired Concentric and recommended it to others in the region.

The frequent travel to Detroit was a strain on Heiber and his family, as was the scramble for new clients. He incurred bills for unpaid taxes and home improvements, leading to court proceedings in Prince George’s County, a Maryland suburb of Washington where he lived. Then came the post-pandemic boom, with new business in Maryland districts. Contracts ranged from $50,000 for home visits in a small district to several million dollars for home visits, plus mentoring and tutoring, in some large ones. In 2021 and 2022, Concentric hired dozens of employees, many of them young Black college graduates. It gave them two weeks of training, which included instruction as basic as how to knock on doors. “I tell everyone, ‘Knock a little harder, but don’t knock like the police,’” a Concentric manager said. The job mostly paid on an hourly basis, as much as $35 per hour. The “professional student advocates” dressed well, in black polo shirts with the company logo or, sometimes, in suits. “I didn’t want people to go into a building and not know that they were our PSAs,” Heiber said.

The company’s rapid expansion, with revenue reaching $8 million last academic year, brought growing pains. Some employees went weeks without getting paid, as income from new contracts arrived too late for payroll, and the company had to turn to lenders, several of whom later filed suit for nonpayment. (Most of the legal actions against Concentric and Heiber have been settled.)

Concentric’s growth only accelerated as the new school year began. For many districts, tracking down missing students was existential. About a million children had left public schools, either because they switched to private or parochial schools or homeschooling, or for reasons unknown. With fewer students, some districts faced teacher layoffs and school closures.

To bring more order to the expansion, Heiber hired experienced managers. In early October came an announcement that a firm called New Markets Venture Partners was investing $5 million in Concentric.

One of the firm’s partners, who was in charge of the investment, told Heiber that Concentric was worth $15 million. The federal pandemic funding that some districts were using to pay Concentric would fade in 2024, but many districts were using state money, which would continue. “He thinks we could be a $150 million business in five to seven years,” Heiber said.

Every few weeks, Concentric received a fresh list of absent kids from each district, often about 50 names. Shepria Johnson’s list brought her to tiny bungalows, ramshackle apartments and public-housing complexes. Sometimes she arrived at homes that appeared abandoned. “I pull up and am, like, No way, nobody lives here,” she said. “And I would knock on the door, and I see people peeking out, and I think, Oh, my God, someone does live here.”

She was able to stave off demoralization by feeling a purpose far greater than she’d had at her previous jobs — she’d worked as a manager at a shoe store and at a Verizon store, while making efforts to complete her college degree. “You don’t know what you’ll go and see, but if you’re not doing it then you can’t help,” she said. “It doesn’t make me sad anymore, it’s just, ‘How can I help?’”

She took pride in her ability to get parents to open up to her. “They go off of your energy. If you’re at the door, and you’re upset with me, I’m not going to get upset with you,” she said. “We should all consider the person on the other side of the door. We know what we’re trying to do — we’re trying to make a difference — but they don’t know that when we’re knocking at the door.”

The conversation was only the first half of the job; next was relaying what information she had learned to school officials or to Concentric employees stationed at schools. A mother in a mobile-­home park said that her son, who was in high school, needed tutoring; another mother said that her son was always late to school because he hated algebra, his first period, and suggested changing his schedule. Even when Johnson found an address uninhabited, with nothing but a can of air freshener visible in the empty living room, she considered it useful, because it alerted the school that it needed updated contact information for a student.

These sorts of home visits are so new that there has been little chance to assess them. A Johns Hopkins University evaluation of Concentric in the Baltimore school district — its largest contract — during the 2021-22 school year reported that a majority of home visits found nobody there. The evaluators struggled to judge the impact even of the visits that did reach family members, because there was no attendance data from the pandemic year of 2020-21 to compare the new numbers with.

The Johns Hopkins study found, however, that school administrators praised the company’s efforts. Superintendents in Michigan echoed this praise. “The number of companies that pledge or promise to address inequities or def­icits that are experienced in urban schools — it’s exhausting,” Derrick Coleman, the superintendent of Michigan’s River Rouge school district, told me. But Concentric, he said, is “able to go into places that many educators are reluctant to go into, for safety reasons, and make families feel comfortable. They create psychological safety to share whatever those challenges are. And that then gives us data and information to make adjustments.”

Connecticut, which has launched a home-visit initiative in 15 districts, has taken a slightly different approach: Outreach workers call ahead to schedule visits with families, which can last longer than an hour. A study found that the program — which is carried out by school employees or community members and which has cost $24 million — resulted in an increase in attendance of 15% to 20% among middle and high schoolers nine months after the first visit.

But Johnson preferred arriving unscheduled, believing that it gave her a clearer picture of the household context. “When you’re on the spot, you have the pure parent,” she said. “If you schedule it, they’re prepared, they already know why you’re coming, they already know their story, but you’re not getting the raw reason.”

“I’ve had a parent tell me, ‘Well, hey, she wasn’t there because of my life problems.’ I get it, but you can’t just leave a student out of school because you have issues,” said Johnson, at an apartment complex to check on a student. (Brittany Greeson for ProPublica)

On a couple of occasions, visits by members of Michigan’s Concentric team uncovered situations so troubling that they prompted calls to child-­protective services. More often, the team found a different recourse. Michigan is one of the few states that still enforce legal repercussions for truancy: A school police officer or administrator or a Concentric PSA can send a JC 01 form to the prosecutor’s office for Wayne County, where most of the Concentric districts are.

If the prosecutor’s office finds sufficient evidence, it typically offers students who are 10 or older a diversion program — the chance to improve attendance and have their records wiped clean. If that fails, students may be brought before a judge. (Cases of younger kids are referred to the adult division, and charges may be brought against their parents.)

Johnson, her colleagues and the superintendents in the Concentric districts in Wayne County all said that the JC 01 forms have been a valuable tool in the most extreme cases — sometimes the court would even threaten to block parents’ welfare payments. “It was very powerful,” Josha Talison, the superintendent in Ecorse, said.

But during the pandemic, the superintendents said, the process broke down — it took much longer to hear from the prosecutor’s office about forms that had been filed. “When the pandemic started, they just stopped doing it,” Talison told me. Stiles Simmons, his counterpart in the Westwood district, which is nearby, told me the same. “The courthouse pretty much shut down,” he said. “And then there was a backlog.”

(Robert Heimbuch, the chief of the juvenile division at the prosecutor’s office, said that his team had continued to handle JC 01 forms, shifting meetings and hearings to Zoom, but that some steps in the process might have taken longer. He didn’t know if referrals for chronically absent students had fallen off, because JC 01s were filed for all manner of juvenile-delinquency cases, and his office did not keep a tally of how many were for truancy.)

After a morning of home visits with Johnson, I met with Sarah Lenhoff, a professor of education policy at Wayne State University, who started studying absenteeism in 2016. She joined a coalition to tackle the problem in Detroit and became convinced that the crisis is now so severe that it requires a greater response. “We’re thinking about school attendance all wrong,” she said. “It’s societal.”

Several of the Wayne County superintendents working with Concentric agreed. “The issue of chronic absenteeism is much broader than what the school and its partners can handle,” Simmons said. “There needs to be something else done.” It was a compelling argument: Throughout the country, local and state government officials, school boards and others had decided that it was in the public interest to close school buildings for a year or more, and now it was going to take a group effort to rebuild the norms. The issue couldn’t be left to individual schools or districts — or to a single company.

Society, as a whole, needed to reinforce — as it had in Massachusetts more than a century ago — the importance of school. It was where children awakened to the world’s opportunities, where they learned how to be productive citizens and, for some, where they found a daily routine and regular meals.

Instead, as Lenhoff noted, families often got the opposite message. Inadequate infrastructure had led Detroit to cancel school for several days last year because of excessive heat. Schools had also closed in the face of forecasts of snow that brought no actual snow. Districts get penalized by the state’s funding formula if attendance drops below 75% on any day, and so they may close schools when they fear that too few kids will show up. “If you have that happen often enough, it does erode your feeling that the system is there for us, and not just when it’s convenient for them,” Lenhoff said.

One day, shortly after noon, I encountered several 15- and 16-year-old boys who had recently arrived from Latin America and were walking a dog in the quiet streets of River Rouge. But they weren’t playing hooky. School had been closed that day, owing to plumbing problems.

A short drive away, a middle school girl was playing in a front yard, while her older sister and some of her friends, in their late teens and early 20s, were hanging out in a nearby car, one with a baby on her lap. The younger sister was also not missing school: It had been only a half day in her district, to allow for professional-development courses.

Asked why absenteeism had increased, the young women didn’t hesitate. “That’s what the corona did,” Serenity, who is 21, told me. Now “they’re sending the kids back to school, and they don’t want to no more. They want to stay home and play on their computers.”

When December arrived, the weather became another obstacle: Leaving home was even less appealing when it was dark and cold out. One mother told Johnson that her son had been missing school because she hadn’t been able to buy him a winter jacket.

Another mother told Johnson that she had just been crying on the toilet: Her rent had doubled, so she wasn’t going to be able to afford Christmas presents for her kids. The rent increase had forced her to pick up a second job, at a fast-food restaurant, which had disrupted her school drop-off and pickup routines. Johnson alerted the children’s school and suggested that it put the family on its list for gift donations.

In Ecorse, Kuanticka Prude was worried about money, too. She had less coming in now than a year earlier, when she had been working a second job, at a Wendy’s. The reason her nanny cam wasn’t working, she told me, was not the cats, as she had said to Johnson, but because she couldn’t afford the monthly ­payments.

But she told me that she might quit her security job, too, to better ­monitor the schooling of her kids, who also included a girl in ninth grade, twin girls about to turn 8 (who were in special-­education programs) and a 4-year-old girl in preschool. “I’m going to get it together,” she said. With Jisaiah and King, “it’s going to take me to sit them down and talk to them really good and let them know, to understand what they’re doing and causing. Because this is not a game or a joke. Not only can you get people in trouble but you need an education.”

The next morning, it was just getting light as Jisaiah and King were scheduled to bring their little sister two blocks away for her preschool bus. A cat pawed at the front door, as if to remind them. And then they emerged. They were a few minutes late, which meant that King needed to wave at the bus as Jisaiah hustled her sister down the sidewalk, a hand on her shoulder. Then Prude’s mother emerged to load the two of them and their older sister into her car. On this day, they were going to make it.

Kirsten Berg contributed research.

Correction

Jan. 12, 2024: This article originally misstated the number of children who have left public schools in recent years. About a million have left, not several million.

by Kathleen McGrory and Neil Bedi, ProPublica, photography by Loren Elliott for ProPublica

This article contains descriptions of mental illness, violence and sexual assault.

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Marty and Candy Larsen were in their pajamas, getting ready to watch a movie in the living room, when they heard their 27-year-old daughter scream.

“I need help!” Julia cried.

They could see her standing just a few feet away, her long blond hair unkempt, her blue-gray eyes at once alert and vacant. She’d looked like this in other moments when fear overtook her and reality slipped away. But a new sight jolted them upright: their daughter’s fingers, wrapped around a pink handgun.

Julia pounded the weapon against a wall, then squeezed its trigger, sending a bullet down an empty hallway. “Help me!” she shrieked.

The parents scrambled in different directions. Candy was on with 911 while Marty reached toward his daughter. “Julia, stand down,” he said. “How can we help you if you don’t stand down?”

But Julia fired again, repeating her plea like a mantra.

“Help me!” she cried. “Help me!”

The need had been building for almost six years, since she returned home from a stint as a Navy firefighter aboard a warship in the Persian Gulf. She was tormented by the rippling trauma of an on-duty sexual assault and grappling with symptoms that led her to be diagnosed with a psychotic disorder.

She was dependent on the Department of Veterans Affairs for care. Just that morning, when her latest crisis began, a nurse at the local VA clinic in Chico, California, had told her mother to bring her in. When they arrived, a telehealth provider was too busy to see Julia. A social worker asked questions to gauge her risk of suicide or violence; even though Julia refused to answer, she was sent out into the world and told to return for the next available appointment, in 11 days.

If you or someone you know needs help:

• Call the National Suicide Prevention Lifeline: 988
• Text the Crisis Text Line from anywhere in the U.S. to reach a crisis counselor: 741741
• If you are a veteran, call the Veterans Crisis Line: 988, then press 1

Such dysfunction had become the norm at the Chico clinic, one of several hundred such community facilities designed to serve veterans who live far from the nation’s big cities. From the outside, it looked like a haven for heroes: a state-of-the-art building with a gleaming atrium, a large American flag flying out front. But the clinic hadn’t had a full-time, on-site psychiatrist in five years. A single nurse was responsible for connecting hundreds of veterans, some with serious mental illness or active suicidal thoughts, with an ever-changing lineup of telehealth providers in different time zones.

The military has long drawn recruits from remote towns across America, promising them a lifetime of health care in return for their service. But the VA has seldom staffed those same communities with the mental health professionals needed to help them once they return home. Two decades of war in Iraq and Afghanistan have turned this chronic shortcoming into an emergency. The demand for mental health care has grown at a rate that’s triple the rate of growth for all VA medical services. Anguished employees, doing what they can with threadbare staffing and glitchy technology, are burning themselves out trying to avert disasters that feel inevitable. In Chico, nurses and social workers cried after their shifts, and the new site manager, a veteran and longtime health care administrator, had made a grim prediction: “We are going to kill someone,” she told colleagues.

If hindsight is 20/20, agency officials should have exquisite vision by now. Their files are littered with cautionary tales of missed screenings and insufficient follow-up; in at least 16 instances since 2019, veterans who received inadequate care wound up killing themselves or other people; an additional five died for reasons related to the poor quality of care. Each time, investigators with the VA’s Office of Inspector General swooped in to determine whether the system failed; each time, they concluded it had.

