ProPublica

by Kavitha Surana

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Candi Miller’s health was so fragile, doctors warned having another baby could kill her.

“They said it was going to be more painful and her body may not be able to withstand it,” her sister, Turiya Tomlin-Randall, told ProPublica.

But when the mother of three realized she had unintentionally gotten pregnant in the fall of 2022, Georgia’s new abortion ban gave her no choice. Although it made exceptions for acute, life-threatening emergencies, it didn’t account for chronic conditions, even those known to present lethal risks later in pregnancy.

Why should I trust your reporting? I (Kavitha Surana) am a reporter that has been covering reproductive health care access since Roe v. Wade was overturned. I’ve spoken with doctors, community workers and patients across the country about how abortion bans have made pregnancy more dangerous in America, and I’ve written about the Republican lawmakers who refused to listen.

If you want to get in touch and learn more about how I work, email me. I take your privacy very seriously.

At 41, Miller had lupus, diabetes and hypertension and didn’t want to wait until the situation became dire. So she avoided doctors and navigated an abortion on her own — a path many health experts feared would increase risks when women in America lost the constitutional right to obtain legal, medically supervised abortions.

Miller ordered abortion pills online, but she did not expel all the fetal tissue and would need a dilation and curettage procedure to clear it from her uterus and stave off sepsis, a grave and painful infection. In many states, this care, known as a D&C, is routine for both abortions and miscarriages. In Georgia, performing it had recently been made a felony, with few exceptions.

Her teenage son watched her suffer for days after she took the pills, bedridden and moaning. In the early hours of Nov. 12, 2022, her husband found her unresponsive in bed, her 3-year-old daughter at her side.

An autopsy found unexpelled fetal tissue, confirming that the abortion had not fully completed. It also found a lethal combination of painkillers, including the dangerous opioid fentanyl. Miller had no history of drug use, the medical records state; her family has no idea how she obtained them or what was going through her mind — whether she was trying to quell the pain, complete the abortion or end her life. A medical examiner was unable to determine the manner of death.

Her family later told a coroner she hadn’t visited a doctor “due to the current legislation on pregnancies and abortions.”

When a state committee of experts in maternal health, including 10 doctors, reviewed her case this year at the end of August, they immediately decided it was “preventable” and blamed the state’s abortion ban, according to members who spoke to ProPublica on the condition of anonymity.

They came to that conclusion after weighing the entire chain of events, from Miller’s underlying health conditions, to her decision to manage her abortion alone, to her reticence to seek medical care. “The fact that she felt that she had to make these decisions, that she didn’t have adequate choices here in Georgia, we felt that definitely influenced her case,” one committee member told ProPublica. “She’s absolutely responding to this legislation.”

This is the second preventable death related to abortion bans that ProPublica is reporting this week. Amber Thurman, 28, languished in a suburban Atlanta hospital for 20 hours before doctors performed a D&C to treat sepsis that resulted from an incomplete abortion. It was too late. “This young mother should be alive, raising her son and pursuing her dream of attending nursing school,” Vice President Kamala Harris said of Thurman on Tuesday. “This is exactly what we feared when Roe was struck down.”

There are almost certainly other deaths related to abortion access. Georgia’s committee, tasked with examining pregnancy-related deaths to improve maternal health, has only reviewed cases through fall 2022. Such a lag is common in these committees, which are set up in each state; most others have not even gotten that far.

The details of their reviews are not shared with the public, but ProPublica obtained the Georgia committee’s summary report of Miller’s death. ProPublica also reviewed death records and Miller’s autopsy and spoke to her family.

Her case adds to mounting evidence that exceptions to abortion bans do not, as billed, protect the “life of the mother.” Harrowing stories about denied care have been at the center of the upcoming presidential election, during which the right to abortion is on the ballot in 10 states. ProPublica’s new reporting makes clear, for the first time, that in the wake of bans, women are losing their lives in ways that experts have deemed preventable.

It also underscores the reality that abortion bans have not actually led to a decrease in abortions. But for people like Miller, they have increased the degree of difficulty and risk.

Miller’s husband, Alex, and son Christian, with her ashes, at home in Atlanta (Rita Harper, special to ProPublica) No Health Exceptions

Miller grew up in Alabama and spent most of her adulthood in Atlanta, where she made a living braiding hair and doing nails. She had a soft spot for stray cats, nurtured a garden and was known to break into dance at the sound of old school funk like the Commodores. At 4 foot 9, she was a “firecracker,” her family said — quick to stand up for those she loved. That included her three kids, who range in age from 5 to 16.

But about eight years ago, she was diagnosed with lupus, an autoimmune disease in which the body attacks healthy tissue, her sister said. Symptoms include extreme fatigue; painful, swollen joints; heart complications; and kidney disease.

Miller experienced flare-ups of debilitating pain for which she had to seek radiation treatments. She often wasn’t able to stand for long periods and her hair fell out. It distressed her how often doctors dismissed her pain; she grew to doubt they could give her help when she needed it.

Soon after she was diagnosed, she suffered a major depressive episode, Tomlin-Randall said. For months, she barely left her bed. Tomlin-Randall cared for her sister’s children during that time.

Miller, right, and Turiya Tomlin-Randall (Courtesy of Turiya Tomlin-Randall)

There is no cure for lupus, but patients can manage symptoms with a mixture of drugs and therapies; 90% of those afflicted are women, and the condition is three times more common in Black women than white.

Miller also had diabetes and hypertension. Those conditions, layered on top of her lupus, can be dangerously exacerbated by pregnancy and are highly unpredictable, during both the pregnancy and the aftermath, according to the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. Patients with those conditions are also more likely to have a pregnancy that ends in miscarriage or premature birth and are more likely to need a cesarean section, a major surgery that is especially hard for patients with diabetes to recover from.

With support, some patients can remain stable and have healthy pregnancies, though the experience can be physically taxing and painful. In the worst cases, pregnancy with lupus can lead to high blood pressure that can quickly progress to seizures, kidney and liver dysfunction and, ultimately, death. Studies have found the maternal death rate for women with lupus is 20-fold higher than for those without lupus. The chance of relapses and flare-ups are also high in the postpartum period.

Each patient’s situation is different and needs careful evaluation of their particular health risks, including discussion of the option to end the pregnancy, said Dr. Sarah Horvath, an OB-GYN representing ACOG.

Politicians who support abortion bans often point to their exceptions, which they say protect “the life of the mother.” During last week’s debate, former President Donald Trump called them “very important.”

