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by Alec MacGillis

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The scene outside Fairfield Court Elementary School in Richmond, Virginia, at 7:40 last Thursday morning was so festive that one might have assumed it was the first day of school. Upbeat music blared from a speaker on the sidewalk. Sgt. Edward R. Gore II, the school’s “climate and culture specialist,” the district’s term for its school resource officers, opened his arms to the kindergartners and first graders who came running toward him, as well as to some who wavered. Also on hand to greet children and parents was the principal, Angela Wright.

But in fact, the first day of school was receding in the distance: Fairfield Court was one of two local schools that had started the year on July 24, as part of a hotly contested trial: adding 20 days to the customary 180, to help make up ground lost after Richmond kept schools closed to in-person learning for 18 months during the pandemic. Families had only six weeks of summer vacation — closer to the European norm than the American one — before kids returned, and Wright and her staff were doing everything they could to make early-August school seem welcoming. Thus, the daily embraces and music, with a track list chosen by Gore.

“It brings a smile to put on their face every morning,” he said. “I’m out here every day.”

Beneath the good cheer of the greetings were weighty implications. The results of the 200-day academic years at Fairfield and Cardinal elementary schools will help determine whether Richmond adopts a similar approach at more schools across the 22,000-student district. For nearly three years, district leaders have been proposing to add days to the school calendar for some or all students or keep the same number of days but with a shorter summer break, to reduce what educators call “summer slide.” But, as ProPublica recently reported, that plan ran into stiff resistance from some school board members, teachers and parents. In the end, only two of the district’s 50-odd schools adopted the extended calendar for the coming year.

The pilot is being watched more widely too, as one of the highest-profile examples nationwide of schools taking aggressive action to address the unprecedented declines in student achievement since the pandemic’s onset.

The first big test has been simply seeing whether students show up. To qualify for the pilot, Fairfield Court, which has 217 students this year, had to demonstrate backing from its families, who are almost entirely African American and many of whom live in an adjacent public housing development. But a survey was one thing, warned skeptics of the proposal; getting kids to come to school in midsummer was quite another.

The turnout lagged initially, with about 80% attendance in the first week, below Fairfield Court’s average rate of 91% last year. The school’s “attendance engagement team” made repeated calls and even some home visits to absent students, trying to discern why they were out. In some cases, it was simply a matter of lacking money for new clothes or a haircut. With these targeted efforts, which included Wright herself offering to pick up kids whose parents weren’t able to walk them to school, they lifted the rate to an average of 87% by last week. “We’re down to the ones that aren’t here, we know exactly why they aren’t here,” Wright said.

The other school in the pilot project, Cardinal Elementary, which is three times larger than Fairfield Court and has a heavily Latino population, had strong attendance from the very start, 95% in the first week of the pilot, according to district data.

Principal Angela Wright of Fairfield Court advocated for the extra days and even offered to pick up kids whose parents couldn’t walk them to school. (Brian Palmer for ProPublica)

Not that everyone at Fairfield Court had needed cajoling. Several parents said their kids had been eager to return, a judgment buttressed by the alacrity with which the kids ran toward the music and into the building, where free breakfast awaited all. “They like going to school,” said Kay Brown, after her sons, a first grader and kindergartner, had dashed in. “Some kids give their parents a hard time. My kids love it.”

Renarda Bacon’s daughter, who is in third grade, had spent most of her summer break at a day care program, but Bacon was glad to see her back at Fairfield Court, where she would be getting more actual instruction. “I’m all about progressing,” she said. “If they’re going to get in a couple more days of learning, it’s not going to hurt them.”

Ashley Martin had driven her own two kids, a third grader and kindergartner, as well as three others from the neighborhood before heading to her job in a call center. She had been a staunch supporter of an extended school year from the get-go, she said, after seeing the news about Richmond’s plunging test scores during the past two years. She also thought that adding instructional time could help reduce the city’s high levels of youth violence. (Last year, a 17-­year-old boy was fatally shot and found in a garbage can in the adjacent housing development, and the school year ended two days early in June after a graduating senior and his father were shot and killed outside one high school’s commencement ceremony.)

“I definitely love this program,” Martin said. “They should keep it, and hopefully the school board expands it, so we can get these kids back on track.”

Inside school, veteran teacher Philip Canady started the day with math lessons for a dozen fifth grade boys. (This year, for the first time, the school had decided to separate fifth graders by sex, thinking it might improve outcomes.) Canady, regal-looking with a trim gray beard and wooden bowtie, moved back and forth among the desks, coaxing the boys through worksheets on identifying place value in numbers ranging to the millions.

“How many hundreds in that number?” he asked one boy. “Five? OK, put five in the hundreds column. How many tens do I have? OK, add two tens. No, no, that’s not tens. Put a two there. How many ones do I have? Four ones. Now I want you to create 2,034 for me. Do you have any hundreds? No. So what are you going to put there? Zero. You got it.”

And so on, on and on around the room, with only a few interruptions to address some minor squabbling at one table. If any calming was needed, a YouTube video waited on the big computer screen at the front of the room: “3 Hours of Amazing Nature Scenery and Relaxing Music for Stress Relief.” Nearby, some small fish swam in a tank.

For this extra month in the classroom, Canady and his fellow teachers were receiving an extra month of salary — roughly 10% of the usual annual sum — plus a $10,000 incentive and the chance at an additional $5,000 if the school met certain “accelerated learning goals” set by its leadership team. The district was paying for this, a total of a couple million dollars between the two schools, out of its slice of the $190 billion in pandemic recovery funds that the federal government has sent schools since 2020. (District Superintendent Jason Kamras has said that if the district chooses to expand the initiative, it could apply for special state funding for innovative programs or other outside funding.)

To qualify for the pilot, Fairfield Court also had to show support for it among its staff; only two employees had opposed it and transferred to other schools. In a room across from Canady’s, the operational base of the school’s academic dean and the instructional leaders for math and reading, the three educators said that they were liking the pilot. It had meant adjusting their vacation plans, but they had made good use of their five weeks off (faculty had started school a week before the kids, for professional development and classroom preparation), including going to a conference in Las Vegas with some R&R attached. And now, they were getting the satisfaction of seeing students get a head start on the year.

“I know there were a lot of naysayers, but I see a lot of happy children every morning,” said the academic dean, Nsombi Morrison.

It was time for one of the trio’s regular check-ins with the teachers for each grade level, this time with the third grade team. The three teachers came in, and together the six women reviewed tables with each student’s progress toward grade-level metrics in math and reading, and discussed upcoming assessments to gauge whether the school was reaching the goals it had set for the extra month. The educators were so fully into the stride of the year’s instructional march it was hard to believe that nearly all of the district’s other schools remained closed, with some 21,000 students not returning until Aug. 21.

Back in the principal’s office, Wright said she was keenly aware of the responsibility the school bore in showing the rest of the district that the extra time can make a difference. She had recently attended a meeting with other principals, she said, and her message to them had been this: “My whole goal is for this to run so effectively and to see that data increase so much that when two or three schools come on board next year, that here’s a blueprint. Here’s what you need to do to make it.”

She added: “I would love to hear, OK, this has now gone so well at these two schools, we’re bringing in four more schools next year.”

by Paige Pfleger, WPLN/Nashville Public Radio, with research by Mariam Elba, ProPublica

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

This story contains a description of a 911 call that took place as a homicide was being committed.

Michaela Carter felt like she was being hunted.

She fled her family’s home on Nov. 15, 2021, and called 911 with her mother, pulling into the parking lot of a discount store in southeast Nashville, Tennessee, to await the police.

“Are they sending people?” Carter can be heard asking her mom on the 911 call.

An excerpt of the first call Carter and Jones-Mbuyi made to 911. Jones-Mbuyi told the dispatcher that Carter’s estranged husband, James Leggett, had been seen with a gun. (Obtained by WPLN)

Her mother, Kimberly Jones-Mbuyi, told the dispatcher that Carter’s estranged husband had just been seen walking around a family member’s apartment complex with a gun.

James Leggett had gotten out of jail 10 days earlier. He’d been locked up since Carter reported to police that he’d repeatedly hit her in the face with a bottle of Jack Daniel’s. Since he was released, he’d started calling her and sending increasingly desperate text messages.

The night before, he posted on Facebook: “Somebody with nothing to lose won’t give a fuck when shit gets real.”

Then, that morning: “Today is the day.”

Leggett posted on Facebook before and after Carter was shot. (Obtained by WPLN)

Federal and state laws should have protected Carter by preventing Leggett, who had a felony record, from having a gun. And Carter had an extra safeguard: an order of protection against Leggett. That meant he was barred from contacting her, coming near her or having a firearm. According to the law, if he violated the order, he would be arrested.

But weak oversight of gun laws allowed him to get a weapon. And when the officers arrived, they said they didn’t have enough evidence to prove that Leggett had violated the order.

The officers escorted Carter and her mother home. Carter had packed a go-bag, and she wanted to get her ID and the paper copy of her protection order. One of the officers, who was still in training, did a sweep of the yard.

According to Carter’s family, the officers suggested that if she saw Leggett with a gun, she should try to take his photo.

Then the police left.

Ten minutes later, according to police records, Leggett busted down the door and shot Carter.

The Metropolitan Nashville Police Department declined to comment because of a pending lawsuit filed against it by Carter’s family. An internal investigation found the officers broke department protocols for domestic violence cases.

Carter had packed a go-bag with basic necessities in case she needed to flee. (Carter’s ID has been blurred by ProPublica.) (William DeShazer for ProPublica)

While the botched police response received local media attention at the time, what hasn’t been reported is that it was only the final mistake of a criminal and civil justice system in Tennessee that has repeatedly failed to stop dangerous people from accessing guns.

In fact, what was remarkable about Carter’s shooting was not that it was atypical, but just how common it was.

Carter was one of at least 75 people killed in domestic violence shootings in Nashville since 2007, when the police switched to a searchable record system. Of those, at least 29 victims — nearly 40% — were shot by people who were legally barred from having a gun, according to a WPLN and ProPublica analysis of court records in Davidson County, where Nashville is located.

One of the youngest victims was 5 years old while the oldest was in his 70s. Some were shot during heated arguments. Others were killed while playing in the snow.

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The problem of how, or even whether, to separate dangerous people from their guns is now front and center on the state and national agenda. Next week, legislators will gather for a special session on public safety in response to a Nashville school shooting in March that claimed the lives of three young children and three school staffers. And this fall, the U.S. Supreme Court will hear arguments in a case on whether it’s constitutional to bar people subject to domestic violence orders from possessing guns.

There’s a lot at stake in Tennessee, which consistently ranks in the top 10 states in the rate of women killed by men. As in most states, Tennesseans convicted of certain types of felonies and domestic violence misdemeanors or who are juveniles or subject to protection orders are explicitly prohibited from possessing guns.

But while other states have policies to get people to turn over their weapons, Tennessee’s laws offer few mechanisms to retrieve guns after someone has been barred from having them.

Law enforcement rarely goes to someone’s home to make sure they don’t have a firearm, unless an incident prompts them to. And at protection order hearings, judges seldom ask follow-up questions about weapons like: “How many guns do you have? Where are they kept?” Or even, “Who are you going to give them to, now that you’ve been ordered to relinquish them?”

That last question is part of a dangerous loophole in Tennessee called third-party dispossession. In some states, when people are ordered to give up their guns, they have to give them to law enforcement or a licensed firearms dealer. However, in about a dozen states including Tennessee, they can also give guns to a friend or a relative.

An excerpt from an order of protection states that firearms must be transferred to “any person who is legally allowed to have them.” (Obtained by WPLN)

Tennessee doesn’t require the third party to even be identified on the firearms dispossession affidavit. There are also no guardrails to ensure that those third parties aren’t themselves also prohibited from having guns or to punish them if they give guns back to the owners.

In response to the March school shooting, Republican Gov. Bill Lee has proposed expanding those dispossession laws to people with mental illnesses who are deemed a threat to themselves or others. It would essentially be an expansion of the system that is failing victims of domestic violence by allowing guns to slip through the cracks.

But even the smallest of reforms might be in doubt: Time and again, the conservative Tennessee Legislature has not only refused to pass tougher gun laws but loosened restrictions, making it easier for people to buy and carry guns.

An Easily Accessible Gun

Carter met Leggett about a decade ago when they were both in high school. She excelled at track and liked to read and to write in her journal. One day, she wrote, she walked into class, and Leggett couldn’t take his eyes off her. Carter had the kind of smile that lit up her whole face, even the whole room, her mom said. Leggett and Carter started dating, and from the outside, they seemed like a happy couple — always laughing and dancing together.

Carter, left, and Jones-Mbuyi (Courtesy of Kimberly Jones-Mbuyi)

But they drifted apart when Leggett ran into trouble with the law and spent time in and out of jail. His criminal record has several felony convictions from 2013 and 2017 for robbery, burglary and drug possession — convictions that barred him from having a gun.

WPLN and ProPublica requested an interview with Leggett through his lawyer and by sending him a letter in prison. But the letter was never answered, and Leggett’s lawyer said his client declined to comment. Leggett was charged with first-degree murder. He has not yet entered a plea and is set to appear in court in September.

Despite Leggett’s history and occasional probation violations, Carter always held out hope that he might change, her family said.

Carter and Leggett were back together but living separately in April 2020 when police were sent to his parents’ house for a domestic assault — but not one involving Carter.

Marvin and Elizabeth Leggett were both 60 years old and lived in a two-story house with a brick facade in Antioch, a neighborhood in southeast Nashville. According to a police report, they were trying to kick their son out and gather his belongings when he turned violent, pushing his mother to the ground, then throwing his father against the wall.

When Elizabeth Leggett approached him, the police report says, he grabbed his dad’s revolver and pointed it at her.

“Get back, bitch,” he said coolly.

Then he fled, taking the gun with him.

Marvin and Elizabeth Leggett told law enforcement they wanted to press charges. But the charges were later dismissed by a judge in August 2021 when they didn’t show up to court. The Leggetts declined to comment for this story.

Marvin Leggett also decided not to report his gun as stolen. But thanks to the initial charges, the police, courts and probation office all had access to information that a gun was easily available to Leggett and that he had been accused of threatening people with it.

It’s unclear if Leggett returned the weapon to his father. But according to the police, it was the same gun he would use to kill Carter.

“This Person Is Dangerous”

Of the people charged with domestic violence homicides who were barred from having a weapon, most were prohibited by state law because of a prior felony conviction. Those ranged from drug charges to homicide. In some cases, the person had already been charged once with unlawful possession of a gun.

But despite being barred for a felony, the law doesn’t spell out how to ensure the person doesn’t have guns. Often, it’s discretionary if law enforcement pursues a search warrant to retrieve someone’s gun, said Jenny Charles, an assistant district attorney in Nashville with nearly two decades of experience on domestic violence cases.

“There have been a lot of cases where I feel like I’m on a mountain screaming: ‘This person is dangerous. This person is dangerous,’” she said. “But without the person being on probation or under an order of protection, there’s just very little we can do.”

Because the state’s probation office is required to monitor people after they leave prison, it often has the best chance of catching people if they illegally have a gun. The probation office declined to comment on what it knew about Leggett’s access to guns or what it did to check on him.

But it said its officers explicitly tell offenders during intake that they can’t have access to weapons and ask others in the home to remove or secure weapons. They also ask about weapons during home visits and routinely do searches for them, the agency said.

Tennessee’s other gun laws have also made it more difficult for law enforcement and the courts to track illegal gun ownership, Charles said. Tennessee, like more than half of the United States, allows private sales without background checks, which opens the door for people prohibited from buying firearms to purchase them anyway. In addition, the state does not require a permit to carry and is one of only eight states that prohibit the creation of a gun registry entirely.

As a result, even after a crime is committed with a gun, it’s rare to have a full understanding of where that weapon came from.

“If I Stay, I’m Going to Die”

While there are gaps in enforcement when it comes to felony gun prohibitions, Carter also had a safeguard many other victims didn’t have — a protection order, which she got after a brutal beating in July 2021, four months before the shooting.

KiAndrea Jones remembers her little sister coming around the corner with her head hung low, her long dreads falling over her face. The only illumination was from a nearby streetlight.

When she came closer, Jones gasped.

Carter was brutally beaten in July 2021, and afterward she got a protection order against Leggett. (Courtesy of Kimberly Jones-Mbuyi)

Half of Carter’s face was swollen beyond recognition. Leggett had hit her in the face multiple times with a glass bottle of Jack Daniel’s, according to criminal court records.

Jones pulled her sister into her arms.

“You don’t have to be scared,” she told her. “I’m not going to ever let him hurt you again.”

Earlier that night, Carter’s family had thrown Leggett a surprise 27th birthday party. Afterward, some of them had gone to Lower Broadway, Nashville’s tourist strip of bars and honky tonks.

There, Jones said, she noticed Carter and Leggett arguing.

She said it was like Jekyll and Hyde: One side of Leggett was charming, the life of the party. But this other side of him was angry and controlling.

“His whole demeanor just changed,” she said. “Like, I’d never seen him the way that I seen him that night.”

But it turned out that night wasn’t the first time he’d lashed out. As Carter sat in a hospital bed early the next morning with her battered face, her family listened as she recounted the history of violence to a police officer.

She told them that since they eloped in December 2020 and moved in together, Leggett had become controlling. He would listen in on her phone calls, read her text messages and take her phone away to isolate her. He tried to convince her that her family didn’t really love her, she told the police. He started abusing drugs again and cheating on her. She had tried to leave him a few months earlier, she said, but he beat her up until she wasn’t able to walk.

Carter told her family that the abuse had gotten so bad that she had tried to kill herself by overdosing. She said she felt that the only way out of her relationship with Leggett would be if one of them were dead.

As she recounted the horrors, it was clear to her family that she had hit her breaking point. She was ready to leave him.

“She looked at it like: ‘If I stay, I’m going to die. And if I leave, I’m taking a chance,’” her mom said. “And she took that chance.”

First image: Jones-Mbuyi. Second image: Jones-Mbuyi wears a lock of her daughter’s hair around her wrist every time she goes to court. (William DeShazer for ProPublica)

She told police she wanted to press charges against Leggett. And after leaving the hospital in the morning, Carter petitioned the court for a protection order against him.

Leggett was arrested. But the assault charges were dismissed less than two weeks later. Right before a hearing, Carter found out that she’d have to face him in court. She had a panic attack and left the courthouse. While the family said they had communicated her fear to the district attorney’s office, prosecutors said they could only go forward if she identified him in court.

Though the charges were dropped, Leggett remained behind bars for violating his probation. And in August, Carter’s protection order was granted. A judge ordered Leggett to stay away from Carter when he got out of jail, and he was barred from having a gun.

Yet after exhausting legal options to protect herself, Carter still didn’t feel safe.

“She was holding up the paper that they gave her,” Jones said she remembered from the day the protection order was granted. “And she was saying: ‘This is just paper. This is just a piece of paper. He can shoot me through this piece of paper.’”

An excerpt of Carter’s order of protection against Leggett (Obtained by WPLN) “The System Failed”

On paper, protection orders are considered one of the most powerful tools for domestic violence victims. If someone violates the terms, they can be arrested and held for at least 12 hours, separating them from their victims. They also require people subject to them to turn over their firearms to someone else within 48 hours and to file declaration forms in court listing the make, model, caliber and serial numbers of the guns they relinquished.

But there are problems with Tennessee’s system: Protection orders can be hard for domestic violence victims to get. They aren’t always enforced. And people subject to them can simply turn their firearms over to a friend or relative, leaving them with easy access to their guns. There isn’t even a space on the gun dispossession form for the name of the person holding the weapons.

WPLN and ProPublica found that of the approximately 75 domestic violence homicides, only three cases had an active order of protection at the time of the shooting.

At least three other people had protection orders filed against them leading up to the incident, but the orders were dismissed after the court had trouble reaching the victim.

“If the petitioner is going into a shelter, they might be harder to reach,” said Becky Bullard of Nashville’s Office of Family Safety.

Sometimes protection order hearings can be delayed for months, she said, even though the statute indicates they should be held within 15 days. “We’re giving the respondents a lot of time to ramp up their violence and to potentially coerce the petitioner not to come to court,” she said.

And occasionally, Bullard said, victims choose not to pursue an order of protection at all out of fear that it might enrage their abuser and escalate the violence. WPLN and ProPublica found that in some cases just a few months passed between the petition for a protection order and the homicide.

For 30-year-old Temptress Peebles, that window was just one week. She asked for an order of protection on Oct. 10, 2019. By Oct. 17, 2019, she was dead.

An excerpt of Temptress Peebles’ petition for a protection order against Brandon Horton (Obtained by WPLN)

“The system failed my child terribly,” said her mother, Karen Peebles, who described her daughter as free-spirited and outgoing, with a high and lilting voice, which earned her the nickname Chippie. “They didn’t respond like they should have, which I think cost my daughter her life.”

According to court records, the order was the third she had sought against her ex-boyfriend, Brandon Horton, in the year leading up to her death.

In January 2019, she told the court, Horton threatened to kill her rather than see her date someone else. Six months later, she reported, he burst through her back door with a gun and pointed it at her.

Her final petition for a protection order includes a statement from Peebles that is especially prescient.

“Brandon has threatened to kill me before,” she wrote in the document. “He once said to me, ‘Since you put all that warrants on me, before they catch me, I am going to kill you.’”

“I am terrified that Brandon is going to kill me,” she wrote.

A week later, police said, he did — in front of her 8-year-old daughter — with a gun he wasn’t supposed to have.

An excerpt of Peebles’ July 2019 temporary order of protection against Horton (Obtained by WPLN)

WPLN and ProPublica contacted Horton through his lawyer and by writing a letter to him in prison, but his lawyer said he declined to comment. He was charged with first-degree murder. He has not yet entered a plea, and his trial is forthcoming.

“Help Me”

A little over three months after Carter got her protection order, her fears that it was no more than a piece of paper came true.

Shortly after the police left her house on Nov. 15, 2021, she ran outside to get in her friend’s car. She had stuffed clothing, a toothbrush and her protection order into her green camouflage backpack and planned to get as far away from home as possible.

But when she looked down the street, her family said, she realized it was too late. Leggett was walking quickly toward the house with a gun in his hand, his face set in angry determination.

She ran back into the house, yelling: “Mama, mama! He’s here! He’s here!”

Jones-Mbuyi’s former home, where the shooting took place (William DeShazer for ProPublica)

Jones-Mbuyi went to the window with her phone in her hand. She tried to take a photo of Leggett like the police had asked. But she was shaking too hard. Her phone kept falling to the floor.

Carter called 911. The two women ran into the bedroom and locked the door.

When the dispatcher answered, Carter spoke in a low, urgent whisper.

“He’s here, he’s here,” she said. “The police just left, but he’s here.”

The dispatcher started asking questions: How do you spell his name? How old is he? What does he look like?

One minute into the call, Carter asked: “Are you sending somebody? Did you already send somebody?”

The dispatcher didn’t answer. Instead, she kept asking questions.

Two minutes into the call, Carter pleaded, “Can you just send somebody?”

“I have to ask these questions for police safety,” the dispatcher snapped back.

“Did you already send a squad car or not?” Carter asked again. “Why are you not answering me?” Jones-Mbuyi took the phone.

Three minutes into the call, and the dispatcher was still asking questions: Has anyone been drinking? Is he by himself? What was that address again?

But before they were able to answer, Jones-Mbuyi said, “He just bust the door down.”

There’s a loud boom — the noise of her bedroom door being knocked off the hinges.

Then, a scream. The sharp pops of gun fire.

“Michaela, what’s happening?” the dispatcher asked.

“He just shot her,” Jones-Mbuyi cried out.

In the background, Carter screamed in agony. She was shot twice — once in the chest and again in the leg. She fell face down onto the floor.

Four minutes into the call, Jones-Mbuyi was overtaken by the horror in front of her. She screamed. It was guttural. Heart-wrenching.

“Send an ambulance, send an ambulance!” she shouted into the phone.

Five minutes into the call, the dispatcher confirmed that an ambulance was on its way.

Carter’s screams turned into labored moans.

“Ambulance,” she slurred.

Ten minutes into the call, the paramedic arrived.

“Are you still able to breathe?” he asked her.

“Barely,” she choked out.

“Help me,” she said. “It’s getting hard — it’s getting hard to breathe.”

Then, the call ended.

A few days later, Carter died of her injuries at the hospital. She was just hours away from turning 25.

“Life has been stagnant — so I feel like every day is Nov. 15, 2021,” said Jones, her sister. “It’s hard to heal and move past something when we have been failed so many times. And now we have to fight. Not just for Michaela, but for other women in her situation.”

Jones-Mbuyi with Jones (William DeShazer for ProPublica) Help Us Report on Tennessee’s Gun Dispossession Laws

by Beth Hundsdorfer and Molly Parker, Capitol News Illinois

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

State officials this week named a new leader of Choate Mental Health and Developmental Center amid a drumbeat of criticism and investigations into abuse and poor care at the southern Illinois facility.

Bryant Davis, who served as Choate’s top administrator since 2014, has been replaced by Stephany Hoehner, who has worked as a project manager at the facility since March, according to an email to staff on Monday obtained by reporters.

In March, Illinois Department of Human Services Secretary Grace Hou unveiled a plan to move more than half of Choate’s 225 residents with developmental disabilities out within three years and improve safety at the center for those who remained. She also announced that the state would undertake a review of the best use for the facility. At the time, Hou told reporters that she decided to keep the facility leaders in place during the transition for continuity because they’ve known many of the patients and their guardians for years.

The department’s about-face on Choate’s top leader follows months of reporting on poor conditions at the facility by Capitol News Illinois, Lee Enterprises Midwest and ProPublica. And it comes on the heels of a sweeping new report from Equip for Equality, the state’s federally designated advocacy and protection agency for people with developmental disabilities.

After months of monitoring the facility at IDHS’ request, the nonprofit made recommendations that drew a hard line: Regardless of who is in charge, “no individuals with developmental disabilities should remain at Choate.”

Equip for Equality’s report, titled “Why No One Should be Left Behind,” detailed ongoing, serious lapses in care and recommended that the remaining residents with developmental disabilities who live there be moved out.

Equip for Equality also reported that its site visits between October and July found that little has changed for the residents of the facility, despite the department’s reforms. Choate patients told the monitors that they continued to feel unsafe. They reported numerous serious abuse allegations, and said many instances of abuse go unreported because the staff has a history of taking away patients’ privileges as retaliation.

Patients told Equip for Equality monitors that they’ve been slapped, punched, choked and threatened as punishment at Choate. In late 2022, a patient said an employee slapped her after she reported that person for abuse. She feels “threatened and scared” and cries everyday, the report stated. She told the monitor, “It hurts my heart to be here.”

The facility has also failed to ensure residents received the care they needed, the report said, leading to instances of self-harm such as an incident in September where a patient tore off all 10 of their toenails.

Keeping people with developmental disabilities at Choate is “antithetical to their well-being and the reason for their placement” because they are subjected to abuse and neglect, and are not receiving the intensive treatment they need to transition out, the report said.

Residents frequently felt “bored” and had few opportunities to engage in meaningful activities such as developing work and life skills, the report said. The monitors also observed that residents spent most of their days watching television, sleeping or doing arts and crafts.

Further, residents were subjected to unnecessary restraints and verbal abuse. These safety issues and failures of care were not isolated to the residents whom state officials have prioritized for relocation, the report said.

The report cited the case of a nurse who, according to IDHS’ inspector general, failed to follow procedures when she ordered a patient into restraints. The nurse told an investigator with the IDHS Office of the Inspector General, the agency’s watchdog, that the patient became angry after she did not immediately answer a question about his medication and he pushed a medicine cart at her, threw a water bottle and tried to attack her. The patient was escorted to his room, then the nurse ordered restraints.

The OIG found she failed to assess the patient’s mental status at the time of the order as required by IDHS policy. At least three technicians and a lead worker told an OIG investigator that the patient was calm at the time a nurse ordered the restraints, though other workers gave conflicting accounts. The nurse was reassigned during the 13-month investigation.

“In the end, it not only appears that the restraints were used in a retaliatory manner, but the whole incident could have been avoided if the nurse had respected his right to ask questions about his medication,” the report stated.

Capitol News Illinois reporters discovered this nurse applied for and received a supervisory position in the midst of that ongoing investigation. Eight months after taking that job, the OIG substantiated the neglect claim against the nurse in the restraint case.

In her request for reconsideration of the finding, the nurse denied any wrongdoing. That request for reconsideration was denied.

IDHS said in a statement that it imposed “administrative consequences” on the nurse after the completion of the OIG investigation. She remains a nursing supervisor at Choate.

The report also faulted administrators for not taking timely and robust action to address problems, and said they have “failed to demonstrate the ability to right the ship and keep individuals safe.” That finding echoed a June OIG report, which said leadership had failed to hold employees accountable and accepted “substandard work performance.” That same month, the Illinois Department of Public Health found filthy conditions in the units, including peeling paint, feces in the shower and on a patient’s bedding, and dried tobacco spittle covering a clock radio

In July, the news organizations documented ongoing problems under current leaders at Choate despite IDHS’ reform promises.

Davis began at Choate as a social worker in 2000. He became facility director in 2014, responsible for staffing decisions, employee evaluations, responding to critical incidents and discipline for both the mental health and developmental disability divisions at Choate, according to job descriptions. Davis received an annual salary of $133,000. He declined to comment through an IDHS spokesperson.

Davis, along with Assistant Facility Director Teresa Smith and Quality Assurance Manager Gary Goins, faced charges of official misconduct last year for allegedly interfering with a patient abuse investigation. The charges against the three were later dropped by the prosecutor.

Smith and Goins will remain in their current positions. They also declined to comment through an IDHS spokesperson.

In response to a question about Davis’ future with the agency, IDHS said in an email: “Davis will no longer work at Choate following a one-month transition period. At this time, we are not able to share anything beyond that.”

But Equip for Equality, in its report, cautioned that changing leadership isn’t enough to fix conditions for the residents with developmental disabilities at Choate. It found deeper cultural problems at the facility have taken root over several decades. Appointing new leadership “could serve as a distraction that only delays the timely transition of all individuals with developmental disabilities away from Choate,” according to the report. The report did not address the much smaller state-run psychiatric hospital that is also on the grounds of the 229-acre campus.

Equip for Equality has had monitors stationed at Choate on and off since 2021. IDHS officials requested their assessment of Choate on the heels of a rash of arrests of employees on felony charges alleging abuse and cover-ups. Since then, the monitors have logged more than 2,000 hours on the facility’s grounds.

Last summer, in part based on Equip for Equality’s review, IDHS implemented a series of care and safety reforms. Those included adding surveillance cameras to public areas, beefing up security and improving services for residents who needed therapy to address trauma they’d experienced and for those who wanted help transitioning from the institution and into a community home.

“Despite the state’s ongoing investments in this institution and the high level of scrutiny it has been under since early 2021,” Equip for Equality’s report said, it is clear that “an influx of more resources will not fix the multiple and serious problems at Choate.”

This is the second comprehensive report on poor conditions at Choate from Equip for Equality in the past two decades. It was strikingly similar to the organization’s 2005 monitoring report detailing abuse and poor care, which was followed by a Department of Justice investigation two years later.

“Here we are 20 years later with the same problems,” said Stacey Aschemann, vice president of Equip for Equality’s monitoring unit.

IDHS spokesperson Rachel Otwell said in a statement that the agency is evaluating Equip for Equality’s report, alongside other recent reports from the OIG and the Southern Illinois University School of Medicine, which provided recommendations to repurpose Choate and address safety and staffing issues.

