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by Megan O’Matz, photography by Lianne Milton, special to ProPublica

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When the clerk at VJ’s Food Mart confronted Corey Stingley, the 16-year-old handed over his backpack. Inside were six hidden bottles of Smirnoff Ice, worth $12, and the clerk began pulling them out one by one.

Stingley watched, then pivoted and quickly moved toward the door, empty-handed. But there would be no escape for the unarmed teen in the light blue hoodie.

Three customers, together weighing 550 pounds, wrestled the 135-pound teen to the floor of the West Allis, Wisconsin, store. They pinned him in a seated position, “his body compressed downward,” according to a police account. One of the men put Stingley in a chokehold, witnesses would later tell investigators.

“Get up, you punk!” that man, a former Marine, reportedly told Stingley when an officer from the police department finally arrived. But the teen didn’t move. He was foaming at the mouth, and his pants and shoes were soaked in urine.

He’d suffered a traumatic brain injury from a loss of oxygen and never regained consciousness. His parents took him off life support two weeks later. The medical examiner ruled Stingley’s death a homicide following his restraint in “a violent struggle with multiple individuals.”

That was more than 10 years ago.

None of the men, all of whom were white, were criminally charged in the incident that killed Stingley, a Black youth. Police arrested Mario Laumann, the man seen holding Stingley in an apparent chokehold, shortly after the incident in December 2012. But the local district attorney declined to prosecute him or the other two men, arguing they were unaware of the harm they were causing.

When a second police review led to a reexamination of the case in 2017, another prosecutor sat on it for more than three years, until a judge demanded a decision. Again, there were no charges.

Prosecutors move on, but fathers don’t. Refusing to accept that the case had been handled justly, Corey Stingley’s dad, Craig, last year convinced a judge to assign a third district attorney to look at what had happened to his son.

That prosecutor, Ismael Ozanne of Dane County, is scheduled to report back to the court on Friday. He could announce whether charges are warranted.

The case has parallels to a recent deadly subway incident in New York City. Both involve chokeholds administered by former Marines on Black males who had not initiated any violence. But unlike in Wisconsin, New York authorities acted within two weeks to file a second-degree manslaughter charge in the case.

While the New York subway incident grabbed national headlines, Corey Stingley’s death — which happened the same day as the Sandy Hook Elementary School shooting in Connecticut — did not gain much notice outside of southeast Wisconsin.

Years later, Craig Stingley tapped an obscure statute dating back to Wisconsin’s frontier days to convince the system to take a fresh look at his son’s death. The law states that if a district attorney refuses to issue a criminal complaint or is unavailable to do so, a private citizen can petition a judge to take up the matter. Today, it’s loosely referred to as a “John Doe” petition, though in this instance there was no doubt who restrained Stingley’s son: Laumann, who has since died, along with two other store patrons named Jesse R. Cole and Robert W. Beringer.

VJ’s Food Mart in West Allis, Wisconsin

No one is alleging that the men set out to kill Corey Stingley. His father is asking the prosecutor to consider a charge of reckless homicide or even a lesser offense for using extreme force to detain his son.

“He wasn’t trying to harm anyone. He was trying to leave that store,” said Craig Stingley, who thought his son made a youthful mistake. “I believe he was scared.”

“You Guys Killed That Kid”

VJ’s Food Mart is a typical small convenience store, packed with chips, candy, soda, beer, cigarettes and liquor. On Sunday mornings it offers a special deal on hot ham and rolls, a local tradition for an after-church meal. To combat theft, the store is equipped with security cameras.

On Dec. 14, 2012, Thomas Ripley and Anthony Orcholski stopped by the store for beer and snacks. Only a few steps in, they saw that three men had someone firmly pinned on the ground.

Watch video ➜

Security video shows Ripley and Orcholski pausing next to the pile of people and watching intently. In statements to police they both said they saw Laumann lying on the ground with his arms around Stingley’s neck in a “chokehold.” Beringer had grabbed Stingley's hair, they said; the third man, Cole, had his hands on Stingley’s back.

Ripley told police the teen was not moving and appeared to be limp.

“I don’t think he could breathe,” Ripley would later testify during a special review of the case to determine if there should be charges.

Orcholski told a detective that he was concerned about the teen on the ground and may even have instructed the men to let Stingley go.

A decade later, Orcholski is still bothered by what he saw. “I’m upset,” he told ProPublica. “Three men thought they were going to be heroes that day because a 16-year-old boy was shoplifting. There could have been numerous different ways to restrain him other than choking him to death.”

He added, “It’s common sense: When you squeeze somebody that hard for that long, they’re not going to be alive after it.”

West Allis Police Department report. Highlights by Stingley family legal counsel.

The security video is grainy, and much of the confrontation took place out of view of the cameras.

Authorities had a third witness, though. Troubled by what he’d seen, store customer Michael Farrell felt compelled to go to the West Allis police station that evening and give a statement.

“I felt bad. I’m a dad,” he explained, court records show.

Farrell told police he could see through the store’s glass door that a man with a “crazed look on his face” had someone in a chokehold, very near the entrance. The guy was “squeezing the hell out of this kid and never let up,” he said. Farrell picked Laumann out of a photo lineup. (Farrell and another witness, Ripley, couldn’t be reached for comment for this story.)

Corey Stingley and his dad lived just a couple of blocks from the store, making them one of the few Black families in a predominantly white neighborhood and city on the border of Milwaukee. Comments from the three men who held Stingley down imply that they saw him as an outsider.

Ripley told police that Beringer, 54, held Stingley by the hair and shook the teen’s head a couple of times. “You don’t do that,” he said Beringer scolded Stingley. “We’re all friends and neighbors around here.”

With Stingley subdued, the store clerk held a phone to Beringer’s head so he could talk to a police dispatcher. “We have the perp, three of us have the perp on the ground holding him for you,” Beringer said, according to a transcript of the 911 call.

Police estimated that the men held Stingley down for six to 10 minutes. When Stingley stopped struggling, Cole later told police, “I thought he was faking it.”

He added: “I didn’t know if he was just, you know, playing limp to try and get real strong and pull a quick one, you know.”

When an officer arrived, she handcuffed Stingley with Beringer’s assistance but then realized that he wasn’t breathing and called for help.

Beringer walked outside the market, according to Farrell, only to be confronted by another bystander who said, “You guys killed that kid.”

“We didn’t kill anyone,” Beringer responded.

At nearby Froedtert Hospital, doctors concluded Stingley’s airway had been blocked while he was restrained.

He had petechial hemorrhages — tiny red dots that appear as the result of broken blood vessels — to his eyes, cheeks and mouth. A deputy medical examiner attributed this pattern to “pressure applied to the neck.” There also was a bruise at the front of Stingley’s neck, she testified.

She noted that his asphyxia also could be linked to compression of the chest.

Doctors put Stingley in a medically induced coma, attached him to a ventilator and inserted a feeding tube. As the situation became increasingly hopeless, his family spent Christmas at his bedside. Four days later, his parents made the agonizing decision to take him off life support.

“Mario Did Have a Temper”

In the New York subway case earlier this month, it took less than two weeks for the Manhattan district attorney to charge Daniel Penny, a former Marine, with second-degree manslaughter for the choking death of Jordan Neely, a homeless man who had yelled at other subway passengers. A prosecutor emphasized that Penny continued to choke Neely even after he stopped moving.

Penny’s lawyers have defended his actions by saying he was protecting himself and other passengers. Laumann, in contrast, never claimed Corey Stingley was a danger. But he did dispute that he put his arm around the teen’s throat.

Interviewed by police that night, Laumann, then 56, recalled “just leaning on him.”

Pressed by a detective, Laumann appeared less confident, saying, “A headlock is when you got your arms locked, right? And I didn’t have him locked.” He added: “I had my arm around like this, yeah, but I didn’t have him in a headlock. Unless maybe I did, maybe I — I don’t, no, I, I don’t remember that, no.”

His account conflicted with that of witnesses. And Laumann’s older sibling Michael, also a former Marine, isn’t so sure, either. Chokeholds are a part of basic combat skills, he said, used to restrain a person and take them down.

“That’s the first thing they teach you, not only in boot camp but also in subsequent infantry training. It becomes an automatic restraint, to save your own life,” Michael said. “I’m not saying that Mario did that. Because I don’t know the situation. But all I’m saying is that when you’re in the Marine Corps you’re taught how to save your own life. And to save the lives of your brotherhood. Sometimes it becomes, say, an automatic response.”

Michael Laumann said he and Mario — who died last year at age 65 — seldom talked, and when they did, the store incident never came up.

Mario Laumann, who worked in construction after leaving the Marines, lived about two miles from the store. His family had been dealing with a variety of crises. His wife was battling cancer. She had been arrested four years earlier for driving under influence of prescription medications. She died in 2013.

And, by the time of the encounter with Stingley, Laumann’s youngest son, Nickolas, was serving time in prison for sexual assault of a 15-year-old girl, intimidation of a victim and theft.

Writing online while in prison, Nickolas said his father would “scream at me” for drug use and “whoop my ass.” The police report about Stingley’s death notes that Laumann had been arrested twice for battery, but charges in both cases had been dismissed.

“Mario did have a temper,” another brother, Mennas Laumann, said recently.

The three men who held Stingley down didn’t know each other. Beringer, who lived next door to the food mart, told police he only recognized Laumann as “a neighborhood guy.”

Like Laumann, Beringer had had previous encounters with police. In 1996, Beringer pulled a gun on a Pakistani-born man and told him he hated “fucking Iranians,” according to a police sergeant’s sworn criminal complaint. Beringer pleaded guilty to misdemeanor gun charges and was jailed briefly then put on probation. A judge ordered him to complete a course in violence counseling or anger management and continue with mental health treatment, court records show.

Beringer, who no longer lives in West Allis, declined to talk to ProPublica. He came to the door of his apartment building and when asked to discuss Stingley’s death said, “No, no, see you later,” and closed the door.

The third man to wrestle Stingley to the ground, Cole, was a 25-year-old electrician who lived about a mile from the store. He’d gone there to get cigarettes. The prior year he had pleaded guilty to disorderly conduct, a misdemeanor, for carrying a Glock handgun in the center console of his car and a magazine with 11 hollow-point bullets in the glove box. Cole didn’t respond to ProPublica’s attempts for comment.

In the immediate aftermath of the incident, all three men cooperated with police.

Cole said that as he and the others tried to halt Stingley’s attempt to flee, the teen took a swing at him and landed a punch. He ended up with a black eye.

Asked by police why he restrained the teen, Laumann replied: “Because he’s a thief.”

“He Was My Buddy”

Several days after the struggle, West Allis police arrested Laumann and processed him for second-degree reckless injury. It was up to Milwaukee County District Attorney John Chisholm to decide whether to prosecute him and the other men.

Chisholm eventually arranged for a judicial proceeding where sworn testimony could be heard. There, the three men invoked their Fifth Amendment right against self-incrimination in declining to answer questions. The original witnesses recounted seeing Stingley grabbed around the throat.

Though Farrell said he couldn’t recall telling police that Laumann was “squeezing the hell out of” Stingley, he didn’t back away from his original description of a chokehold.

Months went by with no word on charges. But Craig Stingley, a facilities engineer, couldn’t just sit and wait. He rallied support from politicians in the community and tried to keep the pressure on Chisholm.

Stingley brought state Sen. Lena Taylor to meetings with the prosecutor to discuss the case. They came away discouraged. Taylor got the impression that the case was challenging for prosecutors on many levels. The video was not sharp, for one thing. Taylor also believed that race relations in Milwaukee County fed Chisholm’s concern that a jury might not convict anyone in the case.

At one meeting, Taylor said, she questioned what would have happened if the people involved had been of different races. “They wouldn’t let a group of Black guys do that to a young white guy, without any consequences,” she said.

More than a year after the incident, in January 2014, Chisholm announced he would not bring charges, on the grounds that the men did not intend to injure or kill Stingley and didn’t realize there was a risk to his life or health. “It is clear that the purpose of restraining Corey Stingley was to hold him for police,” Chisholm wrote in a five-page summary of his investigation.

“None of the actors were trained in the proper application of restraint,” he added

Corey’s mother, Alicia Stingley, was stunned. “It’s just mind-boggling to me, just the decision that was made that it was more so because he didn’t think he could win a case or didn’t think what they did was on purpose,” she said. “There were no repercussions for a grown man taking a young child’s life — by choking him.”

For Craig Stingley, it’s inconceivable the men did not know his son was in distress during the prolonged time they held him down. Applied properly, a chokehold “can render an aggressor unconscious in as little as eight to thirteen seconds,” according to a 2015 Marine Corps instructor guide.

Chisholm is still the district attorney. Through an assistant, he declined comment, citing the new review. Among the questions sent by ProPublica to Chisholm was whether he investigated Laumann’s training in restraints as a Marine.

Chisholm’s decision sparked media coverage and community protests. To Craig Stingley, Corey was more than a symbol, he was a cherished son.

Craig Stingley made a shrine for Corey at his new home. First image: Craig Stingley views photos of Corey. Second image: A black and white photograph, center, of Craig Stingley’s children, including Corey at right.

“He was my buddy,” Stingley said, describing how he and Corey would watch sports together. A skilled athlete, Corey Stingley was a running back on his high school football team and a member of the diving team. He took advanced placement classes in school and made the National Honor Society at school, his father said. He also worked part-time at an Arby’s.

His social media accounts include references to girls and partying. It also catalogs his love of Batman, the Green Bay Packers and Christmas and shows him gently mocking his friends and family.

“My dad just got texting and he’s experimenting with winky faces,” he wrote in 2012, ending with “#ohlord.”

Corey Stingley with friends before a school dance (Courtesy of Craig Stingley)

Craig Stingley and his ex-wife filed a wrongful death suit in 2015 against the three men and the convenience store, which led to a settlement. Records show that Laumann’s homeowners insurance paid $300,000, as did Cole’s. (Beringer didn’t have homeowner’s insurance.) There was no admission of wrongdoing by the defendants. In court filings the three men said their actions were legal and justified, citing self-defense and their need to respond to “an emergency.”

A good portion of the proceeds from the suit went to pay for hospital and funeral costs and lawyer fees, Stingley said.

In the civil suit, an expert forensic pathologist hired by the Stingley family’s lawyer concluded the teen died because his chest was compressed and he was strangled.

“Once his airway became completely obstructed,” Dr. Jeffrey Jentzen of the University of Michigan wrote, “Corey would have experienced severe air hunger, conscious fear, suffering and panic with an impending sense of his own death for a period of 30 seconds to approximately one minute until he was rendered into a fully unconscious state.”

Craig Stingley still obsessed about what had happened and how to revive a criminal case. He relived his son’s death over and over, watching the surveillance video of his last moments frame by frame, looking for something new.

Using a movie maker app on his computer, he slowed the video down and grabbed individual frames. He concluded that Cole initially had his son in a headlock, but that Laumann too had an arm around his neck before bringing him to the ground. That conflicted with Laumann’s statement to police.

Stingley took his findings to the West Allis police, where a detective agreed they’d missed this detail. The department wrote a supplemental report for Chisholm, who asked a judge to appoint a special prosecutor for another look.

Racine District Attorney Patricia Hanson got the case in October 2017. But what followed was more waiting.

Stingley said he called Hanson’s office routinely in the years that followed, but she never met with him. Reached via email recently, Hanson declined to comment.

The case “has not even been assigned a referral or case number after three years in that office,” state Rep. Evan Goyke complained in a December 2020 letter to Milwaukee County Circuit Court Chief Judge Mary Triggiano. “This is unacceptable,” he wrote.

In later correspondence, Triggiano noted Hanson had refused to say when her decision would be forthcoming because in the midst of the pandemic, she had a lot of cases needing attention.

In March 2021, Hanson told the court in a one-page memo that she had reviewed Chisholm’s file and agreed with his earlier decision: “I do not find that criminal charges are appropriate at this time.”

“My Son Got His Humanity Back”

John Doe proceedings allowing citizens to directly ask a court to consider criminal charges date back to 1839, when Wisconsin was still a territory, according to an account in state supreme court records. The law is used infrequently, legal experts said, and rarely successfully.

Petitions have been filed by prisoners, by activists alleging animal cruelty in research experiments and by citizens claiming police misconduct. The efforts typically fail, ProPublica found in reviewing court dockets, news accounts and appellate rulings. In Milwaukee County, Wisconsin’s most populous, there were only 19 such cases in 2020, dockets show, including Stingley’s. None succeeded.

Other states have similar methods of giving citizens a voice, but none are exactly like Wisconsin’s. According to the National Crime Victim Law Institute, six states — Kansas, Nebraska, Nevada, New Mexico, North Dakota and Oklahoma — allow private citizens to gather signatures to petition a judge to convene a grand jury to investigate an alleged crime. In Pennsylvania, individuals can file a criminal complaint with the district attorney; if rejected, they can appeal to the court to ask it to order the district attorney to prosecute.

Milwaukee attorney Scott W. Hansen, who has served as special prosecutor in a John Doe case, is critical of the Wisconsin process. He said it allows citizens to present a one-sided, skewed version of facts to a judge, “without benefit of cross-examination or adverse witnesses.”

The law, however, does state that the citizen’s petition must present facts “that raise a reasonable belief” a crime was committed.

Former state Supreme Court Justice Janine Geske described the John Doe petition as a check and balance on prosecutors by citizens. “If people believe a crime has been committed, and you’ve got prosecutors not living up to their responsibilities, and you think somebody ought to be held accountable, it’s a way to have some judicial review,” she said.

Stingley has known all along that the odds were against him, so turning to a longshot petition didn’t daunt him. Writing to Chief Judge Triggiano in late 2020, he alleged “dereliction and breach of legal duty” by the Milwaukee and Racine county district attorneys to conduct thorough criminal investigations into his son’s death.

Triggiano assigned the case to Judge Milton Childs. He formally appointed Ozanne, the first Black district attorney in Wisconsin, as special prosecutor last July. Ozanne’s inquiry has included reviews of court transcripts and interviews with West Allis police and others.

Craig Stingley was pleased that Ozanne and his staff met with him for several hours to listen to his concerns and to hear about his son.

“When I left that meeting,” Stingley said, “my son got his humanity back.”

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by Annie Waldman

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In the suburbs of Maryland, Dr. Jeffery Dormu’s presence is hard to miss. He’s a regular on the local TV station, which has featured him and his practice five times over the past five years. And he smiles down from an electronic billboard outside a three-story vascular center he calls The Watcher. “It has a biblical reference, which is to watch over the community,” he said at its 2018 opening. In response to the country’s “tragedy of cardiovascular disease,” the center trademarked the phrase “vascular devastation,” a slogan frequently invoked in its marketing, along with a claim to have “saved over 34,000 lives and limbs.”

Dormu and his group, the Minimally Invasive Vascular Center, have been a magnet for people with leg pain who worry they have peripheral artery disease, a condition that afflicts more than 6.5 million Americans and happens when fatty deposits narrow the arteries and block blood from flowing to the legs.

But Dormu’s portrayal of his practice as a heroic refuge hid a distressing statistic: The vascular surgeon was performing an invasive leg treatment more often than almost any other doctor in the country, even when his patients didn’t need it and even as evidence of harm mounted.

One man had to have his leg amputated after Dormu administered multiple invasive treatments for mild pain, according to legal filings. A 62-year-old grandmother bled out and died shortly after Dormu cut into her, according to another lawsuit.

Dormu’s go-to procedure, the atherectomy, involved shaving blockages with blade-topped catheters. Best practices recommend that doctors hold off on invasive procedures like these, which can lead to complications including limb loss, on patients in the earliest stages of disease; doctors should first see how the patients do with exercise and medication. Dormu defaulted to atherectomies almost immediately, patient legal and medical records show.

An image of Dr. Jeffery Dormu appears on an electronic billboard outside the Minimally Invasive Vascular Center, which he founded, in Laurel, Maryland. (Shuran Huang for ProPublica)

Four years ago, leading researchers warned the Centers for Medicare and Medicaid Services that some doctors were potentially abusing interventions. The researchers implored the government insurer to scrutinize its own data to identify overuse, noting that some of the doctors could present an “immediate threat to public safety.”

There is no public evidence that CMS meaningfully responded.

But a ProPublica analysis of CMS data suggests that if the agency had reviewed its own figures, it would have discovered that Dormu was part of a small pool of physicians performing a disproportionate number of treatments. From 2017 to 2021, the analysis shows, the top 5% of doctors conducting atherectomies — about 90 physicians overall — accounted for more than a third of all procedures and government payments, totaling nearly a billion dollars.

Near the top of the list sits Dormu, logging more atherectomies — and making more money from them — than almost every other doctor in America.

CMS paid Dormu more than $30 million in the past decade for vascular procedures he performed on hundreds of patients.

Dormu declined to be interviewed and did not respond to emailed questions.

But a chorus of experts told ProPublica that the federal government’s decision to provide unconditional payments for vascular procedures — and then not pay attention to what happened — is a prime example of what’s wrong with the American health care system.

“The government is really to blame for setting these tremendously high reimbursement values without looking into whether these procedures are helping people or are just worthless procedures or, in fact, are hurting people,” said Dr. Dipankar Mukherjee, a vascular surgeon and chief of vascular surgery at Inova Fairfax Hospital in Virginia.

CMS kicked off the problem 15 years ago, when it tried to rein in the swelling hospital costs for vascular care. Over the past few decades, advances in technology allowed patients with serious circulation problems to avoid open surgery and instead undergo minimally invasive treatment with cutting-edge devices. As they flocked to hospitals for these procedures, patients with clogged leg arteries became even more expensive than patients with clogged heart arteries.

In 2008, recognizing that the procedures could be done safely and more efficiently outside hospitals, CMS officials turbocharged payments to doctors’ offices that deployed balloons and stents to widen arteries. And in 2011, they began to reimburse those offices for atherectomies.

Before the change, an office provider inserting a stent could make about $1,700 from Medicare; deploying a balloon could bring in roughly $3,800. By 2011, the payments rose to about $6,400 and $4,800 respectively. But nothing compared to the payout for atherectomies conducted in offices: about $13,500 per procedure, as opposed to roughly $11,450 in a hospital.

Instead of saving money, the government started a boom.

Atherectomies increased by 60% from 2011 to 2014; Medicare’s overall costs for peripheral vascular treatments climbed by nearly half a billion dollars, or 18%.

The government insurer didn’t change course in 2014, when research began to indicate that atherectomies may not be more effective than cheaper alternatives, or in 2019, when experts warned the procedure may be associated with a higher risk of complications.

From 2013 to 2021, the most recent year of Medicare data, the number of atherectomies has doubled and payments to doctors have nearly tripled, totaling about $503 million in 2021.

“There’s definitely places where atherectomy is very helpful,” said Dr. Caitlin Hicks, an associate professor of surgery at Johns Hopkins University School of Medicine. “But it’s definitely being used inappropriately, and that’s when bad things happen.”

Experts fear patients are being caught up in a new era of profit-driven procedure mills, in which doctors can deploy any number of devices in the time it takes to drill a tooth and then bill for the price of a new car.

The generous reimbursements have created a conflict of interest for doctors running their own practices, who are supposed to make unbiased medical decisions while also being responsible for a lease, overhead and staff. And unlike hospitals, which have panels and administrators who spot adverse events and questionable billing, these offices don’t face such scrutiny.

CMS, experts say, should step up: It could reduce its reimbursements or even investigate doctors with outsized procedure patterns.

ProPublica reached out to CMS more than two weeks ago, listing the facts in this story, asking questions and requesting an interview. CMS did not make an official available to talk or provide any written answers.

“Vascular medicine now is the frontier of the Wild West,” said Dr. Marty Makary, a professor of surgery and health care quality researcher at Johns Hopkins University School of Medicine. “People are flying blind walking into the clinics of these doctors with egregious practice patterns, and we know that their pattern is indefensible.”

It was at the cusp of this lucrative new era in vascular medicine that Dormu, an ambitious young doctor from Washington, D.C., entered the scene.

After earning his medical degree at the New York Institute of Technology College of Osteopathic Medicine and completing an additional eight years of training in New York and New Jersey hospitals, including a residency in general surgery and two fellowships in cardiothoracic and vascular surgery, he received his license to practice medicine in Maryland in 2007. That year, he founded the Minimally Invasive Vascular Center.

“People in general are just afraid of surgery,” he later told a local TV journalist. “They can get by with minimally invasive surgery, a needle puncture without having to be cut, without having to worry about an amputation. They walk in and within hours they walk out, and pretty much healed.”

Advertisements outside the three-story vascular center, which Dormu calls The Watcher. (Shuran Huang for ProPublica)

Dormu opened several vascular offices in the region. At one point, his group also partnered with the Washington, D.C., Department of Aging and Community Living, providing hundreds of free vascular screenings for elderly patients at senior centers and residences across the capital.

But according to public records and lawsuits, as his profile and his practice grew, so, too, did evidence of harm.

In March 2016, while he was performing an elective aorta repair at Providence Hospital, the patient began to hemorrhage, according to a District of Columbia Board of Medicine document on the incident. After trying to control the bleeding, Dormu transferred the patient to the intensive care unit for resuscitative efforts and then left the hospital for his private practice and other appointments.

He was gone for more than two hours, and in that time, hospital staff couldn’t reach him. The hospital patient died in the recovery room from hemorrhage and organ failure, the report said. Six years later, the District of Columbia Board of Medicine would reprimand him for the incident alongside a $5,000 fine, finding that he abandoned a patient in need of further emergency care, “knowing the high risk of mortality and without adequate communication to other hospital staff.”

The death of the patient did not interfere with his medical license or appear to slow his career.

Nine months later, a mechanic sought his care for mild leg pain. As the owner of his shop, Steve Rosenberg clocked long hours, six days a week, repairing anything with wheels or an engine. But as he reached his mid-50s, the long days of standing under vehicle lifts had begun to strain his legs.

His primary care doctor suggested that he see a vascular specialist and handed him a list of physicians to choose from. Dormu happened to have an office in the same plaza as Rosenberg’s auto shop, between a jujitsu studio and a dentist’s office.

He first visited Dormu’s practice that December.

Instead of starting with more conservative treatment, Dormu deployed a trifecta of interventions on both of Rosenberg’s legs within three months, widening his arteries with stents and balloons, and debulking his vessels with atherectomy devices, according to later legal filings.

Shortly after one of the procedures, Rosenberg’s left foot grew numb and was cool to the touch. He went to the emergency room, where doctors discovered that one of his stents had clogged, hindering his vessel from carrying blood.