But the anti-abortion groups that drafted the bans wrote the exceptions to be as narrow as possible and persuaded lawmakers to impose steep criminal penalties, fearing doctors might stretch definitions to create loopholes.

The exceptions are limited to acute emergencies, usually defined as when “necessary in order to prevent the death of the pregnant woman or the substantial and irreversible physical impairment of a major bodily function.” They also specifically prohibit mental health reasons from counting as health emergencies, even if a pregnant woman says she is thinking about harming herself. In Georgia, violating the law can cost doctors their license and subject them to prison terms of up to 10 years.

The laws typically don’t include any leeway for intervening earlier to treat patients with broader health risks that could make pregnancy more dangerous, such as lupus.

ProPublica surveyed dozens of doctors in nine states with abortion bans. None of their hospitals approve abortions for women with high-risk complications like lupus or diabetes unless the patient is already deteriorating and the issue is urgent.

Horvath regularly sees patients with complications from those conditions in Pennsylvania because they can’t get care in their own state. Often, the delay in figuring out where to go means their pregnancy is further along — and, as a result, their conditions have become more dangerous. They show up to outpatient clinics already displaying signs of trouble, Horvath said, and immediately have to be sent to the hospital where there’s an operating room and a blood bank.

It often takes time for patients and their providers to coordinate care in other states because there is so much confusion about the laws.

“People who are really suffering in these pregnancies really don’t know where to go,” Horvath said. “Or if they even can.”

Miller’s husband, Alex, wears her engagement ring around his neck. (Rita Harper, special to ProPublica) An Unsupervised Alternative

Miller’s third pregnancy was difficult and she never fully recovered, Tomlin-Randall said.

When Miller learned she was pregnant again in 2022, she ordered abortion pills for about $80 from a website called AidAccess, according to her 16-year-old son, Christian Cardenas.

The organization, based in the Netherlands, is devoted to expanding abortion access to places where it is not legal. Patients contact a doctor in Europe who sends them pills from a supplier in India. According to one researcher, Aid Access serves about 7,000 patients a month in the U.S., nearly 90% of them in states with abortion bans or severe restrictions. Its founder, Dr. Rebecca Gomperts, said it was clear the abortion pill did not cause her death.

The committee also did not believe Miller’s death was caused by the abortion medication. Her autopsy found extremely high doses of diphenhydramine (the main ingredient in Benadryl) and acetaminophen (what’s found in Tylenol) in Miller’s system, along with the fentanyl. Considering the quantity of drugs and the timing of her death, the committee also did not suspect the abortion pills themselves were in any way tainted.

Self-managing abortions at home has skyrocketed since the Supreme Court overturned the constitutional right to abortion, because of access to pills that can be ordered online, researchers say.

Major studies, the Food and Drug Administration and the World Health Organization have found abortion pills to be more than 90% effective when taken correctly and in the first trimester. Deaths due to abortion pills are exceedingly rare. Complications can develop if some fetal tissue remains in the uterus, where it can lead to sepsis, a grave infection. Patients are supposed to follow up with a doctor to make sure the abortion has fully completed and go to the hospital if bleeding heavily or exhibiting other symptoms.

Miller’s family does not know how far along her pregnancy was when she took the abortion pills.

But soon enough, she was in excruciating pain.

And that’s how she remained, for days, until she took the potent drug mixture. Her family doesn’t know what she was thinking when she did it, but can’t fathom that she would want to end her life; she was excited about the future and drawing closer to her church, her sister Tomlin-Randall said.

“She was trying to terminate the pregnancy, not terminate herself,” she said.

Miller’s 16-year-old son, Christian, holds his mother’s ashes at home in Atlanta. (Rita Harper, special to ProPublica)

It was significant to the state maternal mortality review committee that Miller did not feel she could seek medical care.

Although Georgia courts have said women can’t be prosecuted for getting abortions, the state has sent mixed messages. While some state bans explicitly say women can’t be prosecuted, Georgia’s ban leaves open that possibility. In 2019, a district attorney on the outskirts of metro Atlanta called abortion “murder” and said women “should prepare for the chance that they could be criminally prosecuted for having an abortion.”

That was the understanding in Miller’s family.

“If you get caught trying to do anything to get rid of the baby,” her son Christian told ProPublica, “you get jail time for that.”

Cassandra Jaramillo contributed reporting. Mariam Elba, Jeff Ernsthausen and Kirsten Berg contributed research.

by Jake Pearson

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

The chair of the New York City Council’s Committee on Aging is calling on Gov. Kathy Hochul and legislative leaders to overhaul the state’s beleaguered guardianship system in response to a ProPublica investigation that found elderly and infirm New Yorkers living in dire conditions while under court-mandated oversight.

City Councilmember Crystal Hudson introduced a resolution last week intended to force Albany to take up the cause of those whom judges have deemed incapable of managing their own affairs — a constituency without powerful lobbyists or political influence whose needs have long been ignored by state legislators.

“Too many people have been failed by this system, and a real overhaul is long overdue,” said Hudson, a Democrat. “We need a system that instills confidence — one that guarantees people in need of guardianships a dignified existence.”

More than 28,000 people statewide are currently under the care of court-appointed guardians, and nearly 60% of them live in New York City.

Hudson’s bill, which calls for an annual infusion of state funding to serve poor New Yorkers in the system, will be the subject of public hearings later this fall.

The proposal cites a series of stories this year by ProPublica that revealed how thousands of residents who have no family or friends to look after them are ill-served by many of the nonprofits and private attorneys that judges appoint to oversee their well-being. In the guardianship industry, this group of wards is known as “the unbefriended.”

The news organization found that there are too few guardians available to serve the people who need them and even fewer overseers, called examiners, to review the guardians’ work. A dearth of court staff and judges has compounded the problem. ProPublica found that annual assessments of guardians’ care can take years to complete, and even then the court oversight mostly focuses on financial paperwork, with officials rarely visiting wards in person.

The lack of scrutiny and long delays can result in unchecked neglect, as well as financial exploitation of New York’s most vulnerable people. A woman featured in ProPublica’s reporting lived for years in a home that had no heat and was infested by bedbugs and rats — conditions her legally appointed guardian did not rectify and her examiner did not question. Another man’s guardian spent more than half of her ward’s life savings for care provided by her own private business — a flagrant conflict of interest that a judge permitted for years.

Hudson’s resolution would pressure state legislative leaders and the governor to bolster the system by allocating state money to pay for more guardians. The current system is largely unfunded. So judges often ask lawyers to take on cases pro bono or assign nonprofits, which take monthly fees directly from their wards’ accounts. For a small group of people in need, county social service departments pick up the tab, though judges say the groups they contract with to provide those services are overburdened and understaffed.