“Ultimately, the department wants to serve patients and residents in the best possible way, retain excellent staff, and strengthen the Choate campus to serve the public interest,” she said.

At present, the department is committed to “the careful transition of the 123 residents” previously identified to be moved by state officials. “It is critical to focus on these early moves to ensure they are smooth and successful for the long term.”

Since the plan was announced in early March, 19 residents have moved out of Choate. About half of those moved to other developmental centers, which have also been linked to cases of abuse and neglect.

by Cezary Podkul

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

Imagine if each time your wages were deposited in your bank account, your employer deducted a fee of 1.5% to 5% to provide the money electronically. That, increasingly, is what health insurers are imposing on doctors. Many insurers, after whittling down physicians’ reimbursements, now take an additional cut if the doctor prefers — as almost all do — to receive funds electronically rather than via a paper check.

Such fees have become routine in American health care in recent years, according to an investigation by ProPublica published on Monday, and some medical clinics say they’ll seek to pass those costs on to patients. Almost 60% of medical practices said they were compelled to pay fees for electronic payment at least some of the time, according to a 2021 survey. With more than $2 trillion a year of medical claims paid electronically, these fees likely add up to billions of dollars that could be spent on care but instead are going to insurers and middlemen.

Congress had intended the opposite to happen. When lawmakers passed the Affordable Care Act in 2010, they encouraged the use of electronic payments in health care. Direct deposits are faster and easier to process than checks, requiring less labor for doctors and insurers alike. “The idea was to lower costs,” said Robert Tennant of the Workgroup for Electronic Data Interchange, an industry group that advises the federal government.

When the Centers for Medicare & Medicaid Services created rules for electronic payments in 2012, the agency predicted that shifting from paper to electronic billing would save $3 billion to $4.5 billion over 10 years.

That’s not how it played out. CMS quickly began hearing complaints from doctors about fees. An industry of middlemen had begun sprouting up, processing payments for insurers and skimming fees off the top. Sometimes they shared a portion of the fees with insurers, too. The middlemen companies say they offer value in return for their fees and insist that it’s easy to opt out of their services, but doctors say otherwise.

CMS responded to the complaints in August 2017 by publishing a notice on its website reminding the health care industry that electronic payments were not a profit-making opportunity. The agency cited a long-standing rule that prohibited charging fees. (Technically, the government banned “fees or costs in excess of the fees or costs for normal telecommunications,” such as the cost of sending an email.) The rule had been on the books since 2000, but the insurers and their middlemen weren’t abiding by it.

Within six months of that pronouncement, however, CMS suddenly removed the fee notice from its website. The decision baffled doctors such as Alex Shteynshlyuger, a New York urologist who has made it his mission to battle the fees. Shteynshlyuger began filing voluminous public records requests with CMS to obtain documents showing why the agency reversed course. The records that he eventually obtained, which he shared with ProPublica, provided a rare nearly day-by-day glimpse of how one industry lobbyist got CMS to back down.

The lobbyist, Matthew Albright, used to work at the CMS division that implemented the electronic payment rule. In fact, he was its chief author. He had since moved on to Zelis, a company that handles electronic payments for over 700 insurers and other “payers.” Internal CMS emails show that Albright protested the notice prohibiting fees and demanded that CMS revise the document. Over the ensuing months, as ProPublica outlined, Albright used an artful combination of cajoling, argument and legal threat. He claimed the rule against fees applied only to direct transactions between insurers and doctors, but electronic payments involved middlemen such as Zelis, so the prohibition didn’t apply. CMS ultimately dropped its ban on fees.

The move benefited Zelis and other payment processors. The losers were doctors, who say they’re often not given an option to get paid electronically without agreeing to a fee. In March, for example, when Shteynshlyuger called Zelis to enroll in electronic payments from one insurer, a Zelis rep quoted him a fee of 2.5% for each payment. When he complained, the call got transferred to another rep who said, “The lowest we can go is 2.1%.”

Zelis said in a statement that it “removes many of the obstacles that keep providers from efficiently initiating, receiving, and benefitting from electronic payments. We believe in provider choice and actively support their ability to move between payment methods based upon differing needs and preferences.” Zelis did not respond to detailed questions about Albright’s interactions with CMS or make him available to discuss that topic. CMS said that it “receives feedback from a wide range of stakeholders on an ongoing basis” to understand “where guidance and clarification of existing policy may be needed.”

As for Shteynshlyuger, he’s still on a quest to help doctors avoid electronic payment fees. Meanwhile, his inability to persuade the insurance middlemen often leads him to a step that is the antithesis of efficiency: Whenever he’s asked to pay a fee for an electronic payment, he requests a paper check instead.

Read the full story of the rise of electronic payment fees in ProPublica’s investigation.

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

by Cezary Podkul

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

It was a multibillion-dollar strike, so stealthy and precise that the only visible sign was a notice that suddenly vanished from a government website.

In August 2017, a federal agency with sweeping powers over the health care industry posted a notice informing insurance companies that they weren’t allowed to charge physicians a fee when the companies paid the doctors for their work. Six months later, that statement disappeared without explanation.

The vanishing notice was the result of a behind-the-scenes campaign by the insurance industry and its middlemen that has largely escaped public notice — but that has had massive financial consequences that have rippled through the health care universe. The insurers’ invisible victory has tightened the financial vise on doctors and hospitals, nurtured a thriving industry of middlemen and allowed health insurers to do something no other industry does: Take one last cut even as it pays its bills.

Insurers now routinely require doctors to kick back as much as 5% if they want to be paid electronically. Even when physicians ask to be paid by check, doctors say, insurers often resume the electronic payments — and the fees — against their wishes. Despite protests from doctors and hospitals, the insurers and their middlemen refuse to back down.

There are plenty of reasons doctors are furious with the insurance industry. Insurers have slashed their reimbursement rates, cost them patients by excluding them from their provider networks, and forced them to spend extra time seeking pre-authorizations for ever more procedures and battling denials of coverage.

Paying fees to get paid is the final blow for some. “All these additional fees are the reason why you see small practices folding up on a regular basis, or at least contributing to it,” said Dr. Terence Gray, an anesthesiologist in Scarborough, Maine. Some medical clinics told ProPublica they are seeking ways to raise their rates in response to the fees, which would pass the costs on to patients.

“It’s ridiculous,” said Karen Jackson, who until her retirement in March was a veteran senior official at the Centers for Medicare & Medicaid Services, the federal agency that posted, then unposted, the fee notice. Doctors, she said, shouldn’t have to pay fees to get paid.

But that’s precisely what’s happening. Almost 60% of medical practices said they were compelled to pay fees for electronic payment at least some of the time, according to a 2021 survey. And the frequency has increased since then, according to medical clinics. With more than $2 trillion in medical claims being paid electronically each year, these fees likely add up to billions of dollars annually.

Huge sums that could be spent on care are instead being siphoned off to insurers and middlemen. The fees can cost larger medical practices $1 million a year, according to an April poll by the Medical Group Management Association, which represents private medical practices. The figure sometimes runs even higher, according to a 2020 complaint to CMS from a senior executive of AdventHealth, which has 53 hospitals in nine states: “I have to pay $1.8M in expenses that I could use on PPE for our employees, or setting up testing sites, or providing charity care, or covering other community benefits.” Most clinics are smaller, and they estimated annual losses of $100,000 or less. Even that figure is more than enough to cover the salary of a registered nurse.

The shift from paper to electronic processing, which began in the early 2000s and accelerated after the Affordable Care Act went into effect, was intended to increase efficiency and save money. The story of how a cost-saving initiative ended up benefiting private insurers reveals a lot about what ails the U.S. medical system and why Americans pay more for health care than people in other developed countries. In this case, it took less than a decade for a new industry of middlemen, owned by private equity funds and giant conglomerates like UnitedHealth Group, to cash in.

How these players managed to create this lucrative niche has never previously been reported. And the story is coming to light in part because one doctor, initially incensed by the fees, and then baffled by CMS’ unexplained zigzags, decided to try to figure out what was going on. Dr. Alex Shteynshlyuger, a urologist who runs his own clinic in New York City, made it his mission to take on both the insurers and the federal bureaucracy. He began filing voluminous public records requests with CMS.

Dr. Alex Shteynshlyuger is on a crusade against payment processors’ fees, which he says threaten his practice. (DeSean McClinton-Holland for ProPublica)

What he discovered in internal emails and government documents, which he shared with ProPublica, was a picture sharply at odds with the image of CMS as a hugely powerful force in health care. The records showed, again and again, federal officials deferring not only to a single company, but to a single executive.

Over the past five years, CMS adopted that company’s positions on fees. Shteynshlyuger discovered that, when it comes to the issue he cares about, the most powerful decision-maker wasn’t a CMS official. It was the chief lobbyist for a middleman company called Zelis. And that man just happened to be a former CMS staffer who had authored a key federal rule on electronic payments.

For Shteynshlyuger, the intersection of medicine and money has a particular resonance. He was born in the Soviet Union, in what is now Ukraine, and his brother nearly died of pneumonia as an infant because doctors refused to administer an antibiotic. The doctors wanted his family to pay a “bribe,” according to Shteynshlyuger. His grandmother ended up finding a different doctor to pay off and his brother got the medicine. Shtenynshlyuger’s parents emigrated to the U.S. in 1991, when he was an adolescent, and they settled in Brooklyn’s Brighton Beach area.

Today, Shteynshlyuger sees the fees for electronic payment through a similar lens. He’s a gadfly, but one with a wry, sometimes humorous disposition and an intellectual bent. He studied biology and economics in college and is capable of both rage at perceived unfairness and dispassionate observations about health policy. The unjust fees, as he sees them, threaten his medical practice, which he designed to serve middle-class patients. He prices his services at a discount. “Low cost is what keeps me in the business,” he said.

As a result, administrative combat has become a big part of his life. Unmarried, Shteynshlyuger, 45, stays up into the wee hours, writing lengthy memos to regulators. One recent missive spanned 155 pages, including appendices.

This New Year’s, he joined his family for a week off at his parents’ condo near Miami. Shteynshlyuger arrived with a desktop computer, which he set up in one of the bedrooms alongside two monitors that he keeps at the condo. While his nieces and brother enjoyed the beach, Shteynshlyuger sat indoors, drafting a 38-page memo to aid in one of two lawsuits he has filed in an effort to pry documents out of CMS.

Shteynshlyuger’s accent, with its distinctive Brooklyn-Russian mix, is unmistakable in calls with customer service representatives at insurance companies and payment processors. (He recorded many of the calls and shared them with ProPublica.) The calls follow a similar pattern: Posing questions in the manner of a genial but persistent litigator, Shteynshlyuger asks why he’s being charged a fee.

Ultimately, he’s informed that there’s no way to have an electronic funds transfer, or EFT, sent straight to his bank account without paying a fee. When the calls get escalated, representatives sometimes offer to shave a tiny amount off the fees — charging, say, 2.1% rather than 2.5%, a proposal made on one recent call with Zelis — but rarely is he offered a free transfer.

Shteynshlyuger spends hours on the phone with payment processors like Zelis, fighting their attempts to impose fees on electronic payments. (DeSean McClinton-Holland for ProPublica)

A spokesperson for Zelis, the payment-processing company that Shteynshlyuger has tangled with most often, said the company refers requests for free electronic payments to the insurers, but recordings and transcripts of recent calls show that did not happen when Shteynshlyuger called.

Shteynshlyuger and other doctors say payment processors routinely sign them up for high-fee payment methods without their consent. A brochure for one payment company, Change Healthcare, boasted of automatically enrolling 100,000 doctors and hospitals in a plan to receive virtual credit cards and sharing some $8 million a year in revenues with the large insurer it was working for. (Virtual credit cards are a form of electronic payment in which a payer sends a string of numbers that are typed into a credit card reader to generate a one-time payment. Fees for VCCs run as high as 5% versus a typical 2.5% for other kinds of electronic payments.)

Payment processors often boost insurers’ revenues by sharing the fees from virtual credit cards. One processor, VPay, says in its marketing materials that insurers can “make money on every virtual card transaction.” In response to questions from ProPublica, UnitedHealth, which owns Change and VPay, asserted that its services help medical clinics streamline recordkeeping, reduce administrative burdens and accelerate payments.

Zelis and other payment processors say they offer value in return for their fees: Doctors can sign up to receive reimbursements from hundreds of insurers through a single payment processor, and they can also get services that help match up electronic payments and receipts. Zelis asserted in a statement that its services remove “many of the obstacles that keep providers from efficiently initiating, receiving, and benefitting from electronic payments.” Zelis and other companies insist that it’s easy to opt out of their services, but Shteynshlyuger and other doctors say otherwise.

Virtual credit cards come with fees as high as 5%. (Courtesy of Dr. Terence Gray. Redacted by ProPublica)

When Shtyenshlyuger embarked on his mission of fighting the fees in 2017, his first step was research. He quickly came across an article from the American Medical Association that said the law was on his side.

Shteynshlyuger then approached the companies. He emailed senior executives of Zelis and VPay, asserting that the fees violated CMS rules. The companies denied breaking any rules and wouldn’t budge on the fees.

So Shteynshlyuger started filing complaints with CMS. The responses he received struck him as curious. CMS itself usually didn’t offer an opinion. Instead, it forwarded letters from a Zelis executive named Matthew Albright, who answered Shteynshlyuger’s complaints on at least five occasions. (The agency said this passive approach is part of its “informal” complaint resolution process.)

When Shteynshlyuger pressed a CMS official to articulate the agency’s position after it passed along Albright’s answer, the official wrote that the agency receives the “identical legal response” from Zelis to all such complaints. She added: “They believe that, according to their interpretation of the regulation, they are compliant.”

Shteynshlyuger was flummoxed. Who was Matthew Albright? A quick Google search revealed that Albright had once worked for CMS. That only piqued Shteynshlyuger’s interest. Had Albright been involved in the removal of the CMS notice prohibiting fees?

To Albright, the 2010 passage of the Affordable Care Act was a historic event of a magnitude akin to the moon landing. Then a policymaker with Washington state’s Health Care Authority, Albright was awed by the importance of the looming rewrite of U.S. health care rules. He felt he had to be part of it. “This is the Apollo 11 for regulators,” he recalled thinking, in an interview with ProPublica. “I’ve got to get to D.C. and write regulations.”

Matthew Albright, now chief legislative affairs officer at Zelis, made a series of explanatory videos in his days at the Centers for Medicare & Medicaid Services. (Screenshot via YouTube)

Now 55, Albright had unusual training for his new role. Instead of following the typical path through law school, he had studied sacred texts, first at the Pontifical University of St. Thomas Aquinas in Rome and later at Harvard University, where he earned a master’s degree in divinity. Those studies, Albright said, fostered what he called a “scholastic fascination with words and how they’re used to tell people what to do,” whether those words are in the Ten Commandments or the Code of Federal Regulations.

Articulate and cheerful, today Albright can still sound more like a divinity professor than a lobbyist when he describes his current job as studying laws and rules. “Hermeneutics,” he said, “it’s just like Bible study, right? Breaking it down into its understandable parts. And then, frankly, turning around and teaching it or turning around and explaining it in the vernacular, if you will. So I think that most of my job is looking at regulations and reading them and then explaining them to internal and external audiences.”

At CMS, Albright drafted a rule, published in 2012, that laid out standards for paying doctors via electronic funds transfers. The Affordable Care Act required all insurers to offer EFTs and encouraged doctors to accept them, and electronic payments quickly became the go-to method for handling medical claims. A CMS analysis predicted that eliminating the labor of manually processing paper checks and receipts would lead to savings of $3 billion to $4.5 billion over 10 years.

Albright became the agency’s point man on the issue. He looked every bit the government bureaucrat in a gray shirt and dark suit as he extolled the virtues of “administrative simplification” in earnest-but-stiff video segments that emulated a talk show. (Albright also created a personal YouTube channel when he taught a philosophy course. It had bite-sized explanations of, among other things, Kantian ethics — “do not use people” — and Ayn Rand’s philosophy — “selfishness is good.”)

Albright’s work at CMS, by his description, became a “turning point” for health care payments. The shift to electronic funds transfers facilitated the growth of an industry of payment processors. It also made Albright’s skill set very valuable. In 2014, he was recruited to the industry he previously regulated. Two years later, he landed at Zelis. The company had just been created via a merger of four businesses owned by Parthenon Capital, a private equity firm. Zelis is now co-owned by private equity giant Bain Capital and headed by a former Bain partner. (Parthenon declined to comment; Bain referred a request for comment to Zelis.)

Zelis, which once described itself as having a “regulatory-based business model,” touted Albright’s government resume when it hired him as vice president of legislative affairs. Albright said at the time he would “advocate for rational regulatory approaches.”

Rational regulatory approaches, from Zelis’ perspective, included the right to charge doctors for electronic payments. That was a crucial revenue stream for the company, but it could dry up if CMS enforced a rule prohibiting such fees. Who better than Albright, the man who had drafted rules on electronic payments, to help the company navigate the situation?

When Shteynshlyuger began to receive documents from CMS in response to his Freedom of Information Act requests, he was first struck by how deferential CMS officials seemed to be to Albright. In July 2019, for example, as Shteynshlyuger continued to complain about Zelis, a CMS official named Gladys Wheeler contacted Albright. “You may be familiar with Dr. Alex Shteynshlyuger,” Wheeler wrote. “To assist with resolution of the complaints, I have a few questions. Can I send the questions to you, or can you redirect me?” She added, “Just let me know the best approach. Thanks, and take care, Gladys.” (Wheeler did not respond to requests for comment.)

The tone of the conversations between Albright and CMS could be downright chummy. “Should we respond to it as per usual?” Albright asked in another July 2019 email about a new complaint filed by a doctor in Washington state. “Send the Zelis response for documentation purposes,” Wheeler responded in between banter that she and Albright exchanged about Chicago’s winter weather (bad) and architecture (great).

Shteynshlyuger was growing more frustrated. He didn’t understand why CMS had yanked the notice about the prohibition on fees from its website. If his months of effort couldn’t extract clear answers, how could other doctors with less inclination for bureaucratic battle figure out what to do?

What Shteynshlyuger didn’t know was that, less than two years earlier, a lobbying campaign had begun behind the scenes at CMS. The documents that he eventually obtained would provide a rare, nearly day-by-day glimpse into how one lobbyist — Albright — managed to bend the agency to his will with an artful combination of cajoling, argument and legal threats.

On Aug. 11, 2017, CMS’ website had posted the notice that EFT fees were prohibited. Such notices, presented in the form of answers to frequently asked questions, are meant to explain the agency’s complex rules in plain language. CMS based the notice on a rule from 2000 that banned fees in excess of normal telecommunication costs (such as, say, the tiny fractions of a penny to cover the cost of an email) that a doctor would incur if they were receiving the bill “directly” from an insurer.

The notice triggered an immediate protest from Zelis, according to emails and an internal CMS memo. Albright had “multiple conversations” with CMS staff and demanded that the agency revise the notice.

The nub of Albright’s argument was that CMS’ 2000 rule prohibited insurers from charging excessive fees for “direct” transactions. But, he argued, the rule was meant to apply to insurers dealing with doctors. Albright represented payment processors who work for insurers; those weren’t direct transactions between insurers and doctors. Thus, he argued, the fee prohibition couldn’t apply to EFT payments.

CMS, which took months or longer to respond to Shteynshlyuger, quickly complied with Albright’s request and removed the fee notice on Aug. 14, 2017, only three days after it was posted.

CMS published an updated notice in late September 2017. But the agency stood firm on the key point: The new document stated that insurers and payment processors “should not charge providers communications fees” for EFTs.

Shortly after the revised notice went up, Albright emailed the director of the CMS division that issued it. “Hope the kids have settled into the school year okay,” he began. He then asked for “our day in court to educate” the agency. He suggested that Zelis was preparing to escalate its complaints but offered to “work through this without causing too much noise.”

Two days before Thanksgiving, Albright confronted Christine Gerhardt, then deputy director of the CMS division that issued the fee notice. In a phone call, Albright demanded that CMS revise the document again, according to Gerhardt’s summary of the call. Gerhardt refused. Albright began debating her on the legal differences between the explainer and the regulation that it summarized.

The following week, Albright pressed harder, asking Gerhardt whether the prohibition on fees was enforceable. He told Gerhardt that if she did not answer, that itself would be an answer. It would, Albright said, “give me a sense of what steps need to be taken next” to challenge the agency’s notice. Gerhardt, who is now retired, said she assured him that the agency wasn’t implementing a new rule; only clarifying existing rules. Albright was pushing hard, but at that point, Gerhardt hadn’t bent.

Then, in January 2018, Zelis brought in the lawyers. A firm called Nixon Peabody wrote to CMS, demanding that the agency “withdraw or correct the offending language” in its notice. Nixon Peabody argued that the fee prohibition wasn’t a restatement of existing rules but that it amounted to a new rule that should have been issued via the formal rulemaking process. Nixon Peabody threatened to sue if CMS didn’t comply with Zelis’ demand. (Nixon Peabody did not reply to a request for comment.)

The legal threat set off a scramble within CMS. “Let’s just take it down,” Gerhardt wrote in a Feb. 9, 2018, email to colleagues. Her division not only removed the notice saying that fees were prohibited but also went so far as to institute a moratorium on any new notices. CMS was essentially depriving all medical providers of guidance on these issues because one company had complained.

The response puzzled even some within CMS. “What was the basis for withdrawal if the request was from a single entity and potentially harms providers?” Jackson, then CMS deputy chief of operations, wrote in an email.

Albright, his goal accomplished, sought to soothe Gerhardt and two of her colleagues. “I know I butted heads with all three of you,” he wrote a few weeks later. Albright offered to meet to explain why Zelis is not “one of the bad guys in this area.” (Zelis did not address detailed questions about Albright’s interactions with CMS.)

In March 2018, after Zelis complained and CMS removed a notice saying that payments to doctors couldn’t carry fees, Albright emailed three key agency staffers to patch things up. (Email exchange provided by Alex Shteynshlyuger)

CMS told ProPublica in a statement that it reversed its position because it concluded that it had no legal authority to “flat-out prohibit fees.” The agency declined to comment on Shteynshlyuger’s complaints, but said it takes seriously any allegations of noncompliance with its rules. As for Zelis’ lobbying, CMS said it “receives feedback from a wide range of stakeholders on an ongoing basis. The information received helps the agency understand where guidance and clarification of existing policy may be needed.”

The American Medical Association and over 90 other physician groups have urged the Biden administration to reinstate guidance protecting doctors’ right to receive EFTs without fees. For its part, the massive Veterans Health Administration system has been refusing to pay the fees, which it has described as illegal in letters to Zelis and insurers.

So far the protests have had no visible effect. In fact, when CMS finally issued a new explainer that addressed fees in July 2022, more than four years after erasing the previous one, the agency made explicit what had previously been implicit: EFT fees are allowed.

Shteynshlyuger is continuing his lonely campaign. Two months after CMS stated that fees are OK, a Zelis customer service representative contacted him. Shteynshlyuger had just submitted his 80th complaint to CMS. Emails show the rep offered to help him get signed up for no-fee EFTs — but the offer only applied to payments from one of the more than 700 insurers and other payers that Zelis represents. Shteynshlyuger demurred, saying he did not want the issue resolved without CMS’ intervention because then other doctors could not get the same assistance. As often as not, Shteynshlyuger and other doctors are left with little recourse; many insist on being paid by paper check rather than allowing Zelis to take a cut.

In mid-December, Shteynshlyuger finally got the long-awaited replies to eight other complaints he had filed over the years. CMS dismissed all eight because Shteynshlyuger didn’t file them against insurers but instead against companies like Zelis, which CMS referred to as “business associates” of the insurers. CMS said it now believes its oversight extends only to insurers, not to their business associates. The phrasing may have been bureaucratic, but the news was dramatic: CMS had fully surrendered, giving up on regulating payment processors entirely.

Shteynshlyuger hasn’t filed a new document request yet to uncover whether Zelis or perhaps another company influenced that decision. He has his suspicions.

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

by Robin Urevich, Capital & Main, and Gabriel Sandoval, ProPublica

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

The Los Angeles Housing Department has sent warning letters to the owners of 17 buildings meant for low-cost housing, demanding that they stop renting rooms to tourists in violation of city law.

The action follows a Capital & Main and ProPublica investigation that found 21 buildings, known as residential hotels, had advertised short-term rentals on travel websites despite a 2008 ordinance aimed at preserving residential hotels for affordable housing. Residential hotels mostly consist of basic single rooms and are often the only housing that many low-income, elderly and disabled people can afford.

The Los Angeles City Council will also soon consider a motion, filed last week, to require the Housing Department to report on its enforcement of the residential hotel law. The motion, in response to Capital & Main and ProPublica’s reporting, raises the possibility of creating a right for individuals to sue landlords who convert such housing without the city’s permission.

“I know very dramatically the impact of not having that enforced because that means more houses, more low-income units, that we as a city have to figure out how to build,” City Councilmember Bob Blumenfield, who presented the motion, said in an interview. “It means more people on the street and more services and more costs and more human suffering.”

The motion, which was seconded by City Councilmembers Monica Rodriguez and John Lee, notes that as the city contends with rising construction costs for affordable housing and a shortage of landlords who will accept emergency or long-term housing vouchers, “the loss of residential hotel rooms to tourist units may be exacerbating our homelessness crisis.”

Much of the information that the councilmembers requested is already supposed to be reported annually by the Housing Department under the terms of the residential hotel law. But in the 15 years since the ordinance was passed, the Housing Department hasn’t filed the reports, according to agency officials and the city clerk’s office.

In issuing the notices to comply last month, the Housing Department cited violations of both the residential hotel law and the city’s home-sharing ordinance, which is meant to crack down on illegal rentals on sites like Airbnb. The department used both laws “to aggressively pursue compliance,” Housing Department spokesperson Sharon Sandow said in an email.

Among the hotels cited were three that were highlighted in our initial story: the American Hotel in the Arts District, and the H Hotel and Hometel Suites, both in Koreatown.

The American’s owner, Mark Verge, said he’s hired an attorney and will discuss the matter with the Housing Department. “Our argument is we are a hotel,” said Verge, who previously said he had been unaware of the American’s residential designation. But he added, “Whatever they come up with will be fine.”

Becky Hong, the Hometel’s general manager, said in an email that the hotel has submitted documents to the city in response to the notices. Neither the H Hotel’s owner nor its manager responded to emails or a call for comment. Previously, the H’s manager said the hotel hasn’t accepted long-term residents since 2019 and has asked the city to remove its residential designation.

All three hotels continue advertising rooms to tourists on their websites.

The citations and the City Council motion are the latest fallout from Capital & Main and ProPublica’s reporting. In July, Mayor Karen Bass asked the Housing Department to investigate the 21 residential hotels in our story and report back on how to improve enforcement efforts.

Blumenfield’s motion also requests that housing officials recommend ways to strengthen the ordinance and asks the department to identify potential funding sources and additional resources needed to enforce it.

The Housing Department has pointed to short staffing as one reason it has struggled to enforce the residential hotel law. But Blumenfield, who chairs the council’s budget committee, said the agency hasn’t requested additional funding for enforcement.

“Nobody’s ever come to me and said, ‘We don’t have the money to enforce our residential hotel conversion’” law, he said. “Now that I’m aware of it, I’m going to do what I can to make sure that it does get enforced.”

Blumenfield’s motion has been referred to the council’s Planning and Land Use Management Committee. If approved, it will go to the full City Council for a vote.

by Melissa Sanchez

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.

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When Judy Kalepp became the municipal court judge in Abbotsford, Wisconsin, more than a decade ago, she was shocked to see how many Latinos were ticketed for driving without a license. She asked herself: Couldn’t they just get licensed and stop breaking the law?

Then she got to know some of the drivers, mostly Mexican immigrants who lived and worked in the community. Despite not speaking Spanish, she was able to communicate with many of them and learn that they were undocumented and prohibited by state law from getting driver’s licenses.

Over time, her views changed. While she still worries about road safety with so many unlicensed immigrants driving, she’s also come to recognize how important their labor is to the area around Abbotsford, a Central Wisconsin town that’s home to a meatpacking facility and is surrounded by dairy farms.

“The more I see of it,” Kalepp said, “the more I think we’re probably wrong in not allowing them to get a license.”

Last week ProPublica reported on how Wisconsin, a state that bills itself as “America’s Dairyland,” relies on undocumented immigrants to work on its dairy farms but doesn’t let them drive. As a result, many undocumented dairy workers struggle to take care of some of their most basic needs — from buying groceries and cashing in checks to visiting the doctor or taking their kids to school. They say they are trapped on the farms where they work and often live, dependent on others to take them where they need to go.

Immigrants who break the law and drive anyway risk getting ticketed and receiving hefty fines or even being arrested or deported. “It’s scary to drive,” said an undocumented Honduran immigrant who works on a farm near Abbotsford.

He’s lived mostly in isolation in his 10 years in Wisconsin: He’s never visited Milwaukee, he rarely sees friends from back home (they can’t legally drive either), and he doesn’t know how or when he’d ever meet a romantic partner. But he still gets behind the wheel six days a week to get to work — and then again every two weeks to go into town to cash his check, buy groceries and do his laundry. “To get anything done,” he said, “you have to drive.”

For years, advocates for immigrants have tried to persuade lawmakers in Wisconsin to allow undocumented immigrants to get driver’s licenses. Democrats have been mostly on board, with Gov. Tony Evers inserting the issue into his budget proposals. The challenge has been convincing Republicans, who control the state Legislature, to take an action that some of their constituents might fiercely oppose.

“I have some Republican voters and Republican colleagues that say, ‘Hey, they came here illegally. They didn’t come here through legal channels, so they shouldn’t be rewarded,’” said Rep. Patrick Snyder, a GOP lawmaker whose district sits a little to the east of Abbotsford and includes parts of Marathon County. “I understand their concerns. But in the same sense, if we suddenly kicked out all of the people here, the undocumented, our dairy farms would collapse. We have to come up with a solution.”

Snyder is one of a number of Republican lawmakers and local officials from the area who met with law enforcement officials, dairy farmers, civic leaders and immigration rights advocates in Abbotsford in March to discuss the impact on the community of a 2006 law banning undocumented immigrants from obtaining driver’s licenses. Wisconsin is one of 31 states that doesn’t allow undocumented immigrants to drive legally.

The meeting in Abbotsford, which straddles the border of Clark and Marathon counties, offers a window into how the politics around this issue might be changing. Some local officials who live in these places and routinely interact with undocumented immigrant drivers or hear from local dairy farmers are becoming more vocal about changing the law.

Like much of rural Wisconsin, both counties voted solidly in 2020 for then-President Donald Trump, whose stance against illegal immigration was a hallmark of his presidency.

Abbotsford, with a population of about 2,100, has a downtown that’s lined with Mexican restaurants and grocery stores. Local residents and dairy workers from around the area drive in to cash their checks, buy tortillas and other staples from back home, and go to the municipal court to pay their tickets for driving without a license.

This $124 citation is, by far, the most common processed in the municipal court, accounting for nearly one in three cases that ended with a guilty disposition and more than $19,000 in fines last year, records show. The court does not track defendants’ race or ethnicity, but ProPublica found that 134 of the 157 tickets for driving without a valid license involved defendants with common Hispanic surnames, such as Cruz, Lopez and Garcia. (The U.S. Census Bureau says more than 85% of people with these last names are Hispanic.)