Angioplasty: A compact balloon is inserted into a blood vessel and inflated to flatten plaque against its walls.

Stent: A metal mesh tube is implanted into a narrowed blood vessel to hold open its walls.

Atherectomy: A catheter, often capped with a blade or laser, is inserted into a blood vessel and removes plaque off its walls.

(Illustrations by Now Medical Studios, special to ProPublica)

Dormu called him back to his office, where he repeated the procedures: shaving the blockages, ballooning the artery walls and installing another stent.

The next day, he repeated the procedures again, ballooning his vessels and installing yet another stent.

Dormu sent Rosenberg to Providence Hospital in Washington, D.C., for further treatment. Within a day, his left foot had grown cold, a sign that blood likely no longer flowed freely through his vessels.

According to the terms of a legal settlement in a malpractice suit against Dormu, Rosenberg cannot comment on his care. However, public documents filed in his case, including assessments from medical experts, illuminate the cascade of procedures and the outcome.

A vascular surgeon Dormu retained for his defense, Dr. Garry Ruben, said the interventions were warranted; he said Rosenberg had been prescribed an anti-platelet medication, which he did not consistently take. In legal filings, Dormu blamed Rosenberg’s injuries on his preexisting medical conditions and circumstances outside his control.

However, after reviewing medical records and diagnostic studies, Dr. Christopher Abularrage, an expert retained by Rosenberg and a professor at Johns Hopkins who specializes in vascular and endovascular surgery, found several “breaches of the standard of care.” Dormu had failed to prescribe conservative therapy and lifestyle modifications first, he found, and “persisted with unindicated, endovascular interventions in the face of persistently poor outcomes and diminishing returns.”

In less than six months, Rosenberg had been transformed from a patient with mild leg pain to one with a high risk of limb loss, he concluded.

Rosenberg spent nearly a week at Providence Hospital, the life slowly draining from his leg, before he was transferred to Washington Hospital Center on April 8, 2017, according to records. By then, his left leg was gangrenous and had no pulse. All of the stents had become blocked.

Without better options, doctors amputated his leg.

Between 2013 and 2017, Dormu earned about $14.5 million from Medicare — more than 99% of other vascular surgeons across the country — for treating hundreds of patients a year, the vast majority of them in his clinics.

In 2018, he was able to afford an upgrade.

The Watcher was not like other surgical centers. In its entrance stood a juice bar that could serve organic cold-pressed drinks to patients. Crystal chandeliers adorned its hallways. Moist air was pumped through its vents. And more than a dozen original modern paintings lined its walls, making it feel like an art gallery. “We wanted it to give that shock and awe,” Dormu said in a video interview from the facility’s opening day.

The clinic in Laurel. Dormu had also established several other vascular offices in the region. (Shuran Huang for ProPublica)

His clinic provided a litany of medical services, including treatments for uterine fibroids, erectile dysfunction and varicose veins, as well as elective nonsurgical fat reduction.

The expansive facility boosted Dormu’s earnings. From 2018 through 2021, he earned nearly $18 million in Medicare payments for all of his clinic’s activities.

One procedure stood out from the rest: Nearly $12 million of that came from atherectomies, according to Medicare data.

He performed one on Alice Belton, a high school nursing teacher who sought help in 2018 for lower extremity pain, numbness and tingling. Her artery blood flow was normal; even Dormu noted that she didn’t have severe leg pain, according to an ongoing lawsuit. And yet, he conducted multiple procedures over about a year, shaving plaque, ballooning her vessels, treating her veins and running invasive scans; the procedures were unnecessary, according to a medical expert retained in her case.

Belton says she has since developed permanent nerve damage in her leg, which has prevented her from working full time. In legal filings, Dormu denied the allegations and claimed that the alleged injuries were caused by preexisting conditions.

“The experience with Dr. Dormu has shaken my confidence in health care practitioners and more importantly in myself,” she said. “I feel duped that this surgeon convinced me, a nurse, that my problems required such radical surgical interventions.”

And then there was John Malinich, who had no leg pain but wanted to get his circulation checked in 2019 after he saw Dormu’s billboard. At first, Malinich didn’t question Dormu’s treatments; the doctor’s confident demeanor and lavish facility impressed him and put him at ease.

“After surgery on both of my legs, they wanted me to go back and do it over again,” he said. “After that, I started getting suspicious.”

He said he got a second opinion from another vascular surgeon who informed him that the prior procedures, which involved balloons, an atherectomy and a stent, had been unnecessary. To ensure his stent doesn’t collapse or clog, doctors now have to annually monitor Malinich. He filed a lawsuit against Dormu, who has denied allegations of overtreatment. The case is ongoing.

“I trusted the guy,” Malinich said. “But it was just to make money.”

The next year, Heather Terry was looking forward to her mother’s return home after a six-month stint rehabilitating in a nursing home. For years, Heather had helped take care of 62-year-old Linda Terry, who had debilitating epilepsy. After a fall down a flight of stairs and subsequent back surgery, Terry was left paraplegic and unable to walk.

Just before she was supposed to be discharged from the nursing home in August 2020, the staff told Heather Terry that her mother had leg pain and ulcers on her heels that needed treatment. According to her family, Linda Terry had no prior circulation issues. The procedure was simple, the staff said, and would be conducted in a clinic just down the road.

On Aug. 13, Terry was transferred to Dormu’s center, where he started an atherectomy procedure, inserting the small tube capped with blades into her vessels to shave the plaque from her artery walls.

Less than 15 minutes into the treatment, her blood pressure began to drop.

With atherectomy, there’s always a risk that the device may dissect the vessel, which would require immediate care.

Dormu aborted the procedure and brought Terry into the recovery area. She was drowsy and her blood pressure continued to waver, signs that she may have been bleeding internally, according to her family’s attorney. Instead of being rushed to the emergency room, legal filings show, she was sent back to the nursing home, where she became unresponsive.

The nursing home called an ambulance, which ferried her to the emergency room at the University of Maryland Laurel Medical Center. Three hours later, she was pronounced dead, according to the lawsuit, a consequence of severe anemia due to internal blood loss.

Heather Terry holds a photo of her mother, Linda Terry. Linda Terry, who was about to be discharged from a nursing home, was transferred to Dormu’s center for treatment. (Michelle Gustafson, special to ProPublica)

For the aborted procedure, according to the family’s attorney, Dr. Zev Gershon, Dormu charged her insurance about $20,000.

Heather Terry believes that if Dormu had treated her mother with appropriate care and transferred her directly to the hospital, she might have survived. “It went from ‘She’s going to come home tomorrow’ to ‘She’s dead,’” said Terry, whose ongoing malpractice case against Dormu is set to go to trial this year.

In legal filings, Dormu denied any involvement in her mother’s death. He said in a deposition that he did not see evidence of bleeding and that Linda Terry’s anemia could have been due to a prior fall. He said he also gave a directive to send her to the hospital after the aborted procedure, despite EMS records obtained by the family’s attorney showing that Terry was sent back to the nursing home.

“I trusted doctors,” Heather Terry said, “but now I’m starting to think that maybe they shouldn’t be as fully trusted.”

Heather Terry (Michelle Gustafson, special to ProPublica)

By 2021, Dr. Kim Hodgson, a former president of the Society for Vascular Surgery, recognized that unfettered profiteering in his field was not just a threat to patients, it also stood to damage the credibility of his speciality. Notably, abuse in outpatient vascular facilities was the No. 1 complaint he had received from members. That August, the vascular surgeon stood before hundreds of doctors at the society’s annual conference and made a plea.

“Somebody has to address what should never have been allowed to get to this level of threat to us and our patients in the first place,” he said. “We can play whack-a-mole every time the bad actors surface until the cows come home, but that leaves a trail of harmed patients and wasted resources.”

In dozens of slides, he laid out evidence exposing the magnitude of the crisis: the Medicare incentive, the explosive growth of procedures in clinics and the potential for inappropriate treatment. Most critically, he warned about the risk of patient harm. In recent years, researchers have found that patients in early stages of vascular disease had less than a 2% risk of amputation after five years. However, with aggressive interventions, that risk could surge up to 5% or even 10%.

“The problem is that these behaviors — unindicated early interventions and overuse of unproven technologies — still have costs and more often than not, those costs are borne by our patients,” he said. “We can and should do better, otherwise we are also enablers.”

The issue has magnified into a crisis that has splintered the specialities that conduct these procedures, which include interventional radiologists, cardiologists as well as vascular surgeons. Some physicians do not view overuse as an urgent problem and feel the recent academic attention unfairly stigmatizes private practice doctors.

“The majority of operators are doing the right thing,” said Dr. Jeffrey Carr, an interventional cardiologist and the founding president of the Outpatient Endovascular and Interventional Society, which represents physicians working in outpatient settings. “We need to call out the bad actors, but to cast a narrative that puts us all in the same arena is wrong.”

Other doctors recognize a need for considerable reforms.

CMS could reverse the change that kicked off the entire problem, some experts said, by reducing its outpatient reimbursement rates. “If you shut off the money, the whole thing will stop tomorrow,” Mukherjee, the Virginia vascular surgeon, said.

But such cuts might hurt doctors practicing responsibly and could even nudge the least scrupulous ones into higher gear to make up the financial difference. “You could incentivize people to do more procedures, and some of them may be inappropriate,” said Dr. Peter Lawrence, the former chief of vascular and endovascular surgery at the University of California, Los Angeles, who developed an outpatient center connected to the university.

More critical than payment cuts, Lawrence said, is greater oversight of office-based facilities. Many states don’t require doctors in those settings to have special vascular training or hospital privileges in case of complications, he said. “You could be a psychiatrist and do these procedures,” he said.

Many physicians also support improved data collection, particularly for newer technologies like atherectomy, to ensure that they’re not only safe but result in improved outcomes.

“Many of the vascular procedures that are done are relatively safe or can be done with good short-term results, but the failures are long term — it’s what happens in two to five years,” Lawrence said. “Unless you have a reimbursement system, which not only pays you for the initial procedure, but whether or not it’s durable, you can have procedures done in our society that have great short-term results but have poor long-term results.”

CMS could require physicians to participate in patient registries, said Dr. William Schuyler Jones, an interventional cardiologist and associate professor of medicine at Duke University School of Medicine. “That type of required reporting would make our system better,” he said, “and would ultimately put the onus on all of us to do more appropriate care.”

For Dormu, patients were the ones to prompt accountability, airing their grievances to the Maryland Board of Physicians. Among them was a woman who sought his care for excessive leg itching and said he tried to pressure her into an invasive artery scan. When she sought a second opinion, the doctor concluded that her itching likely stemmed from a reaction to an insect bite.

The medical board examined the records of 11 of Dormu’s patients. Two peer reviewers, board certified in vascular surgery, independently concluded that Dormu had performed “medically unnecessary and invasive vascular procedures” and failed to meet appropriate standards of care for 10 of the 11 patients, “exposing them to potential risks such as bleeding, infection, blood vessel injuries which could acutely or chronically worsen the patient’s circulation, and limb loss.”

One patient who sought Dormu’s care to evaluate blockages in their legs could walk a mile before treatment, but after the procedures, they could not walk at all.

The center claims to have “saved over 34,000 lives and limbs.” (Shuran Huang for ProPublica)

“There exists a substantial likelihood of risk of serious harm to the public health, safety, and welfare in Dr. Dormu’s continued practice,” the board’s executive director, Christine Farrelly, concluded.

Last October, the board found him in violation of state medical law, citing his overuse of procedures and his failure to uphold standards of care. It fined him $10,000, suspended him and put him under a two-year probation, during which he must be supervised and enroll in an ethics course.

Maryland Department of Health spokesperson Chase Cook said the agency’s Office of Health Care Quality, which is responsible for oversight of the state’s surgical centers and licensed Dormu’s current facility, was not aware of his sanctions nor the allegations of harm. The office “will follow-up in accordance with federal and state regulations,” Cook said.

Despite lacking an active license to practice medicine in Maryland, Dormu is still listed on his clinic’s website as the lead vascular surgeon, “currently available for office visits and in-patient consultations.”

When ProPublica called Dormu’s office to inquire whether he was still practicing, the receptionist said he was no longer seeing patients and that “Dr. Seibles” was providing all the same services. According to the Virginia Board of Medicine’s directory, Dr. Ayana Jonelle Seibles spends 20% of her time practicing at Dormu’s center in Maryland.

An emergency medicine physician who does not have specialty training in vascular surgery, Seibles appears to have a close relationship with Dormu; according to county property tax records, they have owned a home together since at least 2017. Seibles did not respond to ProPublica’s questions that were sent by email.

In a lawsuit deposition last month, Dormu said that he stopped doing surgery this year as a “personal choice.” When asked the name of his supervisor, he stated that he couldn’t recall it. He also couldn’t recall how many times he had been sued for malpractice, any of the details of the cases, nor the names of the attorneys representing him. He also couldn’t specify how many atherectomies he had performed, only estimating that he had done more than 100.

According to Medicare data, over the past decade, he has done at least 3,400.

For most of his life, Rosenberg trusted doctors; his own father was one. But the mechanic has lost faith in medicine. Memories of his 2017 amputation have been largely buried by the trauma, but he recalls lying in his hospital bed after the operation, the remnants of his left leg wrapped in a cloud of white bandages. “Life isn’t supposed to turn out like this,” he said.

He was discharged to his three-story colonial home, where two steps led to the front door and 13 steps gave way to the second floor; he could only ascend them by crawling backward. Eventually, he sold the house and his family moved into a flat, ranch-style home.

He tried to maintain his auto shop, relying on his wife and teenage stepson to help out. But with his limited mobility, first in a wheelchair and later maneuvering with his prosthetic and a cane, he could not repair cars like he used to and was forced to sell his business and retire.

Before, he could get dressed and out the door in less than 30 minutes; it now takes more than an hour. He used to prepare meals for his family, but after, his stepson had to learn how to cook. In the months following the surgery, he often fell asleep by 7:30 p.m., tired from carrying his body around all day. Discomfort would awaken him by 4 a.m.

Half of his days are now spent navigating the complex web of amputee providers, arguing with insurance agents, attending physical therapy and meeting with specialists to keep his vascular system in check.

Above all, managing the pain has remained a lingering burden. Even though he lost most of his left leg, its memory has been indelibly burned into his brain, haunting him like a phantom. Sometimes the bottom of his missing foot itches or a jolt surges down his absent calf.

“And there’s nothing anyone can do about it,” he said, “because it’s not there.”

Do You Have Experience With Peripheral Artery Disease? Have You Had a Procedure on Your Leg? Tell Us About It.

by Abigail Kramer, THE CITY; Photography by Sarah Blesener for ProPublica

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.

In a panic, if she floors it, Marilyn Blanco can drive from her job at the Rikers Island jail complex to her son Ian’s school in Harlem in less than 18 minutes.

Nine times since December, Blanco has made the drive because Ian’s school — Success Academy Harlem 2 — called 911 on her 8-year-old.

Ian has been diagnosed with ADHD. When he gets frustrated, he sometimes has explosive tantrums, throwing things, running out of class and hitting and kicking anyone who comes near him. Blanco contends that, since Ian started first grade last year, Success Academy officials have been trying to push him out of the school because of his disability — an accusation similar to those made by other Success Academy parents in news stories, multiple lawsuits that resulted in settlements and a federal complaint.

When giving him detentions and suspensions didn’t stop Ian’s tantrums, Blanco said, the school started calling 911. If Blanco can’t get to Ian fast enough to intervene, a precinct officer or school safety agent from the New York Police Department will hold him until an ambulance arrives to take him to a hospital for a psychiatric evaluation — incidents the NYPD calls “child in crisis” interventions.

The experience has been devastating for Ian, Blanco said. Since the 911 calls started late last year, he’s been scared to leave his house because he thinks someone will take him away. At one ER visit, a doctor wrote in Ian’s medical file that he’d sustained emotional trauma from the calls.

Citywide, staff at the Success Academy Charter School network — which operates 49 schools, most of them serving kids under 10 years old — called 911 to respond to students in emotional distress at least 87 times between July 2016 and December 2022, according to an analysis of NYPD data by THE CITY and ProPublica.

If Success Academy were run by the city Department of Education, it would be subject to rules that explicitly limit the circumstances under which schools may call 911 on students in distress: Under a 2015 regulation, city-run schools may never send kids to hospitals as a punishment for misbehavior, and they may only involve police as a last resort, after taking mandatory steps to de-escalate a crisis first. (As THE CITY and ProPublica reported this month, the rules don’t always get followed, and city schools call 911 to respond to children in crisis thousands of times a year.)

But the regulation doesn’t apply to Success Academy, which is publicly funded but privately run and — like all of the city’s charter school networks — free to set its own discipline policies.

Success Academy Harlem 2, where Ian attends school.

The consequence, according to education advocates and attorneys, is that families have nowhere to turn if school staff are using 911 calls in a way that’s so frightening or traumatic that kids have little choice but to leave.

“Sure, you can file a complaint with the Success Academy board of trustees. But it isn’t going anywhere,” said Nelson Mar, an education attorney at Legal Services NYC who represented parents in a 2013 lawsuit that led to the restrictions on city-run schools.

Success Academy did not respond to questions about the circumstances under which school staff generally call 911 or the criteria they use to determine whether to initiate child-in-crisis incidents.

Regarding Ian, Success Academy spokesperson Ann Powell wrote that school staff called EMS because Ian “has repeatedly engaged in very dangerous behavior including flipping over desks, breaking a window, biting teachers (one of whom was prescribed antibiotics to prevent infection since the bite drew blood), threatening to harm both himself and a school safety agent with scissors, hitting himself in the face, punching a pregnant paraprofessional in the stomach (stating ‘I don’t care’ when the paraprofessional reminded him that ‘there’s a baby in my belly’), punching a police officer and attempting to take his taser, and screaming ‘I wish you would die early.’”

Powell also provided documentation that included contemporaneous accounts of Ian’s behavior written by Success Academy staff, photographs of bite marks and a fractured window, an assessment by a school social worker concluding that Ian was at risk for self-harm, and a medical record from an urgent care facility corroborating the school’s account that a teacher had been prescribed antibiotics.

Blanco said that Success Academy administrators have regularly exaggerated Ian’s behaviors. When he was 6, for example, Ian pulled an assistant principal’s tie during a tantrum, and school staff described it as a choking attempt, according to an account Blanco gave to an evaluator close to the time of the incident. Each time Success Academy has sent Ian to an emergency room, doctors have sent him home, finding that he didn’t pose a safety threat to himself or others, medical records show. (Success Academy did not respond to questions about the assertion that staffers have exaggerated Ian’s behaviors.)

Blanco knows that Ian is struggling. No one is more concerned about his well-being than she is, she said. But villainizing her 8-year-old only makes the situation worse.

“It’s like they want to tarnish him,” Blanco said. “He’s just a child, a child who needs help and support.”

“Things are already hard enough” for Ian, Blanco continued. “Kids born with special needs — they didn’t choose that walk of life. Ian didn’t pick this. They don’t have the right to punish him for it.”

Back in 2020, when Ian was 4, Blanco was thrilled to get him a spot at Success Academy. She and Ian live in the South Bronx, in the same neighborhood where Blanco grew up. At Ian’s city-run neighborhood school, P.S. 62, just 14% of students passed state reading exams last year.

Success Academy Harlem 2

Success Academy, which has avid support from many parents and is led by former New York City Councilmember Eva Moskowitz, promotes itself as an antidote to educational inequality, offering rigorous charter school options to kids who might not have other good choices. On its website, the network advertises its students’ standardized test scores (pass rates for Black and Latino students are “double and even triple” those at city-run schools) and its educational outcomes: 100% of high school graduates are accepted to college, the network says.

Success Academy administrators say that strict and consistent discipline policies are essential to kids’ learning. Students are required to follow a precise dress code and to sit still and quietly, with hands folded in their laps or on their desks. When students break the rules, the school issues a progressive series of consequences, including letters home, detentions and suspensions.

Once students are accepted through the Success Academy lottery, the network is required to serve them until they graduate or turn 21, unless they withdraw or are formally expelled.

But critics, including parents who say their kids were pushed out of Success Academy schools, have long claimed that the network achieves its academic results by getting rid of students with disabilities — especially those with mental health or behavioral challenges that make it impossible to follow the school’s rigid comportment rules. In 2015, The New York Times reported that a Success Academy school in Fort Greene, Brooklyn, had drawn up a list of students with the heading “Got to Go.” The network’s officials responded to the report by saying that the list had been a mistake, and that the school’s principal had been reprimanded.

A year later, a group of parents, accompanied by then-New York City Public Advocate Letitia James, filed a complaint against Success Academy with the federal education department, claiming that the network discriminated against students with disabilities, including by threatening to file child welfare reports and to call 911 on children if their parents didn’t pick them up on demand. (The investigation is still open.)

In 2019, the New York State Education Department found that Success Academy had failed to provide mandatory services for students with disabilities and refused to follow orders issued by hearing officers.

Success Academy did not respond to questions from THE CITY and ProPublica about the investigations.

Critics have paid less attention to the fact that Success Academy is not subject to city rules governing 911 calls — an exemption the network takes full advantage of, according to accounts from parents, attorneys and two former staff members who spoke to THE CITY and ProPublica.

“The path is detentions, suspensions, parent meetings. A 911 call is the next step in the escalation,” said Livia Camperi, who was an English teacher at a Success Academy school in Brooklyn until March. Camperi said she was fired because she disagreed with a new principal about increasingly “draconian” discipline practices. On the day she left the school, an assistant principal called an NYPD safety agent on a middle school student who stayed seated after being instructed to leave a classroom, according to Camperi, who showed THE CITY and ProPublica text messages from students and staff that corroborate her account.

In response to questions about this incident, Powell, the Success Academy spokesperson, wrote that the student was shouting and banging on a desk. Educators “were concerned that the student wasn’t following directions and might become violent so they called school safety,” Powell wrote. “It is appropriate to involve school safety when there are possible safety issues.”

Powell did not comment on the circumstances under which Camperi was fired.

In Harlem, Ian started struggling at Success Academy just a few weeks into first grade. He’d never been aggressive before he started school, Blanco said. Because of the COVID-19 pandemic, he’d attended kindergarten online. When schools went back to in-person instruction, he was a high-energy 6-year-old who couldn’t follow Success Academy’s strict rules requiring him to sit still and stay quiet. By the end of first grade, he’d been suspended nearly 20 times.

The more Ian got in trouble, the worse he felt about himself and the worse his behavior became, Blanco said. He started falling behind because he missed so much class time during his suspensions, according to his education records. At home and at school, he said that teachers disciplined him because he was a “bad kid.”

At first, Blanco worked hard to cooperate with the school, she said. She was worried by the change in Ian’s behavior, and she thought that school staff had his best interests at heart. But then an assistant principal called her into an office and told her that Success Academy wasn’t a “good fit” for Ian, Blanco said to THE CITY and ProPublica, as well as in a written complaint she sent to Success Academy at around that time. (Success Academy’s board of trustees investigated the complaint and did not find evidence of discrimination against Ian, according to a September 2022 letter to Blanco from a board member.)

“That didn’t sit right,” said Blanco, who is an investigator at Rikers Island and is accustomed to gathering paper trails. She asked the assistant principal to put the statement in writing, but he told her she had misunderstood, she said. (Success Academy did not respond to questions about this incident.)

Several times, when the school called Blanco to pick Ian up early, staff told her to take him to a psychiatric emergency room for an evaluation. But the visits didn’t help, Blanco said. “You could be sitting there for six, seven, eight hours,” waiting to talk to a psychologist. Because Ian never presented as an immediate threat to himself or others, hospital staff couldn’t do much but refer him to outpatient care and send him home, according to hospital discharge records.

Eventually, Blanco found an outpatient clinic that would accept her insurance to evaluate Ian for neurological and behavioral disorders. She said she begged school staff to stop disciplining Ian while she worked to get him treatment, but the suspensions were relentless. Once, he missed 15 straight days of school.

At the beginning of Ian’s second grade year, Blanco reached out to Legal Services NYC, where Mar, the education attorney, took her on as a client.

Mar filed a complaint on Blanco’s behalf with the state education department, which concluded that Success Academy had failed to provide Ian with services required by his individualized education plan. He also represented her in hearings to determine whether Ian’s suspensions were for behavior that resulted directly from his disability, which ultimately reduced the number of days that Ian was barred from school. But there was little they could do about the fact that the suspensions just kept coming.

When parents of kids at city-run schools believe their children have been unfairly disciplined — including through inappropriate suspensions or unnecessary 911 calls — they can appeal for help first from the superintendent of their community school district or the city’s Department of Education, and then from the state education department, which oversees the city agencies.

Charter school families, on the other hand, often have “no opportunity for redress,” Mar said. In certain cases, students or parents can file a complaint with the State University of New York, which authorizes Success Academy’s charter and has the power to revoke it. But neither SUNY nor the state education department have regulations governing 911 calls, and SUNY will only consider a complaint if students or parents can show that a school violated the terms of its charter or broke the law — which is very difficult to prove in the case of 911 calls, since school staff have room for discretion in emergencies, including serious threats of suicide or self-harm.

“SUNY does not condone the use of 911 as a form of discipline and that is made clear when schools seek guidance. We also do not substitute our judgement if a school administrator believes a child in distress needs emergency services,” wrote Mike Lesczinski, director of communications for the SUNY Charter School Institute.

The state education department did not respond to requests for comment.

In January, Blanco called Mar again as she sped from Queens to Harlem. Ian had had another tantrum, and Success Academy had once again called 911. Mar raced to the school, where he and Blanco found Ian in a hallway, sobbing. Four uniformed police officers and two EMTs towered over him, Mar and Blanco said.

School staff said that they had isolated Ian in an office because he was behaving aggressively, and then he’d tried to open a window. “They claimed he was exhibiting suicidality,” Mar said.

But Ian told Mar and Blanco that he’d never planned to hurt himself; he just didn’t want to be confined alone in an office. “He was trying to do what any logical person would do,” Mar told THE CITY and ProPublica. “He wanted to get out of the situation.”

Blanco told the EMTs that she did not consent to them putting Ian in an ambulance. Instead, she drove him herself to the psychiatric emergency room at Manhattan’s Bellevue Hospital for an evaluation, she and Mar said. As with all the other ER trips, hospital staff evaluated Ian, determined that he wasn’t at risk of harming himself and sent him home.