To fix the problem, the legislation suggests a plan developed by Guardianship Access New York, a coalition of nonprofit providers. It calls for a “significant and permanent statewide investment in nonprofit guardianship services” of $15 million annually. That’s similar to what happens in Florida, which publicly funds 16 nonprofits that serve thousands of eligible wards. In GANY’s proposal, the funding would go to vetted groups that would then serve 1,500 New Yorkers each year to “ensure access to an ethical, reliable, and effective guardian.”

Kimberly George, a leader of GANY who also runs Project Guardianship, a nonprofit group that serves as guardian to about 160 New York City wards, said in an interview that the proposal “wouldn’t fix the whole system, but it’s a big piece of it.”

“If judges have reliable good guardians to go to, maybe they won’t have to appoint ones that they know are questionable or aren’t sure about,” she said.

Judges, for example, have long relied on a guardianship company featured by ProPublica even as it failed to meet the needs of more than a dozen wards. In one case, it collected monthly fees from an elderly man even after he left the country — and also after he died. The group, which serves hundreds of poor New Yorkers, continues to receive appointments. The company has declined to answer questions about specific clients but previously told ProPublica that it was accountable to the court and that its work was scrutinized by examiners, who are empowered to raise any issues.

The city resolution comes as the state court system crafts its own guardianship proposals in advance of next year’s legislative session, which begins in January.

According to an internal proposal obtained by ProPublica, an advisory committee of judges and lawyers has recommended that the state’s top judicial leaders and court administrators ask Albany to create a “fully funded statewide entity” to serve as a public guardian. Such a government entity, the committee estimates, would cost $72 million to staff and would serve the “unbefriended” in each county — a population the proposal estimates represents about 20% of all wards statewide.

The committee also recommended that the courts seek to increase compensation for court examiners, as well as court evaluators, who assess the needs and capacities of people before a judge imposes guardianship. That money would come from funding that is now reserved for lawyers who represent the indigent in criminal cases, not from wards’ own funds.

A court spokesperson said the state’s top judicial leaders “have made clear to our partners in other branches of government that we support the creation of a statewide public guardianship program as a key component of an overhaul of the system.”

Spokesperson Al Baker added: “We are proud to be advocating for additional funding to cover the costs of guardianships, particularly to assist those who are the most economically constrained.”

State lawmakers last seriously addressed the court-appointed guardianship system 30 years ago, when they passed the state’s main guardianship statute, Article 81 of the Mental Hygiene Law. This year during budget negotiations, lawmakers secured just $1 million to fund a statewide helpline, despite a request to provide $5 million to combat some of the bigger problems detailed in ProPublica’s reporting. Spokespeople for the Senate majority leader, Andrea Stewart-Cousins, and Assembly speaker, Carl Heastie, didn’t respond to requests for comment on Hudson’s resolution.

Neither did the office of Hochul, whose support will be essential to any guardianship reform. The Democrat, who took office three years ago, has proposed a plan to confront the needs of the state’s aging population, which mentions guardianship, among other measures, though it spells out few details.

Advocates hope Hochul will be receptive to an overhaul, given her record on a related issue. In July 2022, she signed into law a bill that provides an alternative to guardianship for people with intellectual and developmental disabilities, permitting them, not a guardian, to make decisions about their own lives.

At the bill signing, according to a transcript, she acknowledged the power of government to better the circumstances of the vulnerable.

New York, she said, had “a well-intended Legislature and a governor who wanted to make sure if there’s any issue that comes to our attention where a wrong needs to be righted, we will take the pen and do just that. And that is what today is about.”

by Marilyn W. Thompson and Alex Mierjeski

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Federal Judge Aileen M. Cannon, the controversial jurist who tossed out the classified documents criminal case against Donald Trump in July, failed to disclose her attendance at a May 2023 banquet funded by a conservative law school.

Cannon went to an event in Arlington, Virginia, honoring the late Supreme Court Justice Antonin Scalia, according to documents obtained from the Law and Economics Center at George Mason University. At a lecture and private dinner, she sat among members of Scalia’s family, fellow Federalist Society members and more than 30 conservative federal judges. Organizers billed the event as “an excellent opportunity to connect with judicial colleagues.”

A 2006 rule, intended to shine a light on judges’ attendance at paid seminars that could pose conflicts or influence decisions, requires them to file disclosure forms for such trips within 30 days and make them public on the court’s website.

It’s not the first time she has failed to fully comply with the rule.

In 2021 and 2022, Cannon took weeklong trips to the luxurious Sage Lodge in Pray, Montana, for legal colloquiums sponsored by George Mason, which named its law school for Scalia thanks to $30 million in gifts that conservative judicial kingmaker Leonard Leo helped organize.

Current rates for standard rooms at Sage Lodge can exceed $1,000 per night, depending on the season. With both Montana trips, Cannon’s required seminar disclosures were not posted until NPR reporters asked about the omissions this year as part of a broader national investigation of gaps in judicial disclosures.

Cannon did not respond to repeated requests for comment.

In response to questions from ProPublica, the clerk in the Southern District of Florida wrote in an email that Cannon had filed the Sage Lodge trips with the federal judiciary’s administrative office but had “inadvertently” not taken the second step of posting them on the court’s website. She explained that “Judges often do not realize they must input the information twice.”

The clerk said she had no information about the May 2023 banquet.

“Judges administer the law, and we have a right to expect every judge to comply with the law,” said Virginia Canter, chief ethics counsel for the watchdog group Citizens for Responsibility and Ethics in Washington.

Cannon’s husband, Joshua Lorence, a restaurant executive, accompanied her to the 2021 and 2022 colloquiums, which featured noted conservative jurists, lawyers and professors as well as lengthy “afternoon study breaks,” according to records obtained by ProPublica. Cannon emailed university staff to submit airport parking expenses and inquire about rental car reimbursement.

The rule for paid seminars is among the policies set by the Judicial Conference. Federal judges are also required by law to file annual financial disclosures, listing items such as assets, outside income and gifts.

Cannon’s annual disclosure form for 2023, which was due in May and offers another chance to report gifts and reimbursements from outside parties, has yet to be posted. (Cannon reported the two Montana trips on her annual disclosure forms, but the required 30-day privately funded seminar reports had not been posted. In 2021, Cannon incorrectly listed the school as “George Madison University.”)

The court’s administrative office declined to say if she requested a one-time extension to give her until Aug. 13 to file. A spokesperson would not discuss whether she met the deadline or the status of her disclosure, which must be reviewed internally.