To plug the holes, the VA grew its nationwide mental health workforce by more than 4,000 last year and plans to hire an additional 5,000 professionals over the next five years. But the sense of dread lingers. It’s a “perfect storm of real potential for gaps in care,” said Alyssa Hundrup, a director on the Government Accountability Office’s health care team.

Just as violence was erupting in Julia’s home on Jan. 3, 2022, another veteran sat alone in his dark bedroom, not far away, ruminating. Deep circles hung below his eyes. An unruly beard covered his chin.

Andrew Iles, 33, had come to believe the government was monitoring him and that his mother was in on the conspiracy. He, too, had tried to get help at the Chico clinic but for years was passed from provider to provider. Recently, all he could get was a psychiatric pharmacist who prescribed him pills. He felt abandoned, concluded the VA had never wanted to help him and slipped into a state of paranoia so intense that he threw away his belongings and holed himself up inside his mother’s house.

His sister, once his protector and closest ally, had stopped bringing her family to see him. His mother had tried to remove all of the firearms from the house but missed a few. Andrew had stowed them away.

Concow Elementary School (Loren Elliott for ProPublica)

Chico, California, sits in the northern Sacramento Valley, in the shadow of the Sierra Nevada mountain range. It’s a college town home to museums and breweries, funky cottages and trendy restaurants. Climb into the foothill elevation, though, and you enter another world. Aside from some big-box stores and picturesque downtowns, it’s mostly wilderness dotted with private homes. Cellphone service is spotty. Roads snake through dense forests.

Andrew Iles grew up in a particularly isolated community called Concow. When he was a kid, only a few hundred people lived there. They drove the same mountain roads, shopped at the same convenience store. There were enough children for a small school, but each grade level had just a handful of students. Most were eligible for free lunch.

Andrew’s family lived a mile off the main road in a one-room, A-frame home that sometimes had no electricity or running water. His parents, Glen Iles and Sue Hill, used methamphetamines. They disappeared, often for days at a time, and let other drug users hang around the house. Some of them forced Andrew and his big sister, Ashley Hill, to engage in horrific sex acts. The kids stayed quiet about the abuse. “We were so afraid to say anything,” Ashley recalled.

The siblings sought refuge on the mountainside. It was their own wild playground, full of creeks to splash in and salamanders to chase. But violence was never far. Once, when Andrew and Ashley were in grade school, they found their mother handcuffed to a refrigerator, bleeding from three gunshot wounds. A few years later, they watched Glen hold Sue at gunpoint and threaten to shoot her. Ashley called 911. Glen fled into the forest on his ATV but was caught and sent to prison. The ordeal made the local newspaper.

The arrest was a turning point. Sue stopped using drugs. She found a new partner and moved the family a few times, ultimately settling in a small city in the foothills called Oroville. After finding steady work at a rent-to-own furniture store and a new place to live, she started rebuilding her family.

Andrew grew into a gangly teenager with a sly sense of humor who wore braces, dyed his hair bright colors and swept his long bangs across his face. He and his friends were emo kids; they listened to Fall Out Boy and spoke out against the war in Iraq. Andrew dated the same girl for years. He showered her with attention and wrote her silly notes. He put considerably less effort into his schoolwork. As graduation neared, he started to believe he needed structure and discipline, and he thought the Air Force might provide it. Plus, he had a mind for math and technology, and the idea of working on multimillion-dollar airplanes appealed to him. “If I don’t do something like this,” he told his mother, “I’ll be in Oroville for the rest of my life.”

As a new airman, Andrew was stationed in Arizona as an aircraft electrical and environmental systems apprentice. His supervisors rated his performance as “truly among the best.” His first evaluations touted his “unrivaled initiative” and described him as a “superior performer” and “stellar airman.” One evaluation ended with a simple declaration: “Promote now!”

Andrew raised his hand for an assignment on Kunsan Air Base in the Republic of Korea where he could work on F-16 fighter jets. He traveled the country by train, visiting university cities so he could meet people his age. He found it thrilling to be somewhere so different from Concow with such freedom to explore.

His next tour took him to Ramstein Air Base outside Frankfurt, Germany, to work on hulking C-130s. He was 22 then, excited to visit Berlin, Amsterdam and Paris. But he was increasingly looking over his shoulder, wondering what his peers were saying about him.

Around that time, Andrew sent emails to his mother and sister that described neighbors spying on him. Sue and Ashley found the letters troubling. In some ways, Andrew sounded like his father, who had never been diagnosed with mental illness but was prone to paranoia and conspiracy theories.

Andrew had reached the age when, experts say, a typical life can start to veer off course. It is generally believed that some people have a greater biological risk of developing psychotic disorders than others. Genetics can play a role. Environmental factors like stress can trigger the onset of illness or make it worse than it would have been. Symptoms tend to begin when people are in their late teens or early 20s, as their brains mature.

Andrew sought out behavioral health services on the base, he said. But he was certain his bosses saw him differently after that. He felt some treated him like he was less capable, while others seemed to think he was faking. He considered ending his life.

In late 2010, long before Andrew was supposed to leave Germany, he wrote his commanding officer saying he no longer believed he could do his job and asking to leave the military, he recalled. The Air Force approved his request for separation, giving him an honorable discharge, records show, but required him to transfer his remaining active duty service to the reserves, he said.

When asked about the circumstances of Andrew’s separation, an Air Force spokesperson, Michael T. Dickerson, said he could not comment on anything related to an individual’s physical or mental health or the nature of his or her discharge.

Andrew flew back to the United States. He was active in reserves in northern California for a period. But his growing fears about government surveillance kept his mind in constant motion. At night, he thought he could hear strangers talking about him through doors and windows. By 24, he’d moved back in with his mom and stepdad in Oroville, the one place he’d dreaded ending up.

First image: Andrew Iles and his sister, Ashley Hill, as young children. Second image: Andrew’s high school ID card. Third image: Andrew’s Air Force portrait. (First and second image: Courtesy of Ashley Hill. Third image: United States Armed Forces.)

Julia Larsen grew up a 40-minute drive from Andrew in a quaint foothills town called Paradise. Her father worked for the post office. Her mother ran a home day care. The youngest of three daughters, Julia was bound by few rules. She spent most of her time outdoors, searching for animals or digging in the red earth. A treasured family photo shows her holding a catfish she reeled in herself.

People who knew Julia as a teenager describe her as bubbly and a free spirit. Her senior superlative in high school was “biggest daredevil.” Her family was always camping or hiking together. On weekends, when her friends came over for backyard sleepovers, her mother often joined them around the campfire. In Julia’s mind, Paradise lived up to its name. But like many young people, Julia was eager to escape the place she was from. So one day, she and some girlfriends struck up a conversation with the local Navy recruiter.

Julia told her parents while the family ate dinner together at the kitchen table. Marty, a Navy veteran with an anchor tattooed to his forearm, was elated. “I couldn’t stop bragging about her,” he would later recall. Candy worried about Julia’s safety overseas but trusted her to make the right decision. The two were more like sisters sometimes than mother and daughter.

Julia arrived at boot camp outside Chicago in June 2012. She was 18. She traded a colorful sweater and jeans for a Navy-issued T-shirt and shorts and lined up to have her hair cut. The recruits marched and swam and studied and shot. It was easier than she expected. Her parents and middle sister came to watch her graduate. They cheered from the bleachers and then celebrated over deep-dish pizza and White Castle hamburgers.

When it came time to specialize, Julia became a flight deck firefighter. She went for additional training in the Florida Panhandle, where she learned to work a high-pressure hose and handle rescue equipment. That fall, she was assigned to the USS Theodore Roosevelt, an aircraft carrier undergoing major upgrades near the Naval base in Norfolk, Virginia. Her home was a cramped bunk with a flimsy mattress deep in the ship’s belly. She placed the few personal possessions she had in a tiny locker and reported for duty.

She doesn’t remember much about the first day or even the first week. But she remembers the comments a supervisor started making about her body, and the way he pressed himself against her when she was chopping lettuce for the salad bar. Later, while she was on dishwashing duty in the ship’s scullery, he approached again, she said. He grabbed her arms and folded them across her chest. Unbuttoned her top. Turned her around. He was bulky, much taller than her 5-foot-7-inch frame, and had a thick, dark mustache. Julia had never felt so helpless. She fought to free herself from his grasp, burning her right wrist on a hot dishwasher in the struggle, but was completely overpowered. Before he could get much further, another young sailor walked in. The supervisor got spooked and scurried out.

Julia told a friend. Then she told the team that handled sexual assault allegations, she said. She wasn’t afraid of repercussions. She had been so excited to enlist. Was this what the rest of her military experience would be like? The Navy gave her the option to transfer to a different ship. For Julia, it was an easy call. She no longer wanted to be on the Roosevelt.

But while the Navy offered Julia a fresh start, it didn’t offer her mental health services, she said, as Department of Defense policies demanded. “I would have taken them up on it,” she told ProPublica. Asked to respond, a U.S. Navy spokesperson said, “While we cannot comment on the care Ms. Larsen may or may not have received, the Navy takes mental health for our Sailors seriously.”

It was, experts said, a crucial missed step. Research shows a clear association between military sexual trauma and mental health conditions including post-traumatic stress disorder, depression and suicidal ideation. Studies have shown treatment can help reduce PTSD and depression symptoms, which sometimes emerge years after the traumatic event.

Julia was assigned to the USS Kearsarge, a massive assault ship that was already in the Middle East to support troops in the global war on terrorism. During her second deployment to the region, in the spring of 2016, a Harrier jet burst into flames departing from the Kearsarge’s flight deck. Julia was startled by the deafening pop. She sprinted toward the burning aircraft with the other firefighters to battle the blaze. “Her initial response, quick action and knowledge during an AV-8B Harrier fire on the flight deck was pivotal in the prevention of a major catastrophe and loss of lives,” her supervisors wrote in her performance evaluation.

Almost four years to the day after she began boot camp, Julia returned to California. She moved into a house in the southern Central Valley with her boyfriend from the Navy and enrolled at the local college. She set a goal of earning a degree in social work and becoming someone who could help veterans. But Julia couldn’t shake the feeling that something was wrong. She had trouble concentrating on schoolwork. Some nights, she couldn’t sleep. She sought out counseling through the VA.

By June 2017, Julia had started feeling scared of the world around her. One night, she was certain she could hear people walking on her roof and called the police. The officers who showed up made her feel even more anxious. She worried they would take advantage of her. She pushed one and wound up at the police station. She was later taken to a psychiatric unit.

As soon as Marty heard what happened, he drove six hours to pick up his daughter. He packed her belongings into suitcases and hitched her car to the back of his truck. On the ride back, Julia was convinced they were being followed. She begged her father not to draw attention by driving too fast or changing lanes. Marty was stunned to see his easygoing daughter acting so out of character. “It was like a switch had flipped,” he recalled.

First image: Julia and her father, Marty Larsen, fishing in the 1990s. Second image: Julia and her mother, Candy Larsen, on a family trip. Third image: Julia’s senior portrait at Paradise High School. Fourth image: Julia’s Navy portrait. (First, second and third image: Courtesy of Marty Larsen. Fourth image: United States Armed Forces.)

For veterans in the foothills like Andrew and Julia, the Chico clinic was all they had.

Its mental health team had been trying for years to convince regional leaders to add more positions. Even when the staff included two psychiatrists and a psychologist, plus a nurse, counselor, social workers and designated mental health administrators, the team struggled to keep up with growing demand, former employees told ProPublica. The clinic had more than 500 mental health patients, many of whom had complex illnesses.

The department’s longtime manager, a psychiatrist named Russell Cottrell, recalled once noticing that other rural mental health departments in the region had more personnel per patient than Chico did, he said. When he asked about the discrepancy, his bosses stopped sharing the data. He fumed, he said.

“I don’t think they paid attention to the growth we had,” Cottrell told ProPublica. “I would point it out and I’d get in trouble.”

By the summer of 2016, the staff had gotten smaller, and Cottrell was the only psychiatrist in the building. Cottrell was no stranger to hard work; an Army veteran, he had devoted his career to treating the most challenging mental health cases. But he was tired of begging for personnel and running out of energy. That fall, he made plans to retire.

The lead mental health nurse, Michelle Angela, sent an email to a regional mental health leader in the wake of Cottrell’s retirement announcement. “We would like to invite you to come visit us at Chico Behavioral/Mental Health for an update on what the plan will be,” she wrote. “In addition to our concerns as staff members, our local veterans have been asking if there will be [a medical doctor] on site for their mental health needs.”

No such doctor was hired. Instead, the clinic filled the gap with a combination of visiting doctors and doctors in other locations who connected with patients through computer screens.

In many ways, the Chico clinic was on the forefront of telepsychiatry, then an emerging way to deliver treatment that had the potential to broaden access to veterans in remote locations. But some mental health professionals had reservations. While virtual sessions might work for some patients, they worried others needed the trust and connection that could only be established in person.

For Andrew, who started coming in for treatment after his father died in 2013, the changes were disorienting. Andrew had been seeing Cottrell and starting to untangle his thoughts. When Cottrell retired in February 2017, Andrew was assigned to a temporary doctor, then a specialized pharmacist who wrote prescriptions, he said. Andrew resented the arrangement. “I wanted to talk to someone routinely,” he said, “not just get a load of meds.”

Julia first arrived at the clinic on June 23, 2017. She wouldn’t maintain eye contact with anyone; while in the waiting room, she rearranged the chairs. That day, clinic staff offered her little in the way of answers. “She was informed that Chico VA Behavioral Health is an outpatient clinic and we do not have a psychiatrist on site,” a social worker wrote in her medical records.

The following month, Julia started coming into the clinic for telehealth appointments with an off-site provider. Her records show she was diagnosed with PTSD from combat and military sexual trauma and bipolar disorder, the latter of which she disputes.