Jason Bauer, the chief of the Colby-Abbotsford Police Department, said he wishes the state would allow undocumented immigrants to get trained and tested to get driver’s licenses. But in the meantime, he said, he can’t tell his officers to stop enforcing the law when they encounter a driver without a license. “Then I’d have to say, ‘You’ve got to treat everybody the same,” he said, “including the 15-year-old white kids” who are driving.

Still, tickets for driving without a license are so common that Bauer has asked his officers to stop seeking criminal charges on repeat offenses — which is what typically happens — to help drivers avoid mandatory court appearances. Bauer said he also wants to avoid overwhelming his local county district attorneys. (Melissa Inlow, Clark County’s district attorney, said she stopped pressing criminal charges on repeat offenses for driving without a license last fall due to limited resources, but drivers still have to pay a fine.)

Abbotsford Mayor Jim Weix said he talks to Bauer several times a week and knows just how frequently drivers are ticketed for this offense. Weix is a Republican who backs Trump and supports tougher border policies. But he doesn’t think the current state law, which lets undocumented immigrants own cars but prohibits them from driving, makes sense.

“We need these people to learn how to drive and our rules and regulations and everything,” Weix said.

But like many fellow Republicans, Weix worries about voter fraud and said he wouldn’t want undocumented immigrants to use driver’s licenses to vote illegally. Since Wisconsin residents can use driver’s licenses as proof of ID for voting, he would urge lawmakers to ensure that any type of driver’s license that’s created for undocumented immigrants be clearly marked “not to be used for voting.”

At the March meeting, law enforcement officials expressed concern about having so many people on the road who haven’t passed a local driving test. “That’s a danger. We want to keep roads safe,” Clark County Sheriff Scott Haines said in an interview. “I am looking more for the safety of all citizens.”

Haines said the meeting opened his eyes to the issue’s complexities. But he said changing the law “is out of our hands.” Like Bauer, he said that unless the Legislature allows undocumented immigrants to get licenses, he has to enforce the law.

Dairy farmers at the meeting spoke about how the state law makes it difficult for their workers to get to and from work without risking tickets and arrest. Among the farmers: Hans Breitenmoser, who operates a 470-cow farm in Lincoln County, northeast of Abbotsford.

“Dairy cows are 24/7,” Breitenmoser said in an interview. “I don’t have the luxury of just shutting down the machines. We have to milk them every single day, three times a day. If someone doesn’t show up it’s kind of a big deal compared to in other industries; we’re dealing with live creatures.”

ProPublica reached out to the four Republican lawmakers who attended, as identified by the meeting’s organizers and other attendees. Sen. Jesse James declined to comment, though he recently told Wisconsin Public Radio he would be open to considering legislation to give undocumented immigrants access to driver’s licenses. Rep. Calvin Callahan did not respond to interview requests. But in a June press release, he explained how Republicans had removed “liberal wish list” items from the governor’s budget proposal, including driver’s licenses and other “new benefits for illegal immigrants.”

Meanwhile, Snyder and Rep. Donna Rozar, whose district includes Abbotsford, said they’d support legislation restoring driving privileges to undocumented immigrants in Wisconsin. But both acknowledged it’d be a tough sell to some of their Republican colleagues.

The real problem, they said, is Congress’ failure to fix the country’s broken immigration system.

“There are a lot of us that believe we’re being invaded and the federal government doesn’t care,” Rozar said. “And I get the sense that some of my colleagues believe that if we start chipping away at this undocumented worker issue, we are taking some of the responsibility away from the federal government to do their job.”

Maryam Jameel contributed reporting.

by Jodi S. Cohen and Jennifer Smith Richards

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

Update, Aug. 10, 2023: This story has been updated throughout with additional comment after Amara Harris was found not liable of violating Naperville, Illinois’ ordinance against theft.

Earlier this week, Amara Harris had one last chance to take a plea deal. For $100, she could have avoided a trial, the testimony of her former high school classmates and deans, and the stress of not knowing whether a jury would believe her when she said she had mistakenly picked up a classmate’s AirPods — not stolen them. It would’ve been over.

Instead, as she had for more than 3 ½ years, she chose to fight. Like other families and students across Illinois who have been ticketed by police for alleged behavior at school, Harris and her mother saw the system as unfair and capricious.

But in a rare move, Harris, now 20, went to trial, hoping to clear her name — even as she knew that municipal tickets are hard to beat because the burden of proof is so low.

On Thursday, Harris won her case when a six-person jury concluded the city of Naperville did not prove she knowingly took the AirPods and found her not liable of violating the local ordinance against theft.

“I feel vindicated, a weight lifted off my shoulder, and I can finish out my school year with nothing held over my head,” said Harris, who will return to Spelman College in Atlanta for her senior year next week. She said her heart was racing as the jury returned with a verdict, and her mother cried after it was read.

“I am just glad it’s over. I maintained my innocence, and they saw that I maintained my innocence,” Harris said.

Naperville prosecutor Joseph Solon Jr. declined to comment. City spokesperson Linda LaCloche wrote in a statement that there was enough evidence to ticket Harris and that it was “incontrovertible that this was a triable case.”

“We are glad that this matter has come to a conclusion,” LaCloche said. “The Defendant wanted her day in court and now that she has had it we are ready to move on.”

The verdict capped an extraordinarily unusual, drawn-out saga over a controversial municipal ticket issued to Harris when she was a junior at Naperville North High School, in DuPage County, west of Chicago.

The ticket issued to Harris in 2019. Redactions by ProPublica.

The case was decided after a three-day trial heard by a jury of two young women, including an 18-year-old college student, and four men, three of whom are fathers of teenagers. A trial over an ordinance violation, which carries a fine only and no jail time, is so rare that the judge and lawyers had to repeatedly tweak instructions and other procedures to adapt to this type of case.

Unlike in a criminal case, the prosecution only needed to prove that the allegation is more likely than not to have happened, a concept known as preponderance of the evidence.

The jurors’ decision came down to whether they believed Harris, who said she did not realize she had the wrong AirPods until a dean pointed it out, or her two classmates, who believed Harris purposely took them. To rule against Harris, the jury had to believe both that she had someone else’s property and that she “knowingly” took it, according to the city ordinance.

The jury deliberated for nearly four hours over two days.

“I don’t think there was enough evidence to show the case the city had to make,” said juror Jeff Talbot, 46, who has school-age children. “It wasn’t clear she knowingly took them.”

Between the time Harris was ticketed in 2019 and the trial this week, Illinois officials have taken steps to stop school administrators from working with police to punish students with municipal tickets for their behavior at school. Following a ProPublica and Chicago Tribune investigation, “The Price Kids Pay,” the Illinois schools superintendent told administrators to stop outsourcing discipline to police, and state lawmakers are considering ways to end school-based ticketing.

The investigation found that an assembly-line system of justice for municipal tickets made it nearly impossible for students to avoid fines, and that fines and administrative fees could reach hundreds of dollars, money some families could not readily pay. (Harris’ theft ticket carried a maximum $500 fine.) Unlike in juvenile court, there is no option for a public defender. And taking the case to a jury, as Harris did, requires incredible resources and commitment.

Students of color were ticketed more often than their white peers, the investigation found. At Naperville North, Black students were nearly five times more likely than white students to be ticketed by police over three school years examined, up until the spring of 2022. Racial disparities were not discussed in court; ahead of the trial, the prosecutor had successfully argued that the jury be instructed it could not decide the case based solely on race or other characteristics.

Harris, her family and attorneys said they will now turn her ordeal into an advocacy effort to stop the ticketing of students at schools across Illinois. They also intend to urge the Naperville school district to rethink how it involves police in low-level matters.

“We’ve got more work to do,” said Harris’ other attorney, S. Todd Yeary, the former CEO of the Rainbow PUSH Coalition, a Chicago-based civil rights organization founded by the Rev. Jesse Jackson.

They said Illinois must pass a law to protect students at school from being ticketed by police, an effort that stalled last session. They said they’ll look to the governor and legislators to take action so that other students don’t find themselves in the same situation as Harris.

“I hope they call it the Amara Harris bill,” said attorney Juan Thomas, founder of the civil rights and social justice section of the American Bar Association.

Even as schools reevaluate ticketing, Harris was still holding the ticket she was written at 17. She continued to be weighed down by the accusation that she was a thief even as her life moved on: She graduated early from high school, earned an associate’s degree at a local community college and has worked multiple jobs, even heading straight to her restaurant job from the trial two days this week.

Naperville police did not issue tickets at high schools through at least the first semester of last school year, and the district has tried to distance itself from Harris’ case, in part by saying the decision to ticket Harris was made by police. However, four school administrators, including the district superintendent, were called to testify and point out the defendant, their former student, in the courtroom. The principal said while she initially suggested that Harris get a one-day in-school suspension for the AirPod incident, the suspension was never issued.

First image: Civil rights attorney S. Todd Yeary represented Harris. Second image: Naperville prosecutor Joseph Solon Jr. arrives at the DuPage courthouse for Harris’ trial. (Taylor Glascock, special to ProPublica)

Minutes before jury selection began on the first day of trial Tuesday, Solon offered Harris a deal to settle the case with no fine and a $100 court fee — an offer he said he had made several times before. Harris would have had to agree that she could be found liable by a jury, something she said she could not accept since she says she accidentally picked up the AirPods and returned them to the rightful owner when school officials determined they weren’t hers.

“We offered to waive the fine because the case dragged on so long,” Solon told reporters outside the courtroom.

The testimony from nine witnesses, over two days, largely centered around two questions: How did Harris come into possession of AirPods that weren’t hers and when did she realize they weren’t hers?

The prosecution argued that Harris must have realized she took someone else’s AirPods when they didn’t automatically connect to her iPhone.

“She knew they weren’t hers and possessed them anyway,” Solon said. He said she didn’t turn them over until she was “caught with her hand in the cookie jar.”

On the witness stand, Harris and her mother, Marla Baker, established that Harris owned her own pair of AirPods before being accused of taking her classmate’s.

Harris took the stand in her own defense. (Cheryl Cook, special to ProPublica)

The defense introduced into evidence the receipt for Harris’ AirPods and a photo of her wearing them at a dinner celebration for her 17th birthday, just days before the alleged theft. Then Harris explained to the jury what happened.

On the morning of the alleged theft, Harris said she realized she’d left her own AirPods in a school common area, retraced her steps and saw an identical pair where she thought she left them. Thinking they were hers, she picked them up.

They didn’t sync initially, which wasn’t a red flag for Harris, she testified: “AirPods were notorious for unsyncing. I thought I had to resync them.” She said she easily resynced them and went on with her day, thinking they were hers, and got no alert on the device that they weren’t.

But Solon questioned Harris’ explanation that the AirPods automatically showed up with her name. He said that at that moment, she must have known they weren’t hers and manually renamed them. Harris corrected him: “If you know how AirPods work, when you sync them up, whatever name appears on your phone, appears on AirPods,” she explained.

From left to right, Solon, attorney Juan Thomas, Harris and Yeary. At back right is Judge Monique O’Toole. (Cheryl Cook, special to ProPublica)

No expert witness was called to testify about the technology and how it worked at that time. So the testimony about the device — about how those AirPods would have synced and been named at the time — was left unresolved.

Testifying for the prosecution, Ashley Sanchez, now 19, explained that she could not find her AirPods that day, either.

She told her father, who called the school to report them as stolen. (He was on the city’s witness list but did not show up at court; he previously told reporters he wanted nothing to do with the case.)

Sanchez explained during her testimony why she believed Harris had stolen them.

Ashley Sanchez, a former Naperville North High School student, is the owner of the AirPods that Harris is accused of stealing. (Cheryl Cook, special to ProPublica)

Days after Harris picked up the AirPods from the common area, Sanchez said a friend alerted her that she saw “Amara’s AirPods” show up as a paired device on her Chromebook, and “Ashley’s AirPods” no longer showed. (They had been paired before.) That friend, Gabriella Unabia, took a photo of what appeared on her Chromebook and sent it to Sanchez.

Sanchez went to Harris and asked her about them directly, Harris testified.

“She said, ‘Did you take my AirPods?’” Harris said, “I replied, ‘I don’t know what you’re talking about.’”

But Sanchez relayed her suspicion to a school dean that Harris had taken them from her backpack during a class they shared — and where her bag had been left unattended.

That became enough proof for the school police officer to accuse Harris of theft, and the prosecutor logged the photo as evidence in the trial.

“You have no evidence that Amara stole your AirPods?” Yeary asked Sanchez on the stand.

“Other than the picture, no,” she replied.

A series of other city witnesses acknowledged a lack of direct evidence that Harris knowingly took AirPods that weren’t hers.

Unabia, when pressed on how she could be sure Harris had stolen the device, said there wasn’t any direct evidence.

“So, you made an assumption?” Yeary asked.

“Yeah, I guess,” Unabia said.

James Konrad, one of Naperville North’s deans, also testified he had “no reason to think” Harris, whom he described as a well-rounded student with no disciplinary history, had stolen them.

Later in the day, after Sanchez went home and got the AirPods box, Konrad took Harris out of class and compared the serial number on the AirPods with the box. They matched. Solon repeatedly used that as evidence that Harris should have known the AirPods weren’t hers because of the serial number. But Harris said she had no idea about the serial number, and other witnesses testified that they also never had a reason to know the serial numbers on their devices.

Harris testified that after realizing she had Sanchez’s AirPods, she had no qualms about turning them over to the dean.

“I expressed to him that I don’t know how that happened, and if they’re not mine, I am not going to keep them,” Harris testified.

“You didn’t object?” “You didn’t run?” “You didn’t yell?” Yeary asked in quick succession. She answered no after each question.

The jury consists of two young women, including an 18-year-old college student, and four men, three of whom are fathers of teenagers. Also depicted is an alternate. (Cheryl Cook, special to ProPublica)

Even the officer who issued the ticket, Juan Leon, testified he had no direct evidence that Harris had sought to steal the AirPods instead of picking them up in error.

“You never got any factual information that Amara Harris knew the AirPods were not hers?” Yeary asked.

“No,” Leon said.

Leon testified that he initially wanted to give Harris a “station adjustment,” which requires parental approval and involves the minor talking with police and possibly doing community service. But when Harris’ mother refused to discuss that option with him, Leon said, he issued the ticket.

“Because she refused to have a conversation with you … you used your discretion to issue a ticket?” Yeary asked.

“Correct,” Leon replied.

Yeary reminded the jurors later in his closing argument of that testimony.

“He decided he would get mad and write a ticket because he could,” Yeary said. “That should be chilling to anyone who has children.”

After Leon issued Harris a ticket, the teenager refused to pay the fine. Naperville tickets are contested in DuPage County court proceedings, and after refusing to accept settlement offers in which Harris felt she’d still be admitting guilt, the case advanced to trial by jury.

“I didn’t steal them, so there was no need for me to pay a fine,” Harris testified Wednesday afternoon, repeating for the jury what she has said for years about why she didn’t simply pay the fine that came with the ticket. “I didn’t take the AirPods.”

Before the case went to the jury, Solon called Harris’ story “wholly unbelievable” and told jurors she must have gone into her classmate’s backpack, swiped the AirPods and then actively renamed them as her own.

Yeary appealed directly to the parents among the jurors.

“Imagine if it were your children sitting in Amara Harris’ seat. Would you want someone to tell you your child was liable for a mistake?” Yeary asked. “It’s almost like they are just saying pay the ticket and make it go away. Can you imagine how that sounds?”

LaCloche has said the city hasn’t spent extra money on legal fees for the case because it’s being handled by a city prosecutor, though he has spent many days in court handling it. A school district spokesperson would not immediately say whether the district has incurred costs, but multiple attorneys representing it were at the trial this week.

Harris and Baker outside the courthouse (Mustafa Hussain for ProPublica)

Outside the courtroom, Baker and Harris prayed together throughout the trial, sometimes holding hands. Baker said the case was about more than the ticket issued to her daughter, pointing to the reporting that has exposed how students across Illinois are ticketed by police for their behavior at school — with little chance of winning.

“We now know it’s not just us. This is about the thousands of children being thrown into the system without proper legal representation,” she said. “We hope this encourages people to fight even the smallest of injustices and fight for the truth.”

Correction

Aug. 10, 2023: This story originally misstated the day a verdict was handed down. It was Thursday, not Wednesday.

by Brett Murphy and Alex Mierjeski

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During his three decades on the Supreme Court, Clarence Thomas has enjoyed steady access to a lifestyle most Americans can only imagine. A cadre of industry titans and ultrawealthy executives have treated him to far-flung vacations aboard their yachts, ushered him into the premium suites at sporting events and sent their private jets to fetch him — including, on more than one occasion, an entire 737. It’s a stream of luxury that is both more extensive and from a wider circle than has been previously understood.

Like clockwork, Thomas’ leisure activities have been underwritten by benefactors who share the ideology that drives his jurisprudence. Their gifts include:

At least 38 destination vacations, including a previously unreported voyage on a yacht around the Bahamas; 26 private jet flights, plus an additional eight by helicopter; a dozen VIP passes to professional and college sporting events, typically perched in the skybox; two stays at luxury resorts in Florida and Jamaica; and one standing invitation to an uber-exclusive golf club overlooking the Atlantic coast.

This accounting of Thomas’ travel, revealed for the first time here from an array of previously unavailable information, is the fullest to date of the generosity that has regularly afforded Thomas a lifestyle far beyond what his income could provide. And it is almost certainly an undercount.

While some of the hospitality, such as stays in personal homes, may not have required disclosure, Thomas appears to have violated the law by failing to disclose flights, yacht cruises and expensive sports tickets, according to ethics experts.

Perhaps even more significant, the pattern exposes consistent violations of judicial norms, experts, including seven current and former federal judges appointed by both parties, told ProPublica. “In my career I don’t remember ever seeing this degree of largesse given to anybody,” said Jeremy Fogel, a former federal judge who served for years on the judicial committee that reviews judges’ financial disclosures. “I think it’s unprecedented.”

This year, ProPublica revealed Texas real estate billionaire Harlan Crow’s generosity toward Thomas, including vacations, private jet flights, gifts, the purchase of his mother’s house in Georgia and tuition payments. In an April statement, the justice defended his relationship with Crow. The Crows “are among our dearest friends,” Thomas said. “As friends do, we have joined them on a number of family trips.”

The New York Times recently surfaced VIP treatment from wealthy businessmen he met through the Horatio Alger Association, an exclusive nonprofit. Among them were David Sokol, a former top executive at Berkshire Hathaway, and H. Wayne Huizenga, a billionaire who turned Blockbuster and Waste Management into national goliaths. (The Times noted Thomas gives access to the Supreme Court building for Horatio Alger events; ProPublica confirmed that the access has cost $1,500 or more in donations per person.)

Records and interviews show Thomas had another benefactor, oil baron Paul “Tony” Novelly, whose gifts to the justice have not previously been reported. ProPublica’s totals in this article include trips from Crow.

Each of these men — Novelly, Huizenga, Sokol and Crow — appears to have first met Thomas after he ascended to the Supreme Court. With the exception of Crow, their names are nowhere in Thomas’ financial disclosures, where justices are required by law to publicly report most gifts.

From left to right, H. Wayne Huizenga, David Sokol and Paul “Tony” Novelly. These business magnates apparently came into Clarence Thomas’ life after he was appointed to one of the most sacrosanct positions of power in American government. (Joel Auerbach/Getty Images, Bloomberg/Getty Images and the Horatio Alger Association Website)

The total value of the undisclosed trips they’ve given Thomas since 1991, the year he was appointed to the Supreme Court, is difficult to measure. But it’s likely in the millions.

Huizenga sent his personal 737 to pick Thomas up and bring him to South Florida at least twice, according to John Wener, a former flight attendant and chef on board the plane. If he were picked up in D.C., the five-hour round trip would have cost at least $130,000 each time had Thomas chartered the jet himself, according to estimates from jet charter companies. In February 2016, Thomas flew on Crow’s private jet from Washington to New Haven, Connecticut, before heading back on the jet just three hours later. ProPublica previously reported the flight, but newly obtained U.S. Marshals Service records reveal its purpose: Thomas met with several Yale Law School deans for a tour of the room where they planned to display a portrait of the justice. (Crow’s foundation also gave the school $105,000, earmarked for the “Justice Thomas Portrait Fund,” tax filings show.)

Don Fox, the former general counsel of the U.S. Office of Government Ethics and the senior ethics official in the executive branch, said, “It’s just the height of hypocrisy to wear the robes and live the lifestyle of a billionaire.” Taxpayers, he added, have the right to expect that Supreme Court justices are not living on the dime of others.

Fox, who worked under both Democratic and Republican administrations, said he advised every new political appointee the same thing: Your wealthy friends are the ones you had before you were appointed. “You don’t get to acquire any new ones,” he told them.

Thomas and Novelly did not respond to a detailed list of questions for this story. Huizenga died in 2018 and his son, who is the president of the family’s holding company, also did not respond to multiple requests for comment.

In a statement to ProPublica, Sokol said he’s been close friends with the Thomases for 21 years and acknowledged traveling with and occasionally hosting them. He defended the justice as upright and ethical. “We have never once discussed any pending court matter,” Sokol said. “Our conversations have always revolved around helping young people, sports, and family matters.”

“As to the use of private aviation,” he added, “I believe that given security concerns all of the Supreme Court justices should either fly privately or on governmental aircraft.”

The justices have said they follow court rules prohibiting them from accepting gifts from a group of people so frequently that “a reasonable person would believe that the public office is being used for private gain.” But what actually constitutes a gift under those rules is ambiguous and, in practice, justices have few restrictions on what they can accept. Other members of the court have accepted travel underwritten by wealthy businessmen and speaking invitations at universities. Stephen Breyer accepted a flight to a Nantucket wedding from a Democratic megadonor. Ruth Bader Ginsburg took a tour of Israel and Jordan paid for by an Israeli billionaire. Those gifts are public because Breyer and Ginsburg disclosed them.

Thomas, however, is apparently an extreme outlier for the volume and frequency of all the undisclosed vacations he’s received. He once complained that he sacrificed wealth to sit on the court, though he depicted the choice as a matter of conscience. “The job is not worth doing for what they pay,” he told the bar association in Savannah, Georgia, in 2001, “but it is worth doing for the principle.”

To track Thomas’ relationships and travel, ProPublica examined flight data, emails from airport and university officials, security detail records, tax court filings, meeting minutes and a trove of photographs from personal albums, including cards that Thomas’ wife, Ginni, sent to friends. In addition, reporters interviewed more than 100 eyewitnesses and other sources: jet and helicopter pilots, flight attendants, airport workers, yacht crew members, security guards, photographers, waitresses, caterers, chefs, drivers, river rafting guides and C-suite executives.

ProPublica has not identified any legal cases that Huizenga, Sokol or Novelly had at the Supreme Court during their documented relationships with Thomas, although they all work in industries significantly impacted by the court’s decisions.

In a small-circulation biography given to Huizenga’s friends and family, Thomas acknowledged that he and Huizenga discussed some of the billionaire’s companies but said their relationship was never transactional. “It wasn’t that kind of friendship,” he told the interviewer. The justice said they’d prefer to go to a small restaurant in a strip mall or sit on the billionaire’s lawn and drink tea or diet soda.

“We are in a society where everything is quid pro quo,” Thomas said, but not with the Huizengas. “I don’t do anything for them and they can’t do anything for me.”

“Four Lucky Couples”

On Labor Day weekend 2019, Thomas boarded a private plane in Washington, D.C., for the first leg of a sojourn out West. The vacation had been months in the making and, thanks to Sokol, it was all taken care of. He’s hosted the Thomases virtually every summer for a decade.

The first stop was the Great Plains. It was the home opener at the University of Nebraska-Lincoln, which Ginni Thomas had attended before transferring. The Thomases were joined there by other couples, including one of the justice’s most vocal advocates, Mark Paoletta, who then worked for the federal government, and his wife.

Sokol, a major university donor who graduated from the Omaha campus, arranged for the group to attend the football and volleyball games with all-access passes. Clarence Thomas met with the football team the day before the game. The group walked out of the tunnel before kickoff. During halftime, they stood on the sidelines to watch the marching band perform, at one point posing for a picture in the end zone: “The Sokols took four lucky couples to the first Nebraska footbal game of the season,” Ginni Thomas wrote in one of the card captions.

Sokol, back left, has arranged for Thomas and others to attend several sporting events at the University of Nebraska-Lincoln. The invitations come with all-access passes and seats in a luxury suite. The justice’s wife, Ginni, has memorialized some of these trips in cards to friends. (Obtained by ProPublica)

Sokol runs a private equity firm and now also chairs a holding company that owns large international shipping and power utility corporations. He resigned from Berkshire Hathaway in 2011 amid an internal investigation by the company that found he had violated its insider trading policy. (At the time, Sokol denied wrongdoing and said his resignation was unrelated to the episode; he was never indicted.)

That Saturday, the group watched both the football and volleyball games from luxury suites. The football skybox, which typically costs $40,000 annually, belonged to Tom Osborne, a former Republican congressman who was also the head coach of the team for 25 years. Hosting the Thomases had ripple effects. A local priest requested a ticket for his 87-year-old mother, but the volleyball coach had to tell him none was available. “All of our tickets have been taken for Clarence Thomas and his group,” the coach wrote.

The Thomases have been treated to at least seven University of Nebraska-Lincoln games — five arranged by Sokol — in recent years. The Times first reported on Thomas’ appearances at some of them.

Thomas has never reported any of those tickets on his yearly financial forms. Judiciary disclosure rules require that most gifts worth more than $415 be disclosed. “It’s so obvious,” said Richard Painter, former chief White House ethics lawyer for President George W. Bush. “It all has to be reported.” ProPublica identified more than 60 federal judges who disclosed tickets to sporting events between 2003 and 2019. In 1999, Thomas disclosed private flight and accommodations for the Daytona 500 but hasn’t reported any other sporting events before or since.

In a statement, Osborne confirmed Thomas has “watched a couple of football games” in his suite, which the university had given to him. He said he is “taxed” for the use of the suite but did not answer whether Thomas has ever reimbursed him. The University of Nebraska-Lincoln did not respond to requests for comment.

On Labor Day weekend, 2019, the group sat in former football coach and ex-congressman Tom Osborne’s suite. Osborne told ProPublica he and the justice became friends years ago, when he was in office. (Obtained by ProPublica) The day before the football game, Thomas met with the team. Sokol arranged these visits in emails with the athletic department. (Twitter)

On Sunday, the morning after the football game in Nebraska, Sokol flew with Thomas by private jet to Sokol’s Paintbrush Ranch just outside Jackson Hole, Wyoming. The property, valued in the low eight figures, sits in the foothills of Shadow Mountain. A local radio personality said of the estate: “This is the ultimate home and it has the most iconic view of the Tetons I’ve seen. Ever.”

Sokol also owns a waterfront mansion in Fort Lauderdale, Florida, currently worth $20.1 million, where he’s hosted the Thomases as well, according to photos of the visits. The 12,800-square-foot property includes a home theater, elevator, walk-in wine cellar and yacht docking. (In addition, Sokol and Thomas have shared an opulent lodge together while vacationing at Crow’s private lakeside resort, Camp Topridge, in the Adirondacks.)

Sokol’s ranch outside Jackson Hole, Wyoming, which he sold in 2020, is a sprawling, 9,000-square foot estate in the foothills of Shadow Mountain, designed like a lodge. (Realtor Website. Personal information redacted by ProPublica.) The Thomases and others spent several days at the ranch in late summer 2019. (Realtor Website. Personal information redacted by ProPublica.)

In Wyoming, the Thomases fished, rafted on the Snake River and sat by a campfire overlooking the Teton Range with the other couples. At one point, the Paolettas serenaded the justice with a song they wrote about him.

Like Thomas, Paoletta did not disclose the trip on his yearly financial filings. At the time, Paoletta was general counsel and the designated ethics official at the Office of Management and Budget. In a statement, Paoletta said he wasn’t required to disclose the trip because he had reimbursed Sokol, but he did not say how much or provide documentation of those payments. “I complied with all ethics laws and regulations,” Paoletta said.

After the football game in Nebraska, Sokol flew the group, including the Thomases, to his opulent ranch overlooking the Teton Range. They rafted, fished and sat by a campfire. At one point, Mark Paoletta and his wife serenaded the justice. (Obtained by ProPublica)

Details of the vacation to Nebraska and Wyoming were drawn from photographs, trip planning emails and social media posts, as well as interviews with airport workers, local residents and others familiar with the travel, including river raft guides.

Since 1990, Sokol and his wife have donated more than $1 million to Republican politicians and groups, along with smaller amounts to Democrats. Last October, in New Orleans, Sokol made a direct reference to a pending Supreme Court case while addressing a group of former Horatio Alger scholarship recipients. (Thomas was not in attendance.)

The speech veered into territory that made many of those in attendance uncomfortable and left others appalled, emails and others messages show. Sokol, who has written extensively about American exceptionalism and the virtues of free enterprise, minimized slavery and systemic racism, some felt. He then criticized President Joe Biden’s student loan forgiveness plan, arguing Biden had overstepped the government’s authority, according to a recording of the speech obtained by ProPublica.

“It’s going to get overturned by the Supreme Court,” Sokol predicted, echoing a common legal commentary.

He was right. This summer, the court struck down Biden’s student loan forgiveness plan. Thomas voted in the majority.

Sokol has also hosted the Thomases and others at his mansion in Fort Lauderdale, Florida. The waterfront property, which comes with yacht docking, has a private movie theater, among other luxuries. (Obtained by ProPublica) Deep Sea Fishing in the Caribbean

Nearly every spring, Novelly, a billionaire who made his fortune storing and transporting petroleum, takes his two yachts on a fishing expedition to the Bahamas’ Exuma Islands. Photographs from the trips show porcelain beaches, cerulean waters and fresh mahi-mahi. Friends and family come and go for days at a time.

Three of Novelly’s former yacht workers, including a captain, told ProPublica they recall Thomas coming on board the vessels multiple times in recent years. Novelly’s local chauffeur in the Bahamas said his company once picked Thomas up from the billionaire’s private jet and drove him to the marina where one of the yachts, Le Montrachet, frequently docks.

Le Montrachet, named after the premium French wine, is a 126-foot luxury vessel complete with a full bar, multiple dining areas, a baby grand piano, accommodations for 10 guests and a handful of smaller fishing boats and jet skis. Novelly charges about $60,000 a week to outsiders who want to charter it.

Novelly often takes his luxury yacht, Le Montrachet, on fishing expeditions around the Bahamas’ Exuma Islands. The billionaire’s former yacht workers said Thomas was one of his guests. (CharterWorld Website)

Another past guest on Novelly’s yacht is “Alligator” Ron Bergeron, one of the biggest land and roadway developers in Florida. Around 2018, Novelly and Thomas went to Bergeron’s private ranch on the edge of the Everglades — a sprawling, gated estate with centuries-old cypress trees and an 1800s-style saloon on site. He described Novelly as a man who likes to share his success with others. “He’s very generous with all his friends,” Bergeron told ProPublica.

Bergeron said his conversations with Thomas at the ranch were strictly about charity work and not business. “You’re talking about a great man,” Bergeron said, “who gives his time to make a difference for America.”

Since 1999, Novelly’s family and companies have publicly disclosed at least $500,000 to conservative causes and Republican candidates in federal elections. (Before then, he had given to both parties.)

Novelly, who recently stepped down from his CEO roles, ran his business affairs aggressively, ending up on the wrong side of the government in at least two cases. He spends much of his time between St. Louis and Boca Raton, Florida, where he has a 23,000 square-foot palatial estate appraised at $22.2 million. In 2002, Novelly established residency and a holding company in the Virgin Islands. During a hearing with local officials, Novelly described the arrangement there as a “quid pro quo,” meaning the U.S. territory received a boost to the local economy in return for offering substantial tax breaks. The IRS would later call it an “abusive tax avoidance scheme” and pursued Novelly for millions in back taxes and penalties. Novelly denied the characterization and eventually settled with the government for a negotiated amount.