Cannon’s performance during almost four years of a lifetime appointment has drawn criticism from lawyers, former federal judges and courtroom observers who told ProPublica that she doesn’t render timely decisions and has made unpredictable rulings in both civil and criminal matters. On July 15, she threw out the case brought by Special Counsel Jack Smith that alleges Trump mishandled classified documents at his Mar-a-Lago residence; Cannon called Smith’s appointment unconstitutional since he was not nominated by the president and approved by the Senate.

Smith is appealing to the 11th U.S. Circuit Court of Appeals, and Citizens for Responsibility and Ethics in Washington has asked the court to remand her decision and replace her.

By contrast, Trump, who appointed Cannon in 2020 to the Fort Pierce courthouse, has praised her brilliance, and Federalist Society founder Steven Calabresi called her a heroine for throwing out the criminal case against Trump.

For decades, judicial education programs sponsored by George Mason’s Law and Economics Center have drawn in 5,000 state and federal judges and four current Supreme Court justices, according to its website. The school says its programs strive for balance and intellectual rigor. But conference agendas and speaker lists that the university must file with the courts detail lectures and panel discussions built around Federalist Society principles that are associated with conservative legal movements.

Ken Turchi, associate dean for external affairs, said the law school plays no role in judicial disclosures. “Judges’ decisions to submit (or not submit) disclosure forms are theirs alone — it’s a self-reporting process,” he said.

The guest list for the May 2023 Scalia Forum included William H. Pryor Jr., chief judge of the 11th Circuit, which is now hearing Smith’s appeal. Pryor and dinner speaker Kyle Duncan, a 5th Circuit judge, did file their required disclosures for the Scalia dinner.

Pryor’s court has overruled Cannon twice in the Trump case. It sided with the government in September 2022 on a motion for a stay and found that it “had established a substantial likelihood of success on the merits.” In December 2022, it ruled that she erred in naming a special master to examine classified documents seized from Mar-a-Lago. After that decision, Cannon had to dismantle an expensive operation set up by her special master, a senior federal judge in New York.

Gabe Roth, who directs Fix the Court, a nonprofit judicial reform group, said compliance with the privately funded seminar rule has improved in some circuits since his group pressed for compliance with the Administrative Office of the Courts.

“They’re a more effective way for litigants and the public to get a sense of what types of individuals and groups a judge might be hanging out with and learning from,” he said.

Records show that Cannon submitted minor reimbursement requests related to the Scalia Forum trip after she returned, including the 158 miles she drove round trip to the airport. She inquired with George Mason staff about details for an Alaska excursion recommended by a former lawyer in the Trump-era White House Counsel’s Office.

Cannon registered for George Mason’s Hill Country Colloquium at a Texas resort in December 2023 but had to back out for scheduling reasons.

“I hope to join that event, and others, in future years,” she wrote.

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If you have information about Judge Aileen M. Cannon, please contact Marilyn W. Thompson at marilyn.thompson@propublica.org.

by Eli Hager

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The state of Ohio is giving taxpayer money to private, religious schools to help them build new buildings and expand their campuses, which is nearly unprecedented in modern U.S. history.

While many states have recently enacted sweeping school voucher programs that give parents taxpayer money to spend on private school tuition for their kids, Ohio has cut out the middleman. Under a bill passed by its Legislature this summer, the state is now providing millions of dollars in grants directly to religious schools, most of them Catholic, to renovate buildings, build classrooms, improve playgrounds and more.

The goal in providing the grants, according to the measure’s chief architect, Matt Huffman, is to increase the capacity of private schools in part so that they can sooner absorb more voucher students.

“The capacity issue is the next big issue on the horizon” for voucher efforts, Huffman, the Ohio Senate president and a Republican, told the Columbus Dispatch.

Huffman did not respond to ProPublica’s requests for comment.

Following Hurricane Katrina and the start of the COVID-19 pandemic, some federal taxpayer dollars went toward repairing and improving private K-12 schools in multiple states. Churches that operate schools often receive government funding for the social services that they offer; some orthodox Jewish schools in New York have relied on significant financial support from the city, The New York Times has found.

But national experts on education funding emphasized that what Ohio is doing is categorically different.

“This is new, dangerous ground, funding new voucher schools,” said Josh Cowen, a senior fellow at the Education Law Center and the author of a new book on the history of billionaire-led voucher efforts. For decades, churches have relied on conservative philanthropy to be able to build their schools, Cowen said, or they’ve held fundraising drives or asked their diocese for help.

They’ve never, until now, been able to build schools expressly on the public dime.

“This breaks through the myth,” said David Pepper, a political writer and the former chairman of the Ohio Democratic Party. Pepper said that courts have long given voucher programs a pass, ruling that they don’t violate the constitutionally mandated separation of church and state because a publicly funded voucher technically passes through the conduit of a parent on the way to a religious school.

With this latest move, though, Ohio is funding the construction of a separate, religious system of education, Pepper said, adding that if no one takes notice, “This will happen in other states — they all learn from each other like laboratories.”

The Ohio Constitution says that the General Assembly “will secure a thorough and efficient system of common schools throughout the state; but no religious or other sect, or sects, shall ever have any exclusive right to, or control of, any part of the school funds of this state.”

Yet Troy McIntosh, executive director of the Ohio Christian Education Network — several of whose schools received the new grants — recently told the Lima News that part of the reason for spending these public dollars on the expansion of private schools is that “we want to make sure that from our perspective, Christian school options are available to any kid who chooses that in the state.”

Administrators at Temple Christian School applaud during an August ribbon-cutting ceremony for their new building. (Mackenzi Klemann, The Lima (Ohio) News)

When they were implemented in the 1990s, vouchers in Ohio, like in many places, were limited in scope; they were available only to parents whose children were attending (often underfunded) public schools in Cleveland. The idea was to give those families money that they could then spend on tuition at a hopefully better private school, thus empowering them with what was called school choice.

Over the decades, the state incrementally expanded voucher programs to a wider and wider range of applicants. And last year, legislators and Gov. Mike DeWine extended the most prominent of those programs, called EdChoice, to all Ohio families.

It was the ultimate victory for Ohio’s school-choice advocates. The problem, though, was that in many parts of Ohio and other states, especially rural areas, parents can’t spend this new voucher money because private schools are either too far away or already at capacity.

This, in turn, has become a major political liability for voucher advocates in many states, with rural conservatives becoming increasingly indignant that their tax dollars are being spent on vouchers for upper-middle-class families in far-off metropolitan areas where there are more private schools.