For a while, the patchwork system in the clinic’s mental health department seemed to be working, current and former employees told ProPublica. But cracks started to show. In 2018, the psychologist left. And the clinic sometimes found itself without a telehealth provider available to refill medications or see patients in crisis, emails obtained by ProPublica show.

That November, a wildfire started burning up in the foothills. It was called the Camp Fire because it originated off Camp Creek Road. The blaze grew into a raging inferno that affected virtually everyone in the region. More than 10,000 homes were destroyed, including the one belonging to Marty and Candy Larsen where Julia grew up. At least 85 people died.

The day after the fire, when the air was still heavy with smoke and ash, Cottrell showed up at the clinic to help. He knew the fire would increase the demand for mental health services, he said. Seven months later, he came back on a part-time basis to help out until the clinic could hire a new full-time psychiatrist on site.

Months passed without a hire. Meanwhile, the Chico clinic moved into a gleaming new facility just a few miles away. The VA’s website trumpeted its status as a green building with energy-reducing and cost-saving features. But none of that improved the mental health department, former employees said. In fact, the new building eliminated a designated waiting area for veterans in crisis as well as private offices for mental health practitioners, meaning patients were seen in bare-bones exam rooms that evoked a school nurse’s office.

Amid the turmoil, Andrew struggled. When he noticed Cottrell back in the clinic, he wondered if Cottrell hadn’t really retired but had discarded him as a patient. Experts who were not involved in Andrew’s care told ProPublica that the constant provider changes would likely have reinforced Andrew’s paranoia and made him feel less connected to his care. One said the churn would have felt like a parent continually rejecting their child.

Julia’s life had become a rollercoaster. Some days, she felt great. She enrolled at Chico State and floated around its red-brick campus. “She could be very lucid and be her old self,” Marty recalled. “We kept thinking, she’s over it.” But stressors would trigger her. She would flash back to her darkest moments, start feeling paranoid. It wasn’t unusual for her to go days without sleeping.

She wanted counseling, she told ProPublica. But at the clinic, there was never enough time to get into it all. The focus seemed to be more on medication than talk therapy, she said. “They wanted to help me and [then] shoo me along,” she said.

An abandoned swimming pool in Paradise (Loren Elliott for ProPublica)

The strain on the clinic would only get worse.

The same month that COVID-19 swept across the country, the mental health team learned its designated administrative assistant would be shared by several departments. That made managing appointments even more difficult. Not long after that, one of the two telepsychiatrists started seeing fewer Chico patients.

Cottrell had had enough, he said. He decided he would retire for good at the end of the year. “I saw it as a lost cause,” he told ProPublica.

That summer, a psychiatrist on the East Coast was hired to do virtual visits on a part-time basis. But increasingly, technical problems were disrupting appointments.

In emails to regional mental health leaders, Chico’s front-line workers insisted that hiring an on-site psychiatrist should be the priority and noted the VA’s own guidelines, which said veterans who were suicidal, violent or in need of immediate medical attention should not be referred for telehealth services. “We currently have numerous serious suicidal ideation patients,” a nurse named Diana McMaster wrote. “With losing Dr. Cottrell, do we not need a psychiatrist in the building? A lot of times it is left up to Michelle and me to manage what happens with these patients on our side of the video. … That puts us in a precarious position.”

Dr. David Gellerman, the chief medical director for mental health services in the VA’s Northern California region, replied, writing, “No, we are not placing anyone in a precarious position. We can't hire someone who does not exist... if we get a good psychiatrist or [psychiatric nurse practitioner] candidate who can be on location, we can try, but so far we have not had any acceptances.”

Gellerman pointed out that precautions were being relaxed in the pandemic. “Care by telehealth is better than no care at all,” he added.

Reached by email by ProPublica, Gellerman did not comment on the correspondence. He referred a reporter to the VA’s public affairs office that covers the broader region of Northern and Central California, Nevada, Hawaii and the Philippines, which did not respond. A national spokesperson said agency guidance does not establish absolute conditions under which virtual care should not be given.

By then, Andrew had been diagnosed with schizoaffective disorder, a mental illness marked by a combination of schizophrenia and mood disorder symptoms. People with the disorder can experience psychotic symptoms, losing their connection to reality.

Andrew hadn’t been employed since returning to Oroville. He had come to believe people were trying to kill him, even his family. He spent most of his time alone in his bedroom. He slept upright in his computer chair and ate only food that came in a can so nobody could poison him.

Sue quit her job to care for her son. She made sure he had canned food to eat and drove him back and forth from his VA appointments. In conversations with her sister, Sue worried Andrew’s doctors were always changing and he wasn’t getting the help he needed. Ashley felt helpless watching her little brother slip away. He was withdrawn and angry, a far cry from the outgoing kid she remembered. She thought back on how she had tried to protect him when they were children. “It felt like I’d failed,” she said.

The pandemic had rekindled Julia’s paranoia, too, so much so that she began to believe strangers wanted her dead. That May, her oldest sister, Jordan Pepper, a clinical mental health counselor in Ohio, traveled to Chico and helped her to seek in-patient treatment at the VA hospital near Sacramento, California. Doctors there diagnosed her with general psychotic disorder.

Records show Julia went to the Chico clinic in the weeks and months that followed. Candy and Marty took turns accompanying her. Candy made it a point to get to know the people who cared for her daughter, in some cases getting their personal cellphone numbers. She tried to stay optimistic.

In the fall of 2021, the telepsychiatrist who had been seeing Julia stopped seeing Chico patients. That November, Julia had a virtual appointment with a psychiatric nurse practitioner she had never seen before who prescribed a drug called atomoxetine to help her concentrate, her medical records show. But two days later, Julia called back and asked for something that would work faster. The nurse practitioner prescribed an antidepressant called bupropion and instructed Julia to take the two medications together, her records show.

More than a year later, in its report on Julia’s case, the VA’s inspector general would note that the combined use of atomoxetine and bupropion can trigger psychotic or manic symptoms. The nurse practitioner told investigators that despite what his notes said, he had not intended for Julia to take both. It isn’t clear which, if any, Julia took. She doesn’t remember.

Around that time, Julia began taking note of unusual things she believed were happening to her: strangers following her at the dog park, electronic files going missing. She installed a camera in her car and started carrying a pink handgun she bought after separating from the Navy.

The Chico clinic’s mental health department, meanwhile, fell further into disarray, current and former employees told ProPublica. Several other telehealth providers left, including the Connecticut-based telepsychiatrist who was seeing Andrew. Those who stayed buckled under the weight. “We were abandoned,” said Belva Fay, a senior social worker who was also the clinic’s acting manager for eight months. “We were trying to run a clinic with nobody to prescribe medications, nobody to see emergency cases, nobody to talk to these clients who are angry. …

“We kept saying, there is going to be a problem,” Fay said. “This is going to blow up.”

By the time Michelle Gradnigo started as the clinic’s site manager in October 2021, disaster felt all but certain. Gradnigo, a retired lieutenant colonel in the Army and longtime military health care administrator, was so troubled by the lack of on-site mental health care providers that she asked if the clinic’s primary-care physicians could handle some of the load, she said. The answer was no, she recalled.

“I reached out to anyone at the time who would listen and said we are going to kill someone,” she told ProPublica.

Michelle Gradnigo, the clinic’s former site manager (Loren Elliott for ProPublica)

VA officials told ProPublica the Chico clinic was trying to recruit mental health professionals by offering special salary rate increases, education debt reduction and relocation incentives.

Northern California VA leaders were also trying to grow the virtual mental health program. A proposal obtained by ProPublica through a Freedom of Information Act request shows that mental health vacancies were dogging clinics across the region and that “painstaking and time-consuming recruitment efforts” were bearing little fruit. The only positions drawing quality applicants, according to the presentation, were virtual.

The new Chico VA clinic (Loren Elliott for ProPublica)

When the sun rose over the Sierra Nevada mountains on the third morning of 2022, Julia’s eyes were already open.

She had been awake for days, a fact she blamed on what felt like a constant barrage of electric shocks. She had tried to stop them by covering her walls in aluminum foil, but it wasn’t helping. She wanted pills to calm her down. At 8 a.m., she left a message at the clinic that she was “in crisis and very anxious,” government records show. An hour later, she started texting her mother, who called the clinic in tears. The mental health nurse was home that day with COVID, so a nurse from another department took the call.

The nurse sent an instant message to Julia’s nurse practitioner, who was seeing patients from another location, asking if Julia should come into the Chico clinic or go to the VA hospital in Sacramento. The nurse practitioner wanted Julia to go to Sacramento, government records show. But the nurse misunderstood and told Julia’s mother to bring her to Chico.

Marty and Candy brought Julia to the clinic around 2:30 p.m. Her body was tense, her eyes red and heavy with tears. But the nurse practitioner never evaluated her. He had nine appointments that day and no time to see Julia, a violation of VA policy requiring same-day availability for patients in crisis.

A triage social worker tried to ask Julia questions to help determine her risk of suicide or violence, but Julia wouldn’t engage, records show. Instead, she quibbled with her diagnoses and voiced frustration over the recent change in her mental health provider. The social worker should have posed the questions to Julia’s mom, who was inside the clinic while Julia’s dad waited in his truck. Instead, she marked Julia’s disposition as “routine” and concluded she wasn’t a threat to herself or others. There is no indication the social worker asked about Julia’s access to guns or other lethal means.

Later, in an interview with the inspector general’s office, the social worker said she was unfamiliar with the protocols. She ultimately gave Julia the nurse practitioner’s next available appointment, in 11 days.

Julia stormed out of the clinic, furious that she had not been given the medication she wanted, her father recalled. Candy was frustrated; she wanted clear direction on how to help. Exhausted, they all headed back to Candy and Marty’s home, a cozy ranch on a remote hillside outside of Red Bluff, California.

Marty at his home in Red Bluff (Loren Elliott for ProPublica)

Back at home, Candy offered Julia some soup and a sandwich and tried to help her calm down. Julia was still agitated, but around 10 p.m., she took a sleeping pill and retired to her parents’ bedroom. When it was quiet, Candy and Marty got ready to watch a movie in the living room, hoping it might help them relax.

Just before 11 that night, a call came into 911 dispatch.

The recording captured Julia as she pleaded for help, then fired one gunshot, then another. The line stayed open for an hour, chronicling all that unfolded.

After the second bullet fired into nowhere, Candy was determined to lower the temperature. “We are trying to help,” she assured her daughter. “You gotta put the gun down first, honey.” Marty followed suit. “We’re here for you, OK?” he told Julia. “It’s not too late. Nothing bad has happened.”

For a moment, it seemed like Julia might relent. “OK,” she said quietly. “OK.”

Instead, she fired again.

Acting on intuition, Marty leaped at his daughter in an effort to disarm her. He wrapped his arms around her, he said, and tried to overpower her. Could it have felt to her, in that moment, like she was back in the ship scullery, trying to escape the grip of her attacker? It’s impossible to know. But she felt threatened and thrashed with all the strength she could summon, smashing at his ribs and clawing his eyes.

The gun fired again. This time, a bullet struck her mother in the thigh, tearing through a large blood vessel.

Julia didn’t realize. She fought her father for control of the gun for the next 10 minutes, pistol whipping his head until he started slipping out of consciousness. After that, she told him she loved him and went outside. He came to, and by the time she returned, had retrieved his own pistol from a drawer in the kitchen. He warned Julia he would shoot and then did, he said, striking her once in each shoulder and once in the thigh.

When the police had Julia in their custody around midnight, both she and her father were seriously injured. Her mother was dead.

The morning after the shooting, her bereaved sister Jordan called the Chico clinic, she said. She wanted someone there to explain Julia’s mental illness to the authorities, to advocate for her sister. The staff member who answered knew nothing about the shooting. “Oh shit,” Jordan recalled hearing from the other end of the phone.

That afternoon, just before 4, the clinic’s phone rang again.

It was Andrew, who was in a particularly rough place. The departure of his telepsychiatrist had made him feel cast aside yet again. He’d enrolled in an intensive VA program for people with serious mental illness, but abruptly withdrawn, believing the VA didn’t really want to help him. On the call, he asked to speak to a doctor, he recalled. When he didn’t get one, he told a pharmacist that he had not been taking his medication and was feeling paranoid again. The pharmacist encouraged him to restart the prescription and scheduled a follow-up appointment in two days.

“Vet does not appear to be a harm to himself or others,” the pharmacist wrote in Andrew’s notes.

The next day, Jan. 5, Andrew sought out the family shotgun. While Sue had gotten rid of most of the firearms in the house just a few months earlier, Andrew had kept three in his possession.

Around 12:30 p.m., Andrew called 911 and told the dispatcher he had shot his mother. He was standing in the driveway when deputies arrived.

Sue died on the scene.

Ashley first learned there had been a shooting at her mother’s house when a friend called. She initially thought Andrew had taken his own life. She and her husband raced to the house, arriving alongside first responders. Deputies wouldn’t let her on the property until well after night had fallen. Ashley struggled to make sense of what had happened. Officials told her Andrew had performed CPR on his mother. “He tried saving her life,” Ashley said.

Background: A roadside sign in Paradise First image: Marty holding his wedding photos. Second image: Andrew and his mother, Sue Hill, at his boot camp graduation. (Background and first image: Loren Elliott for ProPublica. Second image: courtesy of Ashley Hill.)

Over the course of about 36 hours, employees’ worst fears about the Chico clinic had become reality. Many returned to the office in a state of shock.

Gradnigo, the site manager, requested a chaplain be brought into the clinic. But when she asked her supervisors what the next steps would be, she got no response, she said. Hoping the VA’s central office might intervene, she sent a tip about the shootings to the agency’s inspector general’s office, she said. She withheld her name so she wouldn’t face retaliation.