There’s no evidence his friendship with Thomas helped Novelly in one of his most significant disputes. In 2005, the Justice Department sued Novelly’s company, Apex Oil, because its corporate predecessor had contributed to a massive groundwater contamination beneath an Illinois village and then Apex refused to help with the cleanup. Apex argued the spill had occurred before the company went through a bankruptcy years earlier. Several judges ruled against Apex, which eventually appealed to the Supreme Court in 2010. The justices declined to hear the case, and the company had to pay about $150 million to help remove oil from the soil.

It’s not clear how Thomas voted in the case because such votes are not typically public. The vacations ProPublica identified appear to have occurred after the case was resolved.

In 2020, Apex Oil, Sokol and Crow helped fund a documentary defending Thomas as a response to an HBO film that was critical of the justice. Sokol called the HBO movie a “Molotov cocktail into our homes” and a prime example of America’s eroding civility.

The “Most Coveted” Invitation in the World

Thomas’ first billionaire benefactor is likely H. Wayne Huizenga, believed to be the only person in American history to build three separate Fortune 500 companies. One of the three was AutoNation, which Huizenga founded in 1996 before building it into the largest car dealer in the country. Between 1998 and 1999, Huizenga’s holding company spent $500,000 lobbying federal agencies that regulate the automotive industry, according to OpenSecrets data. Over the years, the Huizenga family and companies gave millions to state and federal Republican candidates and once threw a fundraiser for the Florida GOP that helped keep the party afloat for months.

The billionaire was known to regularly lavish gifts and perks on those in his orbit. He routinely took friends on opulent vacations. He paid his employees handsomely and sometimes covered their bills and personal expenses. On a whim, Huizenga once handed box tickets for the opera, which were worth thousands, to his caterer, Bob Leonardi.

“I led the life of a multimillionaire without being one,” Leonardi said.

Huizenga’s employees frequently saw Thomas around the billionaire’s mansion in Fort Lauderdale. Bob Leonardi, middle, was Huizenga’s caterer for years and said his boss liked to share his wealth with friends and employees. (Obtained by ProPublica)

For 20 years, Thomas benefited from Huizenga’s attention as well, availing himself of the billionaire’s fleet of aircraft and other luxuries. Huizenga took Thomas to see the Miami Dolphins and Florida Panthers several times between the mid-’90s and mid-2000s, according to interviews and photographs. Huizenga owned both teams at the time.

Executives saw Thomas around Huizenga’s office often. Richard Rochon, the former president of Huizenga Holdings, said Thomas once shadowed the billionaire during meetings. “He just wants to see what I do every day,” Rochon recalled Huizenga saying.

On at least two occasions, Thomas attended Huizenga’s birthday and Christmas parties, which the billionaire held inside his private hangar at the Fort Lauderdale airport. Van Poole, a lobbyist and former chairman of the Florida GOP, recalled riding down the elevator at the nearby Hyatt Pier 66 hotel — which Huizenga also controlled — when the Thomases stepped in with a security detail. The group discussed college sports and then traveled to the party together, Poole said.

Thomas occasionally flew on Huizenga’s helicopters, sometimes taking off from the roof of the corporate headquarters, and at least one of his Gulfstream jets around Florida, according to his former pilots. But the billionaire’s most luxurious planes were a pair of 737 jets he had retrofitted like a lounge, complete with recliners, love seats, mahogany dining and card tables and gourmet food.

At least two times in the mid 2000s, Huizenga sent one of them to pick up Thomas and deliver him to Fort Lauderdale, said John Wener, the flight attendant on board.

Huizenga owned a fleet of aircraft that he kept in a private hangar at the Fort Lauderdale airport. Two of the planes were 737 jets he had retrofitted to look like lounges. He sent those planes to pick up Thomas at least twice and deliver him to South Florida, according to a flight attendant on board. (Lynne Sladky/AP Photo)

Wener recalled chatting with the justice about his nomination to the Supreme Court and the tumultuous Senate confirmation hearings after Thomas’ former aide, Anita Hill, accused him of sexual harassment. “He said, ‘Just imagine a job interview and you’re in front of 100 people that hate you,’” Wener recalled Thomas remarking. “‘How would that interview go?’”

In the early 2000s, Huizenga gave Thomas something that was priceless at the time: a standing invitation to his exclusive, members-only golf club, the Floridian. Designed by golf legend Gary Player, the course was lined with cottages for Huizenga’s friends, a yacht marina for them to dock and a helipad if they wanted to fly in. One family friend told the Huizenga family biographer that the Floridian was “the most coveted private golf invitation in the world.” Those who worked and played there said the membership rolls were a Rolodex of the rich, famous and powerful: From Michael Douglas and Rush Limbaugh to Michael Bloomberg and former Vice President Dan Quayle. Donald Trump once asked to be a member but Huizenga spurned him, according to three of Huizenga’s former employees.

All 200-plus members were “honorary” and didn’t pay dues — Huizenga covered everything. “It was a little slice of heaven, a magical place,” former media personality Matt Lauer told the biographer. “You drove through the gates and it was this fairytale land that he had created.”

One of the crown jewels of Huizenga’s business empire was the Floridian golf and yacht club. When Huizenga owned the property, he gave honorary invitations to some 200 close friends without charging them an initiation fee or dues. Thomas was seen by several employees at the club over the years. (Floridian Website)

It’s unclear if Thomas was a member or Huizenga’s frequent guest with similar privileges. The billionaire’s former personal photographer and two former golf pros at the club recalled seeing Thomas there multiple times over the years. One of Huizenga’s helicopter pilots said he had picked the justice up from the property. And a fifth employee, a former waitress and concierge, said she once served Thomas and Huizenga, who were wearing golf attire, as they dined alone in the enormous waterfront clubhouse for lunch. “Have you met a Supreme Court justice?” Huizenga asked the waitress before she took their order. “This is Clarence Thomas.”

Today, the Floridian, which the Huizenga family sold in 2010 before it underwent renovations, has a $150,000 initiation fee.

Paying for Access to the Supreme Court Chambers

Thomas first met Huizenga at a formal gala in Washington, D.C., in 1992, when they were both inducted into the Horatio Alger Association. Henry Kissinger and Maya Angelou were among the other honorees that year. The organization, named after the 19th-century novelist who popularized rags-to-riches folklore, gives millions in college scholarships each year and also brings together some of the country’s wealthiest, self-made business tycoons for opulent events. (In real life, Alger was a minister on Cape Cod who resigned from his parish after he was credibly accused of molesting boys.)

“We were proud to honor Justice Thomas more than 30 years ago,” an association spokesperson said in a statement, “and remain grateful for his continued involvement in our organization.” She said Thomas spends countless hours mentoring scholarship recipients.

Thomas met Huizenga in 1992 at their induction ceremony in Washington, D.C. They became close friends for decades afterward and the billionaire, who died in 2018, regularly hosted Thomas in Florida. Thomas acknowledged the pair occasionally talked about business but said their relationship was never transactional. (Obtained by ProPublica)

Thomas appears to have met Huizenga, Sokol, Novelly and Bergeron through the organization. Several of Thomas’ trips to Florida in the 2000s appear to have been connected with the association. In that time period, he joined Huizenga at Horatio Alger scholarship ceremonies in South Florida, travel that the justice disclosed in several of his yearly financial filings.

However, he never identified Huizenga in any of his disclosures. The association spokesperson confirmed to ProPublica that the billionaire hosted those events “and covered all costs involved.”

Experts said that means Thomas’ disclosures would be, at a minimum, incomplete and misleading because the rules require federal judges to identify the source of the gifts they receive. “Source means the person or entity that paid for it,” said Kathleen Clark, a legal ethics authority at Washington University in St. Louis.

Belonging to the association has had its privileges. As part of a board meeting, the Thomases once went on a lavish trip to Jamaica, where they were hosted by a wealthy donor who owned a luxury hotel atop a former sugar plantation. Johnny Cash performed. Horatio Alger Association membership itself is worth at least $200,000, according to the organization’s meeting minutes in 2007, a sum that those who nominate a new member are responsible for raising in that person’s honor. The association spokesperson said there was no requirement to raise money for new members back when Thomas was inducted.

Thomas has likely helped the group earn many times that figure since then. Every year, the justice hosts an event for members inside the Supreme Court’s Great Hall. The Times previously reported that the event afforded the Horatio Alger Association unusual access to the court.

Membership into the Horatio Alger Association itself comes with a price tag. The association requires members to donate at least $200,000 on behalf of new inductees. A spokesperson said that when Thomas was inducted there wasn’t a donation requirement. (Obtained by ProPublica. Highlights by ProPublica)

ProPublica examined boxes of the association’s historical archives, including financial records that show the group has required donations of at least $1,500 — $7,500 for nonmembers — to attend the Supreme Court event. In 2004, those who donated $100,000 for a table at the main ceremony got 10 seats inside the Supreme Court. In the judiciary’s code of conduct — which is general guidance that does not apply to Supreme Court justices, though they say they consult it — there is explicit language advising federal judges against using their position to fundraise for outside organizations.

Financial records from the Horatio Alger Association archives show the group has been fundraising off of an event hosted by Thomas inside the Supreme Court building. (Obtained by ProPublica. Highlights by ProPublica.)

But that’s what Thomas has done, said Virginia Canter, a former government ethics lawyer who served in administrations of both parties and reviewed the association’s financial records at ProPublica’s request.

“To use the Supreme Court to fundraise for somebody’s charity is, to me, an abuse of office,” she said. Canter acknowledged the organization may do good work, but that’s besides the point, she said, because wealthy donors aren’t supposed to be able to pay thousands of dollars to visit a justice inside the courthouse walls.

“It’s pay to play,” Canter added, “isn’t it?”

Do you have any tips on the Supreme Court? Brett Murphy can be reached by email at brett.murphy@propublica.org and by Signal or WhatsApp at 508-523-5195. Justin Elliott can be reached by email at justin@propublica.org or by Signal or WhatsApp at 774-826-6240. Josh Kaplan can be reached by email at joshua.kaplan@propublica.org and by Signal or WhatsApp at 734-834-9383.

Josh Kaplan and Justin Elliott contributed reporting.

by Mary Hudetz

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We had reached the top of a sandstone mesa when Theresa Pasqual set down her hiking pole and scanned the storied canyon before us.

We could see the centuries-old buildings of Chaco Canyon, a site in northwest New Mexico that her tribe’s ancestors, the Ancestral Puebloans, had occupied before eventually establishing other communities in the region. Pueblo Bonito, the canyon’s largest structure, sprawled from near the base of the bluff where we stood, its walls arcing around hundreds of hollowed rooms.

Two colleagues and I had traveled to the canyon with Pasqual as part of our reporting on how the nation’s most prestigious museums and universities had excavated Native American cultural sites like this and how they continued to keep what they took.

Pasqual, who is from the Pueblo of Acoma, roughly 100 miles to the south, has visited this remote canyon countless times, starting some four decades ago as a child on trips with her father. Now, she is the director of the Acoma Historic Preservation Office.

She describes Chaco Canyon as a place to which Acoma people make pilgrimages. It is a sacred site, and multiple tribes trace their ancestry to it. It is also incomplete, void of the thousands of items and hundreds of ancestral remains that museums took during excavations that began in the late 1800s, she said.

“It’s like a looted palace somewhere in some other country,” said Pasqual. “What we see in Chaco now is really only the shell of what was once here.”

Theresa Pasqual, director of Acoma Historic Preservation Office, says Pueblo Bonito will be incomplete as long as items and human remains that came from the site are held in the collections of museums and educational institutions. (Russel Albert Daniels for ProPublica)

I first met Pasqual several months earlier as my colleagues and I began investigating why many museums have been slow to return human remains, burial items and sacred objects to tribes.

I had struggled to decide whether to report on the topic. As an Apsáalooke, or member of the Crow Tribe in Montana, I know how sensitive discussions of museum holdings and matters of repatriation can be for a tribal community. Where I grew up, museums had collected ancestors and precious objects, sometimes through exploitative purchases and sometimes through outright grave robbing. Contemplating this history as an Indigenous person can feel disturbing and dehumanizing.

How could I write about this issue, I often asked myself. But how could I not, given that it has lingered far longer than Congress intended when it passed the Native American Graves Protection and Repatriation Act in 1990.

NAGPRA called for institutions to inventory their collections and publicly report the human remains and items that had come from Native American graves and then return them to Indigenous communities. But Pasqual notes that tribal communities have shouldered the burden of this work — both the financial cost and the emotional distress. Her tribe, like others, had to draw on existing ceremonies to establish a new process for reburials that did not exist before the looting.

“We as a community have to carry that burden,” she told me. “Part of the cost is that emotional toll, the cultural, spiritual cost that is carried by the community.”

Leigh Kuwanwisiwma, former director of the Hopi Cultural Preservation Office in Arizona, shared a similar sentiment when I interviewed him. During his 30-year career, he reburied more than 8,000 ancestors for the Hopi Tribe. The number of belongings he buried with the deceased surpassed 15,000. Now retired, he has a sense of fulfillment, knowing he helped his tribe. But he also has had to cope with trauma, even anger, from confronting how institutions and government agencies have mistreated ancestral remains, he said.

“It’s not well documented what people like me have to go through,” said Kuwanwisiwma, who speaks with a soft and measured voice. “But it’s now part of our current historical trauma.”

Even after ProPublica has published multiple stories on repatriation over the past eight months, it is still unsettling to ponder the sheer scale at which museums stored away the bodies of so many Indigenous ancestors. Six thousand at Harvard University. Nine thousand at the University of California, Berkeley. (Both institutions have pledged to prioritize repatriation.)

In total, museums across the country hold the remains of 104,539 Native Americans, according to the most recent figures we have reported from the National Park Service, which administers NAGPRA.

Historical accounts show that tribal leaders from California to Maine opposed the plundering by outsiders and many tried to block archaeologists from desecrating burials on their lands.

On my reservation, Chief Medicine Crow, one of my ancestors, was so troubled by the looting that he donated some of his land so tribal members could have a cemetery in Lodge Grass, Montana, said Timothy McCleary, an anthropology professor at Little Big Horn College. Until then, the final resting place for many had been in the open, unpopulated countryside of our tribe’s homelands.

I think a lot about how this issue has persisted from Medicine Crow’s lifetime to mine.

Chief Medicine Crow (Edward S. Curtis/Library of Congress)

In the Southwest, where I live now, there was such an intense interest in the ancient dwellings of Ancestral Puebloans that major museums competed with each other to be the first to seize sites.

Richard Wetherill, a rancher-turned-amateur-archaeologist from Colorado, helped steer the American Museum of Natural History to Chaco Canyon. From the canyon, the museum collected the remains of some 150 Native American ancestors during a methodical yet aggressive expedition around the turn of the 20th century that was funded by two heirs to a soap fortune.

The museum’s archaeologists directed the excavations while Wetherill served as their guide. He established a homestead in the canyon during the expedition and managed to keep it after Chaco Canyon became a national park.

Ever since, researchers have been fixated on Pueblo Bonito. Called a “great house,” it once stood four stories tall, according to the National Park Service, and has 40 kivas, ceremonial and social spaces with brick-lined walls.

Our reporting at ProPublica has focused, in part, on how museums have kept many ancestors by saying that, based on their records, they cannot determine which tribe these human remains belong to. Sometimes institutions make these decisions even when tribes have documented ancestral ties to the place that was excavated and have presented that information to the museum or made it publicly known.

The American Museum of Natural History holds the largest collection from Chaco Canyon that has been publicly reported under NAGPRA rules. In a statement, the museum said it recognizes Pueblo peoples’ ties to the canyon. However, the museum said there are gaps in the archaeological record after the Ancestral Puebloans migrated from the canyon eight centuries ago, which makes it difficult to affiliate human remains and items to specific tribes.

For Pasqual, Chaco Canyon, known in her tribal language as Wa’asrp’ashak’a, emerges often in the telling of her ancestors’ migration, she said. She had heard the term often enough in her youth that by the time her father first took her to the site around age 9, she already felt profoundly familiar with and connected to the place, she said.

Others from Zuni Pueblo in New Mexico and the Hopi Tribe in Arizona also shared with me how they see evidence of their cultural ties to Chaco Canyon all around them.

Pueblo Bonito contains dozens of kivas, or underground ceremonial spaces. (Russel Albert Daniels for ProPublica)

Clark Tenakhongva, a former vice president of the Hopi Tribe, understands his cultural link to Chaco Canyon through his tribe’s oral histories, he said. The Hopi believe they had great engineers, astronomers and doctors among their ancestors. At Chaco Canyon, where a southern wall of Pueblo Bonito aligns with the sunrise on the equinox, his tribe refined that knowledge and maintained it after migrating to the mesas in Arizona where many live now, he said.

“All the education and knowledge that we have — we have within our homes, within our kivas, within our plazas — came from here,” said Tenakhongva, who once helped lead efforts to protect cultural landscapes like Chaco Canyon and Bears Ears National Monument in Utah.

Edward Wemytewa, a councilman from the Pueblo of Zuni, simply calls Chaco Canyon a home.

“We’re descendants of Chaco. That’s very clear,” he said. “We are still a living culture. We still practice our ceremonies.”

This year, the Interior Department is considering changes to regulations under NAGPRA that would speed up the repatriation process. But even if change comes, repatriation will take time, likely years.

Yet even though much time has passed, repatriation work that’s just beginning now should not be rushed, Pasqual said. When museums work with tribes to return ancestral remains and items, tribal representatives meet with museum staff in person to discuss what was taken and stored for decades, and the tribes have seen the institutions become better as a result of these consultations, she said.

Pasqual descends a mesa along Chaco Canyon. (Russel Albert Daniels for ProPublica)

One expert we interviewed said that if the institutions continue repatriating at their current pace they would need another seven decades to consult with tribes and return what they have.

As we stood on the mesa, I asked Pasqual what she hoped would come of the repatriation work she and others have done. I was considering a similar question as our reporting team thought about the potential impact of our investigation.

“I would hope that for future generations, like my family’s grandchildren, that there will come a time when they will know that this place is complete,” Pasqual responded.

It was late afternoon as we descended onto a trail that threads between massive boulders and cliff ledges before reaching the canyon floor. Soon, we were walking down a wide dirt path past a cemetery named for Wetherill, the rancher. Wetherill is buried just off the trail; his grave lies undisturbed not far from the burial sites and rooms he helped excavate.

But Pasqual hardly acknowledged this point on the trail. Instead, we made a final stop near a sign on the north side of Pueblo Bonito that details the ways tribes remember their ancestors’ time at Chaco Canyon: “songs, stories, languages, ceremonies, pottery, art, corn, shells, architecture and sun-watching.”

She had read the sign countless times on her visits. People may have moved away, but they did not forget Chaco Canyon, it says.

She climbed into her truck and began her drive back to Acoma Pueblo.

Fajada Butte juts up from the plain near Chaco Canyon in New Mexico. (Russel Albert Daniels for ProPublica)

by Annie Waldman

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Cheryl Lee Carr clutched her phone, willing it to ring. The last time she’d answered it, a hospital surgeon told her he didn’t know if he could save her mother’s leg, let alone her life. But he would try to stop the hemorrhaging from her major leg artery, punctured by a doctor at a nearby clinic.

Carr had spent that morning in February 2020 at the Lehigh Valley Vascular Institute in Bethlehem, Pennsylvania, waiting as her 82-year-old mother underwent what was supposed to be a simple procedure to clear plaque from her arteries. More than four hours in, Carr knew something was wrong. She pushed past the front desk to find her dazed mother in a recovery room, two clinic employees holding a bloody compress over a leg that had turned deep purple.

“Where’s the doctor?” Carr recalled yelling. “Call 911 right now!”

Now, as Carr braced for news about her mother’s fate, her thoughts turned to the clinic’s doctor who, she recalled, was nowhere to be seen as his patient bled. Carr pulled up a search engine and typed in his name: James McGuckin.

A deluge of results poured in.

What the hell? she seethed as she scrolled. Why is he still practicing?

For more than a decade, the Pennsylvania doctor and his national empire of vascular clinics had been scrutinized by agencies at every level — state medical boards, the Food and Drug Administration, the Department of Justice — for conducting experimental or unnecessary procedures on patients, putting their lives and limbs at risk.

He’d been disciplined by medical boards in over a dozen states, lost privileges in multiple hospitals and settled federal allegations of fraud, admitting that his company had performed procedures without any documented need. Pennsylvania had tried to shut his clinics down. Just a few months ago, federal attorneys announced a case against him, claiming he put “profits over the health and safety of his patients” when performing invasive artery procedures, regardless of symptoms or need.

And yet, after all of that, McGuckin is still seeing patients today, still adding to the nearly $50 million he has earned in the past decade in federal insurance reimbursements.

Dr. James McGuckin

Medical boards are supposed to ensure doctors are not endangering their patients. State health inspectors are supposed to make sure facilities are meeting minimum standards of care. And the federal government is supposed to make sure that doctors are not swindling the nation’s largest insurance program, Medicare, by exploiting vulnerable elderly patients.

But the ability of McGuckin to continue practicing, despite scrutiny from each of these regulators, highlights troubling gaps in the public safety net, ProPublica found. Those charged with identifying and stopping problem physicians are often slow-moving, blind to holes in their oversight and frequently unable — and at times unwilling — to stop doctors from practicing, even in cases of egregious harm or brazen fraud. Punishments are often nominal or easy to avoid, especially for well-resourced doctors like McGuckin.

One area that has become perilous for patients is vascular medicine. ProPublica recently uncovered a pattern of excessive and unnecessary vascular treatments in outpatient facilities. Medicare reimburses generously for these invasive treatments, which include using stents and balloons to widen arteries, and spiraling blades or lasers to clear plaque from blocked vessels, in a procedure called an atherectomy. Though they can be done safely outside of hospitals, they carry risks of complications that include clots, bleeding, limb loss and even death.

Over the past decade, federal investigators have accused more than a dozen physicians or companies in the vascular space of performing unnecessary procedures or making false claims. Some have continued to treat patients and profit from government insurance even after settling misconduct claims, only to be accused of committing similar behavior a few years — and millions of dollars — later.

At 61, with eyes that matched his bluish scrubs, McGuckin earned the trust of his patients, many of whom came to him for help with leg pain or circulation problems; several told ProPublica he appeared knowledgeable, caring and charming. One of the perks of going to see him was a limousine service that ferried them to and from appointments, they said.

Several of his patients faced complications after invasive vascular procedures — two lost their legs and several nearly lost their lives, according to interviews and medical and legal records. “The things that have happened to me have been a disaster,” Maria Rohena, 69, said in Spanish as she wept. Her leg was amputated five days after a procedure in McGuckin’s clinic in July 2021, according to medical records.

Maria Rohena’s grandson cares for her in a nursing home. Her leg had to be amputated five days after a 2021 procedure in McGuckin’s clinic, according to medical records. (Kriston Jae Bethel for ProPublica)

McGuckin’s attorney David Heim described him as a “very good, skilled surgeon who has helped thousands of patients,” many of them at higher risk. “Any effort to portray Dr. McGuckin as some ‘greedy’ or ‘bad’ doctor would be completely false and defamatory,” he said. Heim did not respond to ProPublica’s questions about specific patients, citing privacy. McGuckin’s attorneys said that he has never been found personally liable for fraud and that the government’s most recent allegations are “provably wrong.”

Carr could not anticipate, as she waited for the call that winter day, just how bleak it would get. “My mother would never have gone under the knife with that guy if I had known anything about him,” she said.

“A Question of Accountability”

From an early point in his career, McGuckin wanted to be calling the shots.

After completing his medical degree in 1987 from Philadelphia’s Hahnemann University School of Medicine, now Drexel University College of Medicine, he earned his board certification in radiology, eventually publishing articles in academic journals and participating in several professional societies, including the American Board of Radiology, the Society of Interventional Radiology and the Pennsylvania Medical Society.

While working in hospitals, he felt he was just “a small cog” in the system, he said in an interview. So, in 2002, a few years after completing his medical training in Philadelphia, he opened his first private practice office.

Before long, he would open a chain of facilities, Vascular Access Centers, that would reach a dozen states under his leadership, and thousands of patients.

“Here, the physician gets to be the pitcher or quarterback,” he said in the interview, of running an office. “We call the plays, set the schedule, drive the tempo. … There is never a question of accountability or the primacy of the customer.”

But there were soon questions of accountability and appropriate care.

Around 2010, McGuckin started offering a controversial procedure: an invasive, experimental treatment for multiple sclerosis, which involved deploying balloons and stents in veins across the body to improve blood flow. The treatment, which lacked substantial evidence that it improved patient symptoms, was rejected by the medical establishment, and the use of devices for the treatment was unapproved by the FDA. Only about 30 doctors performed it, often charging thousands of dollars to do so.

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)

McGuckin became a leading evangelist for the treatment, conducting hundreds of the risky procedures on patients, including a South Carolina woman who, in May 2012, nearly died after a stent dislodged and traveled to her heart. The Milwaukee Journal Sentinel, which wrote about the case, reported that the patient sued McGuckin in 2015 and the case was confidentially resolved two years later.

In July 2012, FDA inspectors showed up at one of his facilities and cited him for multiple violations, which are spelled out in an April 2013 letter. They included enrolling patients in unapproved clinical research; failing to screen for abnormal kidney function, which could have subjected patients to renal failure; and not reporting serious adverse events.

Despite evidence that such treatments put patients in grave danger, none of the medical boards in the more than a dozen states in which he was licensed to practice took action for more than a year. Some boards took four years.

State medical boards serve as the first line of defense against unscrupulous physicians. Typically composed of doctors and laypeople working part time, boards regulate who can practice medicine and investigate complaints of poor care.

But they are not set up for aggressive or speedy detective work. Take the board in McGuckin’s home state of Pennsylvania, which oversaw more than 75,000 health care workers as of 2021; it had a budget of roughly $1.2 million to investigate misconduct that year, or about $290 per case opened.

For this reason, boards don’t typically seek out investigations; they wait for patients, staff or other doctors to formally complain. They are slow to act and notoriously lax with their sanctions, aware that bold actions may provoke a costly and time-consuming appeals process.

Washington was the first state to sanction McGuckin, in November 2015, after a lengthy investigation that began four years earlier. It charged him with “unprofessional conduct” for performing more than 200 procedures, fined him $17,500, made him return the money patients paid out of pocket and ordered him to stop the treatments.

It also required him to pass an ethics course by writing an essay, which evaluators found unacceptable, saying McGuckin didn’t “demonstrate a capacity to think ethically about why he is being held to account.” McGuckin filed a second draft, which was also unsatisfactory. He only passed the course with help from a one-on-one tutor.

The Washington Medical Quality Assurance Commission, which oversees doctors in the state, also made him sign a consent decree, admitting that the invasive procedures were inappropriate. Years later, during a lengthy bankruptcy lawsuit involving his chain, he would testify that he signed it because he felt he had to but didn’t feel he was guilty of the misconduct.

“It is clear to the Court that McGuckin is willing to sign documents, like the Consent Decree, even if he does not believe that his statements are true,” U.S. Bankruptcy Judge Ashely M. Chan, in Philadelphia, would say in 2020. “The Court finds that McGuckin is not truthful and cannot be relied upon for anything that he says.”

By 2017, 15 other state medical boards had followed Washington in citing McGuckin for the MS treatments. Most of the sanctions, however, constituted minimal fines, often less than what McGuckin could bill for a single two-hour vascular procedure.

Pennsylvania, for instance, charged him $10,000 in 2016. That year, he took in almost $4 million in federal reimbursements alone.

In a letter shared with ProPublica, McGuckin’s attorney George Bochetto said the doctor “was not disciplined because he performed a so-called ‘unproven and risky procedure,’ but rather was ensnared in a complicated administrative bureaucracy.”

While he lost hospital privileges across four facilities in Pennsylvania and New Jersey, no medical board limited his ability to practice.

“Bang ’Em All”

All the while, federal agents were investigating McGuckin for an entirely different set of allegations.

While states regulate medical facilities and doctors, the Department of Justice attempts to protect the nation’s largest insurance systems, like Medicare, from fraud. Its investigations are often instigated by whistleblowers, whose inside testimony is crucial to uncovering details of wrongdoing.

Dr. Michael Levine, a seasoned nephrologist with an expertise in hemodialysis vascular access, started working for McGuckin in 2009 at multiple New Jersey clinics that were part of Vascular Access Centers.

“At first, there was no red flag,” Levine told ProPublica. The clinics mostly treated patients with renal disease whose vessels occasionally needed treatment related to their dialysis lines. But Levine said he quickly learned that patients were being put into treatment loops where they were regularly booked for unneeded tests and procedures. “They were having the patients come back every three months, which to me is corruption,” he said.

While the procedures were relatively low risk, each time a doctor puts a foreign device in a patient’s body, it carries a chance of complication. Levine said he was therefore shocked when McGuckin pushed him to do more procedures without a clear clinical need.

McGuckin ordered each dialysis patient to be “squirted with dye,” Levine said in court records, implying that all patients should be subjected to an X-ray test to fish for blood clots or narrowed vessels to treat, regardless of whether their primary doctor ordered it.

McGuckin also allegedly told Levine to treat patients’ vessels with inflatable balloons and implant stents without a medical need. “Bang ’em all,” McGuckin allegedly told him, according to legal filings.

When Levine refused to go along with this practice, he said he was fired. Shortly after, in 2012, he filed a whistleblower lawsuit, which spurred a federal investigation.

“It’s not an issue of competency,” he told ProPublica. “It’s the issue of using his skills for his own self benefit and seeing his patients not as human beings, but as sources of income.”

David Stebbins, who was the administrator director of the centers from 2006 through 2018, said he also witnessed McGuckin’s drive to increase profits with unnecessary procedures. “McGuckin exerted pressure on all of the MDs working for him to increase procedural ‘acuity,’” he told ProPublica in an email. After more than a decade of working for McGuckin, when Stebbins questioned whether the clinics were possibly violating state regulations, he said he, too, was let go.

“McGuckin is an arrogant Charlatan who expects his senior staff to do whatever they’re told, or they may find themselves looking for work,” said Stebbins, who filed a separate whistleblower complaint in 2020, which is ongoing. “Under incredible pressure, they comply.” Attorneys for McGuckin did not respond to Stebbins' allegations.

Despite allegations that patients might be at risk of unnecessary, invasive procedures, it still took six years for the Justice Department to settle the claims initiated by Levine.

In October 2018, Vascular Access Centers signed a settlement with the federal government, agreeing to a $3.8 million fine. As part of the agreement, the company had to admit that it regularly scheduled, performed and billed for procedures without any evidence of need.

But as is the case with many federal settlements involving doctors, they are rarely held personally liable, or they can just pay steep fines to get out of trouble.

While McGuckin signed the company’s agreement with the federal government, as the company’s general partner and manager of each of its clinics, he was not held personally responsible for its misconduct. No physicians were specifically called out in the federal settlement; McGuckin’s attorney said the government chose not to pursue a case against him because there was no evidence implicating his physician services.

But McGuckin’s business partner claimed in the bankruptcy case that McGuckin had negotiated with the government and agreed to the terms of the burdensome settlement in exchange for securing his own personal release.

McGuckin’s signatures on a settlement (United States Court for the Eastern District of Pennsylvania)

At his clinics across Pennsylvania that were not affiliated with the embattled chain, McGuckin could still continue to treat patients unchecked.