In April, the Buckeye Institute, an Ohio-based conservative think tank affiliated with the Koch brothers’ political advocacy group Americans for Prosperity, recognized the problem. In a policy memo, the institute said that it was offering lawmakers “additional solutions to address the growing need for classroom space” in private and charter schools, “given the success of the Ohio EdChoice program.” Among its recommendations: draw funding from the Ohio One-Time Strategic Community Investment Fund, which provides grants of state money for the construction and repair of buildings, as well as other “capital projects.”

Within months, the Legislature did precisely that. Led by Huffman, Republicans slipped at least $4 million in grants to private schools into a larger budget bill. There was little debate, in part because budget bills across the country have become too large to deliberate over every detail and, also, Republicans have supermajorities in both chambers in Ohio.

According to an Ohio Legislative Service Commission report, the grants, some of them over a million dollars, then went out to various Catholic schools around the state. ProPublica contacted administrators at each of these schools to ask what they will be using their new taxpayer money on, but they either didn’t answer or said that they didn’t immediately know. (One of the many differences between public and private schools is that the latter do not have to answer questions from the public about their budgets, even if they’re now publicly funded.)

The total grant amount of roughly $4 million this year may seem small, said William L. Phillis, executive director of the Ohio Coalition for Equity & Adequacy of School Funding. But, he noted, Ohio’s voucher program itself started out very small three decades ago, and today it’s a billion-dollar system.

“They get their foot in the door with a few million dollars in infrastructure funding,” Phillis said. “It sets a precedent, and eventually hundreds of millions will be going to private school construction.”

Mollie Simon contributed research.

by Ziva Branstetter

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When the Supreme Court overturned Roe v. Wade and the constitutional right to abortion in 2022, strict bans on the procedure kicked in across the country, leaving women in at least 22 states with fewer options to end pregnancies that in some cases endangered their lives.

ProPublica has uncovered at least two cases of women who died after their state banned abortion. In both cases, the women took pills to end their pregnancies and the abortion did not fully complete, causing complications, as can occur in a small number of cases involving abortion medication.

Their stories speak to the challenges women face when abortion is banned, not the safety of abortion pills when taken properly and with appropriate follow-up care.

We reviewed information from the U.S. Food and Drug Administration and from groups that closely track the latest medical advice and scientific evidence to answer the most frequently asked questions about abortion pills.

What is abortion medication?

What some people call the “abortion pill” is actually a combination of two pills — mifepristone and misoprostol — commonly called “abortion medication.”

Mifepristone tablets are also sold under the brand name Mifeprex, which has been approved by the U.S. Food and Drug Administration since 2000 to be used along with misoprostol to end an intrauterine pregnancy through 10 weeks gestation. (That is measured as 70 days or less since the first day of a patient’s last menstrual period.)

Abortion pills are now used in more than 60% of all abortions in the U.S. health care system.

How do abortion pills work?

Mifepristone blocks a hormone called progesterone that is needed for a pregnancy to continue. The FDA-approved regimen is to take 200 milligrams of mifepristone on the first day. Patients are directed to take misoprostol within 24 to 48 hours of the mifepristone. The misoprostol works to expel fetal tissue from the uterus.

In some cases, patients take a regime of misoprostol only to end a pregnancy.

Patients are directed to follow up with a health care provider about seven to 14 days after taking mifepristone or earlier if any unusual symptoms are noted. (See below.)

Are abortion pills safe?

Yes. The FDA first approved Mifeprex 25 years ago, so there’s an extensive record of safety involving this drug.

Out of nearly 6 million women who’ve taken mifepristone since then, only 32 deaths of women who used the drug to terminate pregnancies were reported to the FDA through the end of 2022, regardless of whether the drug played a role in the death.

Of those, 11 involved deaths of women who developed a deadly infection called sepsis. Most of the remaining cases involved intentional and accidental drug overdoses, suicide, homicide and ruptured ectopic pregnancies.

The American College of Obstetricians and Gynecologists has opposed laws and court rulings that limit or ban the availability of abortion pills. “Mifepristone has been used safely and effectively for medication abortion for more than two decades. That safety and efficacy is backed up by robust, evidence-based, clinical data and its observed use by millions of people with support from clinicians, including obstetricians-gynecologists,” the organization states on its website.

Who should not take abortion medication?

Abortion pills are not approved for use in some pregnancies. According to the FDA, people should not use abortion pills if they:

• Have an ectopic pregnancy (a pregnancy outside of the uterus).
• Have problems with the adrenal glands (the glands near the kidneys).
• Are being treated with long-term corticosteroid therapy (medications).
• Have had an allergic reaction to mifepristone, misoprostol or similar drugs.
• Have bleeding problems or are taking anticoagulant (blood-thinning) drug products.
• Have inherited porphyria (a rare disorder that can affect the liver and other organs).
• Have an intrauterine device in place. (It must be removed before taking mifepristone.)

What are the common side effects of abortion pills? How long do they usually last?

Bleeding and cramping initially are expected. If you have abdominal pain or discomfort, or you are feeling sick — including weakness, nausea, vomiting or diarrhea, with or without fever — more than 24 hours after taking misoprostol, doctors say to contact your health care provider without delay. These symptoms may be a sign of a serious infection or another problem.

In the days after treatment, if you have a fever of 100.4°F or higher that lasts for more than four hours, doctors say you should contact your health care provider or visit the nearest emergency room right away. Fever may be a symptom of a serious infection or another problem.

How much bleeding is normal with abortion pills?

Contact your health care provider right away if you bleed enough to soak through two thick full-size sanitary pads per hour for two consecutive hours or if you are concerned about heavy bleeding. If you can’t reach your health care provider, go to the emergency room to seek care.

How effective are abortion pills?

Taken as directed, they are highly effective. In about 1 in 100 women, a procedure will be required to remove remaining tissue. That’s why it’s important to seek follow-up care for any of the symptoms described above.

What happens if abortion pills don’t work?

Doctors say you should seek immediate medical attention if you experience any of the unusual symptoms described above. (This patient agreement form required by the FDA describes what to look for.)

While abortion medication is banned in 14 states, it is not a crime to seek medical attention because you took abortion pills. In fact, the federal government requires hospitals to treat urgent medical conditions like infection. Do not avoid seeking help from your doctor or at the emergency room if you have sustained bleeding, pain and/or fever. An infection of this kind is not likely to go away on its own and could be fatal.

Is it legal to order the abortion pills online?

Yes, in some states. In January 2023, the FDA lifted restrictions that prevented patients from obtaining medication abortion pills from a retail pharmacy and allowed them to be dispensed by mail, with certain requirements.