Gradnigo was fired in March 2022. The reasons provided to her were “inappropriate” comments and interactions with colleagues, records show. Gradnigo says the allegations about her conduct are exaggerated or false. She believes she lost her job because she reported wrongdoing and she is Black. She is pursuing a discrimination claim against the VA. The agency did not comment on the claim and told ProPublica it does not comment on personnel matters.

The inspector general’s office went on to investigate Julia’s case. Its report, which was published in February 2023, ticked off all the ways the clinic had failed, from medication mismanagement to not having a same-day access availability and improperly assessing her risk of violence. But the report did not mention a second patient involved in a violent act. It did not address systemic staffing issues. In fact, the office said it did not substantiate employee claims that facility leaders had failed to address their concerns about mental health staffing. The report found facility leaders had “ensured the use of telehealth and community care.”

The inspector general’s office declined to say why it did not include Andrew’s case in its report or publish a separate review. Spokesperson Fred Baker said the office reviews all complaints it receives. With respect to the employee concerns about staffing, he said, the inspector general’s office “found that leadership was taking steps to fill vacancies.”

The VA declined to make a clinic leader or official at its regional office in Sacramento available for an interview. In a statement, a Washington, D.C.-based spokesperson, Joseph Williams, said the agency “fell short” in treating Julia. “This incident does not represent the quality of care Veterans have come to expect from our facilities, or the standard to which we hold ourselves accountable, and we have taken several measures to ensure that it does not happen again,” he wrote.

The agency later said it could not answer specific questions about the care Julia or Andrew received due to privacy concerns.

After the shootings, the Chico clinic hired an on-site psychiatrist and an additional social worker, according to the inspector general report. The psychiatric nurse practitioner who prescribed the medications to Julia resigned. For the last several months, the mental health team has been fully staffed, the VA told ProPublica.

Andrew was charged with his mother’s murder in January 2022. He remains in the Butte County Jail. As early as this month, a judge could determine whether Andrew was legally sane at the time of the killing.

In an interview with ProPublica, Andrew described being stuck in a loop when he fired the shotgun. He was convinced his mom was poisoning him, something he now says was a delusion. “I love my mom,” he said. “I wish she was here.”

The Butte County Jail (Loren Elliott for ProPublica)

He doesn’t want to scapegoat the military or the VA for what happened, he said. He accepts responsibility. But he stressed that he had tried to get help from the VA repeatedly. “I do believe if there had been some form of intervention on their end, this might not have happened,” he said.

Ashley stayed in Oroville for a while, but it became impossible to go grocery shopping without someone staring at her or asking about her mother. “It felt like we were on display,” she said. Over the summer, she moved to Texas with her husband, young son and stepfather. She’s hoping to give her son the childhood she and Andrew never had.

Ashley is still mourning her mother, whom she described as a devoted grandmother and her closest friend. She has also been doing whatever she can to support Andrew in jail. She calls and texts him regularly and makes sure he has enough money in his account for the commissary. When he texted about playing Dungeons & Dragons recently, she replied like a mother might. “I’m so happy that you’re doing something fun,” she wrote. “I love you, Andrew.”

Ashley and her family at home in Texas (Loren Elliott for ProPublica) Andrew in court in December (Loren Elliott for ProPublica)

Julia was also charged criminally for her mother’s death. In January 2023, she was found not guilty by reason of insanity. She is now a patient at Patton State Hospital, a sprawling forensic psychiatric complex at the base of the San Bernardino Mountains about 60 miles east of Los Angeles. She reads books in the library, helps organize group activities like bingo and keeps her fingernails painted vibrant colors. She has a journal with positive affirmations on each page; she writes down the things she’s grateful for.

For some time after the shooting, Julia didn’t know she had caused her mother’s death. It was only after listening to the 911 recording months later that she began to understand what had happened. Coming to grips with that has been excruciating, she said. Her mom was her best friend. On a recent afternoon, during an open mic event at the hospital, she read a poem she wrote about their relationship. Audience members were brought to tears, she said.

It is hard to say what prompted the shooting. She recalls hearing an explosion in the distance — maybe a gas tank — and feeling like she needed to protect herself from some unknown threat. “It felt like I was unconscious, not awake,” she told a psychologist who evaluated her in January 2023, records show. “It felt like I was in a video game.” The psychologist speculated the explosion triggered her PTSD and may have put her in a dissociated state.

Julia isn’t sure how long she’ll be at Patton. She would have to be cleared by the hospital and the court to be released for supervised treatment in the community.

First image: Julia at Patton State Hospital. Second image: The poem Julia recently wrote and recited. (First image: Loren Elliott for ProPublica. Second image: Courtesy of Julia Larsen.)

It has taken many months for Marty to begin recovering. His ribs were fractured and his back was broken in two places. He needed 15 staples in his head. The emotional recovery, he knows, will be much longer. He’s chosen to stay in the hilltop ranch where the shooting took place. He bought the property to grow old there, and that’s what he still intends to do. He finds comfort in his fruit trees and livestock and the sweeping mountain views.

He said he forgives his daughter. He keeps her military photo in his wallet. But he is furious at the VA. “I want to punch VA in the face,” he said one afternoon late in the summer, while the sun poured into his den. To him, it was obvious what had needed to happen and what went wrong.

It crystallized deep in his mind the night of the shooting, after Julia had finally relented and he picked up Candy’s cellphone to speak with the 911 operator.

“She really, really needs help,” he told the operator while waiting for the police to come and arrest his daughter. “We tried to get her help at the VA. And, God, the VA didn’t really help that much.”

The dispatcher was empathetic. She’d heard Julia’s cries for help all night; dozens of them were captured in a recording of the call.

“I’m sorry the VA didn’t help her,” the dispatcher said.

Editor’s Note

After reading a February 2023 report by the Department of Veterans Affairs’ Office of Inspector General about inadequate mental health care at a VA clinic in Chico, California — a document that did not name any veterans or health care professionals or provide specific dates — ProPublica reporters wanted to more fully understand the tragedy that unfolded and what lessons it offered for the larger VA health care system. They spent months investigating the case at the center of the report involving a veteran named Julia Larsen as well as a second case involving a veteran named Andrew Iles who was also treated at the clinic.

The reporters interviewed Julia in person at Patton State Hospital near San Bernardino, California, and spent many hours interviewing her by telephone and video call. They traveled to St. Louis to meet with her attorneys. They reviewed hundreds of pages of her military personnel and medical records, as well as police reports from the night of the shooting and transcripts of interviews Julia gave to detectives and psychologists after her arrest. They listened to the 911 call Julia’s mother, Candy Larsen, made before she died. They interviewed Julia’s father, Marty Larsen, at his home in Red Bluff, California. They interviewed her sister Jordan Pepper, childhood friend Brittney Apel and former boyfriend Ignacio Gutierrez by telephone. In addition to Brittney and Ignacio, who served in the Navy with Julia, they interviewed four other people who knew Julia from the military, one of whom Julia told about the sexual assault and corroborated her recollections. They also interviewed Laurie Smith, a close friend of Julia’s mother.

The reporters interviewed Andrew in person at the Butte County Jail in Oroville, California, and by telephone. They reviewed some of his medical records, military performance reviews and discharge records, as well as his court records and family photos from his childhood. They interviewed his sister, Ashley Hill, at her home in Texas and his half-brother William Iles, aunt MaryJo Hendricks, former girlfriend Kayley Reni and childhood friend Alex Kenworthy by telephone. They interviewed a second childhood friend who declined to be named.

Both Julia and Andrew consented to ProPublica publishing information from their medical records about their diagnoses and medical histories.

To better understand the issues at the Chico clinic, the reporters interviewed a half-dozen current and former employees. They reviewed emails sent between 2016 and 2022 that detailed staffing issues, as well as hundreds of pages in former site manager Michelle Gradnigo’s discrimination complaint. They also reviewed an internal proposal from 2021 to grow the virtual mental health program and documents from the Office of Inspector General’s investigation obtained through Freedom of Information Act requests.

To put the case into broader context, the reporters reviewed and analyzed more than 300 routine inspections and investigative reports published by the VA’s inspector general since January 2020, some examining events that occurred in 2019. They brought their findings to experts and interviewed the relatives of three veterans who died by suicide after receiving inadequate mental health care from the VA. They reviewed national reports on mental health staffing and outcomes.

Overall, the reporters spoke to more than a dozen mental health professionals, researchers and policy experts. They consulted with some on how to interview people who have experienced trauma and been diagnosed with severe mental illness. They asked others to describe how the treatment Julia and Andrew received from the Chico VA clinic differed from generally established standards of care and offer insight into the issues facing the VA’s health system.

Loren Elliott contributed reporting. Design and development by Anna Donlan.

If you have information about mental health care services provided by the VA, email VAmentalhealth@propublica.org.

Correction

Jan. 8, 2024: This story originally misidentified an aircraft that caught fire. It was an AV-8B Harrier, not an AV-9B Harrier.

by Nicole Santa Cruz, photography 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.

For nearly a year, Melanie Call struggled to balance working from home full time with caring for her new baby.

Her job as a project manager for a Salt Lake City health care staffing agency required spending hours in video meetings. If her son was awake, she would turn off her camera. When he woke from a nap while she was already occupied in a meeting, she would feel her guilt grow as she heard him cry through a baby monitor.

Call, who is married to an architectural designer, had an older daughter in elementary school and a younger daughter already in day care, and wasn’t sure she could afford to send another child.

Having two children in day care would have consumed nearly 20% of her family’s take-home pay, despite her and her husband making six figures combined. Eventually, she put her son on three waiting lists for day care, but before she could find an opening she reached a breaking point and quit her job. A week later, a day care slot opened up.

Melanie Call puts Liam Call in his car seat outside of her mother’s home in Draper, Utah. Call said a lack of affordable day care and support for working mothers prompted her to quit her job at a health care staffing agency.

“I wanted to work but I just didn’t have enough support,” Call said, describing a “layer cake” of challenges: unaffordable and scarce day care and a workplace that was unwilling to accommodate her circumstances as the mother of three young children.

Utah, with the nation’s highest percentage of children, has faced a decadeslong day care crisis. A larger proportion of Utahans live in areas with few or no licensed child care facilities than in any other state, according to a 2018 analysis of census and licensing data by the left-leaning Center for American Progress, the most recent available. A 2020 report by the state’s Office of Child Care found that Utah’s child care capacity was meeting only 35% of its needs.

Federal pandemic relief funding eased the shortage by helping day care owners cover basic expenses like rent and supplies. After Utah received nearly $574 million in aid during 2020 and 2021, the number of licensed child care slots rose by about 30% from March 2020 to August 2023, according to a report by Voices for Utah Children, an advocacy group. The funding also provided child care subsidies to more lower-income families.

But on September 30 most of that federal funding expired, and Utah legislators have rejected proposals to replace it with state dollars — continuing decades of local opposition to expanding and improving outside-of-home care for young children.

The result, according to working parents and child care providers who spoke to ProPublica, is that a state billing itself as the most “family-friendly” in the nation does too little to ensure that care for children of working parents is accessible and affordable.

The child care providers who spoke to ProPublica said the federal funding kept them in business. Now, with the loss of that money, most said they are being forced to raise their rates or let employees go and care for fewer kids while working longer hours for less pay. Some said they are considering closing their doors and changing careers.

An estimate by the Century Foundation, another left-leaning think tank, projected that Utah is one of six states where nearly half of licensed programs could close.

“I see teachers burned out. I see parents leaving the workforce,” said Brigette Weier, an organizer with Utah Care for Kids who works with Voices for Utah Children. “I see parents sobbing when they find child care. I see parents sobbing when they can’t find child care.”

Legislatures in other conservative states have provided their own taxpayer money to help compensate for the loss of federal funding. The Utah Legislature, which convenes this month, has a long track record of opposing such assistance.

The Utah State Capitol

ProPublica spoke to three dozen people involved in child care in Utah, including parents, child care providers, policymakers and advocates, about the impact of the funding loss. They attributed lawmakers’ resistance to subsidizing child care, in part, to the makeup of the Legislature — 74% of lawmakers were male as of 2023, and an even bigger share are Republicans. Some older lawmakers haven’t dealt with the current economic and caregiving realities confronting young parents, they said, or view child care as a personal, not societal, problem that shouldn’t require government intervention.

Johnny Anderson, a Republican state legislator from 2009 to 2016 and president of Utah’s largest private child care provider, ABC Great Beginnings, said among lawmakers there’s still that sense that child care “is a choice rather than a necessity.” And conservative legislators view providing state funding “as a way to manipulate the free market,” he said. “But we all know that child care is a failed market: Child care is not able to charge enough tuition to cover the costs” of providing quality care.

In addition, those who spoke to ProPublica noted that most Utah state lawmakers are members of the Church of Jesus Christ of Latter-day Saints, which emphasizes women’s role as the primary caregivers for their children and has historically discouraged mothers from working outside the home. This religious and cultural influence, while typically going unspoken in public debates, creates added resistance to state child care assistance, some advocates told ProPublica.

The Brigham City Utah Temple

Call, who is a member of the church, said she was taught that it is her divine duty to care for her children. That adds to the pressure for her to stay home with them. But she doesn’t believe it prevents her from being ambitious in pursuit of a career. She said she would like to see state and church leaders acknowledge that.

“Why do we have to choose between having our careers and raising children?” she asked. “Why can’t we have both?”

Melanie Call prepares hot chocolate for her three children at their home in Sandy. “A Gut Punch for Child Care”

Parents placing their kids in day care can choose in-home care, which typically involves smaller groups of children at a provider’s residence; or center-based care, larger group settings where classrooms sometimes separate children by age. Regulations dictate the number of staff per child based on the age group. Because of the demands of caring for infants and younger children, the ratio of caregivers to children is lower for those ages.