Shortly after the January 911 call, Blanco’s doorbell rang. It was a caseworker from the Administration for Children’s Services, New York City’s child welfare agency, there to investigate a report that Blanco was neglecting Ian’s medical care.

The allegation seemed absurd to Blanco, since Ian is under the care of a neurologist, was on waitlists for outpatient therapy at several clinics, and has been assessed multiple times by ER doctors who determined he was not at risk of self-harm, according to Blanco’s account and medical records. “I’ve done everything in my power to try and get him help,” Blanco said.

Blanco and Ian

Because people who report concerns to child welfare agencies are typically kept anonymous and the investigation is still open, Blanco couldn’t immediately find out who made the complaint against her. However, Powell from Success Academy wrote that school staff reported Blanco for child neglect in January, after Blanco refused to allow EMTs to put Ian in an ambulance. (In this instance, the school had called a mobile crisis unit to respond to Ian before calling 911, Powell wrote, but the unit was not available.) School staff were concerned that, despite “Ian’s repeatedly exhibiting self-injurious behaviors,” Blanco had shown a pattern of “neglecting her child by failing to provide appropriate and necessary mental support for him,” Powell wrote.

Success Academy made a second child welfare report against Blanco in April, after another incident in which Ian’s parents refused to allow EMTs to take him from school by ambulance. In that instance, Powell wrote, lieutenants from the NYPD and EMS said that Ian needed to be evaluated in a hospital because he’d said he wanted to harm others, and that emergency services personnel would be required to alert the Administration for Children’s Services if Ian’s parents refused the recommended level of care.

“We had utterly no choice in the matter,” Powell wrote. “Declining to notify ACS when the police have specifically concluded there is a duty to do so would have been a flagrant, deliberate and criminal violation of our reporting duties.”

It’s not uncommon for schools to file child welfare reports against parents who refuse to allow their children to be taken from school by ambulance — even if the kids are in treatment and the parents believe that being forcibly removed from school would be traumatic and unhelpful, according to several education attorneys and parents who told similar stories to THE CITY and ProPublica. School employees, who are legally required to report suspected abuse or neglect, make thousands of unfounded child welfare reports each year.

“I don’t know if schools really understand how much pain they add to a stressful situation when they make a child welfare report,” said Jenn Choi, who works as an educational advocate for parents of children with disabilities. Ten years ago, Choi was subject to a child welfare investigation after a school bus attendant called 911 on her son, who’s autistic.

At Blanco’s apartment, the investigator peered into her refrigerator and cabinets and took Ian into a separate room to interview him alone. “It was very invasive and humiliating,” Blanco said.

She felt besieged by forces she couldn’t possibly withstand. “I know how this works. I’m a single mom, I live in the Bronx, I’m a minority, I’m a dark-skinned woman. So automatically, it must be a broken home,” Blanco said. “I’ve cried my eyes out. I’m not the person that I was prior to my son going into that school.”

The 911 calls and the child welfare case are taking their toll on Ian, too. He gets nervous now when he sees police cars on the street, Blanco said. “I’m law enforcement. I don’t teach him to be afraid of police.” In February, he told a therapist that the only place he feels safe is at home.

One month after the child welfare visit, things got even worse. Blanco was in Queens, heading to work to pick up some overtime, when the school called to say that Ian had had another tantrum. This time, she was too late to bring Ian home herself. He was in an ambulance, on his way to Harlem Hospital.

“I started having a panic attack,” Blanco said. “I just kept thinking about him being taken away by strangers and I’m not there. I don’t know if he complied and got in the ambulance of his own accord. I don’t know if they forced him. I don’t know what they’re telling him, what they’re doing to him, what they’re making him feel.”

She was crying too hard to drive, so she called Ian’s dad, who left a barbershop halfway through a haircut to pick up Blanco and rush to the hospital. When they arrived and Blanco saw that Ian was safe, her panic turned to something else. “I was so angry but at the same time I felt so defeated. I’m fighting a lost cause,” she said. “I felt so small and helpless that I couldn’t even defend my own child.”

Two weeks ago, Success Academy sent Blanco an email informing her that they requested a hearing to have Ian removed from school for up to 45 school days because he “is substantially likely to cause injury to himself and others while in the Success Academy community.”

Ian would be barred from Success Academy immediately, the email said, even though it could take up to 20 days to schedule the hearing, which will be held at the special education division of the city’s Office of Administrative Trials and Hearings. If the hearing officer agrees with Success Academy, Ian will miss the rest of the school year.

“I want to be clear that this action is not disciplinary in nature,” wrote Bridget McNamara, Success Academy’s head of school management, in the May 9 message to Blanco. “We believe Ian is currently not safe in his current school placement.”

To Blanco, the hearing seems like just another way for the school to get rid of her son. She thinks about pulling Ian out of Success Academy all the time, she said, but it feels like there’s no good alternative. She doesn’t want to give up on the idea of him getting a better shot than the one she got at a failing neighborhood school.

“I want him to get free of this cycle of disadvantage,” Blanco said. “I want to fight for my son’s rights and let them know that you’re not going to treat my child this way. I’ve made it my mission. You don’t get to pick and choose who you give an education to.”

Blanco and Ian. Ian is barred from attending Success Academy while he waits for a hearing at the city’s Office of Administrative Trials and Hearings.

Clarification, May 26, 2023: This story has been clarified in two places to specify that Success Academy called 911 when requesting an emergency response to students’ misbehavior, removing any ambiguity about whether the police were called directly.

by Caroline Chen

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The outbreaks keep coming.

Mpox, the virus formerly known as monkeypox, last year crossed borders with unprecedented speed to infect nearly 90,000 people. In the past year, Ebola killed at least 55 in Uganda, and a related, equally deadly virus called Marburg emerged in two countries that have never seen it before. Now, scientists are worried that a dangerous bird flu that’s been jumping to mammals could mutate and spread among humans.

These viruses all came from wildlife. Understanding what conditions prime pathogens to leap from animals to people could help us prevent outbreaks. After COVID-19 showed the world the devastation a pandemic can bring, you’d think this type of research would be among the hottest areas of science, with funders lined up far and wide.

That’s not the case. As ProPublica has shown in a series of stories this year, global health authorities focus far more attention and money on containing outbreaks once they begin rather than preventing them from starting in the first place. This mindset has hindered scientists who study the complex dynamics that drive what’s known as spillover, the moment a pathogen leaps from one species to another.

Australian researcher Peggy Eby and her colleagues have shown that it is possible to predict when spillovers are going to happen by closely tracking bats that spread contagion and patiently observing changes that shape their world. This groundbreaking research on the often-fatal Hendra virus relied on decades of Eby’s field work, some of which she did without pay. Early on, one government funder told her that the project she proposed wasn’t a “sufficiently important contribution.” She and her colleagues had to cobble together a mishmash of different grants and keep impatient funders happy. Their work, published late last year in the journal Nature, highlights ways to intervene and potentially prevent outbreaks.

Scientists want to unlock similar mysteries involving other infectious diseases, but research like this is difficult to do and even more difficult to fund. Here are some of the obstacles that stand in the way:

High-tech research overshadows old-school field work.

Government and scientific funding organizations typically reward cutting-edge technologies, such as using machine learning to build models. But those are only as good as the information fed into them — data that someone like Eby has to collect through painstaking groundwork. Many of Eby’s most important insights have come from visiting and revisiting bat roosts over many years, and there was nothing high-tech or novel about her method: a keen eye, a pair of binoculars, a pen and a notebook.

Wildlife ecologist Peggy Eby scans a tree line for flying foxes in the Pilny Reserve. For decades she has gathered data through low-tech shoe-leather field work. (Kathleen Flynn, special to ProPublica) Funders prize novelty over exploring existing theories.

Some funders prioritize totally new ideas. Eby and her colleagues have found that bats shed more Hendra virus after being stressed by food shortages, which have increased as people cut down native trees that once provided the nectar the bats like to eat. Sarah Olson, director of health research at the Wildlife Conservation Society, has long wanted to conduct similar research on bats suspected of carrying the Ebola virus in the Republic of Congo. Developers have cleared swaths of forest in recent years to build roads and housing, and Olson wants to understand how that’s affected these bats.

Sarah Olson, center, of the Wildlife Conservation Society, collects a bat in an abandoned mine near Ely, Nevada, in 2018. (Kim Raff/The New York Times via Redux)

Olson has applied for grant after grant since 2015 but has struggled to get sufficient funding. Even before she applied, an employee at the National Science Foundation told her the study wouldn’t be novel enough because she wasn’t exploring an entirely new theory. Rather than strengthening her case, Eby and her colleagues’ prior work weakened Olsen’s chances. A spokesperson for the National Science Foundation said the agency could not comment on specific grants. Speaking generally, the spokesperson wrote, “The most competitive proposals are those that advance broad, conceptual knowledge that reaches beyond the specific system under study.”

Olson has lined up Congolese researchers who are willing to collaborate. “We can do it,” she said. “It’s just a matter of getting funding and the interest.”

Funders’ focus is often too narrow.

If you want to predict and prevent an outbreak, you have to answer big questions: What causes spillover? Why this year and not another? How does a changing environment influence animals and their interactions with humans? Experts across disciplines are needed, but cross-disciplinary vision is hard to find among many of the most prominent funding agencies.

The National Institute of Allergy and Infectious Diseases, for example, focuses on research to develop treatments, vaccines and diagnostic tests and to understand viruses at the molecular level. Conservation and environment-focused grants rarely include human health in their scope.

Olson pitched her study on Congolese bats to the National Institutes of Health. She got rejected, she said, because grant reviewers said that it wasn’t clear how the bat results could be linked to human infections. An NIH spokesperson said the agency doesn’t comment on specific grants, adding, “It is incumbent on investigators who want to study overlapping interests of animal and human health to clearly describe the relevance of their proposed research to the advancement of human health.”

Eby and her colleague, Dr. Raina Plowright, a professor of disease ecology at Cornell University, smacked into these same silos when their applications for grant after grant were shot down. An animal foundation, for instance, said it wasn’t within its mandate to care about diseases that jumped to humans.

Dr. Raina Plowright has been studying bats for decades. Here, conducting research nearly 20 years ago, she and employees of the Parks and Wildlife Commission in Australia carry bags containing flying foxes that they studied and later released. (Courtesy of Dr. Raina Plowright)

Thomas Gillespie, a professor of environmental sciences at Emory University, wanted to investigate whether stress affects when cave-dwelling bats in Costa Rica shed leptospirosis, a type of bacteria that can be deadly to humans. A joint program from the National Science Foundation and the NIH said the project was “too ambitious,” he recalled. Gillespie and his colleagues tried for a different NIH grant, but reviewers complained the focus was too much on animals and not enough on humans, he said. In the end, he and his colleagues stitched together funding from a museum, a nonprofit and private foundations, but they had to scale back the project to stay within budget.

Long-term research doesn’t fit into short-term grants.

Research grants typically last two to three years, which is not enough time to observe how climate change, food shortages, habitat loss and deforestation are affecting animal behavior. For their Hendra research, Eby and her colleagues analyzed data that spanned 25 years. To support that long-term data collection, Eby sometimes took on contract work, such as helping local governments figure out how to deal with bats that people in the area considered a nuisance.

Plowright won a grant from an arm of the Department of Defense, but it only allowed two years for collecting field data. “They needed us to wrap things up and show results to justify our funding,” Plowright said. That schedule is the norm, not an outlier, in science.

Some key programs are one-offs.

It’s not just that grants are short term. Some of the rare grant-giving initiatives that focus on prevention don’t last long either.

The Hendra virus researchers received some of their biggest financial support from a Defense Advanced Research Projects Agency program that was unique in its scope and vision. Called Preventing Emerging Pathogenic Threats, the program sought to understand the reasons contagions spread from animals to people. The ultimate goal was to devise strategies to protect U.S. troops in places where there are endemic and emerging infectious diseases, according to Kristen Jordan, the deputy director for the DARPA Biological Technologies Office. Unlike many others, this program was designed to support multidisciplinary research and was squarely focused on prevention. In 2018, it funded five projects, including the Hendra virus research.

But that’s it. After five years, the program is wrapping up for good. “We look to our government partners to pick up the pieces, if they so desire,” Jordan said. “We are ready for the next hard problem; there are many we need to address.”

Similarly, a program at the NIH called the Centers for Research in Emerging Infectious Diseases is among the few that fund scientists across disciplines who are trying to understand spillover. Established in 2020, the program plans to award $82 million over five years. That’s not as much as it sounds. Consider that the NIH receives more than $3 billion annually for HIV and AIDS research. Jean Patterson, the scientist who helps oversee the program, said that when the five years is up, she and her team have to make the case to NIH leaders that their program should continue or it will be dropped.

Money is scarce, even for solutions.

When researchers uncover ways to prevent outbreaks, getting funders to implement those solutions is no sure bet. Emily Gurley, an infectious disease epidemiologist at Johns Hopkins University, succeeded in winning government funding to piece together how the Nipah virus jumped from bats to people in Bangladesh. She and her colleagues figured out a way to interrupt the transmission of Nipah, the virus used as the model for the disease in the movie “Contagion.”

Infrared camera images captured fruit bats licking sap from date palm trees in Bangladesh. The pot under the bats collects sap. (Courtesy of Rajib Ausraful Islam, icddr,b)

Gurley and her team used infrared cameras to determine that bats were drinking sap that residents were collecting in pots attached to date palm trees. People caught Nipah when they drank sap contaminated by infected bats.

Across multiple studies, Gurley and her colleagues showed that bamboo skirts covering the pots were cheap and easy to make, accepted by local sap collectors and effective at keeping out bats. With a proven solution in hand, Gurley wanted to roll this out in other parts of Bangladesh where bats spread Nipah, but she said no U.S. or international agency would step up to fund that work. The Bangladeshi government tells people not to drink raw sap, but this is a long-standing tradition that may be hard to eliminate.

Gillespie, the Emory professor, said that government and private scientific funding groups need to prioritize research into prevention, so we can learn how best to head off deforestation, habitat loss and other causes of spillover. “We have to do something now, or we’ll end up in an era of pandemics,” he warned.

by Kathleen McGrory and Neil Bedi

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The federal government is planning to reform a workplace safety program that was scrutinized in a recent ProPublica investigation.

The Star Program recognizes workplaces with strong safety programs and rewards them by curtailing the number of times government regulators show up randomly. It is based on the theory that motivating companies to adhere to best practices on their own is more effective than punishing them when they fall short.

But last year, workers at one chlorine plant in New York state told ProPublica that they were “swimming” in asbestos while their plant took part in the program from 1996 to 2021, and that participating had helped the company conceal the issue from the public.

After ProPublica revealed problems at other asbestos-dependent chlorine plants, the American Public Health Association questioned whether plants that use the carcinogen should be allowed to apply.

“On its face, a company whose business model relies on using asbestos does not have an exceptional health and safety management system,” the group wrote in a letter to the Occupational Safety and Health Administration, which runs the program. “There are alternative processes available and used by [chlorine] plants in the U.S. and in other nations.”

At the time, OSHA declined to comment on the content of the letter. The agency released a statement saying it was “focused on improving our efforts and looking at ways to protect workers from occupational exposure to asbestos moving forward.”

More recently, however, OSHA has signaled that big changes may be coming to the Star Program and other initiatives included in its Voluntary Protection Programs. The agency has said it wants to “modernize” the initiative as it works to expand it, and it is asking the public to answer a series of questions to help with the effort.

The questions range from technical to broad. Some touch on the issues raised in ProPublica’s reporting, including a question that asks if the exemption from random inspections creates concerns about workplace safety and health at the facilities.

Another echoes the question posed by the public health association about workplaces that use hazardous materials.

In a statement, OSHA said that it had started the process of modernizing the program before ProPublica’s stories were published, but that several of its questions were informed by ProPublica’s reporting. OSHA will hold a meeting for stakeholders on the subject on June 15, and comments from the public are due by Sept. 30.

The Star Program dates to the Reagan administration. To participate, plants must prove they follow best practices and submit to a rigorous inspection. But after that, they are no longer subject to random inspections.

OSHA reevaluates the facilities every three to five years.

Former workers at the facility in New York, an OxyChem chlorine plant in Niagara Falls, told ProPublica they spent months preparing for visits and shut down the dirtiest, most dangerous parts of the plant when OSHA evaluators were on site.

Still, records show that during one visit in 2011, evaluators found asbestos “scattered in certain areas of the floor” and covering much of the mechanical equipment. The plant did not receive a formal citation. It was readmitted to the program anyway.

OxyChem has repeatedly told ProPublica it complies with federal regulations and noted that OSHA has never cited its chlorine plants for asbestos-related violations.

In its letter to OSHA, the public health association raised concerns that the plant’s management had used its status in the Star Program “to game the system” to hide asbestos problems. The group pointed out that other chlorine plants using asbestos were also in the program, and it asked to meet with OSHA leaders.

The February meeting took place just before OSHA posted its questions for the public.

So far, the agency has received several dozen replies from company representatives, industry groups and safety experts. Many expressed satisfaction with the program while also offering suggestions for improvements. One individual, a self-described contractor who said he worked for multiple participants, called the program “a joke.”

A joint response from OSHA’s former Deputy Assistant Secretary Jordan Barab and former Assistant Secretary David Michaels questioned whether the program was worth the resources the agency puts into it.

Addressing the issue of plants that use hazardous substances like asbestos, Barab and Michaels said it was “inevitable” that some companies would use, store or manufacture dangerous materials and that that alone should not preclude their involvement in the program.

“If, however, there are safer alternatives to certain exceptionally hazardous substances or processes that can be feasibly implemented, OSHA should expect [program] participants to set an example by implementing those safer alternatives, even if the hazardous substance — such as asbestos — is still legally permitted to be used in the workplace,” they wrote.

Asked to respond, OSHA said in a statement: “It is premature for OSHA to comment on public comments as we are still engaging in the process, but we value the input and the important point that all employers should strive for safer alternatives.”

ProPublica’s reporting on asbestos has resonated widely. Late last year, it prompted public health advocates and two U.S. lawmakers to renew calls for Congress to ban the carcinogen, a move that would put the country in line with dozens of others across the world.

The lawmakers cited ProPublica’s work when reintroducing the bill this March.

In addition, the Environmental Protection Agency, which is finalizing its own ban, asked the public to weigh in on new information it had received on the issue, including ProPublica’s reports. Soon after, in a dramatic turnaround, one of the few U.S. manufacturers still using asbestos, Olin Corp., said it would support outlawing the carcinogen.

The EPA has said it is “moving expeditiously” to finalize the action this year.

by Caleb Bedillion, Northeast Mississippi Daily Journal

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

The Northeast Mississippi Daily Journal has sued Mississippi’s Union County, asking a judge to order that search warrants in its county-level justice court be made open for public inspection.

The lawsuit comes after an investigation last year by the Daily Journal and ProPublica found that almost two-thirds of Mississippi’s justice courts obstruct access to search warrants and to the affidavits used by police to obtain them.

That thwarts public scrutiny of searches, including no-knock raids in which police sometimes enter people’s homes at night with guns drawn. Last year, two Mississippi counties settled lawsuits involving such raids in which police shot people, one fatally.

Law enforcement usually must get permission from a judge before searching someone’s property, and normally they must knock and announce themselves before entering. But they can ask a judge for a no-knock warrant if they provide specific reasons.

They must bring search warrants back to court after a search, along with a list of what they seized.

The news organizations found that some Mississippi courts break statewide rules that require clerks to keep those warrants on file. Other courts — such as the Union County Justice Court — have the documents but claim the public can’t look at them.

“Our goal is to ensure that judicial records are kept open and that the government at all levels does its work where the public can see it,” Daily Journal Executive Editor Sam Hall said. “It seems clear to us — and to many other courts across the country — that the records we’ve requested should be public.”

The U.S. Supreme Court has recognized a centuries-old norm that court proceedings and papers should be open to the public. Judges can order that certain documents be sealed, but that must be done on a case-by-case basis.

Federal appeals courts have agreed that search warrants are judicial records that should be open to inspection, though they disagree about when exactly the document becomes subject to access.

It is “highly unusual” for a court to claim “that search warrants and related materials are simply never accessible to the public,” Katie Townsend, deputy executive director and legal director for the Reporters Committee for Freedom of the Press, told the news organizations last year.

But many of Mississippi’s justice courts, which frequently handle search warrants, did just that.

An attorney acting on behalf of Union County told the Daily Journal that records of executed search warrants on file with the clerk of the Union County Justice Court are shielded from public view because of a state law that protects the investigative records of law enforcement agencies.

In its lawsuit, the Daily Journal argues that this claim runs afoul of Mississippi’s Public Records Act and the common-law right to access court records. Mississippi’s public records law does contain an exemption for certain investigative records, but the exemption applies only to law enforcement agencies, not courts.

The county later offered to make some search warrants available, but only if a criminal investigation had concluded and a judge gave permission. The Daily Journal’s lawsuit argues that these conditions aren’t supported by law.

A representative of Union County did not respond to a request for comment on the lawsuit.

Experts say it’s not easy to get access to search warrants in many courthouses across the country. Even so, they said the problems with record-keeping and public access in Mississippi’s justice courts were extreme.

After a search warrant has been executed, it “should be a part of the files and available for public inspection,” William Waller Jr., a retired chief justice of Mississippi’s Supreme Court, told the news organizations last year. He helped draft the state’s rules of criminal procedure.

In response to the Daily Journal and ProPublica’s investigation, Mississippi’s judicial training body has advised court clerks and judges at training sessions that executed search warrants must be kept on file by the clerk and that the documents should be considered public if a judge hasn’t sealed them.

Last month, an insurance program run by many Mississippi counties held a risk management conference for law enforcement agencies, featuring sessions on search warrants and no-knock raids. Lawyers warned sheriffs that deputies should carefully document their reasons for conducting no-knock searches.

Rural Monroe County, in Mississippi’s northeast corner, settled a lawsuit for $690,000 last year over a 2015 fatal shooting by sheriff’s deputies during a 1 a.m. raid to look for drugs. Ricky Keeton came to the door with an air pistol as deputies pried open his door. His girlfriend said he thought someone was breaking in.

Also last year, Coahoma County, in the Mississippi Delta, settled a lawsuit that involved a 2020 raid in which sheriff’s deputies shot an unarmed man multiple times. He wasn’t even the target of the search and only happened to be at the house at the time of the raid. The amount of the settlement has not been disclosed.

by Caroline Chen; Photography by Kathleen Flynn for ProPublica

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

We’re investigating the cause of viruses spilling over from animals to humans — and what can be done to stop it. Read more in the series →.

Dressed head-to-toe in protective gear, Peggy Eby crawled on her hands and knees under a fig tree, searching for bat droppings and fruit with telltale fang marks.

Another horse in Australia had died from the dreaded Hendra virus that winter in 2011. For years, the brain-inflaming infectious disease had bedeviled the country, leaping from bats to horses and sometimes from horses to humans. Hendra was as fatal as it was mysterious, striking in a seemingly random fashion. Experts fear that if the virus mutates, it could jump from person to person and wreak havoc.

So while government veterinarians screened other horses, Eby, a wildlife ecologist with a Ph.D., got to work, grubbing around the scene like a detective. Nobody knew flying foxes, the bats that spread Hendra, better. For nearly a quarter century, she’d studied the furry, fox-faced mammals with wingspans up to 3 feet. Eby deduced that the horse paddock wasn’t where the bats had transmitted Hendra. But the horse’s owners had picked mandarin oranges off the trees across the street. The peels ended up in the compost bin, where their horse liked to rummage. “Bingo,” Eby thought. Flying foxes liked mandarins. The bats’ saliva must have contaminated the peels, turning them into a deadly snack.

Eby, however, longed to unlock a bigger mystery: Could she, with the help of fellow scientists, predict when the conditions were prime for Hendra to spill over from bats, before it took any more lives? What if they could warn the public to be on guard — maybe even prevent the virus from making the leap? It would be painstaking work, but it wasn’t a pipe dream; Eby was already spotting patterns as she crawled around infection sites.

But when she pitched her research to a government funder the following year, she got a flat no. She proposed starting small, gathering basic data on flying foxes that could be used to figure out when and why they spread the virus. Her work, she was told, wasn’t considered a “sufficiently important contribution.”

Flying foxes rest in trees in Tamworth, Australia.

Global health organizations and governments have long focused on responding to outbreaks rather than predicting and preventing them. Billions of dollars pour into developing treatments and vaccines for infectious diseases, but only a small fraction goes to understanding why contagions spread from animals to humans in the first place. Some experts reject even that, viewing spillover as too random, mysterious and rare to be observed and studied.

The work Eby does is the opposite of the major research projects on deadly diseases that typically get scientific grants. Government and nonprofit funders are often drawn to studies involving cutting-edge technology like artificial intelligence, and they want results in a few years’ time. Eby had spent decades trekking into the Australian bush, often on her own dime, observing flying foxes for hours on end with only a notebook and a pair of binoculars. To support her research, she took on consulting jobs, such as advising towns whose residents viewed bats as pests. She knew, though, that side hustles would never be enough to support the multidisciplinary team of scientists needed to crack the Hendra virus.

In the years that followed, Eby found like-minded scientists, and the team, led by women, persisted. They cobbled together grant after grant, battled burnout and kept impatient funders at bay. A decade after Eby’s government grant proposal was shot down, they published a groundbreaking paper in the journal Nature that demonstrated it was not only possible to predict Hendra virus spillover, but it might be preventable. Only then did it become obvious just how important Eby’s quiet fieldwork truly was.

A team from Griffith University carefully untangles a bat, captured for study, from a net. First image: Wildlife ecologist Peggy Eby helps set up a net to capture bats for study. Second image: Dr. Alison Peel, a disease ecologist who works with Eby, releases a bat after collecting samples.

Dr. Neil Vora, a tuberculosis physician and former officer at the U.S. Centers for Disease Control and Prevention, said he was thrilled when he saw the paper. “It gave clear evidence that we can take actions to prevent spillovers of viruses,” said Vora, who now works for environmental nonprofit Conservation International. “I hope it helps to convince funders and policymakers that spillover prevention merits implementation now.”

In a world still scarred by the COVID-19 pandemic, Eby’s dogged success exposes a global scientific blind spot. It’s not that trendy science involving the latest AI wonders isn’t worthy of research dollars. It’s that it should not be funded at the expense of the sort of long-term, shoe-leather work that allowed Eby and her colleagues to solve the mystery of a deadly contagion, Vora and other public health experts say. “All of these actions are important if we want to save as many lives as possible from infectious diseases,” Vora added.