But patients can’t legally order abortion medication in 14 states that ban abortion: Alabama, Arkansas, Idaho, Indiana, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, Tennessee, Texas and West Virginia. In 15 states, there are various restrictions that make it more difficult for patients to obtain abortion medication.

Some pharmacies and organizations that provide abortion medication through the mail are not approved by the FDA. Patients should exercise caution when ordering pills from unregulated pharmacies to determine whether the medication is authentic and safe.

by Kavitha Surana

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

In her final hours, Amber Nicole Thurman suffered from a grave infection that her suburban Atlanta hospital was well-equipped to treat.

She’d taken abortion pills and encountered a rare complication; she had not expelled all of the fetal tissue from her body. She showed up at Piedmont Henry Hospital in need of a routine procedure to clear it from her uterus, called a dilation and curettage, or D&C.

But just that summer, her state had made performing the procedure a felony, with few exceptions. Any doctor who violated the new Georgia law could be prosecuted and face up to a decade in prison.

Thurman waited in pain in a hospital bed, worried about what would happen to her 6-year-old son, as doctors monitored her infection spreading, her blood pressure sinking and her organs beginning to fail.

It took 20 hours for doctors to finally operate. By then, it was too late.

Why should I trust your reporting? I (Kavitha Surana) am a reporter that has been covering reproductive health care access since Roe v. Wade was overturned. I’ve spoken with doctors, community workers and patients across the country about how abortion bans have made pregnancy more dangerous in America, and I’ve written about the Republican lawmakers who refused to listen.

If you want to get in touch and learn more about how I work, email me. I take your privacy very seriously.

The otherwise healthy 28-year-old medical assistant, who had her sights set on nursing school, should not have died, an official state committee recently concluded.

Tasked with examining pregnancy-related deaths to improve maternal health, the experts, including 10 doctors, deemed hers “preventable” and said the hospital’s delay in performing the critical procedure had a “large” impact on her fatal outcome.

Their reviews of individual patient cases are not made public. But ProPublica obtained reports that confirm that at least two women have already died after they couldn’t access legal abortions and timely medical care in their state.

There are almost certainly others.

Committees like the one in Georgia, set up in each state, often operate with a two-year lag behind the cases they examine, meaning that experts are only now beginning to delve into deaths that took place after the Supreme Court overturned the federal right to abortion.

Thurman’s case marks the first time an abortion-related death, officially deemed “preventable,” is coming to public light. ProPublica will share the story of the second in the coming days. We are also exploring other deaths that have not yet been reviewed but appear to be connected to abortion bans.

Doctors warned state legislators women would die if medical procedures sometimes needed to save lives became illegal.

Though Republican lawmakers who voted for state bans on abortion say the laws have exceptions to protect the “life of the mother,” medical experts cautioned that the language is not rooted in science and ignores the fast-moving realities of medicine.

The most restrictive state laws, experts predicted, would pit doctors’ fears of prosecution against their patients’ health needs, requiring providers to make sure their patient was inarguably on the brink of death or facing “irreversible” harm when they intervened with procedures like a D&C.

“They would feel the need to wait for a higher blood pressure, wait for a higher fever — really got to justify this one — bleed a little bit more,” Dr. Melissa Kottke, an OB-GYN at Emory, warned lawmakers in 2019 during one of the hearings over Georgia’s ban.

Doctors and a nurse involved in Thurman’s care declined to explain their thinking and did not respond to questions from ProPublica. Communications staff from the hospital did not respond to multiple requests for comment. Georgia’s Department of Public Health, which oversees the state maternal mortality review committee, said it cannot comment on ProPublica’s reporting because the committee’s cases are confidential and protected by federal law.

The availability of D&Cs for both abortions and routine miscarriage care helped save lives after the 1973 Supreme Court ruling in Roe v. Wade, studies show, reducing the rate of maternal deaths for women of color by up to 40% the first year after abortion became legal.

But since abortion was banned or restricted in 22 states over the past two years, women in serious danger have been turned away from emergency rooms and told that they needed to be in more peril before doctors could help. Some have been forced to continue high-risk pregnancies that threatened their lives. Those whose pregnancies weren’t even viable have been told they could return when they were “crashing.”

Such stories have been at the center of the upcoming presidential election, during which the right to abortion is on the ballot in 10 states.

But Republican legislators have rejected small efforts to expand and clarify health exceptions — even in Georgia, which has one of the nation’s highest rates of maternal mortality and where Black women are three times more likely to die from pregnancy-related complications than white women.

When its law went into effect in July 2022, Gov. Brian Kemp said he was “overjoyed” and believed the state had found an approach that would keep women “safe, healthy and informed.”

After advocates tried to block the ban in court, arguing the law put women in danger, attorneys for the state of Georgia accused them of “hyperbolic fear mongering.”

Two weeks later, Thurman was dead.

Thurman and her son in a photo she posted on social media the year before her death (via Facebook)

Thurman, who carried the full load of a single parent, loved being a mother. Every chance she got, she took her son to petting zoos, to pop-up museums and on planned trips, like one to a Florida beach. “The talks I have with my son are everything,” she posted on social media.

But when she learned she was pregnant with twins in the summer of 2022, she quickly decided she needed to preserve her newfound stability, her best friend, Ricaria Baker, told ProPublica. Thurman and her son had recently moved out of her family’s home and into a gated apartment complex with a pool, and she was planning to enroll in nursing school.

The timing could not have been worse. On July 20, the day Georgia’s law banning abortion at six weeks went into effect, her pregnancy had just passed that mark, according to records her family shared with ProPublica.

Thurman wanted a surgical abortion close to home and held out hope as advocates tried to get the ban paused in court, Baker said. But as her pregnancy progressed to its ninth week, she couldn’t wait any longer. She scheduled a D&C in North Carolina, where abortion at that stage was still legal, and on Aug. 13 woke up at 4 a.m. to make the journey with her best friend.

On their drive, they hit standstill traffic, Baker said. The clinic couldn’t hold Thurman’s spot longer than 15 minutes — it was inundated with women from other states where bans had taken effect. Instead, a clinic employee offered Thurman a two-pill abortion regimen approved by the U.S. Food and Drug Administration, mifepristone and misoprostol. Her pregnancy was well within the standard of care for that treatment.

Getting to the clinic had required scheduling a day off from work, finding a babysitter, making up an excuse to borrow a relative’s car and walking through a crowd of anti-abortion protesters. Thurman didn’t want to reschedule, Baker said.