Other doctors have gotten a similar deal.

Take Dr. Feng Qin, a vascular surgeon in New York.

In 2015, he settled allegations of fraud, admitting that he had routinely performed unnecessary procedures on end-stage renal disease patients. He paid a $150,000 fine but was able to continue practicing.

Even after the settlement, Qin performed unnecessary procedures, according to federal legal filings. “The monitoring by the feds, I know how to play Medicare’s asses now,” he told his billing assistant in 2015, according to a later whistleblower complaint.

Three years later, the Justice Department indicted and arrested Qin for fraud, after which he agreed to another settlement, paying $800,000. Lawyers for Qin, who left the country after the settlement, did not respond to ProPublica’s emailed questions.

Though Qin was temporarily excluded from federal health care programs, other doctors have continued to receive government payments even after multiple settlements.

Consider Dr. Mubashar Choudry, a cardiologist in Maryland. He was never found guilty of patient harm, but his medical practices have twice been scrutinized by the Justice Department for alleged misconduct.

In 2014, his medical group agreed to pay about $1.9 million to settle allegations that it was involved in an overbilling scheme. Then in 2020, Choudry and his practices settled allegations of kickbacks with the federal government, paying $750,000. In both cases, neither Choudry nor the companies were required to admit liability.

Kirk Ogrosky, Choudry’s attorney, said such arrangements are typical, and his client settled to “avoid the cost and uncertainty of litigation.” His attorney emphasized that Choudry’s settlement was not about the quality of patient care.

Choudry has not been limited from practicing or accessing federal payment programs. In 2021, the most recent year of public Medicare data, Choudry earned $1.5 million in federal reimbursements.

The settlement against McGuckin’s clinics also didn’t prevent him from continuing to bill Medicare.

Between 2019 and 2021, the most recent years of federal payment data available, McGuckin made more than $17 million.

Putting “Profits Over the Health and Safety of His Patients”

While medical boards oversee doctors, state health departments regulate medical facilities, which can include clinics like McGuckin’s. Their investigations, too, are largely driven by complaints and rarely result in major consequences.

So it was remarkable that, in 2019, Pennsylvania’s Health Department decided to take on McGuckin after officials read about his company’s federal settlement in The Philadelphia Inquirer.

At the time, he owned four clinics in the state that weren’t affiliated with the chain.

The department reviewed their license applications and found that the clinics had “failed to fully, completely, and accurately” disclose pertinent details about the federal scrutiny involving McGuckin and his other company. In January 2019, the department issued rare orders for four of his private clinics, revoking their licenses and cutting off their ability to operate.

McGuckin appealed the orders and his lawyer argued that a shutdown would expose his clinics’ patients to “irreparable harm” without their care. His lawyer also noted that the department had based the order on the assessment that McGuckin was “not a responsible person,” instead of relying on claims of patient harm or complaints. His lawyer also said that because McGuckin was not held personally liable in the settlement, he had been exonerated from its “salacious” allegations.

Garrison Gladfelter, who oversees surgical centers for the state, told McGuckin’s attorney in letters that, pending the appeal, McGuckin’s facilities could continue to operate on one condition: that he not personally perform procedures or provide training to the medical staff.

In response, McGuckin sued Gladfelter as well as the state’s health secretary, Dr. Rachel Levine, alleging that his clinics’ licenses were unlawfully revoked and their attempt to ban him from working at his own practices infringed on his “constitutional right to practice medicine.”

The lawsuit continued for eight months, and in October 2019, it was dismissed with an acknowledgment that the issues between McGuckin and the state had “been settled.”

The details of this settlement were kept secret. There’s no public evidence of why McGuckin’s facilities were allowed to continue to operate, with him performing procedures. The Health Department told ProPublica that, after the confidential settlement, it increased oversight at two of McGuckin’s facilities.

But against the tide of litigation, the Health Department largely backed off, and like the state medical boards and the Justice Department before it, it allowed McGuckin to continue to practice.

And so he did, for almost four years.

All the while, federal authorities had more information indicating his patients were at risk.

Two months after the federal settlement, in December 2018, yet another whistleblower filed a complaint: Dr. Aaron Shiloh, who was employed by McGuckin in his private practice in Pennsylvania. In a letter, McGuckin’s attorney Bochetto called him “disgruntled.” Shiloh’s attorney pushed back, requesting further details, but McGuckin’s attorneys did not respond to ProPublica’s request for more information.

His claims would lead attorneys from the Justice Department to conclude that from 2016 through 2019, McGuckin performed more than 500 medically unnecessary or insufficiently documented procedures, which allowed him to earn at least $6.5 million in Medicare reimbursement. They also found that McGuckin performed several invasive procedures on many patients, regardless of their symptoms, putting “profits over the health and safety of his patients.”

The procedures are intended for patients with peripheral artery disease, a condition that afflicts 6.5 million Americans over the age of 40. According to the federal government, McGuckin not only performed procedures on patients with only “moderate” leg pain, against the widely accepted standards of care, he also performed procedures on patients who were disabled and and unlikely candidates for such interventions.

He performed procedures for leg pain in a patient who was paralyzed on one side of her body and did not walk at all, according to the complaint. On another patient, the government said, he conducted “unnecessary below-the-knee procedures in the small portion of what remained of a patient’s already amputated leg.” One patient told the federal government, according to legal filings, that he felt like McGuckin “was just experimenting on him.”

Earl Toler of Long Pond, Pennsylvania, told ProPublica he also felt part of an experiment. He sought treatment at 74 after experiencing weakness in his leg when walking. Over about a year, Toler underwent 10 vascular procedures, according to later legal filings. His condition progressively worsened until his left leg grew swollen and mottled and one of his toes turned dark blue.

To save his life, in November 2018, doctors at a local hospital needed to amputate his leg above the knee. During a malpractice lawsuit against McGuckin and other doctors at his clinic, medical experts who testified on Toler’s behalf claimed the doctors had deviated from the accepted standards of care, particularly in not referring Toler to a vascular surgeon for more advanced treatment, which they alleged eventually led to his limb loss. In legal filings, McGuckin denied the allegations. The lawsuit went to trial last year, and the jury sided with McGuckin and his doctors, clearing them of any wrongdoing.

Despite the verdict, Toler, an excavation contractor by trade who can largely no longer work after his amputation, still holds them responsible for his condition. And when he read over the allegations of the current Justice Department lawsuit, he was floored. “It’s a pattern,” he said. “I knew I wasn’t the only one.”

Earl Toler had his leg amputated after several procedures in McGuckin’s clinic. (Michelle Gustafson for ProPublica)

Two and half years after Toler’s amputation, Rohena, a churchgoing grandmother from the Allentown area, blacked out and had a heart attack in McGuckin’s recovery room, according to medical records. The clinic called an ambulance to take her to the nearest hospital, where medical staff found a main artery had been nicked, causing extensive blood loss. Rohena was treated for five days before her leg was amputated.

A lawsuit has been initiated, according to her attorney Frank Mangiaracina. “Maria is stuck living in a nursing home, and she doesn’t have her leg or life anymore,” he said.

According to clinic medical records, Rohena had undergone four treatments with McGuckin in two months.

A ProPublica analysis of federal payment data from 2017 through 2021 found that McGuckin ranks among the 5% of doctors who perform the most atherectomy procedures like the one Carr’s mother, Toler and Rohena underwent before facing complications.

Recent research has shown that a substantial number of doctors who treat peripheral arterial disease are quickly resorting to device interventions in the earliest stages against best practices. Doctors have used scare tactics to convince patients to get these painful and risky procedures; McGuckin, for instance, allegedly told patients the interventions were necessary to “save their leg” or “stop the chop.” But patients in early stages of vascular disease have less than a 2% risk of amputation after five years, researchers have found. That risk could surge up to 5% or even 10% with aggressive interventions.

McGuckin’s attorneys argued the federal allegations are “baseless” and “irreparably tarnish” his reputation. “McGuckin did not violate any medical standards of care in treating his patients,” his attorneys wrote in legal filings. “The Government’s medical necessity claims amount to nothing more than a ‘scientific disagreement.’”

Justice Department investigations into whistleblower claims are kept secret until prosecutors are ready to file a lawsuit. They did so in May 2023. Despite McGuckin’s arguments that it should be dismissed, it is ongoing.

According to the Health Department, McGuckin has closed or relinquished ownership of his clinics across Pennsylvania in the past few years. When ProPublica called the Lehigh Valley Vascular Institute in July to inquire whether he was still practicing, the receptionist said he was taking appointments.

“Penniless and Paralyzed”

Cheryl Lee Carr (Michelle Gustafson for ProPublica)

A few weeks ago, Carr pored over the details of the new federal case. It brought her to tears.

Though that phone call back in 2020 brought good news — the hospital surgeon managed to save her mother’s life and leg — the aftershocks took a lasting toll.

While recovering at the hospital, her mother, Elaine Micelli, struggled to use her left arm, and one side of her face drooped. Carr suspected her mother had developed a neurological issue. “She asked me to go down the hall and get her a box of tissues from her closet — she thought she was at home,” she said.

An assessment at the hospital revealed she had suffered strokes, medical records show, likely due to the low blood pressure, which she had when she was admitted.

Before her visit to McGuckin, the 82-year-old still mowed her 2 1/2 acre lawn in the summer and cleared snow with her blower in the winter. She volunteered for the crime watch at the local fire department and, every week, called bingo numbers at the senior center.

Elaine Micelli, a former patient of McGuckin’s (Courtesy of Cheryl Lee Carr)

Now, she lives in a nursing home and requires 24-hour care. She no longer walks, requires assistance to eat and wears diapers. She cannot speak fluidly or remember key moments of her past. “He destroyed my mom’s life,” Carr said of McGuckin. “She’s penniless and paralyzed … just waiting to die.”

Shortly after her mother’s injury, Carr said she filed a formal complaint about McGuckin with both the state’s Medicare office and its medical board.

Three years on, she said, she has not received a response.

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

by Alec MacGillis

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This story is exempt from our Creative Commons license until Dec. 2, 2023.

One fall evening in 2020, Jarell Jackson and Shahjahan McCaskill were chatting in Jackson’s Hyundai Sonata, still on a post­-vacation high, when 24 bullets ripped through the car. The two men, both 26, had been close friends since preschool. They’d just returned to West Philadelphia after a few days hang gliding, zip lining and hiking in Puerto Rico. Jackson was parked outside his mom’s house when a black SUV pulled up and the people inside started shooting. Both he and McCaskill were pronounced dead at the hospital.

In the aftermath, McCaskill’s mother, Najila Zainab Ali McCaskill, couldn’t fathom why anyone would want to kill her son and his friend. Both had beaten the odds for young Black men in their neighborhood and graduated from college. Jackson had been a mental health technician in an adolescent psych ward while her son had run a small cleaning business and tended bar. She wondered if they’d been targeted by a disgruntled former employee of the cleaning business. But then the police explained: Her son and his friend had been killed because of a clash on social media among some teenagers they’d never even met.

Shahjahan McCaskill, left, and Jarell Jackson were close friends since preschool. (Courtesy of Monique Jackson)

For months, a battle had been raging on Instagram between crews based on either side of Market Street. Theirs was a long-running rivalry, but a barrage of online taunts and threats had raised tensions in the neighborhood. Police had assigned an officer to monitor the social media activity of various crews in the city, and the department suspected that the Northsiders in the SUV had mistaken one of the two friends for a rival Southsider and opened fire. An hour after the shooting, a Northsider posted a photo on Instagram with a caption that appeared to mock the victims and encourage the rival crew to collect their bodies: “AHH HAAAA Pussy Pick Em Up!!”

Jackson and McCaskill died in the first year of a nationwide resurgence in violence that has erased more than two decades of gains in public safety. In 2020, homicides spiked by 30% and fluctuated around that level for the next two years. There are early signs that the 2023 rate could show a decrease of more than 10% from last year, but that would still leave it well above pre-pandemic levels.

Najila Zainab Ali McCaskill in front of a portrait of her son Shahjahan (Hannah Price, special to ProPublica)

Criminologists point to a confluence of factors, including the social disruptions caused by COVID‑19, the rise in gun sales early in the pandemic and the uproar following the murder of George Floyd, which, in many cities, led to diminished police activity and further erosion of trust in the police. But in my reporting on the surge, I kept hearing about another accelerant: social media.

Violence prevention workers described feuds that started on Instagram, Snapchat and other platforms and erupted into real life with terrifying speed. “When I was young and I would get into an argument with somebody at school, the only people who knew about it were me and the people at school,” said James Timpson, a violence prevention worker in Baltimore. “Not right now. Five hundred people know about it before you even leave school. And then you got this big war going on.”

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Smartphones and social platforms existed long before the homicide spike; they are obviously not its singular cause. But considering the recent past, it’s not hard to see why social media might be a newly potent driver of violence. When the pandemic led officials to close civic hubs such as schools, libraries and rec centers for more than a year, people — especially young people — ­were pushed even further into virtual space. Much has been said about the possible links between heavy social media use and mental health problems and suicide among teenagers. Now Timpson and other violence prevention workers are carrying that concern to the logical next step. If social media plays a role in the rising tendency of young people to harm themselves, could it also be playing a role when they harm others?

The current spike in violence isn’t a return to ’90s-era murder rates — ­it’s something else entirely. In many cities, the violence has been especially concentrated among the young. The nationwide homicide rate for 15- to 19-year-olds increased by an astonishing 91% from 2014 to 2021. Last year in Washington, D.C., 105 people under 18 were shot —nearly twice as many as in the previous year. In Philadelphia in the first nine months of 2022, the tally of youth shooting victims — 181 ­­­— equaled the tally for all of 2015 and 2016 combined. And in Baltimore, more than 60 children ages 13 to 18 were shot in the first half of this year. That’s double the totals for the first half of each year from 2015 to 2021 — and it has occurred while overall homicides in the city declined. Nationwide, this trend has been racially disproportionate to an extreme degree: In 2021, Black people ages 10 to 24 were almost 14 times more likely to be the victims of a homicide than young white people.

Those confronting this scourge — ­police, prosecutors, intervention workers — ­are adamant that social media instigation helps explain why today’s young people are making up a larger share of the victims. But they’re at a loss as to how to combat this phenomenon. They understand that this new wave of killing demands new solutions — ­but what are they?

To the extent that online incitement has drawn attention, it’s been focused on rap videos, particularly those featuring drill music, which started in Chicago in the early 2010s and is dominated by explicit baiting of “opps,” or rivals. These videos have been linked to numerous shootings. Often, though, conflict is sparked by more mundane online activity. Teens bait rivals in Instagram posts or are goaded by allies in private chats. On Instagram and Facebook, they livestream incursions into enemy territory and are met by challenges to “drop a pin” — ­to reveal their location or be deemed a coward. They brandish guns in Snapchat photos or YouTube and TikTok videos, which might provoke an opp to respond — ­and pressure the person with the gun to actually use it.

In December, I met 21-year-old Brandon Olivieri at the state prison in Houtzdale, Pennsylvania, where he is serving time for murder. In 2017, Olivieri said, he had a run-in with other teens in South Philadelphia after he tried to sell marijuana on their turf. Later, in a private Instagram chat for Olivieri and his friends, someone posted a picture of a silver .45-caliber pistol. Then another member, Nicholas Torelli, posted a picture of cat feces on the sidewalk, with the caption “Brandon took a shit on opp territory.” It was a joke, but the conversation quickly turned aggressive. Later that day, Olivieri asked Torelli to drop an image of their opponents into the chat, so everyone could see what they looked like. Torelli complied, and, according to court records, Olivieri replied that he would “pop all of them.”

When Olivieri, Torelli and two friends encountered four of their opponents later that month, there were heated words, a struggle and three gunshots from the silver pistol. One bullet struck Caleer Miller, a member of Olivieri’s group. Another hit Salvatore DiNubile, in the other crew. Both died; they were 16. Olivieri was convicted of first-degree murder in DiNubile’s death and third-degree murder in Miller’s. (Torelli testified against Olivieri and was not charged.) Olivieri was sentenced to 37 years to life.

DiNubile’s father, also named Salvatore, believes the ability to share threats online encouraged Olivieri and his friends to make them; having made them, they felt compelled to follow through. “You said you were gonna do this guy. Here’s your chance,” he told me. “You try to live up to this gangster mentality that he’s self-created.” Olivieri maintains his innocence and says that he wasn’t the one who fired the fatal shots, but he agreed that he and his friends often hyped one another up by making boasts online. “It’s what we call pump-faking,” he explained.

Last year, as the number of juvenile shooting victims in Washington, D.C., climbed toward triple digits, the city’s Peace Academy, which trains community members in violence prevention, held a Zoom session dedicated to social media. Ameen Beale of the D.C. Attorney General’s Office shared his screen to display a sequence typical of online flare-ups culminating in a fatality.

The presentation started with a photo, posted to In­stagram in 2019, showing the local rapper AhkDaClicka on the Metro; the caption mocked him for being caught there, without a gun, by adver­saries. Then came a screenshot of private messages between AhkDaClicka and a rival rapper named Walkdown Will that the latter posted derisively on Instagram Live. Next, an Instagram Story from AhkDaClicka insulting another rapper who had allegedly been present at the Metro run-in and a YouTube video of AhkDaClicka rapping about the incident, including the line, “Just give me a Glock and point me to the opps.” Soon afterward, in January 2020, AhkDaClicka was fatally shot. He was 18; his real name was Malick Cisse. That May, police arrested Walkdown Will — ­William Whitaker, also 18. He pleaded guilty to second-degree murder last October.

Beale’s presentation left some participants dumbfounded. “I cannot believe the level of immaturity and stupidity that’s become the norm,” one wrote in the chat. Another asked the question looming over the session: Had anyone in the city’s violence prevention realm asked the social media companies to limit inflammatory content?

“I don’t think we’ve made much progress,” Beale admitted. When the city had sought to have posts removed, he said, the companies had rebuffed its pleas with vague arguments about free speech. Even if social media platforms did remove a post, 20 people could already have shared it with hundreds or thousands more. And given the pace of online life, you might spend five years trying to block harmful content on one platform, only for all the activity to migrate to another.

I asked a spokesperson for Google, which owns YouTube, about the AhkDaClicka video with the line about the Glock, as well as another video posted last summer, titled “Pull Da Plug.”

It showed a Louisville, Kentucky, rapper and about a dozen other young men apparently celebrating a shooting that had left a man on life support (he later died). The head of the Louisville violence ­prevention agency had told me that the victim’s family asked Google to remove the video, but it stayed up, collecting more than 15,000 views. The spokesperson, Jack Malon, told me the company generally had a “pretty high threshold” for removing music videos, in part because company policy allows exceptions for artistic content.

My conversations with Malon and his counterparts at Snap and Meta (which owns Facebook and Instagram) left me with the impression that social media platforms have given relatively little thought to their role in fueling routine gun violence, compared with the higher-profile debate over censoring incendiary political speech. Meta pointed me to its “community standards,” which are full of gray-area statements such as “We also try to consider the language and context in order to distinguish casual statements from content that constitutes a credible threat to public or personal safety.” Snap argued that its platform was more benign than others, because posts are designed to disappear and are viewed primarily by one’s friends. I also reached out to TikTok, but the company didn’t respond.

Communities, meanwhile, have been left to fend for themselves. But violence ­prevention groups are dominated by middle-­aged men who grew up in the pre-­smartphone era; they’re more comfortable intervening in person than deciphering threats on TikTok. Before the pandemic, an intern at Pittsburgh’s main anti-­violence organization scanned social media posts by young people considered at risk of becoming involved in conflicts. The Rev. Cornell Jones, the city government’s liaison to violence prevention groups, told me that the intern had once detected a feud brewing online among teenagers, some of whom had acquired firearms. Jones brought in the participants and their mothers and defused the situation. Then the intern left town for law school and the organization reverted to the ad hoc methods that are more typical for such groups. “If you’re not monitoring social media, you’re wondering why 1,000 people are suddenly downtown fighting,” Jones said ruefully. In early July, a shooting at a block party in Baltimore validated his concern: Though the event had been discussed widely on social media, no police officers were on hand; later, a video circulated of a teenager showing off what appeared to be a gun at the party. The shooting left two dead and 28 others wounded.

A decade ago, Desmond Upton Patton, a professor of social policy, communications and psychiatry at the University of Pennsylvania, got the first of several grants to study what he called “internet banging.” His research team co-designed algorithms with a team at Columbia University to analyze language, images and even emoji on Twitter and identify users at risk of harming themselves or others. The algorithms showed promise in identifying escalating online disputes. But he never allowed their use, worried about their resemblance to police surveillance efforts that had enabled profiling more than prevention. “Perhaps there is a smarter person who can figure out how to do it ethically,” he said to me.

For now, the system is failing to anticipate violence — and even, quite often, to convict people whose social media feeds incriminate them. In May, three teens were tried for the murders of Jarell Jackson and Shahjahan McCaskill in Philadelphia. At the time of the shooting, two were 17 and the third was 16. Social media activity formed a key part of the prosecutors’ evidence: Instagram posts and video feeds showed the three defendants driving around in a black SUV seemingly identical to the one that had pulled up alongside Jackson’s car. Other posts showed two of them holding a gun that matched the description of one used in the shooting. After a day of deliberations, the jury acquitted them of murder, finding two of the defendants guilty only of weapons charges. The verdict left the victims’ families reeling. “For me and my family, [the trial] was like a seven-day funeral,” Monique Jackson, Jarell’s mother, told me. Afterward, the detective who had investigated the murders speculated to her that jurors on such cases often struggle to grasp the basic mechanics of social media and how essential it is to the interactions of young people. As Patton put it to me: “What we under­estimate time and time again is that social media isn’t virtual versus real life. This is life.”

First image: Monique Jackson. Second image: Jackson holding a photo of her son Jarell. (Hannah Yoon, special to ProPublica)

Update, Aug. 9, 2023: This article has been updated to clarify YouTube’s policy for removing music videos.

by Irena Hwang and Al Shaw

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[For more technical details, view this story on our website.]

This year at ProPublica, we’ve paired computer modeling with traditional reporting to explore questions around viral outbreaks: What causes them and what can be done to prevent the next big one?

One of the most feared diseases is Ebola, which kills about half the people it infects and has shown that it can pop up in unexpected countries such as Guinea. The virus jumped from a wild animal to a human there in 2013, leading to an epidemic that ultimately left 11,000 dead around the globe.

Researchers studying how outbreaks begin have learned that deforestation can increase the chances for pathogens to leap from wildlife to humans. Jesús Olivero, a professor in the department of animal biology at the University of Malaga, Spain, found that seven Ebola outbreaks, including the one that started in Meliandou, Guinea, were significantly linked to forest loss. We found that, around five of those outbreak locations, forests had been cleared in a telltale pattern, increasing the chances that humans could share space with animals that might harbor the disease.

We wondered: Could we use what we learned about these locations to find places that had not yet experienced outbreaks but could be at risk for one? Were there places where Ebola could emerge that look a lot like Meliandou did in 2013?

With the help of epidemiologists and forest-loss experts, along with one of ProPublica’s data science advisers, Heather Lynch, professor of ecology and evolution at Stony Brook University, we developed a machine-learning model designed to detect locations that bore striking similarity to places that had experienced outbreaks.

The result? Out of a random sample of nearly 1,000 locations across 17 countries, ProPublica’s model identified 51 areas that, in 2021 (the most recent year that satellite image data on forest loss was available at the time of our analysis), looked a lot like places that had experienced outbreaks driven by forest changes.

These locations fell within forested zones in Africa that have wildlife believed to be carrying Ebola; that had recently experienced extensive forest fragmentation (that is, clearing of forests in many small, disconnected patches); and that have a population baseline that could sustain an outbreak if one emerged. To our surprise, 27 of the locations were in Nigeria, where an Ebola outbreak has never started.

After reviewing our findings, one of the researchers we consulted, Christina Faust, a research fellow at the University of Glasgow, Scotland, called the analysis a “best estimate of risk,” in light of the many outstanding questions about how Ebola arises.

“You’ve clearly identified ecological features that are consistent across the spillover locations,” Faust said. “And these ecological conditions and human conditions are cropping up in other places. And given that we don’t know so much about the reservoirs, I think this is our kind of best ability to do a risk analysis.”

Why Random Forests

This model was developed out of an earlier analysis we published in February. We used satellite imagery and epidemiological modeling to show that villages where five previous Ebola outbreaks occurred are at a greater risk of spillover happening today, including Meliandou, Guinea, the site of the worst Ebola outbreak in history.

In five locations where outbreaks had occurred, we found a distinctive pattern in how forests erode over time. At the highest level of fragmentation, the areas where humans and virus-carrying animals might interact, or “mixing zones,” are largest, and risk is at its peak. But after the forest becomes so eroded by human activity that it can’t sustain wildlife anymore, risk decreases.

That analysis focused on the research led by Olivero and an epidemiological model created by Faust and her colleagues that tracked how spillover risk changes as forests become increasingly fragmented. But there was also other intriguing research on the link between land use and Ebola spillover that caught our attention.

One paper, by a team led by Maria Rulli at the Politecnico di Milano, Italy, found a relationship between increased forest fragmentation over time and Ebola outbreaks. We came across a couple other papers that mapped out where Ebola is likely to exist in wild animals, including one by Olivero himself.

As part of the first project, we created a data set of ecological characteristics from satellite imagery. We were curious if some of the factors, like the number of forest patches or proportion of mixing zones around those patches, could shed additional light on how susceptible a location could be to disease spillover.

Months in, we asked ourselves, could we combine the 23 environmental and population characteristics and what we learned from work by Olivero, Faust and Rulli into a single model? Could such a model reveal new insights into the conditions related to forest change that make it possible for Ebola to jump from animals to humans?

On the advice of Lynch, our science adviser, we started by looking for any clear patterns or clusters among the characteristics.

But after squinting at lots of tiny scatter plots, nothing jumped out. This wasn’t entirely unexpected, because we had only seven outbreaks to compare. When the number of characteristics far outnumbers the events you’re interested in, it can be hard to tease out clear relationships. So Lynch suggested something straight from her own research playbook: decision trees and random forests.

Decision trees, Lynch explained, are machine learning algorithms that create chains of binary decisions to help distinguish groups from one another. We hoped they could help us find places that looked a lot like locations where Ebola outbreaks had occurred. These trees — not to be confused with the leafy trees in our forest data — are useful because they can sort and cluster data based on combinations of characteristics that might not be obvious when considering each individually, and flag potential matches.

Decision trees helped us figure out which population and forest characteristics best explain the differences between locations we’re interested in, and all others.

Here’s an example of one decision tree generated by our model.

Most importantly, they’re easy to understand. Unlike many machine learning models, it’s easy to pop the hood on a decision tree and examine the choices made at each step. But easy doesn’t mean unsophisticated. Many decision trees, each with random, slight differences, can be combined into something called a random forest, which aggregates the results of multiple decision trees. Random forests are a popular and versatile technique that has been used widely in academia and journalism.

Computers can generate many decision trees, each with slight differences. Together, they make up a random forest.

Any single location that is flagged by a majority of trees in a random forest is considered a location of interest.

We created a random forest made up of 1,000 trees. If a location was flagged by the random forest, then it was classified as similar to locations where Ebola outbreaks had been linked to forest loss, and reviewed by us.

Choosing Data

Our ultimate goal was a model that could figure out which characteristics were distinctive in places that had experienced Ebola outbreaks. So we created three buckets of data: outbreaks linked to forest loss, outbreaks that had other origins and random places where outbreaks never happened.

Collecting the first two buckets was easy: the seven Ebola outbreaks previously linked to forest loss by Olivero and his collaborators went into one. The rest of the outbreaks since 2000 (the earliest year for which forest loss data from Hansen/Global Forest Watch is available) went into the other.

For the third bucket, we had lots of options. We started with a database of villages and hamlets in 28 countries. Then, we found which of them overlapped with Olivero’s data that maps where conditions are favorable for wild animals to harbor Ebola. In all, we had 11 million locations to examine.

It was unfeasible to query all 11 million, so we collected a random sample of 50,000 and collected population statistics for each. We then determined which of the 50,000 locations were at least 100 kilometers, about 62 miles, away from the outbreaks already in our two buckets. Finally, we narrowed the sample to villages and hamlets where the human population was within the range of populations in our outbreak buckets, because they might interact with the forest in similar ways; for example, for firewood or hunting. The populations couldn’t be too small, either — spillover events require, by definition, human hosts to jump into.

Our last step was to filter for locations similar to those in our second bucket. In other words, these locations had characteristics that could sustain an Ebola outbreak, maybe even due to a spillover event, but for reasons unrelated to forest loss. We selected 21 of those random locations for our third bucket of data.

For all 35 locations, which we refer to as our training data, we calculated 23 different characteristics about forest change and population using a variety of data sources.

Seven locations used as training data were outbreaks tied to forest loss.

The other locations fell into two buckets: outbreaks not tied to forest loss, or locations where outbreaks were never recorded.

Training and Validating the Model

With training data in hand, we set about trying to get the model to find insightful patterns. It’s a real possibility, especially when the input data is limited, that machine learning models will find patterns where there actually are none. This is called overfitting; think of it as a computer interpreting polka dots as a connect-the-dots game.

To avoid overfitting, we trained multiple random forest models, each time withholding some of the data. This is a common strategy in ecology, where data can be scarce and it’s important to make sure that a model is not overly influenced by the idiosyncrasies of any one data point. In our case, Ebola is such a rare disease that excluding one of seven outbreaks in each training round allowed us to see if any of them were disproportionately affecting the models.

The results from each training round also gave us a better idea about which of the 23 characteristics were most important. Only four characteristics were ranked as important across all training rounds: the number of patches the forest is divided into, the forest area at two points in time and changes in forest fragmentation.

This set of characteristics was exciting, because it confirmed that key concepts from the work by Olivero, Faust and Rulli could be combined into a single model.

Before we ran with these results, though, we wanted to gut-check one last possibility: that whatever pattern our model had found was too general. Sure, maybe we’d built something that identified a handful of shared traits among seven outbreaks, but perhaps our approach would always find key characteristics among a small number of data points.

To test this hypothesis, Lynch proposed something called, intriguingly, a “garbage model.”

Think of an English-Spanish dictionary, except the word pairs are all shuffled — “cat” is linked with “perro,” instead of “gato.” Using the dictionary to translate an English sentence would result in a totally nonsensical Spanish sentence.

Shuffling our data, Lynch said, should result in similarly nonsensical classifications of the data withheld from training. If not, then our approach was likely too general. But if the garbage model generated garbage classifications for the withheld data, then we could have some reassurance that whatever patterns our actual model found were genuine.

We tried it and — out came basura, as expected. It was time to create the final model.

Testing the Model

Our final model only used the four most important characteristics of the nearly two dozen we’d started out with: how much patchier the forest had become in the two years leading up to an outbreak, how much bigger the mixing zones had gotten in that time, the amount of total forest in the year the outbreak happened and the amount of forest two years before that.

Finally, it was time to test the model by showing it completely new places and then asking which of them look like the set of outbreaks in the first bucket.

We took another random sample of approximately 1,000 places from the 50,000 previously sampled random set of settlements. Calculating fragmentation statistics in Google Earth Engine is time consuming — it took us about a week to process 1,000 locations. Collecting data for more locations would not have been feasible.

Out of nearly 1,000 test locations, we found that 51 were consistently flagged. About half of the locations were in southwest Nigeria. Sixteen were in the Democratic Republic of Congo, and the remaining handful were in Ghana, Burundi and Benin.