Novel infectious diseases will keep coming at us, Eby warns. Investing in scientific work like hers “seems like a poor approach now,” she said, “but 20 years from now, we’ll look back and wonder why we didn’t do it.”

Fresh out of college in the 1970s, Eby explored the wilds of Australia on a research fellowship, following the path a German naturalist had chronicled before he disappeared in 1848. Some parts were so remote that she had to hitch a ride on the tiny plane that delivered mail to park rangers. Eby, who grew up in Kansas, was awed by the diversity of the landscape and charmed by the openness of the people. When her fellowship ended, she decided Australia was home.

Eby was in her 30s when she came to love flying foxes. Her boss at the New South Wales National Parks and Wildlife Service asked her to figure out how bats spread fruit seeds in rainforests. She followed signals transmitted by radio collars on flying foxes and knocked on landowners’ doors to ask if she might, please, observe the bats feeding in their trees and collect droppings. She even tracked them from a single-engine Cessna, battling nausea as she discovered that the bats could migrate hundreds of miles, a fact that nobody knew at the time.

When she watches flying foxes hanging in repose, Eby’s breathing slows. It feels like meditation. “It changes my perspective so I feel less significant,” she explained. “I think that’s important for all of us to feel less significant in the world.”

Watch: This Scientist Tracked Bats for Decades and Solved a Mystery About a Deadly Disease

Ecologist Peggy Eby’s discovery underscores the time and shoe-leather research needed to prevent future pandemics.

She was working on her dissertation about the bats in 1994 when a novel virus struck a Brisbane suburb called Hendra. The trouble started when a pregnant racehorse named Drama Series became congested and feverish. A veterinarian gave her painkillers and antibiotics, but she died the next day. As horse after horse got sick, some thrashed in their stalls, unable to breathe. “It’s a horrible thing to see when they’re mutilating themselves,” the veterinarian, Dr. Peter Reid, recalled.

Then the horses’ trainer died. The outbreak had spread to humans.

For more than a decade, Hendra popped up sporadically. It killed another horse trainer and two veterinarians. A veterinary nurse became so ill that she had to learn to walk and talk again and never regained some of her hearing.

First image: Allan Mitchell and his partner, Vicki Kilborn. Second image: Mitchell’s horse Cody, confused after being infected with the Hendra virus, wandered into a dam and was trapped in the mud. Cody died the next day. Now, Mitchell and Kilborn ensure every horse they own is vaccinated for Hendra. Rachel Sullivan and her daughter Ziggy lost their horse, Willow, to Hendra. When Willow was sick and drooling, Ziggy put her hand in the horse’s mouth to feel for an obstruction. Sullivan was terrified her daughter would contract the virus, but she didn’t.

Scientists figured out that Hendra came from flying foxes, and it had to pass through horses before it could infect humans. Eby was aware of those discoveries but didn’t get pulled in until an unprecedented number of horses died in 2011. Nobody knew why so many were getting sick when Hendra had been rare in the past. Media helicopters rumbled over sites where horses died, and people who lived and worked near them panicked. A group of ecologists lobbied the government to add a bat expert to the team deployed to infection sites, a practice that wasn’t common then and still isn’t. The ecologists picked Eby.

Shortly after her 60th birthday, Eby began suiting up in PPE and heading to the scene every time a horse tested positive for Hendra. She soon noticed the bat roosts near these sites were new and small. Something strange was going on.

Around the same time, Dr. Raina Plowright, a professor of disease ecology at Cornell University, proposed working together. Plowright was an Australian who had emigrated in the opposite direction of Eby but had never lost interest in her homeland’s infectious diseases.

They agreed to tackle the mystery together. They applied for multiple grants and were shot down because their ambitions didn’t match the funding silos: Agencies that support human health don’t typically care about animal health, and those that back studies on the environment often aren’t interested in how it affects public health. In saying “no,” one animal foundation explained that its mandate didn’t extend to diseases that leaped to humans.

In 2012, Plowright received a small grant from the Australian government, but that was only for mathematical modeling and didn’t support fieldwork like Eby’s. By 2017, a National Science Foundation grant came through, but it wasn’t enough to cover all of the costs of catching and testing bats. The team spread itself thin. “It was headed to a burnout situation,” Plowright recalled.

First image: A baby flying fox, found malnourished, recovers at a wildlife rehabilitation center in Lismore. Second image: Lib Ruytenberg and Julie Marsh care for an injured flying fox at the center. Ruytenberg shares data on bat health with Eby.

Eby, meanwhile, tapped unusual sources to get data. She befriended beekeepers, who could tell her when and where key species of trees were flowering. This helped them track shortages of the bats’ favorite food: nectar from eucalyptus blossoms. She also asked workers at wildlife rehabilitation centers to keep logs about sick and injured bats that they cared for.

The team studied weather patterns and how the forest cover had changed. Eby contributed field records on the location, number and health of bat roosts. Altogether, their data spanned 25 years.

The team’s resourcefulness paid off. By 2017, the researchers figured out how and why Hendra was spilling over from bats:

(Illustrations by Katherine Lam)

In early 2017, the researchers determined that conditions were ripe for Hendra to leap from bats to horses and potentially to people. A drought, followed by too much rain, had led to a dire shortage of eucalyptus blossoms, and malnourished bats were turning up at wildlife rescue organizations. By then, there was a Hendra vaccine for horses, but few owners had opted for it. It was only a matter of time before a horse nibbled something tainted with the bats’ saliva or droppings.

Eby pushed past the fear that their prediction might be wrong. She and her colleagues published a bulletin that winter, warning veterinarians of an impending Hendra outbreak and their need to wear full protective gear near horses.

The team was right. Four horses on separate properties caught Hendra that season.

No humans got sick.

When the same pattern of weather and food shortages repeated in 2020, Eby and her colleagues were confident that it’d be a calamitous year. They sounded another warning that May, at the start of the Australian winter season: “Conditions predict heightened Hendra virus spillover risk in horses this winter: actions now can change outcomes.”

Later that month, one horse was infected and euthanized. The team braced itself for a wave of horse deaths. But then — nothing. No other Hendra cases were identified, and the outbreak that was supposed to happen just didn’t.

Somehow, they had gotten it wrong.

“We still felt confident in our understanding,” Eby recalled, “but we didn’t have the full story yet.” She ran through everything she knew about bats and Hendra, scouring for what they might have missed. There had, indeed, been a food shortage. So where were all the bats?

Eby was in COVID-19 lockdown in mid-July that year when she got stunning news. Gympie, a former gold-mining town near the east coast, had been less affected by the severe weather than expected, and a few patches of a type of eucalyptus known as the forest red gum were flowering en masse. Their slender branches teemed with fluffy white blooms. Eucalyptus trees don’t flower every winter; their blooms appear erratically. Some 240,000 flying foxes had flown in for the rare feast.

“I immediately knew,” Eby said. “This is what was different.”

Eby holds a branch of flowering eucalyptus. First image: Eby has gathered decades of data on flying foxes. Second image: Eby spends hours on the road visiting flying fox roosts and meeting conservationists to build a database that tracks reforestation projects.

Her collaborators, a field team from Griffith University, rushed to check roosts in areas where Hendra cases had previously struck. Many roosts were empty, the bats drawn away by the Gympie banquet.

Eby and Plowright had worked on this for a decade now, patching together four or five grants at a time to continue their research. Funders wanted results.

But they needed more data. They had to understand how this unexpected winter flowering in Gympie was affecting bats across eastern Australia. With the lockdown preventing Eby from examining the roost herself, she began to compile information on historic mass winter flowerings like this one.

One reason why it wasn’t initially obvious that the Gympie congregation was important was that the bats that had flocked to town were grey-headed flying foxes, not the black flying foxes that spread Hendra. Eby came to believe that a hierarchy of bat species governs which can claim the best food, and the behavior of one affects the other.

Flying foxes congregate in Tamworth.

The greys get dibs on the best food. When eucalyptus nectar is scarce, the greys eat what’s available, pushing the black flying foxes to scavenge for fruits in horse paddocks, their equivalent of junk food. But when the nectar is abundant, like it was in Gympie, the greys will depart for that fine dining opportunity, allowing the blacks to ditch the horse paddocks for better food that the greys leave behind. This draws the bats that carry Hendra away from horses and people.

In the end, what she concluded was astonishing: There had never been a spillover at the same time as a rich winter flowering.

“We said, this can’t be real, it’s too good,” Plowright said. “Those remnant patches of flowering were protecting the whole landscape.”

Patches of eucalyptus around a single town could protect all of eastern Australia. Imagine a few clusters of trees in New Jersey protecting the entire Eastern Seaboard.

(Illustrations by Katherine Lam)

The researchers could see how, between 1994 and 2006, consistent winter flowering was still taking place around the country. But as people cut down more and more trees, reducing the available habitat, winter flowering became unreliable and occasional, leading bats to search in horse paddocks for other sources of food.

Habitat destruction and deforestation has been linked to outbreaks of many notorious viruses, including Ebola, monkey malaria and the brain-invading Nipah virus. The discoveries of Eby and her colleagues show that we can learn all of the elements that lead to spillover — environmental, animal and human — in enough detail to design ways to predict and prevent the next outbreak.

Their discovery comes as the threat of Hendra increases. Deforestation has decimated the bats’ winter foraging habitats and shows no signs of stopping. Climate change likely will cause more extreme weather conditions, which will further disrupt the winter budding of eucalyptus, making food shortages more common.

Builders developing housing near Brisbane have cleared key species of native trees that provide food for flying foxes in the winter.

Eby and her colleagues see a new way forward: If the remaining patches of winter-flowering trees were preserved and more were planted, they could once again reliably draw the bats away from people and protect the entire country from Hendra virus for years to come.

Yet few government agencies and global health authorities are ready to invest in action that comes out of this hard-won discovery.

The Hendra team, in 2018, had managed to score a grant from a program under the U.S. government’s Defense Advanced Research Projects Agency that was unique in its scope and vision. Called Preventing Emerging Pathogenic Threats, or PREEMPT, it sought to understand the mechanisms of spillover with the goal of developing technologies to protect U.S. military forces deployed to disease-prone locations. But the program was a one-off and is ending after five years. DARPA says it is not its role to fund the solution Eby and her colleagues discovered.

“We are ready for the next hard problem,” said Kristen Jordan, the deputy director for the DARPA Biological Technologies Office. “There are many we need to address.”

Eby checks on a roost in the town of Uki.

Department of Defense officials asked Plowright whether the model that predicted Hendra could also predict the next coronavirus spillover in Southeast Asia.

Plowright recalls responding: “Well, you need data. And we have no data.” It’d be impossible to calculate that risk without replicating the years of wildlife tracking, environmental data gathering and number-crunching that the Hendra team conducted. “People just don’t get that.”

On a crisp afternoon last September in the city of Tamworth in New South Wales, Eby pulled into the parking lot of a Hungry Jack’s burger restaurant. She had heard reports of an enormous roost of flying foxes in town and hurried to get there. Eby couldn’t see any bats from where she had parked, but she didn’t need to. Her clear blue eyes lit up and she beamed. “Can you smell them?”

Alongside the aroma of cooking grease was a musky, sweet scent that announced the presence of bats. As Eby walked to the river, she could also hear their shrill chattering. Then, there they were, hanging upside down from every branch on every tree that lined the river, grooming themselves and resting before the evening’s forage. With their wings folded around them, the bats looked like tear-drop-shaped fruit. A week earlier, another researcher had flown a heat-seeking drone over the roost and estimated that the river in Tamworth was hosting about 300,000 bats — more than half of the grey-headed flying fox population in all of Australia.

Eby moved slowly so as not to startle the roosting animals. She raised her binoculars, tallying males and females, noting any that were pregnant and scanning for babies born out of season. The roost looked healthy. She was elated. The Tamworth bats confirmed that a single unusually abundant flowering of eucalyptus could provide a protective effect for the whole system. And sure enough, there were no Hendra virus cases in the winter of 2022.

A few years ago, Eby had thought it might be time to retire. She was nearing 70 and ready to take a break from the physical grind of fieldwork. But then came an unconventional funding opportunity she couldn’t pass up.

After thousands of bushfires burned an estimated 59 million acres in a single season that came to be known as the Black Summer, money poured in to help restore habitat for Australia’s iconic koala. Eby instantly recognized the chance to explore how planting eucalyptus affects flying foxes, which conveniently feed on nectar from many of the same trees preferred by koalas. “The bats are hanging onto the coattails of the koalas,” she said with a wry grin.

There wasn’t a universal data set tracking reforestation projects, so she set out to create one. Today, supported by money from various koala-focused projects, she drives across eastern Australia training koala conservationists to upload records of their tree-planting projects into a common database. She hopes that reforestation efforts will make winter flowering commonplace again and prove the case for preventing spillovers with habitat restoration.

Eby says that she believes preventing outbreaks is possible, and that the methods she and her colleagues have developed can be applied to other disease systems. “There was nothing remarkable about my work. It can be done again in other circumstances, it just takes the will,” she said. “It also takes an understanding that this is a long term quest.”

Even while she embarks on her new mission to prove the power of reforestation, she pauses to cheer the remnant patches of forest when they bloom.

As the sun set over Tamworth, she stood above the riverbank, her hair glowing silver under the light of a streetlamp. She watched as the bats set out into the darkening sky, their long wings beating the air as they soared from the trees and headed out to feed. Eby couldn’t see where they were headed but knew that nearby, eucalyptus trees were blooming, producing sweet nectar that would keep the country safe from a Hendra virus spillover. Smiling to herself, she murmured, “Isn’t it wonderful?”

Eby watches as flying foxes take flight for their evening meal in Tamworth.

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Graphics, design and development by Anna Donlan. Photo editing by Peter DiCampo. Illustrations by Katherine Lam.

by Kathleen Flynn for ProPublica and Caroline Chen

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Wildlife ecologist Peggy Eby fell in love with flying foxes when she moved to Australia from Kansas. She spent decades studying the bats’ movement and behavior. At times she worked without pay to answer questions she had about the fuzzy, fox-faced mammals.

Those bats turned out to be the carriers of the deadly Hendra virus, which can jump from bats to horses and then to humans. Eby began a quest to understand why and how the virus was making these leaps between species, known as spillover. She hoped to predict when the next infection would emerge. The decades of data Eby gathered as she followed her curiosity were key to cracking the mystery. So ProPublica decided to make a video about her.

Eby and her colleagues’ work shows that it’s possible to predict when spillover will happen. Doing so requires long-term research and funding to match. But ProPublica has found that public health authorities focus on responding to outbreaks already underway rather than trying to prevent them. Grants for developing treatments are easier to come by than for studies on spillover.

Eby says she hopes their findings will inspire more research into understanding what’s sparking outbreaks of other diseases like Ebola or Hendra’s equally deadly cousin, the Nipah virus: “Our response to COVID has made it pretty clear that vaccines aren’t going to be the answer, that while they are very important, while containment is very important, having a better idea of what’s causing the spillover in the first place can play an important role in preventing pandemics.”

by Rose Lundy, The Maine Monitor; Research by Mariam Elba; Photography by Tara Rice for ProPublica

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

In the mid-1990s, Maine’s lawmakers and health officials made a pivotal decision to reduce the state’s reliance on nursing homes, a move intended to redirect elderly residents toward“more homelike, less institutional” alternatives.

The policy change, enacted in 1993 amid a severe budget crunch, helped spark a dramatic transformation of the elder care system in Maine, where 21.7% of the population is 65 or older — the highest percentage in the country.

Between 1996 and 2022, the number of nursing home beds dropped by nearly 3,680, from a high of more than 10,000, sparing Maine the financial burden of subsidizing them. During the same period, the number of beds at what are known as residential care facilities almost doubled, jumping by more than 4,200. As a result, older Mainers and other residents with significant medical needs live in these homes. Residential care facilities in Maine resemble what are known generally as assisted living facilities.

Although the state considers residential care facilities to be “nonmedical institutions,” an investigation by The Maine Monitor and ProPublica found that these facilities are routinely called on to provide medical care to their residents — those suffering from advanced dementia or requiring medication management for conditions such as seizures and heart disease.

Maine’s standards for these facilities are more robust than those in some other states, long-term care advocates say. But given the significant shift of beds for seniors from nursing homes to residential care, advocates say that those regulations are inadequate and in urgent need of updating and tightening.

A review by the Monitor and ProPublica of state inspection records underscored concerns about how these facilities are regulated. State monitoring and investigation reports revealed that of the almost 700 violations issued from 2020 to 2022, roughly 200 involved “medications and treatments.” The analysis focused on citations at many of the state’s roughly 190 largest residential care facilities, called Level IV, which serve the largest number of people.

In May 2021, for instance, state inspectors found that one facility had administered morphine to the wrong resident. The mistake led to the resident being hospitalized and treated for a week in the intensive care unit.

Problems with medical care also showed up in other violation categories beyond the 200 related to medication and treatment. Another facility was cited with a resident’s rights violation in May 2022 for failing to get from the pharmacy a resident’s medication for cardiac issues, nicotine cessation, pain control and seizure activity for three days. The resident became agitated about not receiving the medications and went to the hospital at their family’s request over safety concerns.

These facilities “shouldn’t have it both ways,” said Eric Carlson, director of long-term services and support advocacy at Justice in Aging, a nonprofit legal advocacy group focused on ending poverty among seniors.

“You can’t on one hand say: ‘Oh, we’re an alternative to nursing facilities,’” and then when something bad happens say: “‘Well, we can’t be expected to have expertise on that stuff. We’re a social facility. We’re a nonmedical model,’” Carlson said.

While medical errors happen at even the most highly equipped facilities, Maine’s residential care facilities are not set up to handle the level of need they are currently seeing in residents, said Jess Maurer, executive director of Maine Council on Aging, a network of organizations focused on issues affecting the elderly. She said these facilities are grappling with the consequences of the state’s policy change.

“We’re pushing people with a higher level of need than should be in assisted living into assisted living facilities because there are no alternatives,” Maurer said.

According to a 2021 report by the Maine Health Care Association, which represents the state’s elder care facilities including nursing homes, the needs of residents in assisted housing, including residential care facilities, had increased 30% since 1998, and 47% of them suffered from dementia. By 2028, the number of Mainers over 65 is projected to increase about 45% over the decade prior. And 35,000 Mainers are projected to have Alzheimer’s in 2025.

The Maine Department of Health and Human Services, which oversees and licenses residential care facilities, declined to comment on the calls for tighter medical standards or on the violations cited by state inspectors.

But department spokesperson Jackie Farwell said the state is in the middle of a “major long-term care reform effort” aimed at filling the gaps in the state’s elder care system. Within the next fiscal year, the department’s statutory review of assisted housing programs is expected to “lead to the adoption of updated rules relating to the operation of” residential care facilities, among other things. She declined to elaborate whether the updated rules could include tighter medical standards.

Brenda Gallant, Maine’s long-term care ombudsman, who is empowered by the state to receive complaints from elder care residents and investigate their facilities, said the department’s effort could offer an opportunity to review the medical standards for residential care facilities.

“It is the right time to take a look at who we are serving and what regulatory changes need to be made based on resident need,” Gallant said.

Martin Hunt was a highly intelligent, meticulous man who enjoyed tinkering and creating all kinds of contraptions. He fashioned cup holders to his cane, assembled a guitar and built a wooden, collapsible rolling grocery cart. He designed 3D floor plans for a house on a piece of property that one of his sisters, Tania McIntyre, owns in Dedham, Maine.

McIntyre shares a photograph of her brother, Martin Hunt.

But McIntyre and her older sister, Melody Leavitt, witnessed Hunt’s dementia erode his mind since he suffered a stroke in 2020. As the 68-year-old’s condition worsened, they helped him move into Woodlands Senior Living of Brewer, 10 miles from Leavitt’s house.

Within a week, the sisters regretted the move, appalled by the quality of care that Hunt was receiving. For instance, he took about 20 medications every day for a number of ailments in addition to dementia — heart conditions, lung disease, hypertension, among others — and Woodlands’ employees made a mistake when administering them, according to the facility’s daily care notes. More broadly, the sisters worried that he was being overlooked, and that staff did not take his complaints about pain seriously.

A couple months after he moved in, Leavitt confronted Kathleen Olsen, the facility’s administrator, about the overall quality of care. She said she was floored when Olsen told her that Woodlands is not a medical facility.

Matthew Walters, one of the owners of the Woodlands Senior Living, which operates residential care facilities in nine communities throughout Maine, including the one in Brewer, told the news organizations that he had spoken with Olsen and that she did not recall her conversation with Leavitt. But Walters echoed her point: “She’s right. We’re not a medical facility. By definition, we’re a private nonmedical institution,” he told the Monitor and ProPublica.

Medical facilities, such as nursing homes, are required to provide daily nursing care for injured, disabled or sick people who can only be served in a nursing facility, whereas nonmedical facilities are only required to help residents coordinate and gain access to medical care, said Farwell, the DHHS spokesperson.

All this is why the sisters began exploring options for relocating Hunt not long after his move to Woodlands. Convinced that he needed a higher level of care, they set up an assessment for him — a step required by the state before moving to a nursing home.

To qualify, Hunt needed to be evaluated as either requiring frequent nursing or other skilled care for a long list of medical conditions or needed to score high on a points system to show that he had severe cognitive or behavioral problems.

On the day of Hunt’s assessment in late November, conducted via a 10-minute phone call with a registered nurse, Leavitt was there in his room, listening in as he answered the assessor’s questions: Did he need help getting dressed? (No.) Did he eat by himself? (He gave a snarky answer: “When the food is edible.”)

At one point during the call, Hunt put the phone on speaker and placed it on his bed. When he went to pick it up later, he grabbed the TV remote instead and held it to his ear. He continued to speak into it until Leavitt walked over and replaced it with the phone.

Leavitt said the moment felt like yet another example of Hunt’s steady decline. “It was disheartening,” she said. “You’re watching him losing his mind.”

But the assessor wasn’t in Hunt’s room to witness the scene and eventually determined that Hunt’s needs weren’t acute enough to qualify for a nursing home placement.

Three decades ago, the state tightened the requirement for qualifying for a nursing home placement. The policy change reflected the state’s philosophical shift away from nursing homes and toward options that allowed Mainers to “age in place” at home or in less institutionalized settings for as long as possible.

But it was also a financial decision, aimed at reducing nursing home costs, which are covered by a mix of state and federal funds under MaineCare, the state’s version of Medicaid; the costs had doubled over five years and were the single largest component in the state’s Medicaid budget.

The rising costs meant that the state “finally had to admit that we could no longer” sustain the number of nursing home beds it had, according to a 1994 state plan from the Bureau of Elder and Adult Services, an agency under what is now the Department of Health and Human Services.

But the policy change received immediate pushback. Legal Services for the Elderly, a nonprofit, filed a class-action lawsuit to challenge the medical eligibility requirement, which the plaintiffs said made them no longer qualify for a nursing home placement.

Among the plaintiffs were a 78-year-old woman who had a mild seizure disorder and rapidly worsening Alzheimer’s; a 99-year-old woman who was prone to falls, was legally blind and almost deaf and needed help with dressing, bathing, toileting and hygiene; and a 92-year-old man who needed a catheter and paid privately for nursing home services for years until his savings ran out, according to the coverage in the Bangor Daily News at the time.

The following year, the Maine Health Care Association also issued a critical report, highlighting how the policy change was pushing people with a higher level of medical needs into residential care facilities. The situation, it wrote, was putting the pressure on these facilities to provide more medical care.

“Many of Maine’s residential care facilities are moving quickly down that path, being driven by circumstance and department pressure to medicalize their services,” the association wrote.

Under pressure, the state eased the medical eligibility requirement in 1996, taking Alzheimer’s and other dementias more into consideration in determining whether an individual qualifies for a nursing home placement. In light of the changes, the class-action lawsuit was dropped.

Despite that change, experts told the Monitor and ProPublica that Maine’s medical eligibility requirement for nursing homes remained among the strictest in the country, and nursing home beds have continued to disappear since 1996.

Residential care facilities are subject to state regulations, established in 1998, that hold them to much lower minimum staffing, nursing and physician requirements than for nursing homes. Their direct-care workers are allowed to manage twice as many residents as they are in nursing homes. A registered nurse has to make a visit only once a week to residential care facilities with 40 beds or more and even less frequently to smaller ones, while nursing homes are required to hire a director of nursing and have one nurse stationed at all times. And there is no requirement that doctors visit residents at these facilities, while nursing homes are required to have a medical director and make sure that every resident is visited by a doctor every two months.

Regulations of assisted living facilities vary greatly across the country, and experts say it is difficult to compare across states. Some states don’t have specific minimum staffing requirements like Maine does, requiring only “staffing sufficient to meet the needs” of residents.

But just because Maine has minimum staffing requirements doesn’t mean the standards are sufficient; resident needs have increased since they were established 25 years ago, said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, a nonprofit that advocates for elder care residents.

“When you have people with increasing needs, you have to ensure that those needs are being met,” she said. “There needs to be government oversight of that because in too many cases the facilities are falling short and people are experiencing real harm.”

Travis Brennan, a Maine-based attorney who handles medical malpractice claims for Berman & Simmons, said medication mistakes can signal other problems — they may indicate that employees are being rushed, aren’t trained properly or are disregarding their foundational training.

“When you have a medication error, it is symptomatic of the fact that a provider is taking a shortcut,” Brennan said.

From 2020 to 2022, state inspectors issued 18 citations for missing doses and medications, seven citations for wrong doses and two citations for medications given to the wrong residents at Level IV residential facilities, a ProPublica-Monitor analysis shows.

In October, for instance, state inspectors cited one facility for failing to promptly stock one liter of oxygen for a resident who suffered from “acute respiratory failure.” It took the facility seven days after receiving a doctor’s order to contact a pharmacy.

Smetanka said the state can address this problem by enhancing the required training, improving quality-assurance procedures, establishing medication management as a focus for oversight and looking at the penalties when these facilities make mistakes.

“More needs to be done in terms of oversight and accountability for ensuring that these mistakes are minimized as much as possible,” Smetanka said. “A medication error can be deadly for a resident. It could have very serious consequences. So this is not something to be taken lightly.”

Paula Banks, a geriatric social worker who has been licensed in Maine for 30 years and runs a geriatric consulting and care management firm, said the current staff ratios are not stringent enough, particularly at the residential care facilities housing residents with cognitive problems. Under the state’s medical standards, one direct-care worker is allowed to manage 30 residents overnight, but she said that’s not reasonable when the residents suffer from dementia and may not know what time it is. “It’s impossible — those ratios,” she said.