Utah child care operators and workers, who are overwhelmingly women, have for years been pinched by uncertain enrollment and low pay, causing perpetual staffing shortages. People who work in child care in Utah are about four times more likely to report having multiple jobs than those in the overall workforce, according to a 2022 survey of 10,000 child care workers by the state’s Department of Workforce Services. Benefits such as health insurance and paid sick leave are not available to most child care workers in the state.

Labor costs make up a majority of a day care’s expenses. But it’s impossible for providers in the U.S. to charge enough tuition to pay significantly higher wages while keeping child care affordable without government aid, according to a 2017 U.S. Department of the Treasury report on the economics of child care.

Federal policymakers have attempted to address this with subsidies for lower-income families. In Utah, a family of three qualifies for a subsidy if their annual household income is less than $71,940.

Last year, the state child care office raised the income limits to receive a subsidy. If a family receives a state subsidy, their co-payment is capped at 7% of their household income. If the family is slightly above the income requirements and doesn’t receive a subsidy, they could spend as much as 38% of their income on child care, according to a 2020 Utah Office of Child Care report.

In 2022, the average pay for child care workers in the state was $13.10 an hour, compared to the national average of $14.22, according to the U.S. Bureau of Labor Statistics. To receive the federal pandemic grants, providers were required to pay a majority of their employees at least $15 an hour.

Annette Wasden, an in-home care provider in Clinton, north of Salt Lake City, said she used the grants to hire two additional employees, who she can no longer afford. She plans to close her day care and leave the state. Wasden, a second-generation child care provider, said the work is her passion but she doesn’t feel respected.

“They don’t fight for us, our Legislature. They don’t have my back,” she said. “We do not have a voice in this line of business, or even in Utah.”

In September, Anderson, the ABC Great Beginnings president and former legislator, sent two letters to his customers. One detailed why the company needed to raise its rates by an average of about 5% after the relief funding ended. The other urged parents to contact their state representatives and “tell them that the Legislature needs to provide additional and adequate funding for child care” to avoid program closures and tuition increases.

ABC Great Beginnings’ payroll costs rose by about 50% after receiving the stabilization grants, according to the letter. Recently, Anderson has also seen vacancies in his classrooms, which could be due to the state’s expansion of all-day kindergarten. Anderson also wonders if raising rates has led families to turn to child care that is unpaid or unregulated, which is difficult to track. Enrollment at his 15 Salt Lake City area centers has declined 6% compared to last year.

“It’s a gut punch for child care,” he said of the funding loss. But any state response would require families and teachers to engage in “a humongous campaign to make legislators more aware of it.”

A child plays with a toy cash register at Sharon Miller’s day care in Helper, Utah. “Most of Us Would Qualify for Food Stamps”

As director of the Utah Women & Leadership Project at Utah State University, Susan Madsen has traveled around Utah over the past two years asking hundreds of women and girls about their biggest concerns. Child care is “an issue in every single county,” she said, but “rural counties are really struggling.”

Downtown Helper, Utah

The U.S. Department of Health and Human Services considers child care to be affordable if it consumes no more than 7% of a family’s income. An October report by Voices for Utah Children found some counties where families spend more than 17% of their income on child care — all but one of them rural. And licensed child care is scarce in rural areas of the state, with capacity for only 36% of the children under six whose parents work.

Aleatha Child runs a home-based day care in northern Utah’s Box Elder County, which has one of the worst shortages of licensed child care spots in the state, according to the Voices for Utah Children analysis. The bright blue walls of her basement classroom are full of art by the children she cares for, along with notes bearing inspirational messages: “We are all different! But together we are strong and look beautiful” and “You are enough just as you are.”

A child plays at Child’s day care.

She said the federal grants paid for an additional staffer, as well as supplies and toys and replacing aging carpet in the classroom.

As the funding ended, Child considered closing her day care and working at her son’s elementary school, either in the cafeteria or as a teacher’s assistant. She’d still be around children, she reasoned. But for now she is keeping her day care open, raising her rates and cutting expenses where she can. She said she’s begun selling blood plasma to make ends meet.

“It hurts me thinking about” closing, she said. “I have so much joy with these children that I have in my program. I have such a strong bond and connection with their families, with them.”

Child talks with children during snack time at her home daycare.

Sharon Miller, the only day care provider in the central Utah town of Helper, has reduced her hours and enrollment since the grants ended. The money had allowed Miller to hire help, but she recently returned to working alone.

“Every penny I make is just to survive,” said Miller, who in 2019 was named a Provider of the Year by the Professional Family Childcare Association of Utah. Miller, who has provided day care since 1999, said most years she doesn’t make a profit, even when she has gone without a salary. In 2019, before the stabilization grants arrived, she reported a $17,000 loss from her business, according to tax returns she shared with ProPublica.

Miller with several children at her day care: “It’s important that the kids learn how to communicate. I want to set them up for the real world.”

Miller fractured her lower spine in a fall from a ladder in July and wears a back brace during her 10-hour-plus workdays. On a recent afternoon, she watched children as they rode tricycles around her backyard, which she has transformed into a colorful playground with a sandbox, garden, stage for performances and space for creating art projects. The children dropped toys at her feet, but she avoided bending down for them because of the lingering pain in her back.

Miller said she wishes state lawmakers could see firsthand what it takes to provide good child care. Legislators say they support small businesses, she said, but don’t seem to consider that her day care is a small business. House and Senate leadership did not respond to requests for comment.

“We’ve always just taken whatever we can get and just keep going,” she said. “And I think people are to the point where they’re done doing that. It’s really not fair to ask us to keep doing that just because most of us would qualify for food stamps on our incomes.”

Kids watch a children’s dance video at Miller’s day care. “Farmed Out”

Some conservative states have stepped in to help child care operators as federal funding dwindles. Alaska set aside an additional $7.5 million for day care owners. Louisiana made its largest investment in more than a decade to its child care subsidy program for lower-income families. North Dakota added $66 million in new funding to its budget for child care.

In Utah, state Rep. Andrew Stoddard, a Democrat, last January requested $216 million to pay for a one-year extension of the stabilization grants. He told the Legislature’s Social Services Appropriations Subcommittee that this would “prevent the collapse of the system” and cited figures from the U.S. Chamber of Commerce Foundation estimating the child care shortage costs Utah’s economy $1.36 billion a year. “That amount that we’re losing in tax revenue is more than this ask,” he told the committee.

The committee’s chair at the time, Sen. Jacob L. Anderegg, a Republican, said, “If I’m a betting man I’d give you almost next to no odds of getting $216 million.” Anderegg instead recommended a “more balanced” approach — a $5 million request — that went nowhere.

Indeed, even modest child care measures have consistently faced resistance.

In 2020, Rep. Suzanne Harrison, a Democrat, proposed a tax credit for businesses that subsidized or provided licensed child care for employees. She argued the bill would help businesses attract workers and increase access to care.

During a hearing, Rep. Mark Strong, a Republican, questioned whether it was the government’s role to provide such assistance. “I struggle with taxing people, all people, some to cover these for everyone.” Strong, who is a sales representative, acknowledged his wife had been able to stay home and care for their six children.

“It was really disappointing that a modest tax credit to support working families was not more favorably considered,” Harrison, now a member of the Salt Lake County Council, told ProPublica. She didn’t propose any child care legislation during the remainder of her term, which ended in 2022.

Last summer, child care advocates presented to the Legislature’s Economic Development and Workforce Services Interim Committee a report on the economic impact of the state’s lack of affordable child care, the same report Stoddard cited in his funding request.

Strong, a member of the committee, said in response that no one can “provide parenthood like a parent” and that the Legislature shouldn’t incentivize “farming” out children. “What is the ongoing economic impact of a child that is raised in a stable safe home by parents, not being farmed out?” he asked. Strong did not respond to a list of questions from ProPublica.

Advocates said Strong reflects the attitudes of some in the Legislature who view bolstering child care as contributing to the erosion of families.

Rep. Susan Pulsipher, a Republican, sponsored and helped pass legislation in 2022 to increase the number of children an unlicensed provider is allowed to care for. The change was criticized by some child care providers as unsafe.

Pulsipher also sponsored another successful piece of legislation that established a tax credit of $1,000 for families with a child between the ages of one to three. Pulsipher, a homemaker with 20 grandchildren, said the credit allows families to pay for the kind of child care they want, whether at home, at a center or at an in-home provider. But because the tax credit is nonrefundable, meaning it can only be used if a family owes taxes, and limited to lower-income families, only an estimated 1.4% of state taxpayers would benefit from it, according to an analysis by the Institute on Taxation and Economic Policy.

“I don’t think it’s enough,” Pulsipher acknowledged. “But it’s a start. And we need to start and we need to keep going.

“Her Place Is in the Home”

Some child care operators and policy advocates say the teachings of Mormon church leaders contribute to lawmakers’ reluctance to support child care. Forty-two percent of Utah adults consider themselves members of the faith, according to a recent study.

Colleen McDannell, a professor of religious studies at the University of Utah, said church leaders have long encouraged women to pursue an education but have not dealt with the notion that women in the church are transitioning from having part-time jobs to having careers.

While Utah ranks last in the nation for the share of children under six with both parents in the labor force, the percentage of mothers who are working has in the past five years increased to 64%.

“One of the ways that the LDS church deals with difficult things is just to not talk about it — it just disappears from the public conversation,” McDannell said. “So if you add that, along with the notion of a red, Republican individuality — that if you want to work, that’s fine, you should just go and figure out how to do it yourself — that means you’re going to have a difficult time with child care.”

The Brigham City Utah Temple is seen from a nearby neighborhood.

Spencer W. Kimball, the church president from 1973 to 1985, preached that husbands should support the family and “only in an emergency” should wives work. “Her place is in the home, to build the home into a heaven of delight,” said Kimball. He attributed the rise in divorce rates to women increasingly working outside of the home.

His successor as church president, Ezra Taft Benson, gave a 1987 address in which he said that “among the greatest concerns in our society are the millions of latchkey children who come home daily to empty houses unsupervised by working parents.” Benson also encouraged young couples to not delay having children and reiterated that a “mother’s calling is in the home, not in the marketplace.”

In 1995, as the church became an increasingly global organization, its leadership issued “The Family: A Proclamation to the World,” which summarized teachings on gender roles, among other things. It called for egalitarian relationships in the home but designated women as “primarily responsible for the nurture of their children.”

Today, there’s a “gentle recognition” among church leadership that many women must work, said Patrick Mason, a Utah State University professor specializing in Mormon history: “It’s not really a retreat from the ideal; it’s just kind of an acknowledgement of economic realities.” Yet, he added, “the church has never repudiated those former views — you won’t find statements like that. So it’s marked mostly from an argument from silence.”

The result, Mason said, is that older lawmakers may hold on to earlier teachings and “create policies that incentivize the ability of mothers or possibly fathers, but primarily mothers to stay home with the kids.” The church declined to comment for this story.

Rep. Ashlee Matthews, a Democrat who campaigned on improving child care, is a mother of two young boys and an office manager. She said she has had “hard” conversations with legislative colleagues, explaining that the economic realities have changed since older lawmakers raised their kids. Most households need two incomes, she tells them, and child care isn’t a “mom” issue, it’s a parent issue.

Advocates have succeeded with local approaches in places like Park City, where the City Council recently voted to add $1 million to its budget for early childhood education and child care, including scholarships for lower-income families. Park City launched the assistance program this year. It might be the only city in Utah to provide such funding, said Kristen Schulz, the director of the Early Childhood Alliance at the Park City Community Foundation.

In arguing for the proposal, Schulz said, she framed it as an investment in children rather than a city expenditure: The money would help the economy and community and increase equality. “Depending on what people are really concerned about, I feel like there’s a lot of good arguments,” she said.

“Life Is About Choices”

During its 2024 session, the Utah Legislature will consider a variety of proposals to boost public investment in child care. One would extend the expiring stabilization grants for two years at 50% of the federal level, at a cost of $120 million annually. Another would expand Pulsipher’s child tax credit. And yet another, backed by Sen. Luz Escamilla, the Democratic minority leader, would create a pilot program to retrofit vacant state buildings into child care facilities.

Gov. Spencer Cox’s proposed budget supports Escamilla’s plan and expansion of the tax credit.

Escamilla said that for many years ”child care wasn’t even part of the conversation in the Legislature” but the issue has gained some traction as more female lawmakers have been elected.

Call, who left the workforce because of her inability to find affordable child care, said the year since then has been “healing.” She’s looking to start a business and has been involved with organizations advocating for increased support of Utah’s working mothers, including subsidies to lower the cost of child care. She has contacted lawmakers and become more outspoken at church about women’s dual roles as caregivers and professionals.

Call after a meeting with a staffer from the office of U.S. Rep. Blake Moore to discuss child tax credits and child care. Call has advocated for more support for Utah’s working mothers, including child care subsidies.

Last October, Call, with her toddler son and then-12-year-old daughter, traveled to the state Capitol for a “stroller rally” in support of child care. From a podium in the Hall of Governors, she shared her story about leaving the workforce.

“Life is about choices,” she said. “So we must ask ourselves: What choices are we providing to Utah’s women, parents and caregivers?”

Mollie Simon contributed research.

Clarification, Jan. 5, 2024: A photo caption stated U.S. Rep. Blake Moore did not show for a scheduled Zoom call to discuss child tax credits and child care. Moore’s office said it was a staff-level meeting and the congressman was not scheduled to meet with Melanie Call.

by Molly Parker, Capitol News Illinois

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

The judge responsible for the administration of a troubled juvenile detention center in rural southern Illinois abruptly moved to close it as of Dec. 31, citing staffing shortages that made it difficult to meet new state standards governing the treatment of youth in custody.