At the clinic, Thurman sat through a counseling session in which she was told how to safely take the pills and instructed to go to the emergency room if complications developed. She signed a release saying she understood. She took the first pill there and insisted on driving home before any symptoms started, Baker said. She took the second pill the next day, as directed.

Deaths due to complications from abortion pills are extremely rare. Out of nearly 6 million women who’ve taken mifepristone in the U.S. since 2000, 32 deaths were reported to the FDA through 2022, regardless of whether the drug played a role. Of those, 11 patients developed sepsis. Most of the remaining cases involved intentional and accidental drug overdoses, suicide, homicide and ruptured ectopic pregnancies.

Baker and Thurman spoke every day that week. At first, there was only cramping, which Thurman expected. But days after she took the second pill, the pain increased and blood was soaking through more than one pad per hour. If she had lived nearby, the clinic in North Carolina would have performed a D&C for free as soon as she followed up, the executive director told ProPublica. But Thurman was four hours away.

Thurman, left, and her best friend, Ricaria Baker, in 2020 (Courtesy of Ricaria Baker)

On the evening of Aug. 18, Thurman vomited blood and passed out at home, according to 911 call logs. Her boyfriend called for an ambulance. Thurman arrived at Piedmont Henry Hospital in Stockbridge at 6:51 p.m.

ProPublica obtained the summary narrative of Thurman’s hospital stay provided to the maternal mortality review committee, as well as the group’s findings. The narrative is based on Thurman’s medical records, with identifying information removed. The committee does not interview doctors involved with the case or ask hospitals to respond to its findings. ProPublica also consulted with medical experts, including members of the committee, about the timeline of events.

Within Thurman’s first hours at the hospital, which says it is staffed at all hours with an OB who specializes in hospital care, it should have been clear that she was in danger, medical experts told ProPublica.

Her lower abdomen was tender, according to the summary. Her white blood cell count was critically high and her blood pressure perilously low — at one point, as Thurman got up to go to the bathroom, she fainted again and hit her head. Doctors noted a foul odor during a pelvic exam, and an ultrasound showed possible tissue in her uterus.

The standard treatment of sepsis is to start antibiotics and immediately seek and remove the source of the infection. For a septic abortion, that would include removing any remaining tissue from the uterus. One of the hospital network’s own practices describes a D&C as a “fairly common, minor surgical procedure” to be used after a miscarriage to remove fetal tissue.

After assessing her at 9:38 p.m., doctors started Thurman on antibiotics and an IV drip, the summary said. The OB-GYN noted the possibility of doing a D&C the next day.

But that didn’t happen the following morning, even when an OB diagnosed “acute severe sepsis.” By 5:14 a.m., Thurman was breathing rapidly and at risk of bleeding out, according to her vital signs. Even five liters of IV fluid had not moved her blood pressure out of the danger zone. Doctors escalated the antibiotics.

Instead of performing the newly criminalized procedure, they continued to gather information and dispense medicine, the summary shows.

Doctors had Thurman tested for sexually transmitted diseases and pneumonia.

They placed her on Levophed, a powerful blood pressure support that could do nothing to treat the infection and posed a new threat: The medication can constrict blood flow so much that patients could need an amputation once stabilized.

At 6:45 a.m., Thurman’s blood pressure continued to dip, and she was taken to the intensive care unit.

At 7:14 a.m., doctors discussed initiating a D&C. But it still didn’t happen. Two hours later, lab work indicated her organs were failing, according to experts who read her vital signs.

At 12:05 p.m., more than 17 hours after Thurman had arrived, a doctor who specializes in intensive care notified the OB-GYN that her condition was deteriorating.

Thurman was finally taken to an operating room at 2 p.m.

By then, the situation was so dire that doctors started with open abdominal surgery. They found that her bowel needed to be removed, but it was too risky to operate because not enough blood was flowing to the area — a possible complication from the blood pressure medication, an expert explained to ProPublica. The OB performed the D&C but immediately continued with a hysterectomy.

During surgery, Thurman’s heart stopped.

Her mother was praying in the waiting room when one of the doctors approached. “Come walk with me,” she said.

Until she got the call from the hospital, her mother had no idea Thurman had been pregnant. She recalled her daughter’s last words before she was wheeled into surgery — they had made no sense coming from a vibrant young woman who seemed to have her whole life ahead of her:

“Promise me you’ll take care of my son.”

Thurman and her son in a selfie she posted online in 2020, two years before her death (via Facebook)

There is a “good chance” providing a D&C earlier could have prevented Amber Thurman’s death, the maternal mortality review committee concluded.

Every state has a committee of experts who meet regularly to examine deaths that occurred during or within a year after a pregnancy. Their goal is to collect accurate data and identify the root causes of America’s increasing maternal mortality rate, then translate those lessons into policy changes. Their findings and recommendations are sent to the Centers for Disease Control and Prevention, and their states publish an annual report, but their reviews of individual cases are never public.

Georgia’s committee has 32 regular members from a variety of backgrounds, including OB-GYNs, cardiologists, mental health care providers, a medical examiner, health policy experts, community advocates and others. This summer, the committee reviewed deaths through Fall 2022, but most states have not gotten that far.

After reviewing Thurman’s case, the committee highlighted Piedmont’s “lack of policies/procedures in place to evacuate uterus immediately” and recommended all hospitals implement policies “to treat a septic abortion on an ongoing basis.”

It is not clear from the records available why doctors waited to provide a D&C to Thurman, though the summary report shows they discussed the procedure at least twice in the hours before they finally did.

Piedmont did not have a policy to guide doctors on how to interpret the state abortion ban when Thurman arrived for care, according to two people with knowledge of internal conversations who were not authorized to speak publicly. In the months after she died, an internal task force of providers there created policies to educate staff on how to navigate the law, though they are not able to give legal advice, the sources said.

In interviews with more than three dozen OB-GYNs in states that outlawed abortion, ProPublica learned how difficult it is to interpret the vague and conflicting language in bans’ medical exceptions — especially, the doctors said, when their judgment could be called into question under the threat of prison time.

Take the language in Georgia’s supposed lifesaving exceptions.

It prohibits doctors from using any instrument “with the purpose of terminating a pregnancy.” While removing fetal tissue is not terminating a pregnancy, medically speaking, the law only specifies it’s not considered an abortion to remove “a dead unborn child” that resulted from a “spontaneous abortion” defined as “naturally occurring” from a miscarriage or a stillbirth.

Thurman had told doctors her miscarriage was not spontaneous — it was the result of taking pills to terminate her pregnancy.