Angela Cole Westhoff, president and CEO of the Maine Health Care Association, wouldn’t weigh in on tightening medical standards for residential care facilities, but she said that regulations should reflect the difference between nursing homes and residential care facilities, which she said “provide varying levels of care.”

Hunt’s sisters, Leavitt and McIntyre, are quick to acknowledge that Hunt, a divorced father of three sons whom he hasn’t seen for years, could sometimes be a difficult person to be around. And they suspect that this caused his needs to be overlooked by Woodlands’ employees.

First image: Leavitt looks through Hunt’s paperwork from his time at Woodlands. Second image: The facility in Brewer, 10 miles from Leavitt’s house.

The facility care notes detail numerous run-ins with the employees in which Hunt was described as aggressive, rude and insulting. He allegedly called the employees names and yelled at the cook. And he clashed with the employees over his medications.

The sisters said Hunt had long been in charge of his own medications and didn’t trust the employees to handle his prescriptions correctly. He would ask them what they were giving him and get frustrated when they wouldn’t explain. When he got worked up, Leavitt said, the employees would ask if he was refusing the medication.

“He was just stubborn enough. They’d say that, and he’d go, ‘Well, I guess I am,’” Leavitt said.

“He was a challenging person to have in your care. I’m not going to make any bones about it,” McIntyre said.

“That being said, it was their job to take care of him,” Leavitt added. “In my opinion, they really didn’t.”

In December, Hunt did have a scare when the employees gave him medication for anxiety and sleeping problems instead of a painkiller, according to the facility care notes. The employees wrote in the facility care notes that he did not have any reactions, but they called his doctors for “advisement.”

With the sisters’ permission, Walters, one of Woodlands’ owners, discussed Hunt’s experience in detail with the Monitor and ProPublica. He acknowledged the medication mix-up but said Woodlands’ care notes did not document Hunt’s worsening dementia or increasing complaints about back pain. He said there was no significant change in Hunt’s condition that would have alerted the employees to a possible medical emergency, up until the day he was rushed to the emergency room.

“There’s no red flag that occurs anywhere,” Walters said.

He also said the employees tried their best, despite Hunt’s temperament, to care for him.

The employees “worked very hard throughout the entirety of Mr. Hunt’s residency to help make each day the best day possible for him and showed great care, consideration and compassion towards him in the face of persistent challenging and abusive behaviors,” Walters said.

He echoed what other Maine long-term care advocates and experts said: That there are residents in residential care facilities today who would have been in nursing homes 20 years ago.

“That doesn’t mean that those people that are in a residential care facility now shouldn’t be here and should be in a nursing home,” Walters said. “In some cases, it’s just the opposite. Those people would have been in a nursing home, but they’re equally or better served in this setting.”

According to Hunt’s sisters, that winter, Hunt began complaining that his back pain was becoming markedly worse. Around supper time on a weekend night in February, Leavitt got a call from a Woodlands employee about Hunt: He had been found unresponsive on the floor of his room. He looked pale, his lips were blue and emergency responders couldn’t get him to squeeze their hand. He was rushed to a nearby hospital.

The sisters braced for the worst, fearing that Hunt had suffered a second stroke in four years. “I just thought this is going to be the end of him,” McIntyre said.

When McIntyre arrived at the hospital, she initially heard good news: Hunt’s doctors had ruled out the stroke. McIntyre said her reaction was a visible and audible sigh of relief.

But then Hunt was soon moved to the intensive care unit after his doctors found a kidney bleed — it was near a part of his back where the sisters said he had complained about dramatically worsening back pain in the weeks before he went to the ER.

Hunt’s doctors discussed surgery options for him, but the sisters feared that they wouldn’t succeed and he would end up with him on a ventilator — which they knew he wouldn’t want. They opted for comfort care instead.

That night, nurses unhooked his heart monitor and gave Hunt a pump of morphine. Leavitt remembered the stress immediately disappearing from his face. When he woke up, he was starving and asked for a cheeseburger, fries and a hot coffee. The three siblings had their best visit in months.

“You just had to wonder, was pain causing it all?” Leavitt said.

The next morning, as the sisters were walking back down the hospital hallway to visit him again, the doctor called and told them to hurry.

“We get in his room, and they said, ‘Martin, your sisters are here.’ And, within a couple of minutes, he took his last breath,” Leavitt said. “It’s like he waited for us or something.”

First image: Leavitt and McIntyre in Leavitt’s home. Second image: Leavitt holds a stone heart that was left as a tribute on Martin’s chest by the nurse when he died.

Leavitt, meanwhile, said she didn’t blame Woodlands for Hunt’s worsening dementia but held the facility responsible for not noticing the change in their brother’s dementia and pain levels that they say were obvious and for failing to take action to improve his care.

“If they’re going to allow people like my brother to be in their facility, they should be able to care for him,” Leavitt said. “That’s what our intent was: For him to be safe and be cared for when he needed help.”

Help Us Report on Assisted Living Facilities in Maine

Correction

May 22, 2023: This story originally referred imprecisely to a medication that residential care staff had incorrectly provided to Martin Hunt. He was given medication for anxiety and sleeping problems, not seizures.

by Nicole Carr

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.

This story is part of a series that explores how school board meetings across the country are fomenting conflicts and controversies that have led to violence and arrests. Are you interested in a virtual event on this topic? Let us know here.

An image of a shooting target — with two bullet holes to the head and five scattered around the chest — serves as a warning to visitors who climb the brick steps and pass the American flag to reach Eric Jensen’s front door.

“If you can read this you’re in range,” the sign says. Another warning, posted near the doorbell, states: “No Solicitation. … This property charges $50 per minute to listen to any vaccine/medical advice.” He ordered that one in 2021, after mobile units offering COVID-19 vaccines began riding through his community outside Winston-Salem, North Carolina.

For years, Jensen had been looking for a way to voice his many grievances, related not just to masks and vaccines but to “transgender bullshit” and library books “trying to convert kids to gay” and other perceived dangers he says his five younger children face in the public school system. (The 65-year-old retiree has four other children who are adults.) Then he found a place where he could finally be heard.

“You gotta start from the bottom and work yourself up,” Jensen said, not long after he reluctantly opened his front door last November. “I mean, you can’t just go to your governors and try to make a difference. So you start at the bottom, and the bottom is school boards.”

He had intended to wage a campaign against the school board to bring about change. Instead, his efforts got him arrested.

At first he was hesitant to talk about what happened in the lead-up to the February 2022 incident. In the weeks after the arrest, he didn’t comment in any of the news stories that covered it.

Then, as the months wore on and his charges were dropped, he realized that standing up to authorities wasn’t going to lead to any sort of punishment: “I thought, ‘Holy shit, I didn’t have to go through a whole lot of aggravation there.’” He said that, walking away from the ordeal, he felt emboldened.

ProPublica identified 59 people arrested or charged over an 18-month period as a result of turmoil at school board meetings across the country. In the coming weeks, ProPublica will continue to publish stories about how that unrest has played out in various communities and upended once-staid school board meetings.

In the dozens of incidents ProPublica examined, some of which involved threats and violence, only one person who disrupted a meeting was given a jail sentence: a college student protesting in support of transgender rights. By contrast, almost all of the other individuals, including Jensen, railed against the adoption of mask mandates, the teaching of “divisive concepts” concerning racial inequality and the availability of books with LGBTQ+ themes in school libraries. Also like Jensen, the vast majority of people arrested or charged faced few consequences.

Jensen didn’t come up with the idea to target the school board on his own. He’d volunteered to help two women connected to the state chapter of a national group that was rapidly gaining followers through social media sites and YouTube channels promoting the convoluted QAnon conspiracy theory.

Jensen, a solid, gray-haired man with piercing blue eyes, retired about five years ago, though his wife still works as a custodian at the elementary school. He’d been a project manager for a metal building manufacturer that transferred him to North Carolina from Ohio. Prior to that, he and his family owned a campground for three decades.

He described how, several years ago, he made the decision to abandon mainstream media. He said it used to be that “I was always watching the news. But once I found out how much they lie, you have to get back into alternative media to find out the actual truth.” He said he has since become convinced that John F. Kennedy Jr. is alive, Hillary Clinton and Bill Gates are dead, and the COVID-19 vaccine is actually a “death shot.” Echoing a debunked claim, he explained his belief that the vaccine changes your DNA in a way that allows those who patented the modified genetic sequence to “own” you, which is part of an effort to kill people off and depopulate the planet. “I’ve seen it many times, where they’ve got plastic caskets lined up,” he said. “There must be a million of them sitting there in lots waiting for these people to die.”

In January of 2022, shortly after he became interested in what he saw as threats posed by school boards, he logged onto the messaging service Telegram. “I started putting feelers out, trying to find, you know, groups that were involved with it and see what they were doing,” he said.

A Telegram group called North Carolina Bonds for the Win seemed like the right fit. The national Bonds for the Win movement had been gaining steam, promoting its mission to force school districts to drop so-called unconstitutional practices including COVID-19 safety protocols and the distribution of alleged “obscene materials” to minors. To accomplish its goal, its followers would serve local school boards with reams of paperwork outlining an intent to sue their districts’ surety bond (or risk-management plan) providers. The movement, dubbed “paper terrorism” by the Southern Poverty Law Center and the Anti-Defamation League, aims to force school districts into “compliance” to avoid losing federal funding.

The Winston-Salem/Forsyth County school district was one of several North Carolina districts targeted by the Bonds for the Win movement in early 2022. (Matt Ramey for ProPublica)

The tactic was already being tested in North Carolina’s largest school district, where earlier that January a mother had crossed a security barrier to serve the Wake County school board with papers, warning, “You’ve violated your oath of office.” Another local report described how police turned off lights in an attempt to clear people out of an Iredell-Statesville school board meeting. The people yelled, “You’ve been served!” to the school board members and told police they wouldn’t leave unless they were arrested.

“And that’s when I found these ladies.” Jensen said of the two women leading efforts in his school district for North Carolina Bonds for the Win.

On Feb. 22, 2022, Jensen arrived at the lobby of the Winston-Salem/Forsyth County school board meeting and met the women, Deborah Tuttle and Regina Garner, face-to-face for the first time. They handed him a cardboard box of paperwork, which he understood to be “explanations about how they [district officials] were going to get sued against their bonds” for teaching critical race theory — an academic framework sometimes taught at the college level and above that examines U.S. history through the lens of racism — and allowing books containing “profanity” in schools. He also said the documents included proof that masks don’t work.

Tuttle and Garner did not respond to numerous requests for comment.

Just minutes into the meeting, the school board chairperson watched with curiosity and a dose of trepidation as a man with a huge box took a seat a few rows back. She texted the board members sitting next to her, alerting them to the man. They, too, wanted to know what was in the box.

“He was just staring at us, and we were a little worried for our safety,” chairperson Deanna Kaplan recalled.

Both Garner and Tuttle signed up to address the board during the public-comment period. Garner complained about the district’s failure to uphold the Constitution and accused school officials of practicing medicine without a license and violating child abuse laws. Then Tuttle stepped up. “There’s a lot more violations that she didn’t get to, but you can read those for yourself when we serve you your letters of intent,” she told the board.

As the women spoke, Kaplan grew more uneasy about the man with the box. “Then,” she said, “he started charging at us.”

As Jensen, clutching the box, neared the superintendent, school security officers grabbed him and pulled him out of the meeting room. In the adjacent hallway, he strained against the three men it took to hold him down.

“You work for me!” Jensen repeatedly yelled as security guards tried to shackle his wrists and ankles. His deep voice echoed from the hallway into the meeting room, where some attendees began screaming and board members sat in disbelief as they watched the mounting chaos.

As the board hastily called for an impromptu recess, one man yelled: “Commie cowards!”

“Commie bitch!” yelled another.

“If you walk out, you’re walking away from your job!” Tuttle yelled from the podium.

“There was somebody in the audience that was yelling, ‘The patriots are coming.’ I mean, it was just like a zoo. It was crazy,” Kaplan recalled. “The board members were concerned for our safety.”

Two months after his arrest, Jensen came to court prepared to represent himself on misdemeanor counts of trespass and resisting a public officer. He said he carried a folder with some notes he’d made and a printout of the Constitution. As the judge entered the courtroom, Jensen said, he proudly refused to comply with the order, “All rise.”

“That puts that judge above you,” Jensen later explained. “And that judge is not above you. He’s below you. Or she’s below you.”

Jensen said his refusal to stand angered the bailiff. He also said that before he could even open his folder of evidence, the judge dismissed his case.

Court records show Jensen received a voluntary dismissal. Prosecutors have not responded to requests for comment. A court clerk said that the slew of misdemeanor dismissals that day may have resulted from the court’s attempt to clear a pandemic backlog.

Regarding the judge and the courthouse staff, Jensen said: “I didn't allow them to boss me around.” As for the security guards who arrested him, he said he’s now considering filing assault charges against one of them “because he grabbed me and threw me down for no reason.”

He described how, overall, the experience left him feeling empowered, although he was disappointed that the movement that inspired his efforts had fizzled.

“The ladies that I was with, they pretty much dropped it,” he said, adding that their decision “kind of threw me, because they weren’t going to fight for it.” Garner ended up running for a seat on the school board, but she was unsuccessful.

Jensen did face one consequence: He said he was banned from school property for any purpose other than to pick up and drop off his children. “But that’s it,” he said. A spokesperson for the Winston-Salem Forsyth County school district confirmed the ban but declined to detail the terms of it, citing legal concerns. He said the bans typically last a year. “In general, the letters outline situations when principals can grant permission for the person to come on campus. They, however, must ask and be granted that permission by school administrators.”

Jensen admitted during the conversation in November that he hasn’t exactly complied with the ban: When he showed up for his youngest daughter’s elementary school graduation last spring, a neighbor called school security on him. But, he said, school officials let him stay. (The district spokesperson said Jensen was allowed to attend the graduation “in an effort to reduce stress and embarrassment for his student and on the condition that he maintained appropriate behavior.”) Jensen also said he’s not that worried about what would happen if he violated the ban again.

He’s since declined to speak further about his experiences or be photographed for this story.

“One of these days, I’m tempted to just walk in and allow them to throw me out or arrest me or whatever, because they have no right to do it,” Jensen said, not long before closing his door. “So we’ll see what shakes out if I do.”

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Mollie Simon contributed research.

by Kavitha Surana

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Mylissa Farmer knew her fetus was dying inside of her. Her water broke less than 18 weeks into her pregnancy last August, and she was desperate for an abortion.

But according to federal documents, during three emergency room visits over two days in Missouri and Kansas, doctors repeatedly gave Farmer the same chilling message: Though there was virtually no chance her fetus would survive and the pregnancy was putting her at high risk for life-threatening complications, there was nothing they could do for her.

In the 11 months since the Supreme Court overturned Roe vs. Wade, similar stories have been reported in the 14 states where abortion bans have gone into effect. In Texas, five women are suing the state for denial of care, including one who went into septic shock and almost died.

Now, the Biden administration is employing one of the few tactics it has available to try to hold hospitals accountable for denying pregnant patients abortion care for high-risk conditions.

In April, a first-of-its-kind federal investigation found two hospitals involved in Farmer’s care were violating a federal law that requires hospitals to treat patients in emergency situations. If the hospitals do not demonstrate they can provide appropriate care to patients in Farmer’s situation, they stand to lose future access to crucial Medicare and Medicaid funding. Physicians who fail to treat patients like Farmer could incur fines, and patients may be able to sue for monetary damages, Farmer’s attorney, Alison Tanner, said.

The investigation, conducted by the Centers for Medicare and Medicaid Services, documented that both Freeman Health System in Joplin, Missouri and the University of Kansas Health System breached their internal policies for complying with the Emergency Medical Treatment and Labor Act, and that their protocols continue to place patients in “immediate jeopardy” of serious health risks, the highest level of violation.

Investigators concluded that future patients in similar situations could face “serious injury, harm, impairment or death.” The hospitals will remain under investigation while they come up with plans to ensure that patients in need of emergency abortion care are not turned away, federal officials said.

A “statement of deficiencies” from the investigation contains summaries of interviews with doctors, nurses and a risk manager involved in Farmer’s care. They reveal the extent to which health care providers went against their own medical judgment to comply with new state laws or political pressure. They also provide an on-the-ground view of how strict state abortion bans have altered care for patients with high-stakes pregnancy complications.

The agency did not disclose whether it is pursuing other investigations related to abortion denials. A spokesperson declined to share the number of complaints the agency has received related to denials of abortion care.

Health and Human Services Secretary Xavier Becerra has sent letters to all hospitals that participate in Medicare, warning them that federal law supersedes state abortion bans. The Department of Justice has also sued and won a case in an Idaho federal district court, arguing the state’s abortion law violates the Emergency Medical Treatment and Labor Act.

But experts say such efforts do not resolve the conflict. Last year, a Texas federal district court granted a preliminary injunction blocking Becerra’s guidance, siding with the Texas attorney general’s arguments that EMTALA does not cover abortions intended to prevent an emergency.

The court found “EMTALA creates obligations to stabilize both a pregnant woman and her unborn child, and it fails to resolve the tension when those duties conflict.”

Texas law, the court pointed out, allows abortion only in cases “when the medical condition is life-threatening” and the patient’s condition “pose[s] a serious risk of substantial impairment of a major bodily function.”

That’s a narrower range of circumstances than described in the federal government’s EMTALA guidance, which calls for offering abortion care “when the health of the pregnant woman is in serious jeopardy” or when her condition “could … result in a serious impairment or dysfunction of bodily functions or any bodily organ,” the court found. (The judge added italics for emphasis.)

“In addition to requiring a physical threat to life, [Texas law] requires both a greater likelihood and a greater severity than the Guidance’s interpretation of EMTALA does,” the judge wrote. As a result, EMTALA could not compel hospitals to offer abortions that would not be permitted under state law, the judge wrote.

Both cases are under appeal and may eventually make their way to the Supreme Court. In any case, it’s unclear how much impact federal enforcement can have. Though the hospitals who denied Farmer care have been reprimanded, neither has faced sanctions so far.

In a case where providing an abortion would violate state law and failing to provide one would violate federal law, doctors face a lopsided set of potential legal repercussions, said Mary Ziegler, a leading historian of the U.S. abortion debate. The possible penalties for violating EMTALA include fines. The consequences for violating state abortion bans could include prison time and loss of license.

“If [hospitals] interpret EMTALA in keeping with the Biden administration’s understanding of it, they could expose themselves to potentially very serious criminal charges,” Ziegler said. “The incentive structure will be that doctors don’t want to risk legal liability.”

Farmer was told by doctors in two states that she had to wait to get seriously ill before they could terminate the pregnancy that was putting her at risk. (Nathan Papes/Springfield News-Leader/USA Today Network)

Farmer, whose story was first reported by the Springfield News-Leader, was considered a high-risk patient from the beginning of her pregnancy, according to her doctors. She was 41, had a history of blood clots, an irregular heart beat, polycystic ovary syndrome, past abdominal surgeries and a past miscarriage.

She was nearly 18 weeks pregnant on Aug. 2, 2022, when she felt liquid gush from her vagina and began cramping and bleeding, according to the investigation.

Doctors at Freeman Health System, a Level II trauma center, quickly determined she had suffered previable prelabor rupture of membranes, known as PPROM — her water broke too early and she had lost her amniotic fluid.

PPROM occurs in about 3% of pregnancies. When it happens before viability, which is generally agreed to start at about 23 or 24 weeks, the chances of the fetus’s survival are extremely low because their lungs cannot develop without amniotic fluid. The chances of the pregnant patient developing a life-threatening infection are high.

The American College of Obstetricians and Gynecologists says the standard of care in these cases is to counsel patients on the risks and offer a choice between expectant management — waiting for the miscarriage to complete on its own or the patient to become sicker — or immediate delivery, by inducing labor or performing a dilation and evacuation surgery.

Being forced to wait can have dire outcomes. In Ireland, a woman with PPROM died from sepsis in 2012 after doctors refused her abortion care, prompting public outrage that eventually led abortion to be legalized in that country.

Anti-abortion activists say that state abortion bans include medical exceptions to allow abortions to protect the “life of the mother.” But in most laws, the exceptions are written so broadly they can be interpreted to only cover the most urgent emergencies, and doctors could face stiff penalties for violating the law — up to life in prison in Texas, for example. According to media reports, few patients have been able to access abortions under those exceptions.

PPROM cases where the fetus still has cardiac activity are particularly difficult for hospitals to navigate under the laws, because a patient’s health status can change from stable to life-threatening extremely quickly, said Dr. Chloe Zera, a maternal-fetal medicine specialist in Massachusetts. The laws do not clarify whether physicians can act to prevent an imminent health emergency instead of waiting for one to develop.

“There are [PPROM] cases that do OK. And there are cases where there is overwhelming infection or hemorrhage, or hysterectomy or ICU admission or death. And things can turn really fast,” Zera said. “We just don’t have great ways to predict who’s going to get sick.”

When a patient has PPROM at 18 weeks, she advises ending the pregnancy because the risks to the patient’s health outweigh the chances of the fetus reaching viability. If Farmer had walked into her hospital in Boston, where abortion access has been expanded since Roe was overturned, Zera said Farmer would have been able to have the procedure right away if she wanted.

That’s not what happened in Missouri or Kansas.

According to records, Farmer’s OB-GYN at Freeman Health System and a maternal-fetal medicine specialist described in detail the severe risks Farmer faced if she continued the pregnancy: clotting, sepsis, severe blood loss, loss of her uterus and death. At the doctors’ request, ProPublica is not naming them after they expressed concerns for their safety.

The maternal-fetal medicine specialist explained to Farmer that typical treatment options usually include abortion care, according to the documents. But when Farmer requested that labor be induced, the specialist told her it was not possible in Missouri.

“We discussed that the current Missouri law (188.015.7 RSMo) supercedes our medical judgement, and the MO law language states that we cannot intervene in the setting of a pregnancy with positive fetal heart motion unless there is a ‘medical emergency,’” the specialist wrote in Farmer’s charts, according to the investigation. “She is currently medically stable. … Therefore contrary to the most appropriate management based my medical opinion, due to the legal language of MO law, we are unable to offer induction of labor at this time.”

Missouri’s abortion ban is one of the strictest in the country. It bans all abortions, except those that are necessary to save a pregnant patient’s life. Even in those cases, doctors could still be charged with a crime. The exception is allowed as an affirmative defense, which puts the burden of proof on the doctor to show the abortion was necessary — similar to claiming self-defense in a homicide case.

The maternal-fetal medicine specialist told Farmer she could travel to another state for care or stay at the hospital for observation. “We discussed that awaiting a medical emergency may put her at further risk for maternal mortality,” the documents say. The specialist and the OB-GYN declined to comment, and the hospital’s media department did not respond to calls and text messages.

According to a complaint filed on Farmer’s behalf by the National Women’s Law Center, she called multiple hospitals, including two in Illinois and two in Kansas, both states where abortion is legal. She couldn’t get through to some of them. Other hospitals said they were not big enough to provide the care she needed or could only handle miscarriages later in pregnancy. She tried two abortion clinics, but could not reach anyone there. Finally, one hospital recommended she go to the University of Kansas Health System, in Kansas City, Kansas, which has the largest out-of-state emergency room nearest to Farmer. She and her boyfriend drove nearly three hours.

Mylissa Farmer and her boyfriend, Matthew McNeil, missed work and drove out of state in an effort to get her emergency abortion care. (Nathan Papes/Springfield News-Leader/USA Today Network)

In interviews with federal investigators, Farmer said that when she first arrived at the University of Kansas at 11:35 p.m., doctors confirmed she had no amniotic fluid left and discussed either inducing labor or providing a dilation and evacuation procedure. Farmer preferred to induce labor so she could hold her daughter, who she had named Maeve, but she told the doctors she would choose “whatever option to save my life.” An OB-GYN resident suggested that inducing labor would be easier to get past the hospital’s legal team, according to the documents. ProPublica is not naming the resident because the hospital expressed concerns for the person’s safety.

The resident returned and said: “Unfortunately, due to the political climate, it was too hot and heated right now,” Farmer told investigators. Earlier that same day, Kansans had voted on whether to protect their state’s constitutional right to abortion. To the hospital’s legal team, both procedures “resembled an abortion and it was too risky,” Farmer recalled the resident saying.

At the University of Kansas Health System, investigators spoke to a nurse, an OB-GYN resident and a maternal-fetal medicine specialist involved in Farmer’s care, as well as the chair of the OB-GYN department and a risk management coordinator. They all corroborated Farmer’s account and said they believed they were not allowed to provide an abortion until Farmer’s symptoms progressed or fetal cardiac activity ceased.

Unlike Missouri, Kansas does not have a sweeping abortion ban. Abortion remains legal up to 20 weeks, and on the day Farmer arrived at the hospital there, Kansans overwhelmingly voted to keep abortion rights in their state constitution.

But Republican lawmakers, guided by national anti-abortion groups, have worked for decades to chip away at abortion access in other ways. The hospital referred investigators to a statute from 1998 that specifically prohibits doctors at the University of Kansas from providing abortions except for in emergency situations.

Yet the statement of deficiencies points out that the University of Kansas Health System also has specific policies to advise physicians in emergencies, including guidance on how to care for patients with prelabor rupture of membranes.

That guidance warns that, after a patient’s water breaks, the risk of complications, including infections, hemorrhage, oxygen deprivation and death, increase with time. For PPROM before 23 or 24 weeks, it directs physicians to offer immediate delivery as an option and to make the decision taking into account “the patient’s wishes.”

And the hospital’s EMTALA policy states that the definition of an emergency medical condition is broad and is not limited to patients with traditional “urgent” conditions: “The phrase ‘immediate medical attention’ has been applied to situations in which the need for medical assessment and care was in a time frame of days rather than hours.”

Investigators also documented that less than two months earlier, a 40-year-old woman came to the same emergency room when her water broke at 15 weeks and received an abortion.

She was counseled on the same risks as Farmer. Her fetus still had cardiac activity and her condition had not yet progressed to an emergency. In fact, her condition was slightly more stable than Farmer’s: She was not yet bleeding and still had some amniotic fluid left. Yet the patient was offered and received abortion care.

Under EMTALA, the hospital had a duty to transfer her to another facility if it could not provide care. Nothing in Kansas law would have prevented the hospital from transferring her to another hospital that could provide abortion care.