Given that a spillover-induced outbreak of Ebola has never been recorded in Nigeria, we were surprised by the results. But a literature review revealed other papers that warned of the potential for Ebola spillover events in Nigeria. These papers, plus the locations flagged in the Democratic Republic of Congo — the site of the most recent Ebola outbreak with confirmed links to a spillover event — gave us the confidence to hit pause on all the coding and modeling to do some reporting.

You can read about it in our story.

Caroline Chen contributed reporting.

by Caroline Chen, Al Shaw and Irena Hwang

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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.

The bright spots on the map struck us like a lightning bolt.

We had spent months teaching a computer about the Ebola virus –– feeding it information about the landscapes and populations in places where the disease had previously emerged, showing it how to analyze those outbreaks for patterns, and then instructing it to flag other areas that looked similarly perilous.

Some of the highlighted spots were predictable; the virus had repeatedly ravaged one of those countries.

But we didn’t expect our model to light up Nigeria, the most populous country in Africa. The West African nation and international travel hub has never seeded an Ebola outbreak, but just a year ago, it served as the springboard for another virus to travel into Europe and the Americas and spread across the globe. However that virus, mpox, originally known as monkeypox, is rarely fatal.

What if it had been Ebola, which kills about half of the people it infects?

We asked Nigerian public health officials whether they were concerned.

“Ebola is not part of our top concerns any more,” said Oyeladun Okunromade, the director of surveillance and epidemiology at the Nigeria Centre for Disease Control.

In the aftermath of the 2014 West African Ebola epidemic, the worst on record, Nigerian officials were on high alert. But last year, they took the virus off the list of the top infectious diseases the country needed to prepare for, downgrading Ebola in relation to threats like mpox, which Nigeria was actively fighting.

The disjoint between how our model sees Nigeria’s risk and how the nation’s health officials view it reveals a weakness in the way that governments and public health experts are preparing for future pandemics. The methods many countries use to rank threats focus mainly on factors that occur after an outbreak has already begun, such as the potential economic impact of an epidemic. Or they rely on past cases, looking at where a pathogen has previously struck.

Neither approach considers the root causes.

We’ve spent more than a year digging into the question of what causes outbreaks and what the world can do to prevent them. And we’ve learned that while science has advanced so we’re starting to understand the complex factors that trigger an outbreak, the world is not doing nearly enough to try to head off the next big one.

Most emerging infectious diseases come from wildlife. Those outbreaks require two essential elements: animals that carry a virus and opportunities for those animals to infect people.

Many of these fateful jumps, known as spillovers, have happened in forested, but populated, areas where trees have been cut down. Researchers have found that when people cut trees in patches, leaving the landscape dotted with holes like Swiss cheese, that creates more pockets and edges where humans and infected animals can collide. That world-shaking Ebola outbreak in 2014, for example, started in a Guinean village surrounded by a ring of forest.

Models that incorporate these environmental drivers could help countries look forward instead of backward as they determine how to allocate resources. Solomon Chieloka Okoli, an epidemiologist who works for Nigeria’s field epidemiology and laboratory training network, said his country, like many others, tends to react to outbreaks after they’ve started instead of trying to prevent them. That isn’t enough, Okoli said. “Being proactive is the best line of defense — if you wait, a lot of people will have died before you can get yourself together.”

Our model, created in consultation with scientists, was able to identify ecological factors that were common to past Ebola spillovers. The resulting risk map should be enough to prompt action, according to Christina Faust, a fellow at the University of Glasgow, Scotland, whose research focuses on how human activities like deforestation affect disease transmission.

Ebola often starts with a fever, so governments should invest in surveillance systems that help health authorities track patients with fevers, she said. “We should be watching these areas.”

Training Computers to Learn How Outbreaks Work

Models are not crystal balls; they can’t say exactly when or even whether a place will be hit with an outbreak. But they are great for understanding risk — where it is growing and where it may be shifting to.

“I love these as advocacy tools, because they’re meant for action,” said Dr. Maria Van Kerkhove, an infectious disease epidemiologist at the World Health Organization. “We just want these types of maps to inform and say: Make sure you’ve considered what might be circulating that you haven’t yet detected.”

We were curious to see where risky deforestation patterns are happening today. So we turned to a machine learning technique called “random forests” (no relation to actual tree-filled forests!) that can be used to spot patterns that might explain how some previous Ebola outbreaks happened. We limited our analysis to the geographic area where wildlife that can transmit Ebola is most likely to be found. This area covers 27 African countries from Guinea to Uganda.

We started with seven locations of past Ebola outbreaks that researchers have linked to forest loss. Then we selected 23 parameters, including demographic characteristics like the change in population from 2019 to 2021 (the most recent available data), as well as forest characteristics like the amount of tree loss and the patchiness of the surrounding forests.

We pulled data from satellite imagery and online population databases, fed it to the model and asked the computer to examine these factors across the seven known Ebola outbreaks. The model digested all this information and determined the relative importance of each parameter.

We also asked it to compare the outbreak sites to a set of places that were in the area where Ebola-carrying animals could live but had not seen an Ebola spillover.

Then we gave it a list of 1,000 candidate villages that had at least the same population size as previous Ebola spillover sites. (The 1,000 candidates were a random sample of all the villages that met our criteria; we weren’t able to run our model on the full set because of the amount of time and computing power that would have been required.) We asked the computer: Are there places that look very similar to past outbreak sites?

The model identified 51 locations with patterns of tree loss very similar to the seven previous Ebola outbreaks. The Democratic Republic of Congo had 16, which made sense; the country has recorded more than 10 Ebola outbreaks since the 1970s. The model highlighted additional spots in Ghana, Burundi and Benin.

More than half of the locations of concern, 27, were concentrated in Nigeria.

(Source: Hansen/UMD/Google/USGS/NASA, OpenStreetMap)

(If you — like us — are a nerd and want to read about our model in more detail, here is a comprehensive methodology.)

Why Nigeria’s Deforestation May Increase Its Risk

We were initially surprised to see the cluster of flagged locations in the southwest region of Nigeria, since the nation has never been the starting point for an Ebola outbreak. (The country has dealt with Ebola patients before, after an infected traveler flew to Lagos from Liberia during the West Africa outbreak in 2014.)

But we came to learn that Nigeria has experienced rapid deforestation over the past two decades. According to Global Forest Watch, the country has lost over 3,800 square miles of forest since 2001, and the rate of that loss has been accelerating. Nigeria has cleared the equivalent of nearly 170,000 football fields every year since 2017.

This is in part because energy prices have risen, making conventional fuel sources like kerosene unaffordable for many families, said NwaJesus Anthony Onyekuru, a professor of resource and environmental economics at the University of Nigeria. “They don’t want to use kerosene to cook, so they use wood,” he said.

Our model showed that this rapid forest clearing has happened in the dangerous, patchy pattern that researchers say leads to more interactions between humans and wildlife, and therefore increases the chances of spillover.

Scientists have found that bats can shed more virus when they’re stressed, such as by losing their habitats. That means that hunters may now encounter wildlife that is more likely to transmit a pathogen. Some Nigerians eat bats. Hunger has driven other residents to hunt for monkeys and rats in the forests, according to the epidemiologist Okoli. He said that consumption of large rats in the country’s southern region may have spurred the recent mpox outbreak.

Local deforestation has contributed to an increase in Lassa fever cases, said Dr. Charles Akataobi Michael, a senior technical officer at the Africa Centres for Disease Control and Prevention. Lassa fever can cause bleeding from the mouth, nose and gastrointestinal tract in severe cases, as well as neurological symptoms like hearing loss. The virus is carried by rodents, and people can be infected when food or household items are contaminated with the rodents’ urine or droppings.

The virus has been circulating in areas where people burn trees to create farmland, said Michael, destroying the rodents’ habitat. “They go to human habitats as a result of bush burning and deforestation to find food,” he said. “As we continue to alter the environment, the risk of disease outbreaks are increasing significantly.”

As the country’s population continues to grow rapidly, residents are chipping away at the forests to make room for farms. This land-use change is another way that risk may be increasing: Many outbreaks around the world have started when a virus jumped first from wildlife to a farm animal and then made another leap to humans. That includes deadly forms of bird flu and the brain-inflaming Nipah virus, which was immortalized in the movie “Contagion.”

Though we were initially surprised, we’ve since learned that Nigeria has appeared in other academic models as a potential Ebola hot spot. A 2019 analysis, published in the journal Nature Communications, identified Nigeria as a country at risk for an Ebola outbreak based on both current conditions and future climate and socioeconomic drivers.

In 2014, a different group of scientists used human and animal data to map locations most at risk of an Ebola outbreak. Among countries that had never reported an Ebola spillover before, Nigeria was at the top of their list. We know that Ebola isn’t constrained to country borders — after all, the worst Ebola outbreak to date started in Guinea, where the virus hadn’t previously been thought to be a threat. And this year, Marburg, Ebola’s cousin, has spread in two countries that had never before recorded an outbreak.

David Pigott, who led the 2014 analysis, said looking at prior cases isn’t the best way to evaluate risk: “The conversation of preparedness should not just be a function of what happened in the past.”

But that, we learned, is exactly what Nigeria is doing.

The Gap Between Knowledge and Action

The Nigerian experts we interviewed all acknowledged the importance of environmental factors in increasing outbreak risk. But many said that not much has been done to try and mitigate dangerous deforestation.

Okunromade, from the Nigeria CDC, helped create its One Health Strategic Plan — a national action plan based on the “one health” principle that the well-being of the environment, animals and humans are deeply interconnected. She said the government has brought together experts on human and animal diseases so that they can share information about pathogens such as mpox, Lassa fever and bird flu.

Yet when we asked what the country was doing to address environmental risks, she wasn’t aware of any initiatives, though she said it may be possible that other agencies were telling the public about the dangers of deforestation.

Okunromade said that experts used a tool developed by the U.S. Centers for Disease Control and Prevention to assess the risks of dozens of diseases that come from animals. The process has local experts select five criteria, commonly including epidemic potential or a country’s diagnostic capacity, and answer questions about different diseases for each criteria. Based on the answers, the diseases get scored as having a higher or lower priority.

When Nigerian officials ran this exercise in 2017, the devastating Ebola epidemic was fresh in their memories, and Ebola made the top five. “Looking at West Africa, at the countries surrounding us, looking at Sierra Leone, looking at Liberia, they were the worst hit. So that was why it made the list,” she said.

Ebola is a disease that would typically rank highly using the U.S. CDC’s tool because it gives more points to pathogens with a higher fatality rate. In 2022, Nigerian officials re-did the ranking exercise and initially, Ebola was still in the top five, but the officials felt it was more important to look at recent cases. Since there hasn’t been an Ebola outbreak in neighboring countries in recent years, the disease fell off their priority list, according to Michael, from the Africa CDC, who participated in the ranking process.

The CDC’s tool, which has been used by more than two dozen countries, does not require consideration of environmental causes like deforestation when ranking threats. Dr. Casey Barton Behravesh, the director of the U.S. CDC’s One Health Office, said that the process does not mandate which criteria should be considered and “it’s up to the country or region to decide on the criteria of greatest importance to them.” In examples she provided, two workshops, conducted in Alaska and the Economic Community of West African States, included a question about whether climate change would impact a disease. Some other countries considered the environmental impact of a potential outbreak, but they did not look at environmental factors that could increase the chance of a spillover. None of the examples included a question about deforestation.

There’s hope that new tools will evolve. The WHO is currently working with Pigott, who is an assistant professor of health metric sciences at the University of Washington, and other academics to develop risk maps for 16 different pathogens. Their model will incorporate data on environmental drivers of outbreaks. They aim to publish their work in a journal in future months, according to Pigott.

Pigott acknowledged that it can be hard for governments to prioritize a rare event like an Ebola outbreak. Still, he said, preparing for a disease like Ebola can be incorporated into plans for other pathogens. A malaria test may be the most logical place to start in a patient with a fever; if that is negative, health workers should be ready to test for Ebola, he said. But that only works if they are aware of the potential threat.

Ultimately, putting a disease on a priority list is only the first step. True prevention will need to address people’s lives, said Okoli, the Nigerian field epidemiologist: “If you say, ‘Don’t cut the bush to make charcoal,’ then you need to provide gas. If people are saying, ‘When I’m hungry, I get wild game,’ then you need to make it easier to get meat from the shops. You need to provide an alternative.”

Preventing the next outbreak from starting, Okoli said, should not be that hard. “It’s just about the political will and the willingness of the government to do something.”

by Megan O’Matz and Mariam Elba

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Margaret Rose Bostelmann’s ideals are clear from one glance at her well-kept ranch-style house in central Wisconsin.

A large American flag is mounted near the front door, and a “We Back the Badge” sign on her front lawn announces her support for law enforcement. Bostelmann, a Wisconsin elections commissioner, said she voted for Donald Trump in 2020 and added: “I will always vote Republican. I always have.”

But her fellow Republicans have exiled her and disparaged her, sought to upend her career and, on this day in July, brought the 70-year-old to tears as she discussed what she’s been through over the last several years because she refuses to support false claims that Trump won the state in the 2020 presidential election.

Bostelmann, who goes by Marge, previously served for more than two decades as the county clerk in Green Lake County, overseeing elections without controversy. But two years into her term in a Republican slot on the Wisconsin Elections Commission she became a target, denounced and disowned by the Republican Party of Green Lake County, which claimed she had failed to protect election integrity in the state.

Now a suit filed in June by a Wisconsin man who promotes conspiracy theories about election fraud seeks her removal from the commission. Citing her estrangement from the county party, the suit claims she’s not qualified to fill a position intended for a Republican.

The elections commission, which has an equal number of Republican and Democratic members, has faced an onslaught of discredited claims about election fraud in Wisconsin. The most recent drama involves the commission’s nonpartisan administrator, Meagan Wolfe, whose term is expiring and whose future in the role is in doubt. After the three Republican members of the commission supported Wolfe in a June vote, Republicans in the state legislature made it clear they wanted to find a way to get rid of her.

The Republican clashes in Wisconsin exemplify ongoing discord seen across the country, with elections officials shunned, berated and even driven away by members of their own party over their defense of the integrity of the 2020 election.

In Hood County, Texas — a solid red block in a red state — hard-line Republicans successfully pushed for the resignation of the elections administrator, even though Trump won 81% of the vote in the county. In Surry County, North Carolina, where Trump also won overwhelmingly, the Republican elections administrator was threatened with firing or a pay cut for refusing to give a GOP party leader access to voting equipment to conduct a forensic audit. And in Clare County, Michigan, officials are considering possible charges against a GOP activist accused of kicking the party chair in the groin.

The Wisconsin Elections Commission has been sued by numerous parties, verbally attacked by voters and earmarked for elimination by GOP lawmakers. It has survived only because a Democrat still occupies the governor’s office and wields veto power.

In an April survey of local election officials nationwide, the Brennan Center for Justice, an independent, nonpartisan law and policy organization, found that nearly one in three reported being abused, harassed, or threatened because of their job.

In a rare interview, Bostelmann wept at one point. For the most part, though, she was defiant, insisting the 2020 election was not stolen by Joe Biden.

“I’m a Republican who stands up for the truth and not for a lie,” Bostelmann said. And she predicted the latest legal gambit, which seeks her removal, would fail.

Don Millis, the Republican who chairs the Wisconsin Elections Commission, also has expressed frustration with the election conspiracy theorists. At the commission’s June meeting, he said he considered some of the agitators to be “grifters” who are conning people of goodwill into thinking there is something wrong with the election system.

“It’s not about winning or preventing fraud,” he said of the conspiracy theorists’ motives. “It’s about getting publicity or attention. It’s about grifting, convincing others to donate to their cause.”

In a recent interview with ProPublica, Millis said he was referring to a small set of people he believes are trying to raise money by spreading lies through social media or newsletters. “There are many people who believe them, who don’t know any better,” he said.

From Fraudster to Fraud Investigator

The man who brought the suit against Bostelmann is Peter Bernegger, grandson of the founders of Hillshire Farm, the Wisconsin deli meat and sausage company. Now 60, Bernegger has described himself as a “data analyst” and an “independent journalist.”

He has engaged in relentless — and so far futile — legal efforts to prove fraud in the 2020 election. This mirrors a different kind of legal fight from earlier in his life: trying to overturn his own fraud conviction.

A 2008 indictment accused Bernegger and a business partner in Mississippi of deceiving investors, bilking them of $790,000 in various ventures — including the development of a gelatin, intended for pharmaceutical or cosmetic companies, made from the carcasses of catfish. A federal jury acquitted the partner, who has since died, but convicted Bernegger of mail and bank fraud. He was sentenced to 70 months in prison and ordered to pay nearly $2.2 million in restitution.

Bernegger overwhelmed the courts with claims to clear his name, alleging procedural errors, insufficient evidence, judicial bias, ineffective counsel, violations of his constitutional rights and other misconduct.

“Mr. Bernegger, you file an awful lot,” said U.S. District Court Judge William Griesbach of Wisconsin. “Just let me say that. You file so many things. And in all honesty, I don’t have time to keep up on it all.”

Though most of his claims failed, Bernegger did succeed on one front: He got his restitution reduced to roughly $1.7 million. Ordered in 2019 to get a steady job to make payments on the debt, Bernegger testified that he had limited options.

He said his health was too poor for him to be able to lift heavy objects, drive a truck or operate heavy equipment. “I work odd jobs, a wide variety of them. And it is cash, but it's legal,” he explained.

When ProPublica reached Bernegger by phone for this story, he immediately hung up. He did not respond to letters and emails seeking comment.

Much of his energy, it appears, is now devoted to stoking doubt about election integrity. In his social media posts and podcast appearances, he has railed against Wolfe, the Wisconsin elections commission administrator, while repeating sweeping, unsubstantiated claims about problems in voting systems across the country. Along the way, he has made alliances with like-minded individuals beyond his home state.

Bernegger has ties to Omega4America, a website promoting a super-fast computing method to identify fraud by matching voter data with property tax records and other large databases. The site solicits donations to a nonprofit called Election Watch Inc.; Bernegger founded a tax-exempt organization with that same name in 2022.

The Texas Tribune has reported that the Omega4America project was initially funded by MyPillow CEO Mike Lindell, a conspiracy theorist close to Trump. Omega4America makes glowing claims about programming marketed by Texan Jay Valentine as a powerful tool that could replace the Electronic Registration Information Center, or ERIC, a multistate consortium that ferrets out duplicate voter registrations across states. ERIC has been the subject of heavy criticism from conservatives who believe its work identifying unregistered voters for states bolsters the rolls for Democrats.

In a podcast, Bernegger mentioned that he has access to the “Valentine fractal programming system” as he seeks to uncover voter fraud. Valentine, who is listed on the Omega4America website as the site contact, declined to discuss his work or Bernegger, telling a ProPublica reporter: “I have nothing to say to you.”

In an April episode of a podcast called The AlphaWarrior Show, Bernegger said he’s now part of a team of 10 scouring federal campaign data for oddities. He named James O’Keefe as a member of that team. O’Keefeis the former head of Project Veritas, a conservative group known for secretly recording liberal organizations, and has a new media company that encourages “citizen journalists” to investigate election fraud. ProPublica’s attempts to reach O’Keefe for comment were unsuccessful.

Toward the end of the AlphaWarrior podcast, the host urged viewers to “smash” the blue donate button on an Election Watch website to show support for Bernegger and his team.

“It means we sacrifice a movie or a fancy dinner and we throw a couple dollars their way,” he said.

Peter Bernegger, right, on The AlphaWarrior Show (via Rumble) “I Don’t Know That I’d Be Welcome”

Marge Bostelmann still doesn’t fully understand how it got to this point, how she became such a target of Bernegger and others, including people she once thought held similar values.

But she does know that things in Green Lake began to change in 2020, during Trump’s reelection bid. Bostelmann said she stopped paying membership dues to the county party after the party chair became critical of her and of the way the 2020 election had been run in Green Lake County by her successor.

By November 2021, as conservatives carried out investigations into voting accommodations made in Wisconsin during the pandemic — including the use of drop boxes and allowing unsupervised absentee voting in nursing homes — Bostelmann and others on the elections commission came under attack for their votes shaping those procedures.

Kent McKelvey, the Green Lake County GOP chair at the time, issued a press release saying Bostelmann’s actions on the Wisconsin Elections Commission “do not reflect the principles, values and beliefs of the Green Lake County Republicans, in this case, supporting the proper enforcement of the law and of election integrity.”

The press release said flat-out that “Ms. Bostelmann is no longer a member of the Republican Party of Green Lake County.” McKelvey did not respond to requests for comment.

The snub hurt. Bostelmann, a former foster parent who knows many local Republicans through her activities with her church and the Rotary Club, said she stopped attending many local GOP events. “I don’t know that I’d be welcome,” she said.

Even as efforts to prove fraud in Wisconsin fizzled, the pressure on the commission remained intense. Powerful Republicans in the state Senate called for Wolfe’s ouster, blaming her for what they saw as regulatory overreach by the commission, though in her role she carries out the orders of the six voting members.

Prior to the commission’s key June vote on Wolfe, Bostelmann said, she received a disturbing phone call from an acquaintance who had been critical of Wolfe. “The patriots would not be happy” with her, she was told, if she backed Wolfe. Bostelmann took that as a threat.

Still, she and the panel’s two other Republicans voted to reappoint Wolfe. Bostelmann defended Wolfe publicly at the June meeting, saying the administrator had been unfairly targeted “as the scapegoat” by people dissatisfied with the commission and the outcome of the 2020 election.

In a tactical move, Democrats abstained from voting, leading to a final tally of three yes votes. That appeared to mean that the panel did not have the requisite four votes to send the matter to the state Senate for final consideration, and it was widely thought Wolfe would continue in her post because of the impasse.

But the Senate, surprisingly, decided the three affirmative votes were enough for it to take up her nomination. Wolfe’s reappointment is now pending before the Senate elections committee. No public hearing or vote has been scheduled.

Lawsuits are expected, though for now she remains on the job.

“Some judge will tell us who our administrator is. That’s my guess,” said the commission chair, Millis, a tax attorney who favored retaining Wolfe.

Like Bostelmann, Millis has been the target of Bernegger, who on Twitter has ranted about Millis ignoring election system problems, referring to him as “Blind Don.”

Robert Spindell, the third Republican member of the commission, said he hasn’t been chastised for his renomination of Wolfe. He said he thought it best that the Senate take up the matter. “I haven’t had anybody call or criticize me,” he said, noting: “Most of the people I know on this election stuff are not shy.”

Through a spokesperson, Wolfe declined a request for an interview.

Bernegger’s suit against Bostelmann demands that the circuit court remove her from her seat on the commission, citing the disavowal from Green Lake County Republican Party. “She cannot prove she is a member of the Green Lake County Republican Party and is otherwise qualified to hold the designated Republican seat,” he wrote.

The statute that governs commission appointees does not specifically require them to be dues-paying party members.

Records show Bernegger has bombarded the Wisconsin Elections Commission with official complaints and demands for data, often accompanied by threats of legal action and accusations of criminal conduct. In one email he referred to a commission staffer as a “prick.”

“Please note that I am becoming increasingly uncomfortable with this individual’s erratic behavior that is directed at myself, our staff and local election officials,” Wolfe wrote to the commission in October 2022. In May of this year, Wolfe told the commission Bernegger made her feel “incredibly unsafe” when he noted her home address in bold in an email to the commission and called her a “pathological liar.”

The commission fined Bernegger $2,403 in March 2022 for filing frivolous complaints. Records show commission staff have, at times, forwarded his correspondence to the Wisconsin Department of Justice.

On July 7, the Wisconsin Department of Justice’s Criminal Investigation Division served Bernegger with a letter at his home in New London, stating that his actions could reasonably have made Wolfe and others at the commission feel “harassed, tormented or intimidated.” It warned that he could be arrested for stalking if he continued his behavior.

Excerpt of a Wisconsin Department of Justice’s Criminal Investigation Division letter served to Peter Bernegger on July 7 (Obtained by ProPublica)

One of Bernegger’s lawsuits over records against the commission is still ongoing.

He has also sued officials in Dane, Door, Grant, Marathon, Milwaukee and Ozaukee counties, the town of Hudson, the city of Hudson, the city of Milwaukee and the town of Richmond in Walworth County. The suits are related to broad public record requests he made for absentee ballot applications, images of ballots, router logs and other materials and involve disputes over costs and access. While many of those have been dismissed, four are still pending.

“We’re all trying to do our jobs to the very best of our abilities. It makes it difficult when we are constantly being undermined and questioned,” said Marathon County Clerk Kim Trueblood. Her office provided Bernegger with some information when he inquired but denied him certain documentation that Trueblood said was exempt from release. He sued, but a judge dismissed the case.

Another clerk, Vickie Shaw of the town of Hudson, said she had to go to court three times to deal with a Bernegger suit over records. A judge threw out the case, Bernegger appealed, and it was tossed again.

Before Bernegger’s suit, Shaw had quit in 2021, finding the job too burdensome and confrontational. But she returned the following year because, she said, the town “didn't have anybody to run the April election.”

Bostelmann expressed dismay with Bernegger’s tactics against her and the other election clerks.

“It’s bullying is what it is. It’s truly bullying,” she said. “It’s almost like they are trying to get people who are knowledgeable, and do a good job, to quit to have people who don't know how to do the job to come in.”

by Logan Jaffe

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

Illinois Gov. J.B. Pritzker signed into law Friday sweeping reforms that for the first time will give tribal nations — not state agencies, universities or museums — final say over how and when the remains of their ancestors and sacred items are returned to them.

“With the Governor signing these bills into law, Illinois is proving that a government is capable of reflecting on its past injustices and planning for a future that respects and celebrates our interconnectedness,” Prairie Band Potawatomi Nation Chairperson Joseph “Zeke” Rupnick said.

The newly signed Human Remains Protection Act was shaped by tribal nations over more than two years of consultations with the Illinois State Museum and the state Department of Natural Resources. The legislation unanimously passed the state House and Senate this spring and follows publication of ProPublica’s “The Repatriation Project,” an ongoing investigation into the delayed return of Native American ancestral remains by universities, museums and government agencies.

“Here in Illinois we believe in justice, and we won’t hide from the truth,” Pritzker said. “It’s up to us to right the wrongs of the past and to chart a new course.”

The law makes it the state’s responsibility to help return ancestral remains, funerary objects and other important cultural items to tribal nations, and it compels the state to follow the lead of tribal nations throughout the repatriation process. It also establishes a state Repatriation and Reinterment Fund to help with the costs of reburial, tribal consultation and the repair of any damage to burial sites, remains or sacred items.

Existing law to protect unmarked cemeteries in Illinois failed to create a pathway for tribal nations to rebury ancestral remains that had been disinterred. That law, passed in 1989, deemed most Native American remains to be property of the state.

The new law increases criminal penalties for the looting and desecration of gravesites, while adding a ban on profiteering from human remains and funerary objects through their sale, purchase or exhibition. Moreover, it mandates tribal nations be consulted as soon as possible when Indigenous gravesites are unintentionally disturbed or unearthed — such as during construction projects.

The measure follows decades of Indigenous activism, new leadership within the Illinois State Museum and IDNR, and ProPublica reporting that revealed widespread delays in institutions’ compliance with a 1990 federal repatriation law. ProPublica found that more than 30 years after passage of the Native American Graves Protection and Repatriation Act, museums and other institutions nationwide still hold more than 100,000 Native American human remains.

The failure to repatriate expeditiously, as required by NAGPRA, is rife in Illinois, where more than 15,461 Native Americans have been excavated — more than from any other state, the ProPublica investigation found. The vast majority of those ancestors are still held by Illinois institutions. Previous policies at the Illinois State Museum, which holds the remains of at least 7,000 ancestors, favored the scientific study of remains over their return to tribes for reburial.

Sunshine Thomas-Bear, the cultural preservation director for the Winnebago Tribe of Nebraska, said, “It has been a rough road in trying to get the protection and rights that non-Natives have in protecting our ancestral burial sites and homelands.” She added that many Illinois gravesites have been desecrated and destroyed.

“This bill cannot remedy the damage that has been caused thus far, but perhaps it will protect the sites that remain in our homelands,” Thomas-Bear said, though she emphasized that the law is “a step in the right direction” for rebuilding relationships.

Significantly, the law empowers IDNR to set aside and maintain land solely for the reburial of repatriated Native American ancestors and their belongings. Tribal nations have pointed to the lack of protected places for reburial in Illinois as among the highest barriers to repatriation.

For example, in 1999 the Sac & Fox Tribe of the Mississippi in Iowa, the Sac and Fox Nation of Missouri in Kansas and Nebraska and the Sac and Fox Nation, Oklahoma, repatriated the remains of 34 of their ancestors held by the University of Illinois Urbana-Champaign, records show. The tribes wanted to rebury their ancestors at or near the site where they were originally interred: a former Sauk and Meskwaki village in Rock Island County along the Mississippi River. But the state wouldn’t allow the tribes to use the land, said Johnathan Buffalo, the tribal historic preservation director of the Sac & Fox Tribe of the Mississippi in Iowa. They had to rebury the ancestors in Iowa — west of the Mississippi River, the same borderline used by the U.S. government when it expelled all Native American tribes from the state during the 1830s.

“That old wound opened when Illinois did that to us,” Buffalo said.

More than 30 tribal nations are recognized by the state museum as having cultural and historic ties to Illinois. The consultations, which are ongoing, began with discussing the repatriation of more than 230 ancestors unearthed from what today is known as Dickson Mounds.

“The need to rebury and to think about a different way of being in relationship with land from the state side was reiterated to us from just about every tribal nation,” said Heather Miller, the director of tribal relations and historic preservation for the Illinois State Museum. Miller is also an enrolled citizen of the Wyandotte Nation.

The new law is part of a broader effort to recenter Native voices in Illinois and within state institutions, a commitment brought to the Illinois State Museum in part by its former director, Cinnamon Catlin-Legutko, before her death this year. It was signed in tandem with two other laws; one requires the history of Native Americans in the Midwest be taught in Illinois public schools and another that bans school boards from prohibiting students from wearing cultural or tribal clothing and regalia in schools and at graduation ceremonies.

Interim Director Jennifer Edginton said the museum and IDNR, which oversees the institution, have “been looking very inward” to address the previous absence of Indigenous worldviews in their programs, collections and exhibits.

“We don’t want to continue that erasure, or stereotypes, or things that the museum field in general, unfortunately, has done since the inception of museums,” Edginton said.

The Legacy of Forced Removal

Today, no federally recognized tribes reside in Illinois, though Chicago is home to one of the largest urban communities of Indigenous people in the country. The absence of an organized political presence and tribal government has in part led to the state having among the worst repatriation track records in the nation.

“Forced removal affects everything,” said Miller, referring to the expulsion of Native American tribes from Illinois throughout the 1800s. “There was the physical removal, but that also removed [tribal nations] from being able to have a say in law, to have a say in voting, and from participating in all the ways the state operates and functions.”

That legacy has also contributed to Illinois museums designating many of the ancestral remains in their collections as “culturally unidentifiable” under the federal repatriation law. That designation has been misused by some institutions to avoid repatriating remains under NAGPRA, giving museums outsize power in consultations with tribal nations.

With passage of the new Illinois law, that balance of power will for the first time tip toward tribal nations whose ancestral lands became the state of Illinois.

“We have the ability to now bring those communities that were forcibly removed in violent ways back here,” Miller said. “Rather than being a ‘removal state,’ Illinois could be known as a ‘new relations’ state instead.”