The Franklin County Juvenile Detention Center had been featured in a November report by Capitol News Illinois and ProPublica that exposed the state’s lax enforcement of its own standards, despite audits that repeatedly found poor conditions at the facility.

Those standards were updated by the Illinois Department of Juvenile Justice in 2021; the changes aimed to improve education and mental health services for detained youths, and to limit the use of restraints and seclusion, or locking kids alone in their cells for hours. But in an inspection the following year, the state agency described the Franklin County Juvenile Detention Center as a “facility in crisis”: It did not provide the required mental health care, schooling and recreation for the children in custody, and staff locked youth in their rooms for up to 24 hours for behavioral infractions or because of short staffing. Facilities are only allowed to use seclusion to prevent someone from harming themselves or others.

That same year, the Illinois Supreme Court, which shares oversight of the state’s juvenile detention centers, also found that the Franklin County center did not meet its standards. In the summer of 2023, the facility was sued by the American Civil Liberties Union of Illinois, alleging it had violated youths’ constitutional rights by subjecting them to excessive forms of restraint and seclusion while denying them adequate education and mental health services. The facility had still not come into compliance as of the end of 2023.

In the face of these reports, in the late summer and fall of last year, the Franklin county board publicly debated the fate of the building, which is owned by the county. In hopes of keeping the juvenile detention center open, the board approved about $200,000 for upgrades. Earlier, workers’ salaries had also increased from $28,000 to $43,000 annually, according to the juvenile justice department’s January 2023 audit.

The November article by Capitol News Illinois and ProPublica found that some of the conditions noted by state auditors more than a year prior had continued at the facility in Benton, as well as in some of the other 15 juvenile detention centers where problems had been identified.

The news organizations’ reporting also revealed that the center’s staff often relied on backup from the local sheriff’s office, which sometimes used restraints in ways that are not typical or not allowed in juvenile detention centers, as law enforcement records obtained by Capitol News Illinois showed. Franklin County Sheriff Kyle Bacon defended the actions of his deputies and said that he did not believe his office was bound by the state standards for juvenile detention centers as his office was not involved in the center’s administration.

Despite these mounting concerns, the closure of the Benton detention center took some county officials, state lawmakers and employees by surprise. One longtime employee told county officials during a Tuesday night board meeting that staff were “blindsided” by the announcement four days before Christmas.

Two state lawmakers who represent the region, Rep. Dave Severin, R-Benton, and Sen. Terri Bryant, R-Murphysboro, expressed frustration that they had not been made aware of closure plans in advance and had learned of them from an employee after the decision was made.

Melissa Morgan, chief judge of the 2nd Judicial Circuit Court of Illinois, who made the closure decision, declined an interview through her administrative assistant.

Her court issued a statement about the closure late last week. It did not mention the critical audits, but it did say “workforce shortages” made it difficult to comply with the new standards and laws.

Youth detention facilities in Illinois operate like adult jails and hold youth in custody while their cases are pending in court. When the 32-bed facility closed last month, it housed only a handful of youth, though it was designated as a holding place for 26 southern Illinois counties — the lower quarter of the state. Most youth from those counties will now be sent to facilities in metro-east Illinois, bordering St. Louis, or out of state, potentially moving them further from their support systems.

The news organizations’ November reporting highlighted the fact that Illinois officials charged with inspecting the detention centers have little authority to enforce compliance. State Sen. Rachel Ventura, D-Joliet, said that she is in talks with state and court officials about how to strengthen that oversight. She said the many layers of government involved complicates the process, but she plans to propose legislation in the spring session of the Illinois General Assembly that would streamline the process for closing facilities.

Kevin Fee, a staff attorney with the ACLU of Illinois, said that his organization sued the facility in June when it found that the troubling state audits had not led to improvements.

Lawyers for the court and the county denied the allegations in court filings in November. The case is pending, though it may be rendered moot because it sought to improve conditions for youth into the future, not to win remedies for those it alleged had been previously harmed.

“I think that the closure of the facility is a good outcome, and we read it as an acknowledgement that the facility really has not been serving the youth that it houses adequately for some time, as we alleged in our lawsuit,” Fee said. “We hope that other facilities in the state that house youth will use this to measure their own conditions, and we’ll continue to monitor them.”

by Patrick Lohmann, Source New Mexico, and Byard Duncan, ProPublica

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

If an arsonist or a construction company had ignited the fire that destroyed Meg Sandoval’s home and nearly everything she owned, New Mexico law would have allowed her to seek compensation for the stress of being forced to flee, the anguish of losing cherished belongings and the depression that set in as she remained in exile hundreds of miles away.

With few possessions to her name before the fire, that money would be a monumental help as she starts over.

But because the wildfire was accidentally triggered by two planned burns set by the U.S. Forest Service, Sandoval and other victims can seek compensation from a federal claims office only for things that have a price tag, like cars, houses and cattle.

That is the predicament facing many residents of northern New Mexico a year and a half after the biggest wildfire in state history drove them from their land and destroyed more than 430 of their homes. Despite what New Mexico law allows, the federal government claims it cannot follow it.

Officials with the Federal Emergency Management Agency say a federal law establishing a $4 billion fund to compensate wildfire victims limits those payments to tangible expenses like destroyed property, lost business and medical expenses.

FEMA officials have said that they “consulted with” the New Mexico attorney general’s office about their conclusion that the law does not permit them to pay for what’s called noneconomic damages. But the attorney general’s office told Source New Mexico and ProPublica it doesn’t agree with FEMA’s conclusion. A year ago, the attorney general’s office filed a public comment on FEMA’s proposed rules, saying victims of the Hermits Peak-Calf Canyon Fire should be paid for noneconomic damages.

Now FEMA is being sued by victims who claim the agency is improperly denying them the money they deserve for the federal government’s mistake.

People with high-dollar ranches and some residents of a hard-hit subdivision with a golf course have already received substantial checks for their losses. Other residents, particularly renters and those who lived on familial homesteads, stand to get small checks because they didn’t own their homes or cannot prove to FEMA’s satisfaction that they did.

Many low-income victims of the fire lived sparely, counting the beauty and bounty of their land among their greatest assets. Payment for intangible losses could add up to more than they will get for the loss of their possessions.

“FEMA is punishing poor and middle-class people, the very people who need help the most,” said Gerald Singleton, a California lawyer representing more than 1,000 fire victims. “It will not have any effect on the wealthy, but it will be crippling to the poor and middle class.”

Some said they feel particularly betrayed because President Joe Biden promised the government would “fully compensate” victims for the Forest Service’s mistake.

A FEMA spokesperson declined to comment on Singleton’s criticism because of pending litigation. But she said the agency strives to treat everyone equally regardless of their income.

“One of the Claims Office’s cornerstone values is equity,” FEMA spokesperson Danielle Stomberg wrote in an email. “The Claims Office is required to compensate all claimants for their losses consistent with the law, and we encourage all claimants to submit their claims and all their documentation.”

At least 25,000 people were ordered to evacuate after the Forest Service’s botched burns escaped and raced across the mountains in April 2022. Many fled more than once over the two months that it took to bring the blaze under control. Some like Sandoval had nothing to return to.

Six years ago, she moved to a ranch in the Sangre de Cristo Mountains that has been in her family since the 1840s. Her elderly parents needed someone to help take care of them and their home, so she moved in with them and remained even as they spent less time there in the past few years.

She had no lease, no rent, no mortgage — no paperwork at all to formalize the arrangement. But between the old mobile home on her family’s land and her Social Security check, the 67-year-old expected to live comfortably for the rest of her life. Then the wildfire came, eventually taking her home, her possessions and her cat, Jinx. She still hasn’t returned to the ranch.

Hermits Peak, not far from where one of the U.S. Forest Service’s prescribed burns escaped and grew into a wildfire, is visible from Sandoval’s family property. She said flames were more than 100 feet high the day the fire ripped through her family’s ranch, burning so hot that glass in her house melted and guardrails on the nearby road “melted into metal ribbons.” (Adria Malcolm for ProPublica)

Though Sandoval was forced to live in Colorado for more than a year after the fire, she expects to get nothing from FEMA other than several thousand dollars for a few possessions and the cost of relocating. Her parents owned the mobile home and have filed a claim for it, but her father, Moises Sandoval, said he and his wife don’t plan to rebuild. The family corporation that controls the land is considering other options, including a guesthouse only for short-term stays, he said.

Living arrangements like Meg Sandoval’s are common in the area. Families that have owned land for generations offer spots to relatives without transferring deeds or subdividing the land.

“In northern New Mexico, they haven’t really had a real good incentive to put title in the names of whoever the new, current owners are,” said Scott Aaron, a former lawyer for the city of Las Vegas, New Mexico, who now represents residents in land disputes. “There was never a reason to until the fire hit and FEMA came in with millions of dollars.”

Sandoval’s living situation was her version of a pension. “My retirement plan is destroyed, and I can’t get that back again,” she said. “And now with the prospect of having that taken away from me for good, all I have is the pain and suffering.”

FEMA Makes the Case to Limit Payments

On May 11, 2022, as the wildfire ignited by the Forest Service was still spreading, U.S. Rep. Teresa Leger Fernandez and U.S. Sen. Ben Ray Luján, two Democrats representing New Mexico, introduced legislation spelling out how a $4 billion compensation fund would be spent.

“While we don’t know the full extent of damage from this catastrophic fire, I’m introducing legislation that would require FEMA to fully compensate New Mexico residents and business owners who’ve been impacted,” Luján said in a press release.

Smoke plumes from the Hermits Peak-Calf Canyon Fire rise above a mountain ridge near Las Vegas, New Mexico, in May 2022. (Adria Malcolm)

That bill, sponsors said, would provide victims with a quick and efficient way to be paid for what they lost. Without it, victims’ only recourse would be to sue the federal government — a long, uncertain process. The bill was wrapped into a larger measure that passed Congress in September 2022.

Leger Fernandez and Luján modeled the Hermits Peak Fire Assistance Act after legislation that followed another wildfire, the 2000 Cerro Grande Fire, that also was accidentally started by a federal agency. Like the Cerro Grande Fire Assistance Act, the Hermits Peak bill said payments would be “limited to actual compensatory damages.”

But the law didn’t define what that phrase means. The most generous interpretation — the one adopted by the state’s attorney general and lawyers representing thousands of victims — is that FEMA is required to evaluate and pay for various kinds of hard-to-quantify losses. Plaintiffs’ lawyers say they include things like the mental health toll of not just the fire, but of being displaced from home for weeks or months, as well as the lost enjoyment of land that is now scarred. FEMA’s reading of the law is much narrower: Intangible losses don’t count.

For victims of the fire two decades earlier, many of whom worked for the Los Alamos National Laboratory, narrower criteria for compensation was less meaningful. They were wealthier and most had property insurance, so they didn’t have to rely on the compensation fund. Few victims of the Hermits Peak fire, however, had insurance or sizable nest eggs; most are relying on the compensation fund to help them rebuild.

FEMA has refused to publicly explain how it came to its interpretation of what it can pay for, aside from a PowerPoint slide shown at public meetings. But an agency memo lays it out. The memo, bearing logos of the agency and its claims office, says “Do not distribute” on every page. Source and ProPublica got it from the New Mexico attorney general’s office through a public records request.

The memo says the federal law establishing the compensation fund bars noneconomic damages through that phrase: “limited to actual compensatory damages.” It notes that noneconomic damages weren’t paid after the Cerro Grande Fire.

FEMA’s memo also asserts that even if the federal law didn’t bar payments for noneconomic damages, New Mexico law allows them in just a few narrow circumstances.

Victims’ lawyers and elected officials in New Mexico contend that FEMA is wrong. “We believe that there is a strong argument that noneconomic damages are authorized under the act and New Mexico law,” said Lauren Rodriguez, a spokesperson for the state attorney general’s office. She declined to elaborate.

Victims’ lawyers argue that if Congress wanted to exclude payments for distress or hardship, the law would say so. Without a clear exclusion, they say, the federal law directs FEMA to make payments in accordance with New Mexico law — which does allow payments for intangible harm in circumstances like the fire.

The dispute over intangible losses from the wildfire centers on the wording of a federal law that established a fund to compensate victims. Officials with the Federal Emergency Management Agency have pointed to language saying payments must be “limited to actual compensatory damages” (yellow highlighting). Victims’ lawyers and New Mexico officials point to language saying New Mexico law should apply and note that the law doesn’t exclude intangible losses (red highlighting). (Obtained by Source New Mexico and ProPublica. Highlighted by ProPublica.)

Source and ProPublica spoke to three lawyers and a former judge, all of whom are well-versed in wildfire litigation and New Mexico law and none of whom have ties to the legal battle. They all said New Mexico case law clearly allows victims of a wildfire to be paid for noneconomic damages resulting from what is legally called a “nuisance,” especially a wildfire that reduced property values for a large number of people.

New Mexico has some of the most expansive legal precedents in the country for paying noneconomic damages, according to Alan Malott, a retired state judge who handled such cases, and Levi Monagle, a plaintiffs’ lawyer who has sought such damages on behalf of clergy sex abuse victims and others.

“Our law is very comfortable with trying to quantify what everyone agrees is unquantifiable,” Monagle said.

Plaintiffs in a lawsuit now pending in state court are seeking noneconomic damages for a different wildfire. They blame a power company for triggering a blaze that destroyed more than 200 homes and burned 10 square miles of forest. (The company declined to comment, apart from denying that it was to blame for the fire.)

Singleton Schreiber, a San Diego-based law firm representing those plaintiffs, is handling one of the suits against FEMA over the Hermits Peak-Calf Canyon Fire. Its complaint argues victims will be deprived of “hundreds of millions of dollars” unless the claims office pays noneconomic damages.