But Farmer, the documents make clear, was not given any of those options. The investigation found that the doctors did not even take Farmer’s temperature or conduct a pain assessment, steps that are required under the hospital’s triage policies and a critical tool in evaluating whether her condition was worsening.

The doctors on the medical team, Farmer told investigators, “were very clear about making sure that she knew she had a very serious situation and that she needed care” but only advised her to monitor her symptoms and told her to go back to her hospital in Missouri to deal with further concerns.

Farmer felt “pretty much abandoned at that point, that there was nothing they could do, and that [she and her boyfriend] were on their own,” she told investigators. She worried about the cost of an abortion at an abortion clinic.

At 1:30 am, she was discharged.

Investigators also cited the hospital for a separate case: A 73-year-old man who arrived at the hospital’s emergency room in September and had an abnormal electrocardiogram was left in the waiting room for nearly 90 minutes without a medical screening examination, until staff realized he had died.

ProPublica sent the University of Kansas Health System detailed questions about the violations cited in the documents. Jill Chadwick, a spokesperson for the hospital, declined an interview. In a statement about Farmer’s case, Chadwick said: “The care provided to the patient was reviewed by the hospital and found to be in accordance with hospital policy. It met the standard of care based upon the facts known at the time, and complied with all applicable law.”

If Farmer’s treatment complied with hospital policy, the standard of care and the law, ProPublica asked, did that mean providing abortion care two months earlier to another patient with PPROM was a violation?

Chadwick said she could not provide further comment. In a later email, a spokesperson said “physicians can and do provide abortions” at the hospital “if there is an emergent need to save a patient’s life, or to prevent serious and irreversible harm to a patient’s major bodily function.”

Farmer returned to Missouri and, later that evening, went back to the emergency room of Freeman Health System for her pain. Again, doctors counseled her on all the risks of continuing her pregnancy. Again, they told her there was nothing they could do until fetal cardiac activity ceased or she got sicker. They gave her Tylenol and anti-anxiety medication.

“The patient’s medical record also indicated that the patient was exhibiting psychological distress associated with the situation and expressed that she perceived financial barriers to seeking further care on an outpatient basis,” investigators wrote. They also found that medical providers did not reexamine Farmer’s cervix to check how quickly she was progressing and whether she might soon go into labor.

According to her complaint, Farmer finally got connected with an abortion clinic in Illinois that agreed to provide the procedure as soon as possible because of the urgency of her condition. In the car on the way there, she began to experience contractions, but did not want to stop at any Missouri hospital for fear of being denied care again. Upon arrival, a physician performed surgery to end the pregnancy.

Because of their travel, both Farmer and her boyfriend missed work. She was docked a week’s pay and he lost his job. Her insurance refused to cover her care at the abortion clinic, according to her complaint. Afterward, she continued to experience pain and doctors told her she had likely developed an infection during the ordeal. Farmer has since had a tubal ligation to ensure she can never get pregnant again, and she has shared her story with multiple media outlets, alerting federal officials and others to her case and prompting investigations. (She declined through her lawyer to speak with ProPublica because of the trauma of reliving the experience.)

“It was dehumanizing. It was terrifying. It was horrible not to get the care to save your life,” she told The Associated Press. “I felt like I was responsible to do something, to say something, to not have this happen again to another woman. It was bad enough to be so powerless.”

How Does EMTALA Intersect With Abortion Law?

What is EMTALA? The Emergency Medical Treatment and Labor Act requires hospitals that receive federal funding to treat and stabilize anyone who presents at their emergency department, regardless of their ability to pay. If the hospital is not equipped to provide treatment, it is required to arrange a transfer to a hospital that is.

Hospitals cannot delay medical screening or stabilizing treatment for any reason.

How does EMTALA apply to abortion care? Some patients experience pregnancy complications that put them at high risk for rapidly developing a life-threatening emergency. Since state abortion bans went into effect, patients in some states have reported being denied abortion care until fetal cardiac activity stopped or they got sicker.

The federal government says that hospitals must provide abortions in these cases, even if that directly conflicts with interpretations of state laws that outlaw abortions.

What do state laws say? Abortion bans have gone into effect in 14 states. Though the language varies, most state abortion laws do include exceptions for medical emergencies. But doctors say the definitions of what constitutes a medical emergency are too narrow and do not encompass the range of complications that can arise during pregnancy and endanger a patient’s health. A doctor who provides abortion care risks prosecution and could face years in prison, fines and loss of their medical license.

This has caused some hospitals and physicians to interpret these laws in the strictest terms to mean that abortion care is not legal until fetal cardiac activity has ceased or the patient’s condition has progressed to an immediate emergency. In the 11 months since Roe was overturned, most state officials have not clarified that interpretation. In Texas, the attorney general has argued that the medical exceptions granted under the ban do not apply to abortions intended to prevent an emergency.

How can I file an EMTALA complaint? The process for investigating hospitals to determine if they are complying with EMTALA is “complaint driven,” a spokesperson with the Centers for Medicare and Medicaid Services said. Anyone can file an EMTALA complaint with their state’s survey agency, which will investigate the issue and, when appropriate, verify that corrective action is taken to ensure the hospital is in compliance.

Are You in a State That Banned Abortion? Tell Us How Changes in Medical Care Impact You.

by Mark Olalde

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 well over a century, the oil and gas industry has drilled holes across California in search of black gold and a lucrative payday. But with production falling steadily, the time has come to clean up many of the nearly quarter-million wells scattered from downtown Los Angeles to western Kern County and across the state.

The bill for that work, however, will vastly exceed all the industry’s future profits in the state, according to a first-of-its-kind study published Thursday and shared with ProPublica.

“This major issue has sneaked up on us,” said Dwayne Purvis, a Texas-based petroleum reservoir engineer who analyzed profits and cleanup costs for the report. “Policymakers haven’t recognized it. Industry hasn’t recognized it, or, if they have, they haven’t talked about it and acted on it.”

The analysis, which was commissioned by Carbon Tracker Initiative, a financial think tank that studies how the transition away from fossil fuels impacts markets and the economy, used California regulators’ draft methodology for calculating the costs associated with plugging oil and gas wells and decommissioning them along with related infrastructure. The methodology was developed with feedback from the industry.

The report broke down the costs into several categories. Plugging wells, dismantling surface infrastructure and decontaminating polluted drill sites would cost at least $13.2 billion, based on publicly available data. Adding in factors with slightly more uncertainty, like inflation rates and the price of decommissioning miles of pipeline, could bring the total cleanup bill for California’s onshore oil and gas industry to $21.5 billion.

Meanwhile, California oil and gas production will earn about $6.3 billion in future profits over the remaining course of operations, Purvis estimated.

Compounding the problem, the industry has set aside only about $106 million that state regulators can use for cleanup when a company liquidates or otherwise walks away from its responsibilities, according to state data. That amount equals less than 1% of the estimated cost.

Taxpayers will likely have to cover much of the difference to ensure wells are plugged and not left to leak brine, toxic chemicals and climate-warming methane.

ProPublica is reporting on oil and gas, with a focus on decommissioning, asset retirement obligations, liability evasion and government oversight. Do you work for an oil and gas company, a state or federal regulator, an insurance company or a financial institution that interacts with the oil and gas industry? Reach out directly at mark.olalde@propublica.org, or find details on how to send us tips securely here.

“These findings detail why the state must ensure this cost is not passed along to the California taxpayer,” state Sen. Monique Limón, a Santa Barbara Democrat who has written legislation regulating oil, said in a statement. “It is important that the state collect funding to plug and abandon wells in a timely and expeditious manner.”

Representatives of the state’s oil regulatory agency, the California Geologic Energy Management Division, did not respond to ProPublica’s request for comment on the report’s findings.

Rock Zierman, CEO of the California Independent Petroleum Association, an industry trade group, said in a statement that companies spent more than $400 million last year to plug and clean up thousands of oil and gas wells in the state. “This demonstrates their dedication to fulfilling their obligations and mitigating the environmental impact of their operations,” he said.

Fees on current oil and gas production will offset some of the liabilities, but they’re nowhere near enough to address the shortfall quantified by the new report.

“It really scares me,” Kyle Ferrar, Western program coordinator with environmental and data transparency group FracTracker Alliance, said of the report’s findings. “It’s a lot for the state, even a state as big as California.”

Industry in Decline

High oil prices have translated to huge profits for the industry in recent years, but Carbon Tracker’s report found that’s likely to be short-lived. Only two drilling rigs were operating in the state at one point this year, meaning few new wells will be coming online, and more than a third of all unplugged wells are idle.

Judson Boomhower, an environmental economist and assistant professor at the University of California, San Diego who has studied California’s oil industry, said there are inherent uncertainties in estimating future oil revenues. For example, one variable is how quickly the country shifts from internal combustion engine vehicles to electric. But, he said, Carbon Tracker’s estimates for environmental liabilities track with his research.

“It’s a state in the twilight of its production period, and that means big liabilities,” Boomhower said. He added that now is the time for regulators to prevent companies from offloading their wells to “thinly capitalized firms” unable to shoulder the cleanup.

As ProPublica reported last year, the major oil companies that long dominated in California and have the deep pockets necessary to pay for environmental cleanup are selling their wells and leaving the state, handing the task to smaller and less well-financed companies.

Roughly half of the wells drilled in California have changed hands through sales and bankruptcies since 2010, according to data Ferrar analyzed.

Smaller companies are often one bankruptcy away from their wells being orphaned, meaning they’re left to taxpayers as companies dissolve. The Biden administration recently committed $4.7 billion in taxpayer funds to plug orphan wells.

And the industry’s environmental liabilities in California are far bigger than Carbon Tracker’s report quantifies.

Purvis only included environmental liabilities associated with onshore oil and gas production. Billions of dollars more will be needed to plug offshore wells, remove rigs and reclaim artificial islands used for drilling off the coast of Long Beach, Ventura and Santa Barbara.

Additionally, the report did not quantify the emerging risk of “zombie wells,” which were plugged years ago to weaker standards and are likely to leak if they aren’t replugged. That’s an expensive endeavor, as the average cost to plug one well in California — to say nothing of cleaning up surface contamination — is $69,000, according to Purvis’ research. But some California wells have already begun failing, including in neighborhoods in Los Angeles.

“They’re Not Going to Have Money to Do It Later”

Time is running out to rectify the funding shortfall, for example by increasing the money companies must set aside for well plugging.

Carbon Tracker’s report — using state production data and financial futures contracts on the New York Mercantile Exchange — estimated that as production declines, 58% of all future profits from drilling oil and gas in the state are likely to come over the next two years.

“We have our backs up against the wall in California right now,” Ferrar said. “If companies don’t put money towards it now, they’re not going to have money to do it later.”

Environmental policies could accelerate the industry’s decline. California voters will decide on a ballot initiative in 2024 that would reinstate large buffer zones between communities and oil wells, limiting drilling.

Purvis said acting quickly to plug wells would also “stimulate economic activity” and help smooth the transition for oil and gas workers who stand to lose well-paying jobs in the shift away from climate-warming fossil fuels. Spending large sums to plug old wells would create short-term employment for oil field workers.

As California faces the consequences of its failure to quickly clean up aging oil and gas infrastructure, there are likely several million more wells around the country that are either low-producing or already orphaned and will soon need to be decommissioned.

“California’s going to be a test case or the leading edge of this,” Boomhower said. “This same problem is eventually going to manifest everywhere.”

by Hannah Dreyfus

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.

One Thursday afternoon in December, a father and two of his estranged children boarded a flight from Salt Lake City to Texas, beginning an effort to repair their fractured relationship.

A family court official had ordered them to attend a reunification camp, Turning Points for Families Texas, to repair damage that the judge said the boys’ mother had inflicted by alienating them from their father.

The following morning, at the vacation rental where their therapy sessions were to be held, the counselor made an unusual request.

Jordan, the boys’ father, was asked to play a recording he’d made of a 2019 domestic dispute with his ex-wife, Hollie, that led to her arrest and their divorce. (ProPublica is using only the first names of adult family members to avoid identifying the children who are minors.) Jordan would later tell the court that he never intended for his sons to hear the sounds of their mother screaming during their fight. “I never even wanted the kids to know it existed,” he said of the recording.

But the Turning Points counselor, Loretta Maase, insisted. The camp claims to remedy parental alienation, a disputed psychological theory in which one parent — in this case Hollie — is accused of brainwashing a child to turn them against the other parent. They needed to hear the truth about their mother so that “the healing can begin,” Maase said of the children.

What unfolded after the recording was played caused the four-day treatment session to spiral out of control.

The younger son, then 12, covered his head with a blanket, shutting out the sounds, while his older brother became violent. When the boys refused to leave their bedroom to take part in therapy, Maase ordered the door removed. Their bedding, shower items, food and clothing were also removed, according to family members who participated in the intervention.

“They would use the blankets to hide underneath so they didn’t have to come out,” Jordan’s new wife would later testify.

The court-ordered intervention failed to reconcile the boys with their father, and beginning in January a judge convened a four-day hearing to understand why. The testimony that followed offered a rare glimpse into Turning Points’ operations and methods, as well as how family courts handle complicated family dynamics.

Custody disputes are often fraught, and courts and child welfare workers have the difficult job of sorting through allegations and counter allegations to decide what’s best for the children. Programs like Turning Points, in effect, allow overburdened family court judges to outsource some of that difficult decision-making: An order to participate effectively transfers to the person running the camp the power to decide if and when a parent can contact their child, regardless of the court’s previous custody rulings. This transfer of power generally lasts from the time the court order is issued until the camp director determines the treatment has been successful.

Despite family courts’ frequent use of Turning Points for Families, little is publicly known about the program, which was founded by New York-based social worker Linda Gottlieb, who describes the intervention as a “therapeutic vacation.”

But its treatments are controversial and frequently fall short of addressing the underlying causes of broken family relationships, experts told ProPublica.

This case is the latest example of Turning Points and programs like it triggering pushback over their methods.

ProPublica reported this year on another Utah case involving siblings who barricaded themselves in their bedroom to avoid being sent to the same Texas program. A judge subsequently backed down on an order mandating that they return to their father’s custody, and the children left their room. In March, a California appellate court reversed a lower court order sending two children to a similar program, saying the judge had not adequately understood or vetted the program before ordering the children to attend.

In April, Colorado lawmakers approved a bill to prohibit state courts from using reunification programs like Turning Points; lawmakers in California and Montana are considering similar bills. And a recent United Nations Human Rights Council special report recommended that court-ordered reunification camps be prohibited.

Maase, who runs Turning Points for Families Texas, told ProPublica she was not able to comment on specific cases. Questions that ProPublica sent to her were included in a motion filed last month by Jordan, asking the judge to restrain the news organization’s reporting on the case. The judge denied the request, stating the court did not have jurisdiction over ProPublica.

Jordan filed a motion against ProPublica requesting the court seal the custody case involving his boys and their mother. (Obtained by ProPublica)

Jordan declined to speak with ProPublica, citing his children’s need for privacy. “They’ve gone through a lot,” he said.

In an interview, Hollie said she faces “an impossible choice: see my kids again or subject them to more of this.”

Maase has blamed Hollie — “the alienating parent,” Maase called her — for the treatment’s failure, according to court documents. She did not comply with “Turning Points Protocols,” specifically writing a letter of apology and another in support of the reunification efforts. The letters, both subject to Maase’s approval, were to “explicitly and convincingly” disabuse the children of “their false beliefs about their father.”

“I’m not signing anything Loretta Maase sends me,” said Hollie, who despite having 50% custody before the Turning Points treatment began hasn’t seen the boys since December. “I’m not putting my kids through more of her ‘treatment.’ I never consented to this, and I never will. How this is not a violation of my parental rights, I do not know.”

“I Don’t Know of Any Other Option”

Years before the children were sent to Turning Points, the court appointed reunification therapists to address their resistance and ill will toward their father.

Karly McGuire said during the year she counseled the family she came to believe that Jordan’s parenting style was the cause of his sons’ continued resistance to him, according to her testimony. Jordan disagreed, she said.

McGuire, who holds a Ph.D. in family therapy, told the court that Jordan constantly sent her videos about parental alienation. And he accused Hollie of spearheading a campaign of parental alienation against him and causing the rift between him and his sons.

After years of therapy, the boys continued to report they were being harmed by their father and violently resisted visitation with him. The 12-year-old posted a video on TikTok with a gun barrel in his mouth, and all three of Jordan and Hollie’s sons declared a “suicide pact” if they were forced to live with their father, according to court documents. (The oldest of the three brothers is an adult and did not participate in the reunification program.)

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

-Call the National Suicide Prevention Lifeline: 1-800-273-8255

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

Bryce Froerer, appointed by the court to represent the boys’ interests in the custody case, cites worries of self-harm by the 12-year-old in his motion recommending treatment at Turning Points. (Obtained by ProPublica)

Bryce Froerer, a guardian ad litem appointed by the court to represent the boys’ interests in the custody case, told the court that their refusal to visit their father and their threats of self-harm were evidence of parental alienation. He also said a more severe intervention was needed to address it, according to court documents.

The “conservative, cautious approach” advocated by McGuire wasn’t working, argued Froerer, who has no psychological training, according to his office. He recommended they instead attend Turning Points and follow its practice of prohibiting the children from seeing the “alienating parent” for at least 90 days. Froerer admitted that he had “very little experience” with Turning Points, beyond speaking with Maase and reviewing some promotional materials.

“I don’t know of any other option at this point besides trying this program,” he told the court. “The alternative, from my perspective, Your Honor, is to linger on. And it is not my recommendation that we linger on.”

Froerer declined to speak with ProPublica. After the news organization requested an interview, he petitioned the court to seal the case.

McGuire testified that she cautioned Froerer against sending the boys to an intervention like Turning Points. She had grown concerned about their increasing despondency during her sessions, which she attributed to burnout from all of the court-ordered therapy. She believed separating them from their mother, the primary caregiver for most of their lives, would further harm their mental health.

But Froerer’s argument prevailed. Christina Wilson, the judicial commissioner overseeing the case, agreed that the court was running out of options. Though she also admitted knowing little about it — asking at one point “how the program works” — she ordered the boys to participate in the intervention.

“When that’s done, we can come back here and talk about what happened,” Froerer said. “And if things have improved, wonderful. And if things haven’t improved,” he paused, “I don’t know.”

A spokesperson for the court said Wilson was unable to comment on “any past or current cases.”

A Courtroom Affliction

The family’s trip to Texas was intended to repair a case of parental alienation. Advocates and critics debate whether it’s a real ailment, but they agree on one thing: It is only diagnosed and treated in the family courtroom.

“Other kinds of psychological dysfunctions that show up in court tend to show up elsewhere as well, whereas parental alienation is a process that is specifically brought to court to remedy,” said Demosthenes Lorandos, an attorney and parental alienation scholar who has written about a reunification program that uses methods similar to Turning Points. Lorandos defends parental alienation as a legitimate diagnosis and believes reunification camps are a safe and effective way to treat the condition. Lorandos, who also holds a doctorate in clinical psychology, said he does not know of another psychological dysfunction that only shows up in court.

Dr. David Corwin, a professor and director of pediatric forensic services at the University of Utah and a past president of the American Professional Society on the Abuse of Children, disputes that parental alienation is a legitimate disorder. It almost exclusively affects children of parents with higher socioeconomic status, he said. “True mental health disorders are more equally distributed throughout the population, regardless of socioeconomic status, class or social context.”

Gottlieb told ProPublica that she created Turning Points at the request of lawyers whose clients were seeking intensive treatment for alienation. Gottlieb, who trained Maase, has expanded to meet the demand, including the Texas location and a program in California.

Maase said Jordan paid her company $12,000 for the Texas sessions. Today, the price for the four-day treatment is $15,000.

Lorandos said he charges $5,000 a day for expert testimony in parental alienation cases, and the bill for his services on a single case has reached $50,000.

“Business is booming,” said Robin Deutsch, chair of the American Psychological Association’s working group on high conflict family relationships involving children.

She is a critic of Turning Points and programs like it, saying their treatments don’t address the complex dynamics that cause fractures within families. “The court has to put all their eggs in the parental alienation basket. And the kids will suffer because of it,” Deutsch said. (Previously, Deutsch ran a reunification camp that she says differed in its approach to family fractures; she said the camp is no longer in operation.)

Outside the courtroom, the ailment that the programs claim to heal — parental alienation — has struggled to gain legitimacy. Medical and psychological professionals, including the American Psychiatric Association, have rejected it as a mental disorder. And the special report released by the United Nations Human Rights Council blasted parental alienation as a “pseudo-concept” and recommended member states prohibit its use in family courts.

The theory has also been shunned by the National Council of Juvenile and Family Court Judges for failing to meet court evidentiary standards.

Jennifer Hoult, an attorney and legal scholar, has written about why parental alienation fails to meet national standards for court admissibility. She said the theory is based on a fallacy that parents have a right to be loved. “There is no legal right to force your children to love you, respect you or even like you,” she said.

Gottlieb, who spoke to ProPublica in February for another story, argues alienation typically begins when people believe children’s claims of abuse. “Everyone knows children lie,” Gottlieb told ProPublica. “Lying is so instinctual — children love to make up stories. Why on earth do we believe that children are reporting accurately?”

Little independent research has examined the long-term effects of reunification camps on children.

A 2021 evaluation led by Jennifer Jill Harman, an associate professor of psychology at Colorado State University who believes parental alienation is a genuine diagnosis, analyzed video recordings of Gottlieb’s intervention with 15 families. Based on Gottlieb’s “self-reported” success during the intervention itself, the evaluation found the program was safe and had a 96% rate of effectiveness.

According to Harman, the analysis didn’t look at the treatment’s long-term effectiveness. And the study was intended to “promote” the program and refute claims that its interventions “are traumatic for children and cause long-term harm,” according to Harman’s application to the Colorado State University Institutional Review Board for the project. Gottlieb was involved in designing and executing the evaluation of her program, records show.

Harman declined to comment. Gottlieb didn’t respond to requests to comment for this story.

Jennifer Bard, an expert in human-subjects research law and a professor at the University of Cincinnati, questioned the value of this evaluation of Turning Points.

“The fact that the person who stands to profit by the findings of this study designed it should cause considerable concern,” Bard said. “It’s almost as if this study was put together to support a predetermined conclusion, which is not what studies are supposed to do.”

Sessions Spiral Out of Control

On Dec. 1, police officers arrived at Jordan’s brick-front home in Syracuse, Utah. He had called for help with a “juvenile problem.” His two sons were refusing to be taken to Turning Points as the court had ordered, according to police records.

Eventually, the boys agreed to go, and the group that traveled to Texas included Jordan’s new wife (the boys had not previously met her) and stepchildren, and the boys’ paternal uncle and cousins, according to testimony. The boys’ older brother, Xander, who is 19, opted out of the program.

Maase held full-day sessions at the family’s vacation rental. (The address on the Turning Points for Families Texas website is a post office box at a strip mall in Austin.)

In discussing the program, the judge and commissioner overseeing the case referred to Maase repeatedly as a “doctor,” though Maase is not a doctor and does not refer to herself as such. She is a licensed professional counselor with a master’s degree in counseling and family therapy. She is not permitted to provide or advertise herself as providing psychological or medical services, according to the executive director of the Texas Behavioral Health Executive Council. Maase also operates a counseling company called ParentRise, which provides therapy to families.

Jordan testified that after the sessions began, Maase instructed him to play for the boys the recording of the July 1, 2019, domestic dispute between him and his ex-wife.

Hollie said during the dispute she lunged to grab a phone when she realized her then-husband was using it to record them. She denies being physically violent with Jordan.

The incident led to Hollie’s arrest. She was charged with domestic violence in the presence of a child and disorderly conduct. She pleaded not guilty to the charges, which were later dismissed.

Maase told the court that introducing children to recordings and documents of their parents’ domestic disputes is “standard procedure” at her camp in order to correct children’s “false narrative” about the alienated parent — in this case Jordan.

In her report to the court, Maase wrote that throughout their time in Texas the boys showed “inadequate compliance, aggressive and violent behaviors, and overall lack of progress.”

Texas police officers were called several times to respond to the 16-year-old’s threats of violence toward himself and others. Though he weighed only 111 pounds, the teenager had to be physically restrained several times by family members before police arrived.

According to accounts from those who participated in the intervention, Maase instructed adult family members to physically coerce the boys to cooperate with the treatment. According to one account, Maase recorded the therapy sessions over the boys’ objections and repeatedly threatened them, including telling the older boy that he would go to jail if he didn’t cooperate and might never see his mother again. According to more than one account, Maase took away the boys’ food during the intervention in order to compel participation.

Maase told ProPublica that these claims are “preposterous.” “I advise that you turn your attention to the motives of those who would make such assertions in the first place,” she wrote in an email.

Since the intervention, the children have been barred from participating in individual therapy.

In her report to the court, Turning Points counselor Loretta Maase states that individual therapy would be considered dangerous to the children. (Obtained by ProPublica)

Such prohibitions are standard Turning Points protocol. Maase explained to the court that interacting with therapists who aren’t part of Turning Points could be “dangerous” because they might encourage the children to believe “they had abusive past experiences when, in fact, they did not.”

Separated From Their Mother

After returning from Texas, the boys remained with their father, beginning the 90-day separation from their mother and any relatives who had defended her in the dispute.

In such programs the separation can be extended by the facilitator if the children or the accused parent fail to comply with the treatment.

“Sometimes the 90-day order can turn into a forever order,” Deutsch said.

On Dec. 6, the day after their return from Texas, Jordan brought the 16-year-old to a Salt Lake City emergency room out of fear he would hurt himself or others, according to court documents.

The teenager told the doctor that he had attended a “brainwashing camp” and felt “unsafe” with his father. He said that he had been physically assaulted while at the Turning Points program, according to medical records. The medical report described “faint linear marks” on his upper arms, where the patient said his father had grabbed him.

Another teenager treated years ago by Turning Points in upstate New York also alleged he was abused during his therapy sessions. According to a July 2016 police report, an officer was dispatched to the home of Gottlieb, the Turning Points founder, to investigate claims that a 16-year-old, Caleb Thomas, had been “dropped off at the therapist's residence” and “assaulted and thrown in a closet.” No charges were filed.

Thomas told ProPublica that when he protested Gottlieb’s attempts to record his therapy sessions, he was pinned to the floor by his father and another man. Thomas said he escaped through a window, intending to return to his mother, but was caught by police.