The Future of Funerary Items

Another significant aspect of the new law is that it prohibits institutions from charging admission to view human remains that are Native American and any items that were originally buried with those individuals. Although the public display of Native American ancestral remains by museums fell out of practice after the passage of NAGPRA in the early 1990s, the public display of their funerary items has not.

After Dickson Mounds Museum in the early 1990s closed a burial exhibit that displayed the remains of more than 230 Native Americans, the institution still maintained a permanent exhibit that featured items taken from Indigenous gravesites across the state. As ProPublica reported this year, in September 2021, curators dismantled much of the exhibit at the request of tribal partners, who wished to see the items reunited with the ancestors they were buried with before their repatriation. Those funerary items made up about 40% of the exhibit.

State museum officials told ProPublica they’re not sure how many museums in Illinois still display funerary items. The law applies to every museum, university and historical society in the state — far more than the 15 institutions in Illinois that have reported their Native American holdings under the NAGPRA.

When asked about what he would say to museums that may push back against the law, Illinois State Rep. Mark L. Walker said: “Too bad.”

Walker, a Democrat who represents part of Chicago’s northwest suburbs, sponsored the legislation. He said he’s already received interest from other states looking to adopt similar laws.

“I think we can be a model for other states,” Walker said. “Whether we can change [Illinois’] image to such an extent that these communities actually trust us? I don’t know. That may take 30 years.”

by Sharon Lerner

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

The Environmental Protection Agency approved a component of boat fuel made from discarded plastic that the agency’s own risk formula determined was so hazardous, everyone exposed to the substance continually over a lifetime would be expected to develop cancer. Current and former EPA scientists said that threat level is unheard of. It is a million times higher than what the agency usually considers acceptable for new chemicals and six times worse than the risk of lung cancer from a lifetime of smoking.

Federal law requires the EPA to conduct safety reviews before allowing new chemical products onto the market. If the agency finds that a substance causes unreasonable risk to health or the environment, the EPA is not allowed to approve it without first finding ways to reduce that risk.

But the agency did not do that in this case. Instead, the EPA decided its scientists were overstating the risks and gave Chevron the go-ahead to make the new boat fuel ingredient at its refinery in Pascagoula, Mississippi. Though the substance can poison air and contaminate water, EPA officials mandated no remedies other than requiring workers to wear gloves, records show.

ProPublica and the Guardian in February reported on the risks of other new plastic-based Chevron fuels that were also approved under an EPA program that the agency had touted as a “climate-friendly” way to boost alternatives to petroleum-based fuels. That story was based on an EPA consent order, a legally binding document the agency issues to address risks to health or the environment. In the Chevron consent order, the highest noted risk came from a jet fuel that was expected to create air pollution so toxic that 1 out of 4 people exposed to it over a lifetime could get cancer.

In February, ProPublica and the Guardian asked the EPA for its scientists’ risk assessment, which underpinned the consent order. The agency declined to provide it, so ProPublica requested it under the Freedom of Information Act. The 203-page risk assessment revealed that, for the boat fuel ingredient, there was a far higher risk that was not in the consent order. EPA scientists included figures that made it possible for ProPublica to calculate the lifetime cancer risk from breathing air pollution that comes from a boat engine burning the fuel. That calculation, which was confirmed by the EPA, came out to 1.3 in 1, meaning every person exposed to it over the course of a full lifetime would be expected to get cancer.

Such risks are exceedingly unusual, according to Maria Doa, a scientist who worked at EPA for 30 years and once directed the division that managed the risks posed by chemicals. The EPA division that approves new chemicals usually limits lifetime cancer risk from an air pollutant to 1 additional case of cancer in a million people. That means that if a million people are continuously exposed over a presumed lifetime of 70 years, there would likely be at least one case of cancer on top of those from other risks people already face.

When Doa first saw the 1-in-4 cancer risk for the jet fuel, she thought it must have been a typo. The even higher cancer risk for the boat fuel component left her struggling for words. “I had never seen a 1-in-4 risk before this, let alone a 1.3-in-1,” said Doa. “This is ridiculously high.”

Another serious cancer risk associated with the boat fuel ingredient that was documented in the risk assessment was also missing from the consent order. For every 100 people who ate fish raised in water contaminated with that same product over a lifetime, seven would be expected to develop cancer — a risk that’s 70,000 times what the agency usually considers acceptable.

When asked why it didn’t include those sky-high risks in the consent order, the EPA acknowledged having made a mistake. This information “was inadvertently not included in the consent order,” an agency spokesperson said in an email.

Nevertheless, in response to questions, the agency wrote, “EPA considered the full range of values described in the risk assessment to develop its risk management approach for these” fuels. The statement said that the cancer risk estimates were “extremely unlikely and reported with high uncertainty.” Because it used conservative assumptions when modeling, the EPA said, it had significantly overestimated the cancer risks posed by both the jet fuel and the component of marine fuel. The agency assumed, for instance, that every plane at an airport would be idling on a runway burning an entire tank of fuel, that the cancer-causing components would be present in the exhaust and that residents nearby would breathe that exhaust every day over their lifetime.

In addition, the EPA also said that it determined the risks from the new chemicals were similar to those from fuels that have been made for years, so the agency relied on existing laws rather than calling for additional protections. But the Toxic Substances Control Act requires the EPA to review every new chemical — no matter how similar to existing ones. Most petroleum-based fuels were never assessed under the law because existing chemicals were exempted from review when it passed in 1976. Studies show people living near refineries have elevated cancer rates.

“EPA recognizes that the model it used in its risk assessments was not designed in a way that led to realistic risk estimates for some of the transportation fuel uses,” an agency spokesperson wrote. For weeks, ProPublica asked what a realistic cancer risk estimate for the fuels would be, but the agency did not provide one by the time of publication.

New chemicals are treated differently under federal law than ones that are already being sold. If the agency is unsure of the dangers posed by a new chemical, the law allows the EPA to order tests to clarify the potential health and environmental harms. The agency can also require that companies monitor the air for emissions or reduce the release of pollutants. It can also restrict the use of new products or bar their production altogether. But in this case, the agency didn’t do any of those things.

Six environmental organizations concerned about the risks from the fuels — the Sierra Club, Natural Resources Defense Council, Moms Clean Air Force, Toxic-Free Future, Environmental Defense Fund and Beyond Plastics — are challenging the agency’s characterization of the cancer risks. “EPA’s assertion that the assumptions in the risk assessment are overly conservative is not supported,” the groups wrote in a letter sent Wednesday to EPA administrator Michael Regan. The groups accused the agency of failing to protect people from dangers posed by the fuels and urged the EPA to withdraw the consent order approving them.

Chevron has not started making the new fuels, the EPA said.

Separately, the EPA acknowledged that it had mislabeled critical information about the harmful emissions. The consent order said the 1-in-4 lifetime cancer risk referred to “stack air” — a term for pollution released through a smokestack. The cancer burden from smokestack pollution would fall on residents who live near the refinery. And indeed a community group in Pascagoula sued the EPA, asking the U.S. Court of Appeals in Washington, D.C., to invalidate the agency’s approval of the chemicals.

But the agency now says that those numbers in the consent order do not reflect the cancer risk posed by air from refinery smokestacks. When the consent order said stack emissions, the EPA says, it really meant pollution released from the exhaust of the jets and boats powered by these fuels.

“We understand that this may have caused a misunderstanding,” the EPA wrote in its response to ProPublica.

Based on that explanation, the extraordinary cancer burden would fall on people near boats or idling airplanes that use the fuels — not those living near the Chevron refinery in Pascagoula.

Each of the two cancer-causing products is expected to be used at 100 sites, the EPA confirmed. ProPublica asked for the exact locations where the public might encounter them, but Chevron declined to say. The EPA said it didn’t know the locations and didn’t even know whether the marine fuel would be used for a Navy vessel, a cruise ship or a motorboat.

In an email, a Chevron spokesperson referred questions to the EPA and added: “The safety of our employees, contractors and communities are our first priority. We place the highest priority on the health and safety of our workforce and protection of our assets, communities and the environment.”

Doa, the former EPA scientist who worked at the agency for three decades, said she had never known the EPA to misidentify a source of pollution in a consent order. “When I was there, if we said something was stack emissions, we meant that they were stack emissions,” she said.

During multiple email exchanges with ProPublica and the Guardian leading up to the February story, the EPA never said that cancer risks listed as coming from stack emissions were actually from boat and airplane exhaust. The agency did not explain why it initially chose not to tell ProPublica and the Guardian that the EPA had mislabeled the emissions.

The agency faced scrutiny after the February story in ProPublica and the Guardian. In an April letter to EPA administrator Michael Regan, Sen. Jeff Merkley, the Oregon Democrat who chairs the Senate’s subcommittee on environmental justice and chemical safety, said he was troubled by the high cancer risks and the fact that the EPA approved the new chemicals using a program meant to address the climate crisis.

Sen. Jeff Merkley (Graeme Sloan/Sipa via AP Images)

EPA assistant administrator Michal Freedhoff told Merkley in a letter earlier this year that the 1-in-4 cancer risk stemmed from exposure to the exhaust of idling airplanes and the real risk to the residents who live near the Pascagoula refinery was “on the order of one in a hundred thousand,” meaning it would cause one case of cancer in 100,000 people exposed over a lifetime.

Told about the even higher cancer risk from the boat fuel ingredient, Merkley said in an email, “It remains deeply concerning that fossil fuel companies are spinning what is a complicated method of burning plastics, that is actually poisoning communities, as beneficial to the climate. We don’t understand the cancer risks associated with creating or using fuels derived from plastics.”

Merkley said he is “leaving no stone unturned while digging into the full scope of the problem, including looking into EPA’s program.”

He added, “Thanks to the dogged reporting from ProPublica we are getting a better sense of the scale and magnitude of this program that has raised so many concerns.”

The risk assessment makes it clear that cancer is not the only problem. Some of the new fuels pose additional risks to infants, the document said, but the EPA didn’t quantify the effects or do anything to limit those harms, and the agency wouldn’t answer questions about them.

Some of these newly approved toxic chemicals are expected to persist in nature and accumulate in living things, the risk assessment said. That combination is supposed to trigger additional restrictions under EPA policy, including prohibitions on releasing the chemicals into water. Yet the agency lists the risk from eating fish contaminated with several of the compounds, suggesting they are expected to get into water. When asked about this, an EPA spokesperson wrote that the agency’s testing protocols for persistence, bioaccumulation and toxicity are “unsuitable for complex mixtures” and contended that these substances are similar to existing petroleum-based fuels.

The EPA has taken one major step in response to concerns about the plastic-based chemicals. In June, it proposed a rule that would require companies to contact the agency before making any of 18 fuels and related compounds listed in the Chevron consent order. The EPA would then have the option of requiring tests to ensure that the oil used to create the new fuels doesn’t contain unsafe contaminants often found in plastic, including certain flame retardants, heavy metals, dioxins and PFAS. If approved, the rule will require Chevron to undergo such a review before producing the fuels, according to the EPA.

But environmental advocates say that the new information about the plastic-based chemicals has left them convinced that, even without additional contamination, the fuels will pose a grave risk.

“This new information just raises more questions about why they didn’t do this the right way,” said Daniel Rosenberg, director of federal toxics policy at NRDC. “The more that comes out about this, the worse it looks.”

by Jessica Miller, The Salt Lake Tribune

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

This story discusses sexual assault.

Andrew was feeling crushed by the cultural expectation to get married.

Twenty-two years old, he had just returned from a mission for The Church of Jesus Christ of Latter-day Saints and was attending a singles’ ward in Provo, Utah — a local congregation of unmarried college students.

But Andrew is gay. And marriage between a man and a woman is a central tenet of the Latter-day Saint faith, which teaches that the highest level of heaven is reserved only for married, heterosexual couples. Same-sex marriage is not an option in the church.

So in the fall of 2015, he did as many Latter-day Saints do when they are having a crisis: He went to his bishop.

The lay leader suggested trying therapy, Andrew remembered. In fact, the bishop said he had just gotten a referral that same day for a local therapist named Scott Owen who worked well with gay men who were members of their faith. Owen co-owned a Provo therapy business called Canyon Counseling and, at that time, was also a regional leader in a Provo-area stake, a cluster of congregations that is similar to a Catholic diocese.

The coincidental timing — that his bishop learned of Owen on the same day Andrew disclosed his internal struggles — felt miraculous.

“It was like, God has a plan,” Andrew said. “This is going to work out. Everything seems dark and depressing. But this therapist is going to fix everything.”

But that’s not what happened. For five months beginning in October 2015, Andrew said, the clinical mental health counselor groped him, encouraged him to undress and kissed him during sessions. Andrew said Owen told him that the touching was a therapeutic way to learn how to accept love and intimacy.

Andrew, now 30, is being identified by a pseudonym to protect his privacy.

Sexual touching in a therapy session is considered unethical by all major mental health professional organizations, and it is defined in Utah rules as “unprofessional conduct” that could lead to a mental health worker losing their license or other discipline. It’s also illegal in Utah.

By March 2016, Andrew had reported Owen to both his bishop and to state licensing officials. A new investigation from The Salt Lake Tribune and ProPublica shows how Utah licensers allowed Owen to continue practicing and church leaders repeatedly heard concerns but took several years to take official action. For nearly two years after Andrew’s report, Owen provided therapy to clients, some of whom were men referred for “same-sex attraction” counseling. During that time, at least three more patients allege they were sexually abused by Owen, including two who reported him to the state licensing body in 2018. Those reports ultimately led Owen to agree to surrender his license.

Owen’s case is indicative of a flawed and misleading system: Officials within Utah’s Division of Professional Licensing encourage the public to look to the agency’s disciplinary records to vet a professional, yet those records rarely offer a full picture of misconduct. Despite Owen’s pattern of alleged inappropriate behavior, his publicly available disciplinary records reference touching but never disclose that the accusations against him were sexual in nature. This is one of a number of shortcomings identified by The Tribune and ProPublica while reporting on how Utah officials fail to supervise medical professionals and to adequately address patient reports of sexual assault.

Scott Owen (Obtained by The Salt Lake Tribune)

Owen, a large-framed bald man with dark blue eyes who speaks with a drawl, built a reputation over his 20-year career as a therapist with Christian values who could help Latter-day Saint men with same-gender attraction. He gave public lectures so often about pornography and masturbation, Owen told a crowd of LGBTQ+ church members in 2016, that he had earned the nickname “The Porn King.”

Although Owen, now 64, responded to an initial email from a reporter, he did not answer detailed questions sent to him via certified mail.

Officials with DOPL say that, given the evidence they had from Andrew’s complaint, they believe they responded appropriately. But, communications between Andrew and an investigator suggest that the agency’s actions rested largely on Owen’s denial that anything improper had happened and a failed polygraph test officials asked Andrew to take — a tool that experts say is known to be specifically unreliable with victims of sexual abuse, and that some states ban for that reason.

Church spokesperson Sam Penrod said the faith made an annotation on Owen’s personal church record in spring of 2019 — three years after Andrew’s initial report to his bishop. An annotation is a confidential marking intended to alert a bishop to someone whose conduct has threatened the well-being of other people or the church. It can affect what roles members are asked to fill within their congregation.

Penrod said in an email: “The Church takes all matters of sexual misconduct very seriously. This case was no exception.”

Both the church and the licensing division declined to comment on whether they reported the therapist to the police. Provo police officials said they had no record of ever receiving any report of sexual abuse against Owen.

Owen co-founded Canyon Counseling in Provo, Utah, in 1998. (Leah Hogsten/The Salt Lake Tribune) Touching in Therapy

Owen pushed physical boundaries from the very start, Andrew said. After their first session, Owen ended their meeting with a quick hug. At his second appointment, Andrew said, Owen held him in a longer embrace.

“I’m doing this because I know you’re uncomfortable with love,” Andrew remembered Owen telling him as they hugged. “I want you to get used to it.” Such touching, he recalled Owen saying, would be “a key step in my therapy.”

Andrew did feel uncomfortable. But he remembered Owen seemed genuine and truthful in their therapy sessions — even “Christ-like” in his caring.

Growing up in the Latter-day Saint faith, Andrew was taught to trust men in positions of authority. There was also the expectation to talk with his bishop about deeply personal sexual details during one-on-one interviews. These annual closed-door discussions generally start when members become teenagers and typically explore whether they are following the faith’s rules; they have been criticized by some parents and therapists as being “inappropriate” and “intrusive.”

These interviews, Andrew said, left him with a skewed view of what was appropriate in a mentoring relationship.

“I felt like a lot of the times I didn’t understand what normal boundaries to have around sexuality,” he said, in part because of how he was instructed to relate to religious leaders. “You have to air it all to these particular people in your life — and then you hide it desperately from everyone else.”

In the late 1960s, church leaders took a hard stance against even identifying as gay, including “homosexuality” in a list of behaviors that could result in excommunication. Bishops and church leaders in subsequent years were taught that being gay was a reversible condition, and church leaders would send gay men to conversion therapy or advise they could be fixed by marrying a woman.

By the time Andrew began seeing Owen in 2015, the church had publicly acknowledged that its members do not have a choice in being attracted to the same sex; today, church policy says a gay member can remain in good standing if they remain celibate and never marry someone of their same gender.

“At the time, I knew it might not be possible for me to get married, and that would still be OK in the church framework,” Andrew recalled. But, he added, “so much of the LDS dream is based on marriage that that was crushing and really depressing to me.”

So Andrew kept going to therapy, even as he said Owen began touching him more, at times rubbing his back or his bottom during hugs. Owen encouraged him to undress during some therapy sessions, Andrew said, which evolved into what he describes as “makeout sessions.” Looking back now, it’s clear to Andrew that this was inappropriate — but in the moment, he felt desperate and confused.

Andrew reasoned with himself that he was not physically attracted to Owen when they touched, which would be similar if he married a woman. Maybe it was a way for him to learn how to express romantic feelings he didn’t have or to fake it until those feelings came.

“I couldn’t accept that I was being taken advantage of,” Andrew said. “That’s a hard thing to be like, ‘Oh, I’ve been sexually abused this whole time.’”

“This was supposed to be my miracle,” he added.

Decorations in Andrew’s room (Leah Hogsten/The Salt Lake Tribune) A Reprimand

Andrew decided to stop therapy in February 2016, as he wrestled with whether what had happened had been abusive. He confided in a friend during late-night study sessions on Brigham Young University’s campus a few days later. In an interview corroborating Andrew’s account, she recalled urging him to tell someone.

Within a week of stopping therapy, Andrew again found himself confiding in his bishop.

Andrew recalled feeling like his church leader, who works as a livestock and pasture insurance agent, seemed confused about how to help a gay member of the church — and whether this type of touching in therapy was supposed to be helpful. He referred Andrew to another therapist who, Andrew said, told him Owen’s alleged conduct was a “gross violation” of patient boundaries.

Andrew went back to his bishop with this information, but the lay leader never reported that information to church authorities. The church’s general handbook for members makes it clear that if a bishop or stake president “learns of abuse of a spouse or another adult,” they are supposed to call a confidential hotline for guidance from lawyers and clinical professionals.

The bishop, whom The Tribune and ProPublica are not identifying to protect Andrew’s identity, said that he struggled to process what Andrew told him, and that he felt it was sufficient that he had encouraged Andrew to report Owen to state licensing officials at DOPL. The division is responsible for licensing Utah professionals, from medical doctors to armed security guards to massage therapists. It is also charged with investigating misconduct and can revoke a license or put someone on administrative probation.

By then, Andrew had stopped seeing Owen. Andrew’s bishop questions now whether he should have said something to a higher church leader, but he said he felt the faith’s guidance for when bishops should report alleged abuse to church authorities pertained more to “something happening that needs to be stopped, like when there’s abuse in the home.” The bishop added that he didn’t feel he knew how he should help members who were struggling with their sexual identity and their faith.

“A bishop is supposed to be a spiritual guide. Not a psychologist, not a family therapist. So I felt equipped to listen and love them, absolutely,” he said. “But as far as to help them process what it means and how to be a part of this religion and be gay — I never figured that out.”

Andrew followed his bishop’s guidance and went to licensers in early March 2016. In a statement Andrew wrote for investigators — which he shared with The Tribune and ProPublica — Andrew described the escalating touching and accused Owen of touching parts of his genital area at their last appointment.

“I left feeling disgusted in what had happened,” Andrew wrote about their last appointment, “and vowed to never return.”

To conduct their investigation, licensing officials offered the therapist a polygraph test. He refused, according to DOPL. They also asked Andrew if he would wear a recording device, he said, and go to Owen’s office to ask him about the touching. Andrew said he didn’t feel like he could go through with that.

That’s when the investigator asked Andrew if he would take a lie detector test.

Andrew said the investigator reasoned to him that if he could pass one, it could bolster what essentially was a case of one person’s word against the other.

The polygraph did not go well, Andrew said — the results suggested he was being deceptive.

“I had so much trauma,” Andrew said. “And so, certainly, when they asked me questions about the particular things that happened in therapy, it’s going to elicit a very strong emotional response.”

Researchers say this is a common response for trauma victims, and many recommend that sexual abuse victims not undergo polygraph exams. Half of states have laws explicitly prohibiting law enforcement from conducting a polygraph test with someone reporting a sexual assault, with some barring any government employee from requiring an alleged sexual assault victim to take one. There is no law in Utah that puts limits on the use of polygraph tests on victims.

Melanie Hall, the spokesperson for DOPL, acknowledged that an investigator did “offer the option” of a polygraph test to both Owen and Andrew. She said that it is “extremely rare” for a polygraph to be used as part of an investigation, but that the agency doesn’t track how often.

Andrew’s failed polygraph sent his own mental health spiraling. He wrote in an email in October 2016 that he no longer wanted to participate in the investigation unless someone else came forward.

A month later, Owen was given a public reprimand from licensers for the one inappropriate action he admitted to: that he gave Andrew hugs. Owen admitted in licensing documents that he “inappropriately touched a client in a non-sexual manner.”

Hall said the “overwhelming majority” of DOPL’s disciplinary actions are negotiated settlements — where a licensed professional admits to lesser conduct than what is alleged by those who say they’ve been harmed.

Owen later told the Clinical Mental Health Counselor Licensing Board, in a hearing in Salt Lake City at which he received an official reprimand, that his client had been struggling with a family issue, and that it was “not uncommon” for him to hug his patients.

But he denied Andrew’s allegations to the board, calling it “quite a story he concocted.”

“I readily agreed and admitted to giving him hugs at the end of the session and that sort of stuff,” Owen said during the meeting, adding that someone at DOPL told him that he should “know better” than to hug someone who was seeking therapy for same-sex attraction.

Owen said that he had changed his practices.

“I don’t do that anymore,” he said. “I have just been a little bit stunned and burned by this. I’ll shake hands, and I don’t even like to shake hands until my office door’s open and completely out in the reception area with my receptionist there.”

Owen left the meeting that day with a reprimand but no other limitations on his license — and no need to tell his other patients.

“I Felt Betrayed”

At precisely the time DOPL was investigating Owen, and then publicly reprimanded him, another man living in Provo and attending the same religious university as Andrew was questioning whether the way the therapist touched him during sessions had crossed the line.

Jonathan Scott had been seeing Owen for three years — and he would continue to see him for nine months more after the reprimand. His allegations bear a striking resemblance to Andrew’s, but he was not aware of the licensing reprimand — and it would be years before he realized that his experience was not unique.

Jonathan Scott began therapy sessions with Scott Owen in 2013 as an effort to heal from childhood sexual abuse. Scott said that the therapist touched him inappropriately but that he did not initially recognize Owen’s alleged actions as abuse. (Leah Hogsten/The Salt Lake Tribune)

Jonathan Scott, a reserved 32-year-old with curly ash brown hair, first started seeing Owen in 2013 as a lanky BYU student struggling to deal with childhood trauma from being sexually abused by his Boy Scout leader in Illinois. His parents found Owen online and met with him first; Jonathan Scott’s father recalls Owen saying that he could help their son have safe relationships with adult men.

Jonathan Scott said his new therapist reminded him of the man who sexually abused him when he was a kid. They had similar nervous tics, and the way each man had looked at him felt the same. They were both middle aged and had the large frame and roundness of a teddy bear.

“That was kind of the point,” Jonathan Scott remembers. Unlike his abuser, Owen was supposed to be “a safe, good man who is supposed to help me reestablish trust with men.”

But Jonathan Scott said Owen frequently touched him under his clothing while hugging him during sessions.

Like Andrew, he said this touching gradually escalated. Eventually, he said, his sessions felt like nothing more than 40 minutes of cuddling. Also like Andrew, he told himself that to heal he needed to learn to accept touch. And because he was raised in the church, he added, he wasn’t going to question a religious leader.

“You justify things. You let things slide. But did it feel comfortable? No, it didn’t feel comfortable. It didn’t feel safe,” he said. “But I was told I needed to work through that.”

Jonathan Scott ended therapy in 2017 when he moved. He never contacted DOPL, or the police, himself. It was only two years later that his partner — upset with the thought that Owen had never faced consequences — was searching online and found the reprimand. She corroborated details of his account in an interview with The Tribune.

It felt like a betrayal, Jonathan Scott said, to learn that Owen had denied touching Andrew around the same time he says the therapist had been groping him.

“When I found out that there were others, I felt not alone,” he said. “I felt justified in my anger of what I thought had happened to me. I felt even less trust in authority.”

Hall said that DOPL may, in some cases, require a disciplined licensee to inform their patients of unprofessional conduct, though that didn’t happen in Owen’s case. Utah has no law requiring this type of disclosure, and there are only three states that do require medical professionals disciplined for sexual misconduct to disclose that to their patients.

“DOPL and/or the licensing board may decide to implement this requirement,” Hall said, “if there is strong concern about an individual treating others without first informing them and receiving consent from the patient.”

But a search of more than 3,200 filings obtained from DOPL’s website, some from as early as 2010, shows the state has rarely required disclosure of unprofessional conduct to individual patients.

A Surrendered License

Owen continued to practice for nearly two years after the reprimand. It would take two more people coming forward before the licensing process was able to take meaningful action.

One of those was Sam, a 43-year-old man who now lives in Arizona. As a Latter-day Saint who was attracted to other men, Sam struggled to feel accepted, his brother Jason recalled. One fall day in 2017, Sam called Jason sobbing to tell him about a therapist he had been going to: how Owen had made him feel loved; how the therapist told him that he could help him learn to accept intimacy; how the sessions had become sexual.

Sam later detailed his experiences in a written timeline, an account that a friend later also shared in a letter to the church: It started in January 2017 with a hug and by August had escalated to mutual masturbation.

He declined an interview request relayed through his brother. Sam and his brother are identified by pseudonyms for this article, and information about Sam’s experience was gleaned from interviews and records provided by his brother and Troy Flake, a friend Sam confided in at the time.

In February 2018, DOPL received another report alleging Owen engaged in sexual misconduct. Details of the complaint were redacted in response to a public records request. And in April, Sam himself spoke to a DOPL investigator.

“Just got off the phone with the investigator,” Sam wrote in a text message to his brother. “It was pretty rough to explain to him all of what happened, but I’m glad I got through it and started this process.”

He wrote that the investigator had “accumulated accounts from several of Scott’s clients.”

Within weeks of Sam speaking to the investigator, Owen surrendered his license as part of an agreement with Utah’s licensing division. According to the DOPL order, investigators believed that Owen inappropriately touched “a number” of clients in a five-year period beginning in 2013. There was no reference to the sexual nature of those contacts. And when Owen surrendered his license, he was able to give it up while neither agreeing with nor denying licensers’ findings.

Reports to Church Leaders

Utah’s licensing division wasn’t the only entity that had knowledge of Owen’s activities for years before he was censured. There was also the church.

Andrew had gone to his bishop back in 2016, but church officials say their legal department did not learn of any alleged inappropriate conduct involving Owen until two years later, after DOPL had already begun to investigate.

As with Andrew, Sam first relayed his concerns to a trusted church leader. In the timeline Sam created, which he had shared with Flake, he wrote that Owen at times had told him that he “didn’t need to run off and talk to my bishop about” their counseling sessions.

If he wanted help processing what was happening, Sam wrote in that document, Owen suggested he talk with Alan Hansen, a psychologist who was also Owen’s business partner at Canyon Counseling. Hansen’s role as Sam’s stake president at that time meant he was also in charge of overseeing thousands of church members who make up local congregations in their area.

A patient of Owen’s twice raised concerns with Alan Hansen, co-owner of Canyon Counseling, about inappropriate touching during therapy. (Leah Hogsten/The Salt Lake Tribune)

In August 2017, Sam went to Hansen’s church office on BYU’s campus, where he disclosed that Owen had been “physical” with him during sessions.

He wrote in his timeline that Hansen encouraged him to keep attending therapy and gave him a priesthood blessing — a prayer of healing and encouragement given by adult men in their church. The blessing made Sam feel better, he wrote, and he continued seeing Owen for therapy for two months. But then, he added, he became too uncomfortable with the sexual touching he said happened inside the Canyon Counseling office.

In December, according to the timeline, he told Hansen again about Owen’s touching. This time, though, he was more explicit — telling the church leader that Owen had kissed him and had engaged in heavy petting and other types of sexual touching.

“Alan acknowledged that some of Scott’s actions clearly crossed some boundaries and that was likely due to Scott’s own weaknesses,” Sam wrote. “He also stated that Scott had done something like this before — and that there were others. I don’t remember his exact language, but that was the effect of what he said.”

Hansen did not respond to a list of questions sent to him, and he referred a reporter to the church’s legal department. A church spokesperson did not address questions about Hansen.

Sam continued to tell other church leaders about Owen’s behavior — and Hansen’s dismissal of it. He also went to his previous bishop in Provo. Sam wrote in text messages to his brother that this church leader confronted Hansen about “essentially doing nothing about my situation with my previous therapist.”

“He thinks it’s possible that it’s a releasable offense for the stake president,” Sam wrote to his brother about the chance that church authorities would strip Hansen of his official role in their faith. But that didn’t happen.

Penrod, the church spokesperson, did not respond to a question asking whether Hansen ever received disciplinary action for not reporting his business partner to church authorities.

He added that “local leaders who are themselves professional therapists should not refer members to affiliated therapists or practices in which they have a financial interest.”

But concerns over Owen’s behavior didn’t end when he surrendered his license. Flake, Sam’s friend, was worried that Owen could still be teaching in a church setting and was frustrated that he believed Hansen had known what was going on and took no action. More than a year later, in December 2019, he sent an email to church lawyers urging them to investigate.

A church attorney responded to his email later that same day, according to correspondence shared with The Tribune and ProPublica, telling Flake the firm would provide the information “to Owen’s current leaders and let you know if we need additional information.” The attorney made no mention of Hansen. Flake says he never heard from the church lawyers again.

The Tribune asked church officials in an email whether Hansen had ever been disciplined in connection to his business partner’s actions, but the church did not respond to that question. Hansen’s psychologist license is in good standing with the state, and no disciplinary action has been taken against him.

“There’s Been Zero Justice”

Years after they say they were sexually assaulted, several of Owen’s former patients are connected now through one more person who says the ex-therapist sexually abused him nearly 40 years ago: Owen’s own cousin, a Boise, Idaho, man named James Cooper.

Cooper wrote to his family in June 2020, telling them that Owen molested him in a shared bed during a trip to Colorado in the 1980s. The email describes how Cooper had learned that past winter that Owen had surrendered his license.

He also sent a separate email to Owen, who denied the allegation and replied: “I don’t see this the same, but I am so sorry for your pain and hurt.”

Cooper wrote in the email to his family that up until then “my strategy has been to forget and avoid Scott [Owen] as much as possible, and admittedly that means I was content to keep my head in the sand in this regard.”