If that suit and a similar one don’t succeed, victims could forgo the claims process and seek damages in federal court. Exactly how much money each could get would be up to a judge and jury, legal experts told Source and ProPublica. It would vary based on their circumstances — how long they were displaced, how much of a toll that took on them, perhaps how strong their connection to their land was.

After a power company caused a series of wildfires in California from 2015 to 2018, victims received payments for noneconomic damages. People with addresses within the boundaries of many of those wildfires were eligible for initial checks of at least $5,000 for unmet needs.

Jon Givens, a lawyer with the San Antonio-based firm Watts Guerra, represented many of the victims of those fires. The average payment for noneconomic damages was $125,000, he said, which is one reason he argues that such payments for the Hermits Peak-Calf Canyon Fire could be substantial.

“The losses are staggering and real and should be paid,” Givens said.

Due to the lawsuits, FEMA declined to say whether it has estimated the potential cost of noneconomic damages across the burn scar. In a March letter to New Mexico Attorney General Raúl Torrez, Angela Gladwell, the head of the claims office, wrote that “outside influencers” were spreading disinformation that “has convinced many New Mexicans that they will be eligible for substantial noneconomic damages.”

The Cost of Being Forced From Home

FEMA has paid victims $276 million as of Dec. 21, about 7% of the $3.95 billion allocation, mostly in recent months. While that money has helped to replace homes and vehicles and to address erosion from post-fire flooding, lawyers say it leaves a whole world of harm unaddressed.

Singleton Schreiber said it anticipates that 1,125 of its 1,214 clients from the Hermits Peak-Calf Canyon Fire would qualify for some form of noneconomic damages under New Mexico law.

Source and ProPublica heard from at least 24 fire victims who described circumstances similar to what experts said would justify payments for noneconomic damages under state law. All told us they had been displaced from their homes — some for a short time, others to this day. The three lawyers and judge we interviewed said intangible harm tied to displacement is a particularly strong argument for compensation.

In May 2022, the fire devoured a cabin that had been in Loma Hembree’s family since 1967. She and her husband, David Hembree, spent the next several months on the run, “chasing decent weather” in an RV. They housesat for friends across Nevada for half a year before finally settling in an RV park in Santa Fe. They don’t anticipate returning to their property for at least another year.

“It’ll never be the same, ever,” Loma Hembree said. “My grandchildren might be able to enjoy it. But it will never be the same. It will never be like what we had.”

Charlie Paynter, the manager of a ranch in Gallinas Canyon, is suing FEMA to force it to pay for the toll that the fire and recovery has taken on him. “We were looking at the fire for a month before it came down the canyon,” he said in an interview. “It was a month of stress before we had to evacuate.”

When he returned to the property, he was overwhelmed by the work that confronted him: Half of the ranch’s roughly 800 acres of forest were burned, and 6,000 feet of water lines had to be replaced. When a small fire broke out nearby a few weeks later, he stayed up all night on his porch, ready to leave again at a moment’s notice.

“You get edgy,” he said. “You get a little short with people that you normally wouldn’t get short with.”

Although the White House supports FEMA’s stance, it noted that the claims office is paying for mental health treatment for “conditions worsened by the fire.” The office recognizes “that individuals are suffering emotionally and psychologically as a result of the fire,” White House spokesperson Jeremy Edwards told Source and ProPublica in an email.

Without payments for noneconomic damages, some victims stand to get little from the claims office.

Many are renters whose homes were destroyed. Their landlords will be reimbursed for the loss of property, but tenants will get nothing for being forced to move — sometimes far away because rental properties are scarce in the burn scar.

And then there are people like Sandoval, who had no legal claim to the place they called home. In a letter submitted for her case, she described fleeing the fire three times before ultimately finding refuge at a friend’s house 340 miles away. “I have gained weight, become depressed and experienced staggering loneliness,” she wrote.

Sandoval was too traumatized to visit the burned remains of her home until December. The last time she had been there, a year and a half before, the fire was still burning. Since then, a layer of ash had been blown away, revealing the remains of items she once held dear: a shattered teapot her grandmother gave her, melted glass souvenirs, a niece’s tiny bicycle coated in rust.

Source and ProPublica asked FEMA whether its requirements to prove ownership are making it harder for people with informal living arrangements, like Sandoval, to get paid. Stomberg, the FEMA spokesperson, wrote that the claims office recognizes “that each claim is unique and represents the individualized needs of the claimant.” The office is identifying what combination of readily available and informal documentation could “help establish ownership or legal responsibility for damaged property.”

Sandoval said a check from FEMA for the costs of relocation and the replacement value of her possessions won’t enable her to rebuild. “This ranch is the soul of our family,” she wrote in her letter to the claims office. “And our soul has been ripped away by the negligence of the U.S. Forest Service.”

First and second image: debris and the burned remains of Sandoval’s home. Third image: Sandoval shows a photograph of her and her dog, Osa, at her home before the fire. She escaped with her dog, but her cat, Jinx, died. (Adria Malcolm for ProPublica) The remains of Sandoval’s home (Adria Malcolm for ProPublica) Delivering on a Promise

The two suits against FEMA argue that the agency’s decision not to pay noneconomic damages was an “arbitrary and capricious” abuse of its discretion. FEMA has not responded in court and declined to comment on the litigation.

Legal experts say the dispute could come down to what a federal judge determines congressional intent was.

The bill’s sponsors won’t say. In a joint statement to Source and ProPublica, Leger Fernandez, Luján and U.S. Sen. Martin Heinrich, a Democrat who also represents New Mexico, did not answer questions about whether they intended FEMA to cover noneconomic damages. Instead, they repeated their praise of the claims process and said victims are free to sue if they’re not satisfied.

Meanwhile, an effort is underway to remove Gladwell, a longtime FEMA employee from Washington, D.C., as head of the claims office. In early December, a group including 11 elected officials asked the Biden administration to replace her with someone who understands New Mexico culture and law and would compensate all victims fairly — including payments for noneconomic damages.

A FEMA spokesperson said the agency was preparing a response to the letter. (Malott was among the six former judges the group suggested; he spoke with Source and ProPublica before the group offered his name.)

The group reminded Biden that the federal government caused the wildfire and that he had pledged to help these communities recover.

“The United States Government has a long record of making promises to New Mexicans that are never kept,” they wrote. It started with the treaty that ended the Mexican-American War and ceded present-day New Mexico to the United States, they wrote, and continues today with shortcomings in the wildfire claims process.

Over the years, land belonging to communities that predated the United States has made its way into the hands of the Forest Service — a fact residents are quick to mention when describing what the fire took from them.

On top of that, this wildfire started in part because the Forest Service didn’t have enough backup staff to respond in case its prescribed burn got out of control, an outside review later found. One reason officials with the Forest Service decided they didn’t need more staff was that it considered the nearby land, communities and historic sites to be only of “moderate” value.

Leger Fernandez said at the time that this finding was a surprise to her — another sign, she said, that the Forest Service didn’t appreciate the unique way of life in the area. Using the Spanish word for “my people,” she said, “They undervalued mi gente.”

Alex Mierjeski of ProPublica contributed research.

by Abigail Kramer, THE CITY

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

If you talk to town officials — the supervisor, the elected board members, the chief of police — they will tell you that mayhem has arrived in Pleasantville.

A quiet, leafy village in the town of Mount Pleasant, less than 20 miles north of New York City, Pleasantville feels like the movie-set version of an affluent Northeastern suburb. Five-bedroom homes overlook tranquil cul-de-sacs and freshly mowed lawns. Kids really do ride their bikes in the street after school. The village is less than two square miles, so if you hit an errant ball at the Pleasantville Tennis Club, you could almost smack a neighbor teeing off at the Pleasantville Country Club.

For more than 100 years, the village has coexisted, more or less peacefully, with the Pleasantville Cottage Campus — a residential program that, in its current iteration, houses about 160 young people with behavioral challenges. Nearly all its residents are in foster care; most are from New York City. While Pleasantville is 87% white, almost all of the youth on the campus are Black or Latino. The majority have histories of severe trauma, according to staff at JCCA, the nonprofit foster care provider that runs the campus. Many were sexually trafficked. Some had multiple psychiatric hospitalizations or lived in five, six or seven foster homes before landing here.

Like other residential foster care programs (there are just over 200 “congregate care” facilities in New York state, with about 3,600 beds), the Pleasantville campus has periodically been the target of complaints from local residents. Young people leave the grounds without permission. They get into fights and shoplift from stores, neighbors and police say.

But during the past several years, those complaints have grown incendiary, erupting last summer into a bitter public battle that threatens to shut the campus down.

The escalating tensions have been well documented in town Facebook groups and the local paper: In 2022, neighbors were aghast when a resident from the Pleasantville campus stole a chicken from a coop in a nearby backyard and bit its head off. Later that year, a video made the rounds of a young man from the campus standing shirtless in front of a car, blocking the road. When the driver demanded that he move, he begged her to kill him.

Meanwhile, the frequency with which local police are called out to the campus climbed from several times a month in 2018 to several times each week in early 2023, according to Mount Pleasant Police Department records. Most of the contact between JCCA and the police involves missing persons: young people who run away from the campus, usually returning on their own after a few days. But disastrous things happen, too. In 2019, for instance, a young man on campus was paralyzed after being restrained by program staff and died a year later, according to Mount Pleasant Police Chief Paul Oliva. (JCCA officials declined to comment on the incident, citing privacy concerns.) Residents also regularly get into fights, break windows, assault staff and threaten to hurt themselves or someone else, police records show.

Town leaders place the blame squarely on JCCA, which has run the campus since 1940, for losing control of its kids.

The Edenwald School is one of two schools on the Pleasantville Cottage Campus. (Natalie Keyssar, special to ProPublica)

But, in fact, what’s been happening in Pleasantville in recent years is an extreme and very public version of something that’s occurring at foster care programs across New York state, an investigation by THE CITY and ProPublica found: Government child welfare authorities are placing kids with acute mental health challenges on campuses that are ill-equipped to handle them — largely because there’s nowhere else for them to go.

As THE CITY and ProPublica have reported, New York has shut down one-third of its beds for youth in state-run psychiatric hospitals since 2014 under a cost-capping “transformation plan” rolled out by former Gov. Andrew Cuomo. The state has also greenlit the closure of more than half of the beds in residential mental health programs during the past decade — all while failing to deliver on promises to expand home- and community-based mental health services to hundreds of thousands of young people. Suicidal foster children sit for months on waitlists for therapy and home-based treatment they are entitled to by law.

Among the consequences: The shortage of mental health care is creating chaos at foster care programs like the Pleasantville campus.

Since the Cuomo reform, the Pleasantville campus has had between 16 and 20 residents at a time with very aggressive or self-destructive behaviors, which is beyond the program’s capacity to manage, said Trevor John, JCCA’s senior vice president of campus services. That number used to be just two or three, he said.

Trevor John, senior vice president of campus services at JCCA, the organization that runs the Pleasantville Cottage Campus (Natalie Keyssar, special to ProPublica)

“We’re equipped to handle behavioral problems — that’s what we’re for,” John said. But with the shutdown of psychiatric beds, kids are frequently discharged to the campus from hospitals before they’re stable, he said.

(JCCA officials said they had brought the young man who killed the chicken to an emergency room twice shortly before the incident happened, but ER staff sent him away without admitting or even evaluating him.)

Once kids are placed on campuses, it’s very hard for facilities to move them off. Program staff can submit a “15-day notice” asking foster care authorities to find a new placement for a child who needs a different setting, said William Gettman, the CEO of Northern Rivers, a social service agency in upstate New York that has seen a similar influx of youth with acute mental health challenges. But he said the process often takes six to nine months. “The system is in crisis,” Gettman said.

When foster care programs can’t manage residents’ needs, there are “more AWOLs, more assaults on other children and staff, more suicidal and self-harming behaviors,” said Maria Cristalli, the president of Hillside, which runs residential programs in central and western New York.

New York’s foster care programs have had serious problems since before Cuomo began downsizing state psychiatric facilities. A January 2023 report by the advocacy group Children’s Rights described group homes and foster care campuses as “punitive, carceral, isolating, and dehumanizing,” citing former foster youth who said they lived in fear of violence from staff and other residents. (The report did not name individual programs or agencies.)

Add in more chaotic environments, with more fights and more running away, and foster care programs become a pipeline directly to the juvenile justice system for some youth.

Meanwhile, those with the most difficult behaviors — often the ones who’ve experienced the most extraordinary trauma — get pushed into a growing cohort of what the foster care system calls “hard to place” youth: children nobody wants. Foster care providers say they can’t handle them. Mental health programs are full or have insurmountable barriers to getting in. And at least in Pleasantville, the neighbors want them gone yesterday.

In July, Mount Pleasant officials held a press conference demanding that New York state shut the Pleasantville campus down. During the following three months, state child welfare officials granted JCCA’s request to remove 12 residents who staff contended were too unstable for the Pleasantville campus. The move was a win for town leaders, and it took pressure off JCCA, where incidents on campus have dropped sharply since the residents were moved.

Downtown Pleasantville (Natalie Keyssar, special to ProPublica) A neighborhood of Pleasantville adjacent to the campus (Natalie Keyssar, special to ProPublica)

But shuffling 12 residents around does not change the fact that “there are not good options” for foster youth with acute mental health challenges, said Ronald Richter, JCCA’s CEO and the former head of New York City’s child welfare administration. The systemic problem “is not solved,” he said.

In fact, only four of the 12 ended up in beds in mental health programs. Some of the others were sent to different foster care campuses or to a temporary shelter for foster children in New York City. And three are now in either the criminal or juvenile justice systems.

“That’s not a positive outcome,” Richter said.

Karen Male, a spokesperson for the state Office of Children and Family Services, which oversees New York’s foster care agencies, wrote in an email: “OCFS continues to work closely with JCCA to support the agency in effectively providing comprehensive, supportive programming for youth in foster care.”