Lt. Craig Wood, the police officer who responded to the report, said he recalled Gottlieb showing him an order from a Delaware family court judge, placing the teen in her care. “I found it unusual that they couldn’t find a doctor closer to where they lived, but she’s a specialist, I guess,” he said.

Gottlieb did not respond to a request for comment.

The week after Jordan took his 16-year-old son to the emergency room, he brought his 12-year-old son to the ER for “suicidal ideation with intent.”

The boy also told medical staff about the “alienation camp,” where he was “threatened that he would be arrested if he didn’t cooperate,” according to medical records. He told hospital staff that while there he had been forced to look at documents and watch video showing that “his mom was a ‘bad person.’”

The 12-year-old said that at his father’s house he was being “restrained daily” if he didn’t do what his dad wanted, and he said he felt “mentally broken down” because of his father’s threats that he would never again see his mother. The boy disclosed to medical staff that his father had sexually abused him at age 11. According to the medical report, Utah’s Department of Children and Family Services is investigating the boy’s claims. DCFS declined to comment.

Jordan did not respond to requests for comment about the allegation. He told hospital staff that multiple DCFS cases had been opened against him and closed because of a lack of evidence. He said he believed his ex-wife had made false claims about him to the children to further alienate them from him, according to court documents.

The child told medical staff that if he was forced to return to his father’s house, he would “find a way to kill himself.” He was admitted for inpatient psychiatric care.

Jordan’s father, Brent, testified in the hearing earlier this year that he has long-standing concerns about his son’s parenting and the effect the reunification camp has had on his grandsons.

“They don’t feel safe with police officers, they don’t trust you, they don’t trust their father. And the reason is because they told their story of abuse and what happens is they get shoved back into the hands of their abuser every time,” Brent testified. “How can you ask a child to rationalize that?”

Police have been called to Jordan’s home multiple times since the family’s return from Texas, according to 911 records. On Dec. 15, a juvenile court judge ordered the children to be removed from the home and placed with their mom. Police brought the 12-year-old to Hollie (the 16-year-old had already run away to his mother’s home). The next day, Jordan secured an order returning the boys to his house. Police assisted with the transfer.

In February, Maase advised the court to continue prohibiting the boys from seeing their mother until Hollie “fully acknowledges the alienation and discontinues her negative behaviors.” The children must first “relinquish their alienating thoughts, beliefs, attitudes, feelings and behavior” before they are allowed to see her, Maase wrote in a report to the court.

Judge Ronald G. Russell ordered the children to continue Maase’s treatment.

Hollie has not been permitted to communicate with her children who are minors since December. In February, she moved from her home in Utah to dissuade the boys from running away from their father’s house to see her, as they had done multiple times. If they do it again, the no-contact order will be extended, Hollie said.

The Oldest Brother

As a legal adult, the court couldn’t force Xander, the oldest of the three brothers, to participate in the reunification program.

Jordan invited him to join them in Texas, texting at the end of November, “It will not be the same without you. I have a ticket ready to purchase for you to come with us. I love you and hope to be your life again.”

Jordan invited his son Xander via text message at the end of November to participate in the reunification program in Texas. (Provided by Xander)

Xander never responded.

He told ProPublica that he had been through years of failed court-mandated reunification therapy and had no intention of participating in more.

Still, he has struggled with feelings of guilt for not being with his brothers as they suffered through the reunification camp.

“Maybe if I had gone, I could have protected them,” he said. “I’m having trouble forgiving myself for that.”

Clarification, May 18, 2023: This article was updated to clarify that the National Council of Juvenile and Family Court Judges has shunned the theory of parental alienation.

Mariam Elba and Mollie Simon contributed research. Michael Squires contributed reporting.

by Daniel Golden, ProPublica, and Kunal Purohit

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published. This article was co-published with The Chronicle of Higher Education.

On a family trip to the Jersey Shore in the summer of 2021, Sophia’s go-to meal was the Chick-fil-A chicken sandwich. The buns were toasty, the chicken was crispy and the fries didn’t spill from the bag.

Sophia was entering her sophomore year in prep school, but her parents were already thinking ahead to college. They paid to enroll her in an online service called Scholar Launch, whose programs start at $3,500. Scholar Launch, which started in 2019, connects high school students with mentors who work with them on research papers that can be published and enhance their college applications.

Publication “is the objective,” Scholar Launch says on its website. “We have numerous publication partners, all are peer-reviewed journals.”

The prospect appealed to Sophia. “Nowadays, having a publication is kind of a given” for college applicants, she said. “If you don’t have one, you’re going to have to make it up in some other aspect of your application.”

Sophia said she chose marketing as her field because it “sounded interesting.” She attended weekly group sessions with a Scholar Launch mentor, a marketing executive who also taught at an Ivy League business school, before working one-on-one with a teaching assistant. Assigned to analyze a company’s marketing strategy, she selected Chick-fil-A.

Sophia’s paper offered a glowing assessment. She credited Chick-fil-A as “responsible for the popularity of the chicken sandwich,” praised its fare as healthier than fast-food burgers, saluted its “humorous yet honest” slogan (a cow saying, “Eat mor chikin”) and admired its “family-friendly” attitude and “traditional beliefs,” exemplified by closing its restaurants on Sundays. Parts of her paper sounded like a customer endorsement (and she acknowledged to ProPublica that her marketing analysis could’ve been stronger). Neither too dry nor too juicy, the company’s signature sandwich “is the perfect blend to have me wanting more after every bite,” she wrote. “Just from the taste,” Chick-fil-A “is destined for success.”

Her heartfelt tribute to the chicken chain appeared on the website of a new online journal for high school research, the Scholarly Review. The publication touts its “thorough process of review” by “highly accomplished professors and academics,” but it also displays what are known as preprints. They aren’t publications “in the traditional sense” and aren’t vetted by Scholarly Review’s editorial board, according to Roger Worthington, its chair.

That preprint platform is where Sophia’s paper appeared. Now a 17-year-old high school junior, she said she wasn’t aware of the difference between the journal and the preprint platform, and she didn’t think the less prestigious placement would hurt her college chances: “It’s just important that there’s a link out there.”

Sophia is preparing to apply to college at a time when the criteria for gaining entry are in flux. The Supreme Court appears poised to curtail race-conscious affirmative action. Grade inflation makes it harder to pick students based on GPA, since so many have A averages. And the SAT and ACT tests, long criticized for favoring white and wealthy students, have fallen out of fashion at many universities, which have made them optional or dropped them entirely.

As these differentiators recede and the number of applications soars, colleges are grappling with the latest pay-to-play maneuver that gives the rich an edge: published research papers. A new industry is extracting fees from well-heeled families to enable their teenage children to conduct and publish research that colleges may regard as a credential.

At least 20 online research programs for high schoolers have sprung up in the U.S. and abroad in recent years, along with a bevy of journals that publish the work. This growth was aided by the pandemic, which normalized online education and stymied opportunities for in-person research.

“You’re teaching students to be cynical about research. That’s the really corrosive part. ‘I can hire someone to do it. We can get it done, we can get it published, what’s the big deal?’”

—Kent Anderson, past president of the Society for Scholarly Publishing

The consequence has been a profusion of published research papers by high school students. According to four months of reporting by ProPublica, online student journals now present work that ranges from serious inquiry by young scholars to dubious papers whose main qualification seems to be that the authors’ parents are willing to pay, directly or indirectly, to have them published. Usually, the projects are closely directed by graduate students or professors who are paid to be mentors. College admissions staff, besieged by applicants proffering links to their studies, verify that a paper was published but are often at a loss to evaluate its quality.

Moreover, ProPublica’s reporting shows that purveyors of online research sometimes engage in questionable practices. Some services portray affiliated publications as independent journals. Others have inflated their academic mentors’ credentials or offered freebies to college admissions consultants who could provide referrals. When asked about these practices by ProPublica, several services responded by reversing course on them.

The business of churning out high school research is a “fast-growing epidemic,” said one longtime Ivy League admissions officer, who requested anonymity because he wasn’t authorized to speak for his university. “The number of outfits doing that has trebled or quadrupled in the past few years.

“There are very few actual prodigies. There are a lot of precocious kids who are working hard and doing advanced things. A sophomore in high school is not going to be doing high-level neuroscience. And yet, a very high number of kids are including this” in their applications.

The programs serve at least 12,000 students a year worldwide. Most families are paying between $2,500 and $10,000 to improve their odds of getting into U.S. universities that accept as few as 1 in every 25 applicants. Some of the biggest services are located in China, and international students abound even in several U.S.-based programs.

The services pair high schoolers with academic mentors for 10-15 weeks to produce research papers. Online services typically shape the topic, direction and duration of the project, and urge students to complete and publish a paper regardless of how fruitful the exploration has been. “Publication specialists” then help steer the papers into a dizzying array of online journals and preprint platforms. Almost any high school paper can find an outlet. Alongside hardcore science papers are ones with titles like “The Willingness of Humans to Settle on Mars, and the Factors that Affect it,” “Social Media; Blessing Or Curse” and “Is Bitcoin A Blessing Or A Curse?”

“You’re teaching students to be cynical about research,” said Kent Anderson, past president of the Society for Scholarly Publishing and former publishing director of the New England Journal of Medicine. “That’s the really corrosive part. ‘I can hire someone to do it. We can get it done, we can get it published, what’s the big deal?’”

The research services brag about how many of their alumni get into premier U.S. universities. Lumiere Education, for example, has served 1,500 students, half of them international, since its inception in the summer of 2020. In a survey of its alumni, it found that 9.8% who applied to an Ivy League university or to Stanford last year were accepted. That’s considerably higher than the overall acceptance rates at those schools.

Such statistics don’t prove that the students were admitted because of their research. Still, research can influence admissions decisions. At Harvard, “evidence of substantial scholarship” can elevate an applicant, according to a university filing in a lawsuit challenging its use of affirmative action in admissions. The University of Pennsylvania’s admissions dean, Whitney Soule, boasted last year that nearly one-third of accepted students “engaged in academic research” in high school, including some who “co-authored publications included in leading journals.” A Penn spokesperson declined to identify the journals. Yale, Columbia and Brown, among others, encourage applicants to send research.

One admissions dean acknowledged that conferring an advantage on those who submit published papers benefits affluent applicants. “Research is one of these activities that we’re very aware they’re not offered equitably,” Stuart Schmill of MIT said. Nevertheless, MIT invites applicants to submit research and inquires whether and where it was published.

Admissions officers often lack the time and expertise to evaluate this research. The first reader of each application typically takes 10 minutes or less to go through it, which means noting the existence of the published paper without actually reading it. If the applicant is on the cusp, a second staffer more versed in the subject area may read their file. The first reader “is very young and in almost all cases majored in humanities or social sciences,” said Jon Reider, a former admissions officer at Stanford. “They can’t tell if a paper in the sciences means anything or is new at all.”

As a result, admissions staff may rely on outside opinions. Schmill said that MIT pays more attention to the mentor’s recommendation than the actual research. Academic mentors, even when paid, “do a pretty good job being honest and objective,” he said. The longtime Ivy League admissions officer was more skeptical, likening the mentors to expert witnesses in a trial.

Brown admissions dean Logan Powell described faculty as “invaluable partners” in reviewing research. But many professors would rather not be bothered. “Our faculty don’t want to spend all their time reading research projects from 17- and 18-year-olds,” the veteran Ivy League admissions officer said.

“Our faculty don’t want to spend all their time reading research projects from 17- and 18-year-olds.”

—A longtime Ivy League admissions officer

Also complicating the admissions office’s ability to assess the papers is staffers’ unfamiliarity with the byzantine world of online publications favored by the research services. Several have confusingly similar names: the Journal of Student Research, the Journal of Research High School, the International Journal of High School Research. Selective outlets like the Journal of Student Research and the Scholarly Review also post preprints, making it hard to determine what, if any, standards a manuscript was held to.

Some also hide ties to research services. Scholarly Review doesn’t tell readers that it’s founded and funded by Scholar Launch. The lack of transparency was “not a conscious decision,” Scholar Launch co-founder Joel Butterly said. “Our intent is to keep it as separate as possible from Scholar Launch.”

The companies are intertwined in at least two respects. Worthington, who chairs the Scholarly Review’s editorial board, also works as a mentor for Scholar Launch and InGenius Prep, a college admissions counseling service co-founded by Butterly. Three of the seven articles in the Scholarly Review’s inaugural issue were written by students who Worthington advised, possibly enhancing their college prospects.

“Editors selecting papers they were involved in is a no-no,” said Anderson, the former New England Journal of Medicine publishing director.

Worthington told ProPublica that he had recused himself from discussing those manuscripts. Then Scholar Launch changed its policy. “For future issues,” Worthington said in a subsequent email, “the company will disclose mentoring arrangements in advance to make doubly sure that nobody will be reviewing work by a former student.” Worthington also said, after ProPublica raised questions, that Scholarly Review would make it “more obvious” that the editorial board is “not responsible” for articles on its preprint platform. (During ProPublica’s reporting process, Sophia’s Chick-fil-A paper was removed from the site.) The platform, which is managed by Scholar Launch and InGenius Prep, has been given a separate section on the Scholarly Review website, and further changes are likely, he said.

Online research services are an offshoot of the booming college-admissions-advising industry. They draw many of their students from the same affluent population that hires private counselors. Many families that are already paying thousands or tens of thousands of dollars for advice on essay writing and extracurricular activities pay thousands more for research help. Scholar Launch charges $3,500 for “junior” research programs and between $4,500 and $8,800 for advanced research, according to its website.

Polygence, one of the largest online high school research programs in the U.S., cultivates college counselors. The service, which was founded in 2019 and worked with more than 2,000 students last year, has developed relationships with counselors whose clients receive a discount for using Polygence.

Polygence proclaimed April to be Independent Educational Consultants Appreciation Month. It planned to raffle off prizes including “an all-expenses paid roundtrip to a college campus tour of your choice” — it suggested the University of Hawaii — and “2 free pro bono Polygence research projects.”

Such perks appear to brush up against ethics codes of two college counseling associations, which prohibit members from accepting substantial compensation for student referrals. Asked about these rules, Polygence co-founder Jin Chow said the event celebrates all counselors, “regardless of whether or not they have partnered with us or sent us students.” Polygence then dropped the tour prize and added two more free research projects.

Then there’s the question of credentials. Lumiere Education’s website has routinely identified mentors as Ph.D.s even when they don’t have a doctorate and described itself as “founded by Oxford and Harvard PhDs,” even though its founders, Dhruva Bhat and Stephen Turban, are pursuing doctorates. It’s “shorthand,” Turban said. “We’re not trying to deceive anyone.” After ProPublica questioned the practice, Lumiere changed mentors’ credentials on its website from “PhD” to “PhD student.”

Paid “mentors,” who are frequently doctoral students, play key roles in the process of generating papers by high schoolers. The job is “one of the most lucrative side hustles for graduate students,” as one Columbia Ph.D. candidate in political science put it. Another Ph.D. candidate, who mentored for two services, said that one paid her $200 an hour, and the other paid $150 — far more than the $25 an hour she earned as a teaching assistant in an Ivy League graduate course.

“[The first reader of a college application] is very young and in almost all cases majored in humanities or social sciences. They can’t tell if a paper in the sciences means anything or is new at all.”

—Jon Reider, former admissions officer at Stanford

In some instances, the mentors seem to function as something more than advisers. Since high schoolers generally don’t arrive with a research topic, the mentor helps them choose it, and then may pitch in with writing, editing and scientific analysis.

A former consultant at Athena Education, a service in India, recalled that a client thanked her for his admission to a world-famous university. Admissions interviewers had praised his paper, which she had heavily revised. The university “was tricked,” the consultant said, adding that other students who were academically stronger went to second-tier universities.

The Cornell Undergraduate Economic Review, which accepts about 10% of submissions, published its first-ever paper by a high school student in 2021. Its editor-in-chief was impressed that the author, a Lumiere client in the Boston area, had used advanced econometrics to demonstrate that a reduced federal income tax subsidy for electric vehicles had caused sales to plummet.

But another editor, Andres Aradillas Fernandez, said he wondered whether the high-level work “was not at least partially” attributable to the mentor, a Ph.D. candidate in economics at an Ivy League university. He also felt uneasy that access to services like Lumiere is largely based on wealth. After Aradillas Fernandez became editor-in-chief last year and Lumiere clients submitted weaker papers, he notified Lumiere that the journal would no longer publish high school research.

The Boston-area Lumiere client declined comment. Turban, Lumiere’s co-founder, said the paper was “100 percent” the student’s work. The mentor said he showed the high schooler which mathematical formulas to use, but the student was “very motivated” and did the calculations himself. “I have to spoon feed him a bit on what to read and sometimes how to do it,” the mentor said.

The oldest online research mentorship program for high schoolers, Pioneer Academics, founded in 2012, has maintained relatively rigorous standards. It accepted 37% of its 4,765 applicants last year, and 13% of its students received full scholarships based on need. Pioneer “never promises academic journal publication,” according to its website.

“In our experience, we have noticed that [the Journal of Student Research] nearly never gives edits, and students always just advance straight to being accepted.”

—Manas Pant, a publication strategy associate at Lumiere Education

“The push for publication leads young scholars astray,” Pioneer co-founder Matthew Jaskol said. “The message is that looking like a champion is more important than training to be a great athlete.”

Oberlin College gives credits to students for passing Pioneer courses. The college’s annual reviews have found that research done for Pioneer “far exceeded” what would be expected to earn credit, said Michael Parkin, an associate dean of arts and sciences at Oberlin and a former Pioneer mentor, who oversees the collaboration. Pioneer pays Oberlin a small fee for each nonscholarship student given credit.

At Pioneer and other services, the most fulfilling projects are often impelled by the student’s curiosity, and gaining an edge in college admissions is a byproduct rather than the raison d’etre. Alaa Aboelkhair, the daughter of a government worker in Egypt, was fascinated as a child by how the stars constantly change their position in the sky. Googling in 2021, before her senior year of high school, she came across Lumiere, which gave her a scholarship. “The fact that we only know 5% of the universe drove me to study more,” she said. “That is my passion.”

At the suggestion of her Lumiere mentor, Christian Ferko, Alaa examined whether hypothetical particles known as axions could be detected by converting them into light. Lumiere was paying Ferko for weekly sessions, but he talked with Alaa several times a week. He emailed some textbooks to her and she found other sources on her own, working late into the night to finish her paper.

Since she chose not to submit her ACT score, the paper and Ferko’s recommendation were vital to her college applications. In March 2022, a Princeton admissions officer called Ferko to ask about Alaa. Ferko compared her to a first-year graduate student and said she showed the potential to make new discoveries. “My impression is this is something colleges do when they’re right on the fence of whether to admit the student,” Ferko said. “I did my best to advocate for her, without overstating.”

Princeton admitted only 3.3% of international applicants to the class of 2026, including Alaa. She said she received a full scholarship. (“Optional submissions are one factor among many in our holistic review process,” Princeton spokesperson Michael Hotchkiss said.)

A short walk from India’s first Trump Tower, in an upscale neighborhood known for luxury homes and gourmet restaurants, is the Mumbai office of Athena Education, a startup that promises to help students “join the ranks of Ivy League admits.” An attendant in a white uniform waits at a standing desk to greet visitors in a lounge lined with paintings and featuring a coffee bar and a glass facade with a stunning view of the downtown skyline. “We all strive to get things done while sipping Italian coffee brewed in-house,” a recent Athena ad read.

Co-founded in 2014 by two Princeton graduates, Athena has served more than 2,000 students. At least 80 clients have been admitted to elite universities, and 87% have gotten into top-50 U.S. colleges, according to its website. One client said that Athena charges more than a million rupees, or $12,200 a year, six times India’s annual per capita income. Athena declined comment for this story.

Around 2020, Athena expanded its research program and started emphasizing publication. Athena and similar services in South Korea and China cater to international students whose odds of getting accepted at a U.S. college are even longer than those American students face. MIT, for instance, accepted 1.4% of international applicants last year, compared with 5% of domestic applicants.

A former consultant said Athena told her that its students were the “creme de la creme.” Instead, she estimated, 7 out of 10 needed “hand-holding.”

For publication, Athena students have a readily available option: Questioz, an online outlet founded by an Athena client and run by high schoolers. Former Editor-in-Chief Eesha Garimella said that a mentor at Athena “guides us on the paper editing and publication process.” Garimella said Questioz publishes 75%-80% of submissions.

Athena students also place their work in the Houston-based Journal of Student Research. Founded in 2012 to publish undergraduate and graduate work, in 2017 the journal began running high school papers, which now make up 85% of its articles, co-founders Mir Alikhan and Daharsh Rana wrote in an email.

Last June, a special edition of the journal presented research by 19 Athena students. They tested noise-reduction algorithms and used computer vision to compare the stances of professional and amateur golfers. A survey of Hong Kong residents concluded that people who grew up near the ocean are more likely to value its conservation. Athena’s then-head of research was listed as a co-author on 10 of the projects.

Publication in JSR was “pretty simple,” said former Athena student Anjani Nanda, who surveyed 103 people about their awareness of female genital mutilation and found that they were poorly informed. “I never got any edits or suggested changes from their side.”

As Nanda’s experience suggests, virtual journals dedicated to high school research tend to be less choosy than traditional publications. They reflect a larger shift in academic publishing. Print journals typically accept a small percentage of submissions and depend on subscription revenue. Online publications tend to be free for the reader but charge a fee to the author — incentivizing the publications to boost revenue by accepting many articles.

The Journal of Student Research exemplifies this turnabout. It describes itself as peer-reviewed, the gold standard of traditional academic publishing. It relies on more than 90 reviewers at colleges across the U.S., and the typical review takes 12-24 weeks, according to its website.

“The push for publication leads young scholars astray. The message is that looking like a champion is more important than training to be a great athlete.”

—Matthew Jaskol, co-founder of Pioneer Academics

In reality, it may not be so stringent. Four of eight reviewers whom ProPublica contacted said the journal has never asked them to evaluate a manuscript. (Some academics agreed to review for JSR but forgot over time, Alikhan and Rana said; others specialize in fields where the journal has received few submissions.)

And while authors pay an “article processing charge” of $50 at submission and $200 at acceptance, for an extra $300 they can expedite “fast-track” review in four to five weeks. One Athena client who fast-tracked his manuscript so that it could be published in time for his college application said JSR accepted it without changes. He was admitted to a top-10 U.S. university. “I think it was important,” said the student. “I didn’t have much leadership in school so [I] needed other ways to get better extracurriculars.”

In “The Ultimate Guide to the Journal of Student Research,” a Lumiere “publication strategy associate” described JSR as a “safety” option that accepts 65% of submissions from Lumiere clients. “In our experience, we have noticed that JSR nearly never gives edits, and students always just advance straight to being accepted,” the Lumiere associate wrote.

Alikhan and Rana defended the journal’s standards. They said that many papers, which are submitted with the guidance of top mentors, hardly need editing: “Honestly, it is not the journal’s fault if their advisors working closely with students produce outstanding manuscripts.”

The journals are deluged with submissions. Founded in 2019, the International Journal of High School Research has expanded from four to six issues a year and may add more, said executive producer Fehmi Damkaci. “There is a greater demand than we envisioned,” he said, adding that the journal has become more selective.

As the pandemic closed labs and restricted fieldwork, forcing students to collect data and conduct interviews online, the Journal of Student Research “received an increased volume of submissions,” Alikhan and Rana said. Polygence complained that several students who wanted to cite publications in their college applications hadn’t heard back from JSR for months. The papers were eventually published.

Preprint platforms don’t even bother with peer review. The usual justification for preprints is that they quickly disseminate vital research, such as new information about vaccines or medical treatments. High school projects are rarely so urgent. Still, Polygence started a preprint platform last fall. “The idea is for students to showcase their work and have them be judged by the scientific/peer/college community for their merits,” co-founder Janos Perczel wrote to ProPublica.

The Journal of Student Research hosts preprints by clients of Scholar Launch and two other services. One preprint only listed the author’s first name, Nitya. Leaving out the last name is a small mistake, but one that hints at the frenzy to publish quickly.

Online research programs could end up victimized by their own success. College admissions consultant Jillian Nataupsky estimated that one-third of her clients undertake virtual research. “For students trying to find ways to differentiate themselves in this crazy competitive landscape, this has risen as a really great option,” she said. But “it’s becoming a little more commonplace. I can see it becoming completely over-inundated in the next few years.”

Then the search can begin for the next leg up in college admissions.

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Kirsten Berg and Jeff Kao contributed research.

by Jeremy Schwartz

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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.

Texas lawmakers have closed a loophole in state law that allowed people who had serious mental health issues as juveniles to legally purchase firearms.

On Wednesday, the Texas House of Representatives voted 116-28 in favor of a bill that requires courts to report involuntary mental health hospitalizations of juveniles age 16 and older for inclusion in the federal gun background check system. The bill, which had already received unanimous support in the Senate, comes nearly a year after a ProPublica and Texas Tribune investigation revealed a gap in the law that required such reporting for adults but not for juveniles.

The passage of the bipartisan measure, authored by Republican state Sen. Joan Huffman, offers a rare example of gun-related legislation that has cleared the Texas Legislature since last year’s school shooting in Uvalde. It is now headed to Gov. Greg Abbott’s desk. Huffman could not be reached for comment. A spokesperson for Abbott did not immediately respond to an inquiry about whether he supports the bill.

“This bill will go a long way to ensuring that our state and federal databases are linked and that the process is more efficient and effective in keeping firearms out of the hands of dangerous Texans who do not need to have them,” Jeff Leach, a Republican state representative from North Texas, who sponsored the legislation said on the House floor. Leach represents the city of Allen, where a gunman killed eight people at a mall on May 6.

Currently, Texas law requires county and district clerks across the state to send information on court-ordered mental health hospitalizations to the Department of Public Safety. The state’s top law enforcement agency is charged with sending those records to the FBI’s National Instant Criminal Background Check System, known as NICS. Federally licensed dealers must check the system before they sell someone a firearm.

Elliott Naishtat, a former state lawmaker from Austin who authored the legislation in 2009, said he intended for it to apply to juveniles as well as adults. But an investigation by the news organizations found that local court clerks were not sharing that information for juveniles, either as a matter of policy or because they didn’t believe that they had to because the law did not explicitly mention them.

Further heightening the importance of closing the reporting gap, Congress passed gun reform legislation in June that includes a requirement that federal investigators check state databases for juvenile mental health records. Such checks would not show many court-ordered juvenile commitments in Texas because they are not currently being reported.