But after he read about Owen surrendering his license, Cooper wrote, it forced him to think about those who allege his cousin later hurt them. The 48-year-old man scoured the internet, searching for any potential victims and posting anonymously on Google reviews asking others to reach out to him.

Owen’s cousin, James Cooper, alleged Owen molested him in the 1980s. More recently, Cooper sought out and connected former patients of Owen’s who allege they were abused in therapy. (Sarah A. Miller for ProPublica)

That’s how he connected with Andrew, Jonathan Scott and Sam’s friend Flake; together, the men grappled with what to do next. All of them described long-term effects of Owen’s alleged conduct and also a sense that there had been no meaningful consequences for him.

Both Andrew and Jonathan Scott have left the church, in part because of the alleged abuse. Sam has been devastated after realizing he had been taken advantage of, according to Flake, which has destroyed his ability to trust his own perception. And Jonathan Scott has thought about reporting Owen to the police, but he continues to struggle to trust authority figures.

“There’s been zero justice, as far as I can see,” Jonathan Scott said.

Owen today is listed as the registered agent for Canyon Counseling in public business records. It’s not clear what his role in the business is, but in 2019, Flake called the police to report seeing Owen’s truck in the Canyon Counseling parking lot, though he did not have a license to practice therapy.

An officer contacted Owen, who said he owns the business — but is not a therapist any more.

The Mental Health Profession Violations

Scott Owen is one of at least 197 mental health professionals who have been disciplined by Utah licensers since 2012, according to a data analysis by The Salt Lake Tribune and ProPublica of available disciplinary documents on the state Division of Professional Licensing’s website as of April 20, 2023. This database is not exhaustive, as older filings may no longer appear on the website.

Of those, 73 — or 37% — had been disciplined for sexual misconduct. Searches of DOPL’s disciplinary records suggest that mental health professionals are more often disciplined for sexual-related misconduct than doctors or nurses. The Tribune and ProPublica also identified 28 other misconduct cases where a therapist had an inappropriate “dual relationship” with a client — such as a client sleeping over at a therapist’s home or cleaning horse stalls together — that did not appear on paper to be explicitly sexual in nature.

Owen is one of five Utah mental health professionals identified by The Tribune and ProPublica who have been disciplined more than once for sexual conduct. Several of them continue to work in the therapy business in some capacity. Two others among the five were put on probation and allowed to continue working as therapists, according to disciplinary filings, while a third opened a life coaching business marketing himself as a “one of the few Ph.D.-level coaches” in southern Utah.

Utah licensers consider any sexual contact with a current patient to be misconduct, and sexual relationships with a former patient are not allowed within two years after they stop seeing a therapist.

When asked if the licensing division knew whether therapists were at higher risk for sexual misconduct, spokesperson Melanie Hall said DOPL is aware that certain license types “have a tendency towards certain types of violations.” She didn’t specifically address mental health professionals, but she gave certified public accountants as an example of professionals who have increased access to bank accounts and are more likely to commit financial fraud than other professionals who do not have that access.

The agency, she said, “takes these factors into account when investigating complaints, and takes appropriate disciplinary action when necessary.”

The news organizations also asked Hall about whether DOPL reports cases to law enforcement. Under Utah law, it is illegal for a health professional to engage in sexual contact with their patient under the guise of providing treatment.

The licensing division, Hall said, is not legally required to forward information to law enforcement — just as the police are also not mandated to share information about a licensed professional they are investigating. The only exception to this, she said, is a requirement that drug thefts be reported to police.

Hall said that licensers do collaborate and report crimes to police agencies “often,” though she did not explain under what circumstances they would do so. She said that licensers may encourage a patient to reach out to the police or decide that the case does not require a criminal investigation. She would not say whether anyone at DOPL ever reported Owen to the police.

Help ProPublica and The Salt Lake Tribune Investigate Sexual Assault in Utah

Editor’s Note: Three sources for this story — Andrew, Sam and Jason — are identified only by pseudonyms because they requested anonymity. Two are alleged victims of sexual assault, and the third is the brother of one of those men. We have granted this request because of the risk to their standing in their communities if they were publicly identified. The Salt Lake Tribune and ProPublica typically use sources’ full names in stories. But sometimes that isn’t possible, and we consider other approaches. That often takes the form of initials or middle names. In this case, we felt that we couldn’t fully protect our sources by those means. Their full names are known to a reporter and editors, and their accounts have been corroborated by documents and interviews with others.

This story was supported in part by a grant from the Fund for Investigative Journalism.

Jeff Kao and Haru Coryne, ProPublica, and Will Craft, special to The Salt Lake Tribune, contributed data reporting. Mollie Simon, ProPublica, contributed research.

by Melissa Sanchez and Maryam Jameel

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.

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Central Wisconsin’s Clark County is home to more dairy farms than any other county in the state, which bills itself as America’s Dairyland. Its identity is so tied to the dairy industry that a 16-foot-tall, black-and-white talking Holstein stands outside downtown Neillsville, the county seat.

To corral the cows, milk them and clear their manure at these dairy farms — the dirty, dangerous work that makes this multibillion-dollar industry go — farm owners here and across Wisconsin rely on a labor force that they know is largely undocumented.

But the state makes it almost impossible for workers to have lives outside the farm without breaking the law. In Wisconsin, undocumented immigrants can own and register their cars and trucks, but they aren’t allowed to drive them. Those who drive anyway are pulled over again and again and again, and issued tickets that eat away at their wages.

The law banning undocumented immigrants from obtaining driver’s licenses has cascading effects across the state. Law enforcement officials say the roads are less safe because undocumented immigrants aren’t trained and tested on basic driving rules but they drive anyway — and often without insurance. Court officials say tickets for driving without a license overwhelm their dockets and drain their limited resources. Farmers say they have to build or find employee housing to help their workers avoid getting ticketed.

The workers, many from remote, impoverished communities in Latin America, are grateful for the jobs. And yet they feel trapped.

They are people like a 33-year-old Nicaraguan who came to Wisconsin two years ago after hearing from friends that it was easy to find work on “los ranchos,” as dairy farms here are known by Spanish-speaking workers. He lives with three other Central American men in a small, white house owned by their boss that sits a few miles down a county road from the farm.

One afternoon in March, as the worker drove a roommate’s Jeep to the grocery store, a Neillsville police officer ran a random check of the license plates. The officer learned that the Jeep’s registered owner didn’t have a driver’s license and pulled him over.

The worker told the officer he didn’t have a license, records show, and the officer issued him a $200.50 citation.

“A day’s worth of work, lost. It hurts,” said the man, who routinely works 14-hour days.

Over the past year, ProPublica has interviewed more than 100 undocumented current and former dairy workers — in farm breakrooms, in the trailers and apartments where they live, in the shops where they wire money home, and at courthouse cashier’s windows where they pay their tickets. They said they are isolated and stuck on the farms where they work and often live. They struggle to get to grocery stores, to their children’s schools and to immigration court hearings. They delay medical care.

So they either rely on others who, for a price, drive them where they need to go, or they break the law and take their chances.

“You can’t call Uber because there isn’t any. You can’t take the bus because there aren’t any,” said John Rosenow, a dairy farmer in western Wisconsin who has become one of the most prominent advocates for immigrant workers in the state. “The closest barber shop is 15 miles away. The closest grocery store is 25 miles away.”

Making matters worse, the punishments for repeat offenses can escalate in severity, exposing workers to stiffer financial penalties, criminal cases and jail time. In counties that have formal agreements with federal immigration authorities, the threat of deportation hangs over every police stop.

What’s happening in Clark County and across Wisconsin is the result of Congress’ failure to figure out what to do about the millions of undocumented immigrants who live here and work in industries that, like dairy, unabashedly depend on them. That leaves state lawmakers to craft legislation to try to address the consequences — or to ignore what’s happening, punishing immigrants in the process.

Wisconsin is home to about 70,000 undocumented immigrants, mostly from Latin America, according to estimates from the nonprofit Migration Policy Institute. These are the people who hang drywall, clean hotel rooms, wash dishes in restaurant kitchens and package the nation’s cheese.

Determining how many of Wisconsin’s dairy workers are undocumented is almost impossible. Workers use fake papers to get jobs, farmers accept those papers without question, and the state and federal governments make little effort to get an accurate count. But a conservative estimate from a recent University of Wisconsin at Madison study puts the number of undocumented Hispanic workers on medium-to-large farms at roughly 6,200. That figure excludes the many immigrant workers on smaller farms, those with fewer than 500 cows.

Advocates for immigrants have worked for years to persuade lawmakers to give undocumented immigrants driving privileges, as 19 states — most of them blue — have done. But those efforts have been unsuccessful in Wisconsin, where legislative districts have been drawn to favor Republicans. Few GOP lawmakers have been willing to support any such efforts; political observers say the lawmakers don’t want to look soft on immigration.

So local communities are left to look for their own solutions.

In one county, officials have been quietly conducting a pilot driver’s education program aimed largely at undocumented immigrants who were caught driving without a license. They are reluctant to speak publicly about it out of fear that any attention will lead to conservative backlash.

Elected district attorneys in several counties have stopped bringing criminal charges against people caught driving without a license; both Democrat and Republican prosecutors say they want to dedicate their limited resources to crimes with victims.

And in four counties in southwestern Wisconsin, community advocates worked with local law enforcement agencies and dairy farmers a few years ago to create identification cards that workers could show officers during traffic stops to prove that they worked in the area and, potentially, keep those encounters from escalating.

“It did not prevent them from getting a ticket, but it prevented them from being handcuffed and hauled off to jail,” said Shirley Barnes, the recently retired co-director of the MultiCultural Outreach Program in Dodgeville. “The fact is, all the police officers in all of these counties know exactly where these people work. They know it is local farmers who are employing these people.”

A dairy farm in south-central Wisconsin (Caleb Santiago Alvarado for ProPublica)

One morning in May, a former dairy worker from Honduras slid into a courtroom bench in the Clark County Circuit Court in downtown Neillsville and waited for his name to be called. His 16-year-old son sat next to him, missing school to serve as his father’s interpreter. ProPublica is identifying the man only by his first name, José. Like other workers in this story, he asked not to be fully identified because he is undocumented and fears being deported.

A month earlier, a state trooper had pulled José over for driving 15 mph over the speed limit on U.S. Highway 10. In addition to issuing a speeding ticket, the trooper had cited him for driving without a valid license.

“We just enforce the law,” Sgt. Brandon Gray, a spokesperson for the Eau Claire post of the Wisconsin State Patrol, said in an interview. “If they don’t have a valid license, then obviously they receive a citation.”

José said he regrets speeding. But he said it’s impossible for him to comply with the license requirement.

“It makes me so damn sad I could cry,” said José, who said he came to the U.S. two years ago to better provide for his son. “I have to drive. Nobody else is going to come to support my son. Nobody else is going to pay my rent.”

José left court with his son after paying $200.50 for driving without a license and another $175.30 for speeding. José drove home, still licenseless.

Of the 35,000 people who live in Clark County, just 6% are Hispanic, according to census estimates.

Yet last year, 187 of the 245 cases that were brought in this court for operating a vehicle without a valid license — or more than 75% — involved Hispanic drivers, according to data compiled for ProPublica by Court Data Technologies, a Madison company.

A similar trend is playing out in circuit and municipal courts across the state, ProPublica found. (Citations for this charge can go to either type of court if it’s a first-time offense; circuit courts also handle repeat offenses, which can become criminal cases.)

Roughly half of the 16,000 circuit court convictions for driving without a valid license involved Hispanic drivers, according to the information provided by Court Data Technologies from cases filed in 2022.

The actual percentage is likely higher, since Latin American immigrants are often marked as “Caucasian” in court records; José, for example, is listed this way.

Hispanic residents make up less than 8% of the population.

“Those numbers are alarming,” said Primitivo Torres Martinez, deputy director for statewide civic engagement for Voces de la Frontera, the state’s largest immigrant rights advocacy group, who learned of the statistics from ProPublica. “The thing is, farmers need [immigrant workers] to drive, so it’s a Catch-22 for a lot of folks.”

Police and the courts don’t track the immigration status of drivers. But across the state, people involved in nearly every step of the traffic enforcement process — police, judges, prosecutors, defense attorneys, interpreters and other circuit and municipal court officials — agreed that most Hispanic drivers who get ticketed for not having a license are undocumented immigrants.

Records from these cases routinely describe drivers who show Mexican or Nicaraguan identification cards to police, don’t speak English and need an interpreter, or tell officers they can’t get a license because of their immigration status. You can see them in courthouse lobbies, glancing hopefully around for an interpreter when the clerk offers to use Google Translate on her phone, or sitting anxiously on courtroom benches, wondering whether they will end up being deported.

Thousands more tickets for driving without a valid license were processed last year in the state’s roughly 230 municipal courts. These courts operate independently from each other and, as a result, there is no one single place to get case information that would allow a statewide analysis of those courts.

But ProPublica obtained data from about a dozen municipal courts and found that, over and over, Hispanic drivers received a substantial share of these citations.

In Milwaukee, the state’s largest city, they accounted for nearly 40% of the tickets. In Waukesha, a Milwaukee suburb, 49%. In Manitowoc, along Lake Michigan, 58%. In each of these places, Hispanics account for 20% or less of the population.

The numbers appear to be starker in municipal courts farther from metropolitan areas. At the Marshfield Area Municipal Court in central Wisconsin, for example, 69% of these tickets issued by the Marshfield Police Department went to Hispanic drivers, records show. Less than 3% of Marshfield residents are Hispanic.

It’s a similar story in Sparta, a small town surrounded by dairy farms in western Wisconsin. Sparta’s municipal court does not track defendants’ race or ethnicity, but ProPublica found that 91 of the 131 tickets issued last year for driving without a valid license — or about 70% — involved defendants with common Hispanic surnames like Cruz, Cortez and Gonzalez. (The U.S. Census Bureau says that more than 85% of people with those last names are Hispanic.) Fewer than 6% of residents in Sparta are Hispanic.

Immigrant dairy workers from around Sparta, Wisconsin, regularly visit Supermercado Guerrero to buy groceries and painkillers, cash their checks and wire money to relatives in Mexico and Central America. (Caleb Santiago Alvarado for ProPublica)

Mention the subject of tickets in a tiny Mexican grocery store there and the tired dairy workers in line will nod their heads with familiarity and indignation.

“I’ve been pulled over probably 15 times,” said one man, a longtime dairy worker from Mexico. Sometimes, he said, it’s the same police officer who pulls him over. “They recognize me immediately and call me by name, saying, ‘I told you not to drive,’” the worker added. “But I have to drive to get to work.”

Most Hispanic immigrant drivers don’t bother to contest the tickets, they simply pay in cash, said Andrea Ziegler, Sparta’s municipal court clerk. Altogether, Hispanic drivers in Sparta paid more than $8,400 in tickets issued last year for not having a license, records show.

“I don’t think it’s right. If you’re going to ticket them, then you need to provide a path for them to get a license so they can work, so they can continue to contribute to our society,” Ziegler said.

“Our farms would not be able to survive without them.”

When we asked farmers about their employees’ immigration status, they told us they merely accept the paperwork that applicants hand them.

“I don’t think it’s right. If you’re going to ticket them, then you need to provide a path for them to get a license so they can work, so they can continue to contribute to our society.”

—Andrea Ziegler, Sparta, Wisconsin’s municipal court clerk

But over the years, the dairy industry has tacitly acknowledged its reliance on an undocumented workforce. At the federal level, it has tried unsuccessfully to gain access to an immigrant guest worker program. Closer to home, dairy farmers have become powerful allies of Voces de la Frontera in its campaign to allow undocumented immigrants to get driver’s licenses.

Almost a dozen dairy farmers across Wisconsin told ProPublica they wish their workers could get licenses.

In one sense, their motivation is economic. Many farmers say they would like to ensure their employees can get to and from work without police stopping and ticketing them. Several described the calls they’ve received in the middle of the night from workers who needed a ride after they got locked up. “If they throw them in jail, they’re no good to us,” said one farmer in western Wisconsin.

Farmers said they are also motivated by empathy.

“It’s basically a human need issue,” said Randy Roecker, a third-generation dairy farmer who runs a 275-cow operation in Sauk County, in central Wisconsin. “They need to be able to drive to go get groceries, the bank, the doctor, but yet they feel they can’t because they’re afraid they’re gonna get picked up all the time.”

Randy Roecker watches as his dairy cows are taken to the milking parlor. (Caleb Santiago Alvarado for ProPublica)

Like many other farmers, Roecker and his family decided to build employee housing when they expanded their operation and hired their first immigrant workers in 2006.

That was the year Wisconsin lawmakers banned access to driver’s licenses for undocumented immigrants. Some dairy workers who were in the state at the time still keep their expired licenses in their wallets in the hope that the old documents may help them avoid tickets in traffic stops.

The change in the law was a response to the federal REAL ID Act — a post-9/11 law sponsored by then-U.S. Rep. James Sensenbrenner, a Wisconsin Republican — which standardized the type of identification that could be used to board planes and enter federal buildings. To comply, Wisconsin and other states began to require proof of U.S. citizenship or other legal status to obtain licenses.

From the beginning it was clear the law would hurt undocumented immigrants living in states that let them drive. For some lawmakers, like Sensenbrenner, this was a good thing; he told reporters at the time that Wisconsin had become a “mecca for illegal aliens” seeking driver’s licenses.

Latino lawmakers and advocates said banning these immigrants from driving would cause more problems than it would solve. Bernard Trujillo, then a law professor at the University of Wisconsin at Madison, told The Capital Times that if Wisconsin denied immigrants driver’s licenses, “they will just drive without it.”

“This is the ‘If I close my eyes, I’ll make them go away’ approach to treating the undocumented, which is ineffective as a policy matter,” he added.

(Caleb Santiago Alvarado for ProPublica)

On a frigid evening in February 2021, John Rosenow stood outside his dairy farm in Cochrane, in western Wisconsin, and watched as a longtime employee got pulled over on his way into work.

A Buffalo County sheriff’s deputy had been parked in front of the farm observing traffic on a stretch of county road where the speed limit is 35 mph. The deputy noted later that he saw a car moving at a “slow rate of speed,” then ran the license plate. The records check showed that the car’s owner didn’t have a license, so the deputy pulled it over.

Despite a language barrier, the worker was able to tell the deputy he didn’t have a driver’s license but showed his Mexican identification card. The deputy told him that he’d be getting a ticket in the mail and warned him not to drive without a license.

Because it was the worker’s second citation in three years, he was charged with a misdemeanor in Buffalo County Circuit Court.

To Rosenow, the traffic stop looked like racial profiling. He wrote a letter to the judge in the case.

“Certainly, the court can understand how important Juan and other Mexicans are to the agricultural and food processing industries in our area,” Rosenow wrote. “Harassment by the Sheriff’s department does not help make our community any safer.”

That argument didn’t sway the judge. The worker, who has since returned to Mexico to be with his family, pleaded guilty and paid $443 for the ticket and mandatory court costs — including a DNA test, a requirement in criminal cases. The total amount was equivalent to about five days’ take-home pay.

In a statement, Buffalo County Sheriff Mike Osmond declined to comment on the traffic stop but said he understood the concerns about potential racial profiling. But he said that his deputies “enforce traffic laws impartially, without discrimination based on race or ethnicity” and that his office is “committed to upholding the constitutional rights of all individuals, regardless of their immigration status.”

Across Wisconsin, dozens of undocumented immigrants who have been stopped and ticketed solely for not having a license told ProPublica they believed they were the victims of racial profiling.

Among them: the 33-year-old Nicaraguan man who was pulled over after a random plate check as he drove to the grocery store in Neillsville this spring. “How did he know I didn’t have a license?” he wondered. “I hadn’t committed any infraction but got pulled over.”

In an interview, Neillsville Police Chief Jim Mankowski said he would support letting undocumented immigrants get licenses as a way to make the roads safer and to help officers more quickly and accurately identify people they encounter.

“How did he know I didn’t have a license? I hadn’t committed any infraction but got pulled over.”

—A Nicaraguan man who was pulled over after a random plate check

But he said random plate checks can help officers discover violations that are tied to the registered owner of a vehicle, from suspended or revoked licenses to outstanding arrest warrants. He said officers should have a reasonable suspicion that the person driving a vehicle is its owner; for example, if a plate check determines the owner is a man who doesn’t have a license, it wouldn’t make sense to pull the vehicle over if a woman is driving.

He added, “If it’s a tool that can help my cops do their job better, that’s something that we have to embrace.”

Records from law enforcement and court cases across the state show that, in many communities, sheriff’s deputies and police officers routinely run the license plates of passing vehicles — regardless of the racial or ethnic background of the driver — and pull people over if they discover a violation. But the issue of not having a license hits Hispanic drivers the most.

One of the underlying factors is the contradiction in state policy that allows undocumented immigrants to register their cars but not drive them.

“They put a bullseye on them,” said Tony Gonzalez, an immigration rights advocate in north-central Wisconsin. “The state collects the money on registration and there is no benefit for that registrant. It’s like taxation without representation.”

A spokesperson for the state transportation department said the agency “implements the laws as written.” The spokesperson could not say how many vehicles are registered to people who do not have driver’s licenses.

Getting pulled over after a random license plate check by police is so common that many undocumented immigrants have turned to a black market for protection: Several people who spoke with ProPublica described paying someone with a license to register a vehicle under their name to help avoid getting pulled over. One man, a home construction contractor in a Milwaukee suburb, said that once he started registering his car under his company’s name instead of his own, he stopped getting pulled over and ticketed for not having a license.

Similarly, a dairy worker in Jefferson County, in southern Wisconsin, said he felt “like an ATM” for police after paying thousands of dollars over the past few years in fines and court costs resulting from not having a license. Then, he said, he heard of someone in another community who, for a price, would register his car under their name.

It has been worth the money, the worker said. He hasn’t been pulled over since.

Help ProPublica Journalists Investigate the Dairy Industry

Alex Mierjeski and Jeff Frankl contributed research.

by Anjeanette Damon and Byard Duncan

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As soon as Lisa Casteel learned her 78-year-old mother had agreed to sell her Kansas City home to a “We Buy Ugly Houses” franchise for far below its market value, she contacted the buyer to halt the deal.

In her letter to the company, she invoked a Kansas state law that grants three days to cancel certain sales agreements. She believed it would protect her mother and any other vulnerable homeowners entangled by questionable real estate deals. Her mother had no other place to live and had recently been showing signs of dementia, she said.

But the representative of the franchise, Red Rock REI, refused.

The experience more than three years ago revealed a glaring hole in regulations meant to protect people from unfair and deceptive practices. Even though HomeVestors franchises are in the business of buying properties, they use many of the same methods found in high pressure sales. In Kansas and many other states, laws that require a grace period for getting out of such sales contracts don’t apply to real estate transactions. Neither does a federal law aimed at protecting people from predatory sales practices.

Only after the Kansas Attorney General’s Office intervened at Casteel’s request was her mom able to keep her home. The attorney general ultimately demanded that Red Rock REI release Casteel’s mother from the contract by relying on state laws that protect the elderly from deceptive practices. And while Casteel succeeded in saving her mother’s house, no other action was taken against the franchise.

“I feel bad for others out there who are getting taken advantage of,” Casteel said. “They’ve got no help. And they feel like there’s no place to turn but to go ahead and sell to Red Rock and Ugly Houses and people like that.”

Adam Hays, who owned Red Rock before selling the franchise in 2021, said his sales representative did not observe that Casteel’s mother had any cognitive issues. He said HomeVestors demanded its franchises maintain a “strict standard of integrity and honesty.”

He said his company did not easily release homeowners from contracts because that would make it difficult to stay in business. His practice was to conduct “due diligence” into a homeowner’s reason for backing out of a deal to ensure another party wasn’t interfering with the homeowner’s decision. He said when he received the letters from the attorney general’s office about Casteel’s mother, he realized she had a legitimate reason for canceling the contract.

A corporate spokesperson for HomeVestors said the company was unaware of Red Rock’s dealing with Casteel’s mother and that it is no longer a franchise. HomeVestors recently prohibited some of the tactics Red Rock used to tie homeowners to contracts.

An investigation this year by ProPublica found some HomeVestors of America franchises used deception and aggressive sales tactics to persuade homeowners in vulnerable situations to sell their homes for far below market prices. The investigation also found few jurisdictions have laws or regulations to protect homeowners from aggressive tactics that fall short of outright fraud or elder abuse.

There have, however, been a few attempts by policymakers to protect vulnerable homeowners. A first-of-its-kind law in Philadelphia regulates real estate investors that participate in wholesaling properties — meaning they buy houses and resell them without making improvements or sell purchase contracts signed by the homeowner to another investor.

“A high pressure sales technique isn’t new, and we’ve been trying to protect people against it in all sorts of areas for years,” said Kate Dugan, staff attorney at Community Legal Services in Philadelphia, which worked on the law.

The law attempts to address a flaw in most consumer protection laws: Because homeowners are being pressured to sell rather than to buy something, the laws don’t cover them as consumers.

“The harm is the same, though: Parties with unequal bargaining power are engaging in a transaction, and the less sophisticated party loses,” Dugan said.

Oklahoma recently became one of a few jurisdictions to require licenses for residential real estate wholesalers. Unethical behavior can put wholesalers’ licenses at risk.

“When you don’t have reasonable guidelines, or restrictions or regulations in place to protect very minimum standards of abuse, then you’re going to open up the door for rampant abuse, like we’re seeing right now,” said Grant Cody, executive director of the Oklahoma Real Estate Commission.

ProPublica spoke to experts, including advocates for homeowners, real estate lawyers, a regulator and an individual in the business of flipping houses, about policies that could better protect homeowners. Here are their suggestions for regulations policymakers could consider.

A Cooling-Off Period

Casteel was quick to answer when asked what policymakers could do to help people like her mother.

“There should be at least a cooling-off period,” she said. “And I don’t think three days is enough. Because for seniors who fall victim to this, they may not mention it to a family member within the first couple of days.”

Advocates for stronger homeowner protections agree the law should provide an efficient way to cancel a signed real estate contract within a set period under certain circumstances. Or, as an alternative, policymakers could adopt something similar to Philadelphia’s requirement that wholesalers give a homeowner three days to consider a contract before it’s signed.

Cooling-off periods are common in other transactions that involve high pressure sales or large assets. Many states, for example, have a right of rescission in timeshare sales, and a cooling-off period is built into many annuity purchases.

In particular, homeowners who have never publicly listed their houses for sale should be allowed a quick way out of a contract, said Sarah Bolling Mancini, co-director of advocacy at the National Consumer Law Center. Public listings attract competing offers and can better determine fair market value. Such a regulation would also protect homeowners from cash buyers who solicit sales.

Casteel said she’d also require that cash house buyers leave a copy of the contract with the homeowner along with the paperwork necessary to cancel it.

Asked by ProPublica whether HomeVestors would support such a regulation, a corporate spokesperson said the company is implementing a 72-hour cooling-off period requirement for its franchises.

“We require our franchisees to comply with our Systems and Standards, which generally go above and beyond state regulations, and we regularly update our standards to ensure our franchisees do the right thing and act to protect consumers,” she said.

Penalties for Persistent Solicitation

HomeVestors and its franchises spend heavily on advertising — peppering neighborhoods with billboards and sending postcards to thousands of addresses at a time, promising quick cash and a painless sale process. Other homebuyers call and text endlessly.

Many homeowners view these aggressive, ground-level marketing strategies as a nuisance. And in some cities, policymakers have taken steps to curb them.

In Houston, residents can report illegally placed “bandit signs” to the city’s Department of Neighborhoods. Violators there can face up to $500 in fines, lawsuits and even arrest. Following reporting from WABE, the Atlanta City Council in 2020 prohibited real estate investors from “repeated and unsolicited attempts” to contact a homeowner after being asked to stop. Such overtures now amount to a form of “commercial harassment.” Violators can face fines or up to six months in jail.

And Philadelphia’s “do-not-solicit” list, launched last year, allows residents to opt out of in-person sales pitches, emails, phone calls and mailers. Offenders face up to $2,000 in fines. The city can ask a judge to assess larger fines on repeat offenders.

Restrictions on Recording Claims on a Property Title

ProPublica’s investigation found some HomeVestors franchises routinely recorded documents against a homeowner’s title to trap them in a deal — a predatory practice known as “title clouding.” In response to ProPublica’s reporting, HomeVestors prohibited its franchises from clouding titles. But other cash homebuyers still do it.

Dugan said policymakers should consider restrictions on title clouding, including a waiting period between signing a contract and recording it and an easy way for a homeowner to contest the recording.

Many jurisdictions, including Philadelphia, allow homeowners to sign up to be notified when any document has been recorded against their title.

In many cases, months pass before homeowners learn that a contract had been recorded against the title. Sometimes the homeowner has died and their family must pay the house flipper to release the claim.

For example, six months passed before Casteel learned that Red Rock REI had recorded the sales contract against her mother’s title. When the Kansas Attorney General’s Office pressed Red Rock to remove the recording, the franchise owner tried to justify the action.

In an email to the attorney general’s office, the franchise owner said he recorded the contract to protect his interest in the property in the event Casteel’s mother “was being dishonest” and tried to sell the house to someone else.

Red Rock didn’t remove the recording until the attorney general’s office issued multiple warnings.

“It might discourage this predatory behavior if the bad actor knows that the homeowner will get notice immediately,” Dugan said.

Requiring a License

A professional license, such as those required for real estate agents, isn’t a guarantee against unethical behavior. But experts said licensing could require a basic education so that wholesalers know such things as real estate laws, what should be included in a contract and what disclosures homeowners are entitled to. A licensing board could investigate homeowner complaints.

Philadelphia’s licensing of residential real estate wholesalers has provided transparency into who is wholesaling, Dugan said. The law also allows homeowners to cancel contracts at any time before closing if they’ve sold to an unlicensed wholesaler, which is a strong incentive for wholesalers to become licensed.

Kevin Link, a former Financial Industry Regulatory Authority investigator who co-owns a house-flipping business in Maryland, said he would welcome more regulation of the industry to weed out bad actors and ensure that those in the business have a minimum level of real estate education.

“Right now, the only regulations in place are those that govern white-collar crime,” he said.

HomeVestors’ corporate spokesperson said the company isn’t opposed to requiring wholesaler licenses.

“We look forward to exploring this, as well as other constructive ideas, on how we can best protect consumers within our industry,” she said.

A Need for Federal Regulations?

Real estate regulation is largely the domain of cities, counties and states, creating a patchwork of policies and varying degrees of oversight and transparency. Because many regulatory bodies can only investigate licensed real estate activity, wholesalers often operate without the same guardrails as real estate agents.

Federal regulations to standardize local oversight, similar to the Secure and Fair Enforcement for Mortgage Licensing Act passed 15 years ago in the wake of the financial crisis, could help. The SAFE Act, which passed in 2008 after the explosion in predatory mortgage practices helped inflate a housing bubble and spark that year’s financial crisis, requires minimum local licensing standards for mortgage originators.

“I think a federal statute could be very helpful and meaningful,” Mancini said.

Rather than leaving it to states to enact a regulatory model, however, Mancini said federal rules could be applied to “we buy houses” transactions, such as by allowing a homeowner to cancel a sale if they have never publicly listed the home or obtained an appraisal, didn’t have a real estate agent or were directly solicited to sell the house.

She said states could also follow Maryland’s lead and ensure their unfair and deceptive acts and practices laws explicitly apply to real estate purchases in which high pressure sales tactics are used or a homeowner has been misled about the value or marketability of their house.

Mollie Simon contributed research.