Male added: “The health and safety of these young people, as well as that of the surrounding community, remain a top priority for our agency.”

But if officials hoped that moving the 12 youth would make town leaders back off from their campaign to shut down the Pleasantville campus, it seems unlikely to pan out that way. “Let it be known, we are still watching and still demanding accountability of this facility at every turn,” Mount Pleasant Supervisor Carl Fulgenzi wrote in an October memo posted on Facebook. “Our substantiated facts and statistics continue to overwhelmingly confirm that the situation at JCCA is worsening and wholly unsafe.”

It’s 4 p.m. on a Tuesday, and 16 teenage girls sit on vinyl-covered sofas in a common room on the Pleasantville campus. A few hug teddy bears on their laps. Two pass a watermelon-flavored lip gloss back and forth. Around them, paper butterflies and unicorns hang from baby pink walls, along with inspirational sayings like “Take time to be kind” and “Be your own kind of beautiful.” The TV is behind plexiglass so that no one can smash it.

At this meeting, the girls’ assignment is to discuss emotional regulation: essentially, how do you do the opposite of the destructive thing you really, really feel like doing? They take turns, offering examples of times they were angry or depressed: “When I went into foster care and my mom didn’t fight to get me back.” “When my dad died.” “When I wasn’t allowed to see my father for five years and my mom kept telling me it was my fault.”

What’s most noticeable is the gravitational pull of the counselor who’s running the meeting — a longtime staff member who oversees this particular cottage. Girls drift toward her, sitting on the floor at her feet or standing behind her chair. One, an older girl who came into the room rolling her eyes and muttering, “Oh, hell no,” ends up with her hands on the counselor’s shoulders, chin resting for a few seconds on top of her head.

Meetings like this are designed to teach kids coping skills: how to understand their trauma, identify their triggers and respond in new ways. The experience of being shuffled from place to place — the accumulated sense of being discarded — can drive foster youth to act out with extreme behaviors, said Jeremy Kohomban, president of The Children’s Village, which runs foster care and juvenile justice programs in Dobbs Ferry, a dozen miles south of Pleasantville. Often, he said, those behaviors are ways of “communicating hopelessness and frustration at a system that took them away from their parents and gave them nothing in return.”

First image: A student in her room in one of the cottages. Second image: A student’s bedroom. (Natalie Keyssar, special to ProPublica)

Reversing that takes time and trust, foster care providers say: Kids need to see that adults care about them and will stick around. And it can’t happen when staff are overwhelmed by residents in acute crisis.

Part of the challenge stems from limitations on what foster care campuses like Pleasantville are allowed to do. They provide clinical services like therapy and psychiatry, but unlike psychiatric hospitals or residential programs licensed by the state’s mental health department, they cannot lock kids into rooms or physically stop them from walking off of campuses. Nor can they force them to take psychiatric medications or inject them with sedatives or antipsychotics to control their behavior.

Faced with the influx of youth with acute mental health challenges, some foster care providers say those rules need to change — they need to be able to isolate or sedate kids for their own safety.

Almost universally, foster care providers also say they need more money. At the state’s current rates, they can’t attract the clinical staff they need to work with acutely ill youth, said Kathleen Brady-Stepien, the president of the Council of Family and Child Caring Agencies, which represents New York foster care nonprofits in negotiations with the state. Jobs for psychiatrists and social workers often go unfilled for months.

Rich Azzopardi, a spokesperson for Cuomo, wrote that the former governor’s transformation plan, which included psychiatric bed closures, was part of a movement to shift funds into outpatient care. If there are problems with the implementation now, “the current administration and the legislature — who are about to begin negotiations on their third budget together — should address it,” Azzopardi wrote in an email.

Under Gov. Kathy Hochul, New York has allocated $14 million to a program to recruit and retain mental health care workers and has promised to increase outpatient care in communities and schools. But those initiatives don’t touch foster care campuses, where turnover among frontline staff is up to almost 60% each year, Brady-Stepien said.

Hochul’s office declined to comment for this story.

The consequence is that foster care programs increasingly rely on inexperienced, minimally trained employees to manage volatile situations with residents in acute crisis. As a result, foster care providers say, they’re less able to do the most basic part of their job: keeping all their kids safe until they can return to homes.

On the Pleasantville campus, one of those kids was a 15-year-old named Janemarie.

In 2022, Janemarie was arrested and put on probation for assaulting an older girl. Her adoptive mom, Michelle, was sure that she couldn’t keep Janemarie out of trouble at home, so she asked her school district to find a residential program. (We’re identifying Michelle by her first name and Janemarie by her middle name in order to protect Janemarie’s privacy.)

When Janemarie’s school district suggested the Pleasantville campus, Michelle thought it might finally be the place to give her daughter the help she needed. Janemarie’s biological brothers were attending the day school on the campus, and Michelle thought maybe they could all get therapy together. She also liked that the program had a specialty in working with kids who’d been sexually abused, since she believed that many of Janemarie’s problems started after she was molested at a babysitter’s house when she was 7.

But that was January 2023, when the Pleasantville campus was calling on police to respond to emergencies more than five times a week. “I had no idea what was going on there,” Michelle said.

First image: Michelle, whose daughter Janemarie lived on the Pleasantville Cottage Campus. Second image: A childhood photo of Janemarie with Michelle. (Natalie Keyssar, special to ProPublica)

Almost as soon as she got to the campus, Janemarie felt scared, she told THE CITY and ProPublica. Staff couldn’t control the residents, she said.

At the time, Janemarie told Michelle that girls were threatening to jump her. She started running away — hopping the Metro-North commuter train to New York City, where she’d couch surf or sleep on the street. Even when Janemarie was on the campus, she wasn’t going to school or to her therapy appointments. Staff “will walk in the room and say, ‘OK, it’s time for therapy,’ and she’ll say, ‘Go fuck yourself,’ and they’ll walk away,” Michelle said. Janemarie carved messages like “Fuck my life” into her arms and texted pictures to Michelle.

Then, in June, Janemarie sent Michelle a video that showed three other girls attacking her in her bedroom on the Pleasantville campus and beating her head with a metal pot until she bled. For the duration of the video — about 30 seconds — there was no adult in sight. Janemarie told Michelle that two program counselors were in the building while she was being assaulted, but the girls left the room on their own before anyone intervened. “They’re understaffed and they’re scared of the kids,” Michelle said. “No one wants to jump in and get hurt.”

JCCA declined to comment on Janemarie’s experience, citing privacy and confidentiality concerns, despite the fact that Michelle gave the agency permission to share information about her daughter with THE CITY and ProPublica. In an emailed statement, Richter wrote that under state regulations, campus staff “cannot engage in disciplinary measures, confinement, or utilize forceful restraints. Altercations can occur suddenly, before staff is able to engage or separate people. However, safety measures are taken when risks are known, including placing children in separate cottages and increasing staff coverage and monitoring.”

Danielle Zaino is the kind of person who shows up for the school dropoff line looking the same as she does for a campaign headshot: two coats of mascara, hair freshly blown out, wedges or heels because she’s only 5-foot-2 and doesn’t like to be towered over. Zaino grew up in Mount Pleasant, meeting her now-husband when she was 10 years old. They moved away for a while, but she wanted to raise her kids back home. “It’s a nice small-town feel,” she said. “You feel safe.”

Zaino is also the kind of person who prides herself on telling the truth and taking care of business, regardless of who gets mad about it. “One of my pet peeves is people complaining about things without doing anything about them,” she said.

Mount Pleasant Council Member Danielle Zaino in her home in Valhalla, New York (Natalie Keyssar, special to ProPublica)

So, in 2016, when she heard about trouble with the foster children in town, Zaino called up a friend and started a group called the Coalition for a Safe Mount Pleasant. Cuomo’s transformation plan had been underway for two years, and foster care providers across the state were seeing an increase in residents with acute mental health challenges. At the time, there were two foster care campuses in Mount Pleasant: Three miles down the road from Pleasantville, in a hamlet called Hawthorne, the Jewish Board of Family and Children’s Services ran a campus with a special unit for kids who’d been commercially sexually exploited. Town residents reported seeing men pull up in black sedans at midnight or 1 a.m. “Barely dressed” girls would run off the campus and jump in, Zaino said. Residents assumed the men were sex traffickers — a suspicion that was later confirmed in federal court, where a ring of adult men were charged with trafficking teen girls, including some from the Jewish Board campus. (The Jewish Board was not implicated in the criminal case.)

Meanwhile, Zaino said, neighbors were seeing a spike in incidents around the Pleasantville campus, including youth breaking into cars and stealing from local stores. People were “afraid to be home alone or to let their kids be home alone. They’re afraid to go into the Mobil, afraid to go into the ShopRite,” Zaino said.

The coalition started organizing local residents, sponsoring public town halls for people to air their complaints and holding regular meetings with JCCA, the Jewish Board and state officials, getting politicians involved. Zaino ran for a seat on the Mount Pleasant town board and won.

But while foster care providers acknowledge that some of the coalition’s concerns are understandable, they say residents have gone too far. People follow foster youth around in stores and videotape them on the street, foster care providers say. Residents call police on kids who are taking a walk or heading to a job in town.

JCCA leaders said kids on campus feel explicitly targeted because of their race. Not infrequently, people in town will call the campus just because someone sees Black kids on the street, even if they have nothing to do with JCCA, John said. Last year, the town started enforcing an ordinance that allows it to fine JCCA $250 every time a resident leaves the campus without supervision. JCCA residents call the fine “the Black tax.”

“For our kids, just being outside is a problem. They too are part of this community. For some kids, this is their only residence,” John said. “When did Mount Pleasant become a sundown town?”

Zaino declined to respond to allegations that kids are targeted based on race. Oliva, the police chief, says that race isn’t a factor in the department’s enforcement. “If we get a call, we investigate it,” he told THE CITY and ProPublica. “If there’s nothing to it, we leave it alone.”

Other Mount Pleasant residents argue that the coalition’s complaints are overblown. “The claim that we are not safe, that’s just not true. This is not a hotbed of crime,” said Francesca Hagadus, who was the first Democrat on record to win a seat on the Mount Pleasant Town Board — which she then lost to Zaino in 2019. “Do the JCCA kids shoplift and get in trouble sometimes? Yeah. But guess what, our high school kids who were born here get in trouble sometimes too. The difference is that they have a home to go to at night.”

Eventually, the Jewish Board shut down its Hawthorne campus. The organization’s leaders never said that the decision was made because of pushback from the town — the agency has invested in programs that keep kids in New York City, closer to their families.

But now, town officials use the closure to threaten JCCA, John said. “They hang it over us like the sword of Damocles: ‘We did it to them. We can do it to you too.’”

If town leaders succeed, John continued, “Where do these kids go? I have youth who are languishing here for a year because their counties don’t have a place to put them. Where would they go?”

A student in music class in the Edenwald School (Natalie Keyssar, special to ProPublica)

By the time Janemarie had been on the Pleasantville campus for a few months early last year, Michelle found herself feeling sick every time she heard a text notification. Janemarie would run away for days at a time, sending Michelle oblique, crazy-making messages about where she was and what she was doing.

In June, she took off for Connecticut with a group of girls from the Pleasantville campus. As far as Michelle could tell, they were crashing at an apartment with some grown men. She was pretty sure they were trading sex for money and a place to stay.

At night, Michelle would have excruciating visions: Janemarie eating a peanut and going into anaphylactic shock without an EpiPen; Janemarie gasping for air with an asthma attack while no one called 911. She couldn’t bring herself to think about the men, though she’d later find a video on Janemarie’s phone of her performing a sex act on what looked like an adult. It made her throw up, so she didn’t look through the phone again.

To Michelle, it felt like a disaster. The whole point of sending Janemarie to Pleasantville was to keep her out of serious trouble. But now, she had “completely unraveled,” Michelle said.

JCCA officials say that in order to focus on young people like Janemarie — those who could, in theory, succeed on their campus — they need more freedom to manage others who are in acute crisis. In 2022, in response to a call for proposals from New York state, JCCA submitted a plan for two “intensive” units on the Pleasantville campus, with eight beds for residents with serious psychiatric challenges and a history of dangerous behavior like running away or being physically or sexually aggressive. If the proposal is approved, staff would be able to lock young people in their units and use injectable sedatives. The model would also come with more staff and more money, via increased reimbursement rates per resident.

JCCA would only use this model in “the most unusual circumstances,” Richter said, to care for residents who would otherwise be eligible for psychiatric hospitals or mental health residences.

But advocates for foster youth say that putting young people in more restrictive environments is not the answer. Foster care programs are not supposed to be juvenile jails or psychiatric hospitals, said Shereen White, the director of advocacy and policy at Children’s Rights. “How about we look at the quality of care these kids are getting in the first place? Did they get the services they’re entitled to in the community?” she said. “Are they getting proper, comprehensive treatment” on the foster care campus?

What everyone agrees on is that when foster care fails to keep young people safe, there is another system that always has room and can’t turn them away: juvenile justice.

In July, Michelle filed a petition in family court, requesting that a judge send Janemarie to a more controlled setting. Janemarie wasn’t safe, she said. But what Janemarie got was not a residential mental health program: The judge sent her to a juvenile lockup, saying that all the fighting, the running away, the refusing to go to school were violations of her probation.

The day Michelle watched Janemarie walk into court in handcuffs, “that was a heartbreak,” she said. “She’s a child who on every level has been failed.”

But there’s also comfort in knowing where Janemarie is and that she can’t run away. “I can sleep at night,” Michelle said. “And maybe she’ll finally get the help she needs. This child suffers so greatly. If they’re smart and they get the right people in there, they’ll see through her antics and behaviors. She needs all systems go, red lights flashing. Hopefully they’ll see that.”