The Texas Judicial Council, which monitors and recommends reforms to the state judiciary, called on lawmakers to clarify juvenile reporting requirements after the ProPublica and Tribune investigation, stating that there was widespread confusion about them.

Pro-gun groups sought to extinguish the bill, arguing that it was a “red flag law,” a reference to laws that allow judges to order that weapons be taken from people who are deemed a threat.

The Texas Gun Rights group on its website called the bill a “Draconian scheme” that “discourages kids from coming forward to seek help for mental health issues by stigmatizing them and removing their Second Amendment rights for the rest of their lives.”

Leach has denied the bill represents a red flag law, arguing that it does not change any existing state or federal laws.

Texas law allows those discharged from court-ordered mental health services to petition the court that entered the commitment order to restore their right to purchase a firearm.

Other legislation sought by Uvalde survivors and family members, including a bill that would have raised the minimum age to purchase a rifle from 18 to 21, has been stymied in the current legislative session, which ends May 29.

Kiah Collier contributed reporting.

by Paul Kiel

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The IRS on Tuesday announced that it would develop an experimental online tool to allow Americans to file taxes directly with the agency for free.

It’s a major development — one in which ProPublica’s reporting played a significant role — given that most U.S. taxpayers pay to file and the tax preparation industry has long held sway in Washington. Only four years ago, the industry nearly succeeded in getting a law passed that would have barred the IRS from providing direct filing.

The limited pilot, as the IRS called it, is only a first step intended to gather information, and the IRS made clear that if it does proceed with a direct filing platform beyond this test, it will scale up gradually. Under the most optimistic scenario, it will be at least a few years before the IRS offers a direct option for millions of taxpayers.

The IRS would need funding to operate a broad program, and there will be continued opposition to the agency taking that path. The tax prep industry, particularly TurboTax-maker Intuit and H&R Block, will likely keep spending big on lobbyists to stop the IRS from competing with them. Republicans in Congress have already criticized the idea of free direct filing and want to cut IRS funding.

But the pilot is a possible turning point in a fight that goes back decades — as ProPublica has covered extensively — and seems sure to continue years into the future.

The IRS announcement came as it released a report, required by last year’s Inflation Reduction Act, on the possibility of a direct file program. The IRS found wide public support in surveys for the idea of a direct file portal and laid out a range of possibilities of who might be able to use it. (It seems certain the tool would be geared toward taxpayers with relatively simple returns.) After the report was completed, President Joe Biden’s Treasury Department directed the IRS to conduct a pilot program.

All that’s clear about the pilot is that it will occur next year, will involve a very limited number of taxpayers and will be a question-based tool similar to commercial tax prep. The point of the trial, IRS and Treasury Department officials said on a call with reporters, was to gather more information on what form such a direct filing tool would ultimately take. It would then be up to the Biden administration “whether to move to the next level of full-scale implementation,” IRS Commissioner Danny Werfel said.

One of the main thrusts of the report was that maintaining a direct filing program would cost a significant amount. The main hurdle was not building the software tool but providing customer service support for users. The more people who use the tool, the more customer service agents are needed. As a result, for 25 million users, the report estimated an annual cost north of $200 million, with over 80% going to customer service. That’s around $10 per return filed.

Americans who purchase tax prep software pay multiples of that figure. TurboTax paid products, for example, range in price from $69 to $129 for federal returns, with additional fees for state tax returns.

The need for continued funds would likely create frictions in Congress. In the short-term, the IRS can tap some of the $80 billion it received as part of the Inflation Reduction Act. But only a small portion of that, $3.2 billion, was directed to taxpayer services, and the IRS has already articulated plans for how to use it. To support a program in the long term, the IRS would need enough money appropriated along with its other taxpayer service demands.

Republicans, who forced huge cuts to the IRS budget last decade, remain critical of the agency and skeptical of the need for increased funding. One of the first acts of the new House majority was to pass a bill to repeal the $80 billion the IRS received in the Inflation Reduction Act.

At a congressional hearing last month, Rep. Jason Smith, R-Mo., chief of the House Ways and Means Committee, said that “asking the IRS to do your taxes is like asking your kid to guard the cookie jar.” Rep. Darin LaHood, R-Ill., observed that “the tax preparation industry already provides free filing services for roughly 30 million returns each year. So, I’m not quite sure why trying to tackle this concept in the near term would be beneficial.”

Since the 2000s, TurboTax has drawn customers with the promise of “free” tax prep while deploying a deep bag of tricks to turn many into paying customers, sometimes by convincing them to purchase add-on services, sometimes by charging them because they have a wrinkle like a deduction for student loan interest. Customers who run that gantlet can indeed receive free tax prep.

The IRS’ Free File Program, a collaboration between the agency and the tax prep industry to provide free services to most taxpayers, will continue to limp along. The industry forged the program as a way to keep the IRS from developing its own direct option. But after ProPublica reported in 2019 that the companies were intentionally downplaying IRS Free File in order to push customers to their own “free” options, the program began to unravel. TurboTax and H&R Block backed out, leaving lesser-known companies as the only participants. Last year, 3 million people used Free File.

Meanwhile, in coming years the filing experience figures to improve, whether taxpayers pay for prep or not. Much of tax filing involves entering in data from forms like W-2s and 1099s, a process that should be unnecessary, given that employers, brokerages and the like also transmit the same data to the IRS each year. The agency has not had the technology to share this data with taxpayers when they file. As part of the tech upgrades the agency is planning with the $80 billion boost, the IRS says that by 2025 it will be able to prefill that info. “The information will be provided in a format that can interact directly with return preparation software or can be taken to a return preparer when authorized by the taxpayer,” according to the agency’s plan.

Dozens of other countries have systems that pre-fill information, making it possible for taxpayers, if they have to file a return at all, to simply make sure the info looks accurate. The idea of anything like that in the U.S. has long been far-fetched, given the entrenched opposition from profit-making corporations. The possibility for even a sliver of Americans to use that tool is still years off. But for the first time, the government is taking real steps in that direction.

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by Marilyn W. Thompson

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The Supreme Court said Monday that it will hear oral arguments in a South Carolina redistricting case where the NAACP is challenging the state’s Republican plan as racially motivated.

The role of the state’s most powerful Democrat, U.S. Rep. James Clyburn, is likely to play an important part in the discussions, legal experts said.

In 2021, South Carolina Republicans reshaped the voting map, taking a district that had been in the hands of a Democrat as recently as 2018 and making it a much safer seat for the incumbent Republican. The NAACP brought a suit against the effort, and in January, three Democratic-appointed judges ruled in the group’s favor.

The Supreme Court could decide to restore the map that the Republicans drew or order the legislature to create a new map. The case comes after a series of rulings from the high court that have made partisan gerrymandering easier, though the court has still deemed redistricting predominantly based on race to be illegal. Legal experts said this week that the South Carolina case will help define the limits of how much a legislature can consider race as it draws new maps.

South Carolina Republicans have defended their efforts, saying they were not motivated to dilute Black political power in the state. Lawyers for state Republican leaders argued during the trial that they did not consider race in making their map. They also contended that their map could not have targeted Black voters because they worked with Clyburn, one of the most powerful Black Democrats in the country.

This month, ProPublica added new detail to this account, reporting that Clyburn had been more involved in the process than previously known. He recommended moving Black and white voters in such a way that made his district politically safer but hurt Black Democrats.

A map of the new district lines. They were the subject of a 2021 lawsuit, and the Supreme Court said it will hear oral arguments in the case. (Cheney Orr for ProPublica)

Clyburn’s role could be an important underlying factor for the court, according to legal experts following the case.

“The court likely will get into the details of South Carolina redistricting, including the role played by Rep. Clyburn, because all this information is potentially relevant to whether racial or partisan factors predominantly explain” a district’s design, said Nicholas O. Stephanopoulos, an election and constitutional law professor at Harvard Law School.

Clyburn’s recommendations for how his district map should be drawn are “potentially relevant” as the court weighs the three-judge panel’s decision that the Republican-led legislature predominantly used race to create the maps, said Justin Levitt, an election law expert at Loyola Law School. Clyburn’s role has already complicated the NAACP’s case. The appellate panel threw out some of the racial gerrymandering allegations, partly because Clyburn’s office had recommended the changes. Nevertheless, it found that the new map of the coastal 1st, which had been the swing district, was an illegal racial gerrymander that deliberately targeted Black Democrats and moved most of them into Clyburn’s district, the 6th.

Court documents and testimony showed that Clyburn, who had no official role in the redistricting, submitted a confidential hand-drawn map that Republican lawmakers said they used as their starting point. None of his requests were made public.

Clyburn’s recommendations sought to move about 85,000 people into the majority-Black 6th District to make up for a population deficit. His map also moved some white Republican-leaning residents out of his district into the 1st, currently represented by the Republican Nancy Mace. Under the redistricting plan, each of the state’s seven congressional districts had to represent 731,203 people.

Clyburn’s office declined to answer specific questions about his requests and said his only input was responding to legislative inquiries. Clyburn said in an interview that he did not get everything he wanted in the plan passed by the legislature, mainly because it lowered the Black voting age population in his district to under 50%. Maintaining a majority-Black district had been important to Clyburn, who was elected in 1992 and rose to become one of the most prominent Democrats in the House.

Clyburn’s office said he opposes the Republican map and hopes the decision of the three-judge panel will be upheld.

The Supreme Court has pending decisions on several other important redistricting cases, including an Alabama racial gerrymandering case that addresses whether legislatures in states with high Black populations have an obligation to draw more majority Black districts.

Richard Pildes, a constitutional law professor at New York University School of Law, said the court generally accepts findings of fact from a three-judge panel unless it concludes they are “clearly erroneous.” In that case, he said, it will look more deeply into the court record and question parties at oral arguments.

Joshua Douglas, an election law and voting rights expert at J. David Rosenberg College of Law at the University of Kentucky, said the South Carolina case is significant because it “involves the interplay of race and politics.”

“The legislature says it was trying to achieve a partisan result, not a racial result. The court had previously said a legislature cannot hide behind politics to justify a racial gerrymander. It’s possible the court will use this case to reevaluate that rule,” Douglas said.

Republican lawyers have asked the Supreme Court to render an early decision in the case because it may require new maps that could impact congressional races in 2024.

Do you have access to information about redistricting that should be public? Email marilyn.thompson@propublica.org. Here’s how to send tips and documents to ProPublica securely.

by Byard Duncan and Anjeanette Damon

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You’ve seen the ads in your neighborhood. They’ve flashed across your television and buzzed your phone to life at odd hours. The slogans and phone numbers might change, but the pitch is the same: “We buy houses for cash.”

Thousands of real estate investors across the country use a variety of techniques to find potential sellers and plan their next deal.

A recent ProPublica investigation looked at how HomeVestors of America, one of the house flipping industry’s leaders, teaches its franchisees to seek out people in “Ugly Situations.” (In a statement, the company said it does not target vulnerable sellers and pointed to an internally calculated 96% seller satisfaction rate.)

In the course of our reporting, we interviewed dozens of experts, attorneys, advocates, sellers and investors to better understand the world of cash home buying. Here’s what they say you should know to get the most money for your home.

Jump to:

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There are many reasons a cash home buyer might advertise to you. You may live in a neighborhood that has a high percentage of homeowners with a lot of equity, meaning you wouldn’t be left underwater on a mortgage even if a company paid you less than your home is worth. Home prices in the area may be going up rapidly, creating opportunities for cash buyers to fix and flip them for a profit. Your contact information may have been scooped up by a company that sells leads to real estate investors.

It’s also possible that you’ve been identified as a so-called motivated seller: someone in a difficult situation who needs money soon. Our reporting shows that some real estate investors comb public records looking for signs of financial hardship, such as foreclosures, divorces or death notices. They scout neighborhoods for signs of disrepair, such as boarded-up windows or water shut-off notices. And they leverage personal connections — with other investors, lawyers, nursing home administrators and others — to locate distressed properties.

I am NOT interested in selling. How do I get them to stop advertising to me?

If you’re approached about selling your home and don’t want to, the easiest solution is simply to ignore the request: Hang up the phone, recycle the postcard, delete the text. If the solicitations keep coming, add your number to the Federal Trade Commission’s Do Not Call Registry.

Some cash home buyers will still find you. That’s why certain states and cities have added additional protections. In Philadelphia, for example, prospective real estate buyers who continue to pester residents after being told to stop can be fined. In Atlanta, a ban on “commercial harassment” prohibits investors from contacting homeowners for six months after their initial overtures are rejected.

In areas without these laws, homeowners have submitted complaints to their state attorney general’s office or real estate commission. If these officials receive repeated complaints about a particular person or company, they may investigate.

I might be interested in selling. What should I expect if I respond to an ad?

If you respond, there’s a good chance the investor or company behind the ad will promptly follow up. They may schedule a walkthrough of your home and ask questions about its condition and your circumstances. Afterward, they may present you with a purchase contract and encourage you to sign on the spot.

Experts caution homeowners against immediately jumping into a commitment. Before agreeing to sell, they say, it’s important to learn as much as possible about your home’s value.

“Don’t sign anything right away,” said Michael Froehlich, the managing attorney for Community Legal Services’ homeownership and consumer rights unit in Philadelphia. “If somebody wants you to sign something that day, that’s a huge red flag.”

How do I figure out how much my home is worth?

To get a ballpark value, search for your address on the online real estate marketplaces Zillow or Redfin. These prices are not always accurate, however: They may not take into consideration a home’s condition or recent improvements. Use Zillow or Redfin to look at the recent sales prices of similar houses in your neighborhood.

If you can afford it, a licensed appraiser can give a more precise estimate of the value of your home. That usually costs between $300 and $500, depending on your home’s size, and can take a few weeks to get scheduled.

You could also ask a real estate agent for a free market analysis, said Grant Cody, executive director of Oklahoma’s real estate commission, which regulates the industry there: In many cases, they “would bend over backwards and would love to come to your house — or email you instantly, right then and there.”

What’s the difference between a real estate agent and a cash home buyer?

A real estate agent markets your house to buyers and has a fiduciary responsibility to you; they’re required to try for the best deal possible. The agent is paid a percentage of the sales price of the house. And you are contractually bound to that person for a period, meaning if you sell your house by yourself during that time, you’d still have to pay the agent a percentage.

A cash home buyer purchases the house or “wholesales” it to another investor for a profit. Their pitch is largely about speed and convenience: They are able to quickly put money in your pocket, free you from burdensome paperwork and even clean up your home. In exchange, they get the property at a discount. They will most likely repair the house and flip it for a profit or hold it as a rental property; or they may enter a “contract assignment,” in which the deal itself is delivered to another party for a fee.

What are the risks of going with a cash buyer instead of a real estate agent?

“Irrespective of jurisdiction, real estate licensees have an obligation to act in the best interest of their client,” said Nick Rhoad, CEO of the Association of Real Estate License Law Officials. Real estate agents are bound by a code of ethics requiring them to make things as clear as possible, not misrepresent pertinent facts and more.

That standard does not apply to cash buyers, who do not always have to be licensed. While the cash buying industry does have a code of ethics, enforcement is spotty. Laws governing unlicensed real estate transactions are generally newer and less developed than those designed for licensed activity.

Our reporting shows that some real estate investors have been accused of deceptive and exploitative behavior. (When real estate agents are accused of unethical behavior, a licensing board polices it.) Wholesaling, in particular, has left many sellers feeling dismayed: Properties they signed away for one price ended up being resold, with few or no improvements, for much more.

What if I need money but don’t want to sell my home?

Don’t be discouraged. Homeowners facing personal or financial distress have a variety of possibilities to explore.

Options vary by state, but here’s where experts say to start:

• Get help from the federal government. The National Council of State Housing Agency’s Homeowner Assistance Fund, overseen by the U.S. Treasury Department, has allotted roughly $10 billion to help homeowners enduring financial hardships due to the COVID-19 pandemic. The NCSHA website summarizes the program and maps where the assistance fund is open (44 states, as of this writing). It also has a directory of state resources.

• Find a local adviser. The U.S. Department of Housing and Urban Development sponsors housing counseling agencies across the country. These agencies provide free advice about foreclosure prevention and homelessness counseling. They may charge a small fee for additional services. To find resources near you, go to HUD’s website. You can also call 888-995-4673, or download the agency’s resource locator app for help in several languages.

• Consult a legal aid office. A good place to start is Legal Services Corporation’s directory of local offices. Once you reach someone, it’s important to be patient, said Lisa Sitkin, a senior staff attorney at the National Housing Law Project. Legal aid offices are usually busy, and the intake process can move slowly. Once an attorney reaches out, they will ask you for information to diagnose the situation. It’s important to have “somebody who can look at your situation holistically and give you sort of realistic advice about what steps you can take,” Sitkin said.

A cash home buyer gave me a sales contract. How do I make sense of it?

What appears — and doesn’t appear — on a sales contract varies widely, depending on state laws and the preferences of the prospective buyer. But there are a few important components to understand.

1. Disclosures: Although laws vary across states, many investors agree it’s necessary to disclose that they intend to turn a profit by buying your house for below fair market value. If the contract says the buyer is paying “below market prices for a profit,” or if it says the buyer has the “option to market this property, and assign this agreement prior to closing,” that means it’s possible there’s a higher bidder out there.

2. A “clear title” requirement: Any debts you owe, including mortgage liens, overdue water bills, property tax delinquencies and more, can be subtracted from the final price. So if the offer is $100,000, but you’re behind $25,000 in bills and back taxes, you’ll only get $75,000.

A title report costs $50 to $250 and can give you a clearer picture of what hidden debts could be deducted in a sale.

3. Cancellation provisions: In many wholesale contracts, the buyer reserves the sole right to cancel the contract. Pay attention to what rights the buyer is asking for — and which ones you’re giving up.

4. Other unexpected costs: Even if you’ve agreed to a price that seems fair, it’s important to review the contract for fine print about other charges that could affect your bottom line. Closing costs or transfer taxes are sometimes deducted from the sale price you see on the page.

5. Earnest money deposit: In traditional real estate deals, an earnest money deposit shows how serious the buyer is about the purchase. If the buyer backs out, the seller gets to keep the deposit. A broad rule of thumb is the deposit should equal 1% of the purchase price. Investors try to put down as little as possible in earnest money. Contracts reviewed by ProPublica included deposits as low as $100 on a $157,000 deal. In such cases, the buyer can bail with minimal consequences.

6. Clouding your title: Look for language that authorizes a buyer to cloud your title and make it more difficult to sell the property to another buyer if your deal falls through. Investors will often record a “memorandum of sale” on the property as a means of locking you into a contract.

I signed a contract, but I’m having second thoughts. What are my options?

Our reporting demonstrates how difficult it can be for sellers to back out of a contract that they later decide is unfair. As mentioned, real estate investors sometimes file memorandums of contract that cloud a homeowner’s title and pressure them to close the deal — even if they’ve found a much higher bidder.

This behavior is predatory, according to four housing experts we interviewed, as well as Charles Tassell, the chief operating office of the National Association of Real Estate Investors. But, barring proof of fraud or elder abuse, it’s legal. If you suspect what happened may have broken a law related to one of those practices, follow the instructions above to get legal aid.

The bottom line, according to Grant Cody of Oklahoma’s real estate commission: Cash buyers “aren’t in a position to do what’s best for the consumer. They’re in a position to do what’s best for them.”

Sometimes what’s best for them is also best for you. But not always.

Mollie Simon contributed research.

by Patrick Rucker, Maya Miller and David Armstrong

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

Update, May 16, 2023: This story was updated with a statement that Cigna provided after publication.

A key congressional committee asked insurance giant Cigna on Tuesday to provide corporate documents so that lawmakers can examine the company’s practice of denying health care claims without ever opening a patient file.

The House Committee on Energy and Commerce joined several state and federal regulators in scrutinizing the legality of Cigna rejecting the payment of certain claims using a system known as PXDX.

Rep. Cathy McMorris Rodgers, a Republican from Washington who chairs the committee, noted that policyholders under Cigna’s Medicare Advantage plans appeal about one in five denials for requests for medical procedures, known as prior authorizations. Of those denials, about 80% are overturned.

“If these figures are at all illustrative of Cigna’s commercial appeal and reversal rates, it would suggest that the PXDX review process is leading to policyholders paying out-of-pocket for medical care that should be covered under their health insurance contract,” Rodgers wrote in a letter to Cigna.

The letter follows an investigation by ProPublica and The Capitol Forum that found Cigna doctors blocked payment for certain tests and procedures by automatically labeling them “not medically necessary.” In two months last year, Cigna doctors refused to pay for 300,000 claims using the PXDX system, spending an average of 1.2 seconds on each case, according to internal spreadsheets that tracked how fast they worked.

A Cigna spokesperson on Tuesday said that the company welcomes “the opportunity to fully explain our PxDx process to regulators and correct the many mischaracterizations and misleading perceptions ProPublica’s article created.”

After publication, Cigna provided four examples of what it called “mischaracterized information” and “omitted facts.”

Cigna said ProPublica had wrongly described the company’s rejections of claims as a denial of care. The story does not say that and quotes Cigna saying the denials were for payments of care.

The statement said ProPublica reported that doctors were incentivized to deny care. The story does not say that, either.

Cigna also said ProPublica’s story “creates the impression” that the company saved “billions of dollars” using denials to boost its bottom line. It said any savings were passed on to clients. ProPublica quoted an expert who developed PXDX as saying the system had saved that much money. Cigna has not provided evidence of its savings or how much was passed on to clients.

Finally, the company said the ProPublica story left the impression that Cigna uses the PXDX process on all health care claims. The story explicitly stated that “not all claims are processed through this review system.”

In the past, Cigna has said the PXDX system was built to process claims more quickly.

But state insurance commissioners contacted in recent weeks criticized Cigna, with several saying that they wanted to more closely examine the company’s use of algorithms to deny claims.

Mike Kreidler, the insurance commissioner for Washington, said it is an “abhorrent” practice “to routinely deny just to enhance the bottom line.”

Kreidler said he and other state insurance regulators are reviewing their records for customer complaints that seem to describe an auto-denial process.

“I’m afraid it might be the tip of the iceberg,” he said. “We darn well better start paying attention to it.”

Industry sources there told the news organizations that other large insurers operate similar systems.

The investigation by ProPublica and The Capitol Forum has also raised red flags in California.

The California Department of Insurance said in a statement that it is “looking closely at health insurance companies’ handling of claims, while simultaneously exploring all options in coordination with other state regulators.”

Other state insurance commissions said they, too, were interested in a deeper examination of Cigna’s practices.

“Given your article, this will likely warrant a closer look,” said a spokesperson for the Delaware Department of Insurance.

The U.S. Department of Labor regulates a common kind of insurance held by many Americans: plans sponsored by employers that cover their own health care costs. Federal officials said they were alarmed by the auto-deny practices.

“This is very concerning,” said one senior Labor Department official who asked to remain anonymous in order to speak on a sensitive matter. “I don’t see a scenario where we’re not taking a hard look at these kinds of practices.”

Two organizations accredit health insurers to make sure plans are abiding by certain standards. Both of these groups, the Utilization Review Accreditation Commission and the National Committee for Quality Assurance, have opened investigations into the denials system. They did not immediately respond to detailed questions about the investigations.

The letter from the energy and commerce committee asked for the company to hand over “copies of all memoranda analyzing the legality of the PXDX review process.”

The records requested include details about the number of claims denied using PXDX, the number denied by individual medical directors employed by the insurer and details on how often those decisions were appealed and overturned.

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

Clarification, May 16, 2023: This story was updated to make clear that the PXDX system was used to deny 300,000 claims in two months last year.

by Emily Hopkins

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

Update, May 18, 2023: The Minnesota Board of Nursing on Thursday accepted the resignation of its executive director, whom it had placed on leave earlier this week for an unspecified “personnel issue.” The action came during an emergency meeting to consider firing Kimberly Miller, who had led the agency since August 2021. In a letter to the board, Miller said she had worked diligently and the agency had made gains under her leadership. She said the pandemic and the board’s transition to computers had caused problems but that the board’s performance was improving. She said she could not address allegations in the media about a toxic work environment or the slow pace of investigations because she had “not received notification of the specific allegations or been asked to participate in an investigation.” Board member Sarah Simons said that after ProPublica reported on Miller, the office of Minnesota Management and Budget, the state’s human resources arm, conducted an investigation into the dysfunctional workplace issues raised in the story and presented findings to the nursing board, which led to the effort to remove Miller.

The Minnesota Board of Nursing has called an emergency meeting to consider removing its beleaguered executive director over an unspecified “personnel issue.”

In an email to board staff Tuesday morning, President Laura Elseth said Executive Director Kimberly Miller was on leave “effective today.”

The move comes at a critical time for the nursing board. It’s been mired in a backlog of complaints against nurses, with some inside the agency blaming Miller for dysfunction in the work environment, according to a ProPublica investigation published in April.

That story detailed how the board’s slow disciplinary process puts the public in harm’s way. The time to resolve complaints had risen to 11 months, on average, and hundreds of cases remained open as of March. As a result, nurses who are accused of serious misconduct are allowed to keep treating patients.

The meeting to determine Miller’s future, scheduled for Thursday, was announced one day after board members, lawyers from the state attorney general’s office and representatives from Minnesota Management and Budget, the state’s human resources arm, gathered in an emergency meeting that was closed to the public. The purpose was “preliminary consideration of allegations against” Miller, according to Elseth.

Management and Budget confirmed last month that the agency had received complaints about Miller and was reviewing them. Additional details about the investigation are not public because they are related to a “personnel issue,” spokesperson Patrick Hogan said.

Current and former staff members and a former board member told ProPublica that Miller’s poor leadership was among the reasons for the backlog and for turnover among the board’s staff. David Jiang, a former board member, wrote in his resignation letter to Gov. Tim Walz that Miller had created a culture among staff that was “strained” if not “dysfunctional.”

William Hager, a former legal analyst for the board, raised concerns about Miller’s capabilities in a 2022 email to another staff member. “I am very concerned the Director seems to have been unaware of this ‘backlog,’” he wrote. Although the board’s backlog started increasing before Miller became executive director in August 2021, it has grown during her tenure.

In a previous interview with ProPublica, Miller acknowledged the backlog and said the board was working to “right the boat,” though she did not respond to questions about complaints surrounding her job performance.

Miller and 11 board members who attended the meeting on Monday did not respond to requests for comment.

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

Jeremy Kohler contributed reporting.