There is also an exception, included in most bans, to allow abortions “necessary in order to prevent the death of the pregnant woman or the substantial and irreversible physical impairment of a major bodily function.” There is no standard protocol for how providers should interpret such language, doctors said. How can they be sure a jury with no medical experience would agree that intervening was “necessary”?

ProPublica asked the governor’s office on Friday to respond to cases of denied care, including the two abortion-related deaths, and whether its exceptions were adequate. Spokesperson Garrison Douglas said they were clear and gave doctors the power to act in medical emergencies. He returned to the state’s previous argument, describing ProPublica’s reporting as a “fear-mongering campaign.”

Republican officials across the country have largely rejected calls to provide guidance.

When legislators have tried, anti-abortion groups have blocked them.

In 2023, a group of Tennessee Republicans was unable to push through a small change to the state’s abortion ban, intended to give doctors greater leeway when intervening for patients facing health complications.

“No one wants to tell their spouse, child or loved one that their life is not important in a medical emergency as you watch them die when they could have been saved,” said Republican Rep. Esther Helton-Haynes, a nurse who sponsored the bill.

The state’s main anti-abortion lobbyist, Will Brewer, vigorously opposed the change. Some pregnancy complications “work themselves out,” he told a panel of lawmakers. Doctors should be required to “pause and wait this out and see how it goes.”

At some hospitals, doctors are doing just that. Doctors told ProPublica they have seen colleagues disregard the standard of care when their patients are at risk of infection and wait to see if a miscarriage completes naturally before offering a D&C.

Although no doctor has been prosecuted for violating abortion bans, the possibility looms over every case, they said, particularly outside of well-funded academic institutions that have lawyers promising criminal defense.

Doctors in public hospitals and those outside of major metro areas told ProPublica that they are often left scrambling to figure out on a case-by-case basis when they are allowed to provide D&Cs and other abortion procedures. Many fear they are taking on all of the risk alone and would not be backed up by their hospitals if a prosecutor charged them with a crime. At Catholic hospitals, they typically have to transfer patients elsewhere for care.

When they do try to provide care, it can be a challenge to find other medical staff to participate. A D&C requires an anesthesiologist, nurses, attending physicians and others. Doctors said peers have refused to participate because of their personal views or their fear of being exposed to criminal charges. Georgia law allows medical staff to refuse to participate in abortions.

Thurman’s family members may never learn the exact variables that went into doctors’ calculations. The hospital has not fulfilled their request for her full medical record. There was no autopsy.

For years, all Thurman’s family had was a death certificate that said she died of “septic shock” and “retained products of conception” — a rare description that had previously only appeared once in Georgia death records over the last 15 years, ProPublica found. The family learned Thurman’s case had been reviewed and deemed preventable from ProPublica’s reporting.

The sting of Thurman’s death remains extremely raw to her loved ones, who feel her absence most deeply as they watch her son grow taller and lose teeth and start school years without her.

They focus on surrounding him with love but know nothing can replace his mother.

On Monday, she would have turned 31.

A photo of Thurman that she posted online in 2020 (via Facebook) How We Reported the Story

ProPublica reporter Kavitha Surana reviewed death records and medical examiner and coroner reports to identify cases that may be related to abortion access. She first reached out to Amber Thurman’s family and friends a year ago. The family shared her personal documents and signed a release for ProPublica to access her medical information. The maternal mortality review committee reviewed Thurman’s case at the end of July 2024.

Do you have any information about how abortion bans have affected medical care? Reach out to ProPublica reporters covering reproductive health care including Kavitha Surana at kavitha.surana@propublica.org or Cassandra Jaramillo at cassandra.jaramillo@propublica.org.

Cassandra Jaramillo, Mariam Elba, Kirsten Berg and Jeff Ernsthausen contributed research.

by Aliyya Swaby

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.

A year ago, sheriff’s deputies in Georgia showed up on the doorstep of middle school student Colt Gray. They were there to question him about an online threat to shoot up his school. Last week, the 14-year-old was charged with shooting and killing four people at Apalachee High School.

As details continue to emerge, the question now in front of Georgia legislators is: How should officials respond to these kinds of warning signs in the future?

Lawmakers are already indicating that they intend to take tougher action against students who make threats. In a Sept. 12 letter to members of the state House Republican Caucus, House Speaker Jon Burns wrote that one of his objectives in the next legislative session will be to “increase penalties for making terroristic threats in our schools — and make it clear that here in Georgia, threats of violence against our students will not be tolerated and will be prosecuted to the fullest extent of the law.” (Burns did not respond to a request for comment.)

But, as ProPublica has reported this year, there can be consequences to increasing penalties: trampling the rights of children who don’t pose a threat to anyone.

Two weeks before the Apalachee shooting, we published a story about a 10-year-old in Tennessee who was expelled from school for a year after he angrily pointed his finger in the shape of a gun. The article explored how a state law, passed in response to last year’s Covenant School shooting in Nashville that left six people dead, requires schools to kick students out for making threats of mass violence.

Another Tennessee law went into effect in July that increases the charge for making a threat of mass violence from a misdemeanor to a felony — without requiring officials to take actual intent into account. Many experts and some officials consider both laws an overreach.

There is no indication that the Tennessee 10-year-old whose case we examined posed a danger to his school or his community. The fifth grader had no access to a firearm, according to his mother. She said school officials described him as a good kid and expressed regret at having to expel him. (The assistant director of his school district declined to comment, even after his mother signed a form permitting school officials to do so.)

Meanwhile, Georgia law enforcement officials were warned a year ago that Gray was making threats, and they heard directly from his father that the teenager had access to guns. (School officials said the warnings were never passed on to them.)

As Georgia lawmakers consider what they can do to keep students safer, experts say they should consider the implications their decisions may have for a broad spectrum of children — from the 14-year-old with access to assault rifles to the 10-year-old pointing a finger gun. People who study the warning signs of and legislative reactions to school shootings have long warned that zero-tolerance policies, such as the ones Tennessee adopted, are not proven to make schools safer — and in fact can harm students.

To deter violence, experts maintain, the research suggests that the most effective strategy is not mandatory expulsions and felony charges but a different kind of tactic, one that federal officials have touted based on decades of interviews with mass shooters, political assassins and people who survived attacks. Threat assessments, when done effectively, bring together mental health professionals, law enforcement and others in the community to help school officials sort out the credible threats from the simply disruptive acts and provide students with needed help.

“It is the best option available for us to prevent these kinds of shootings,” said Dewey Cornell, a psychologist and a leading expert on the use of threat assessments in schools. A threat assessment team is supposed to interview anyone involved with a threat to assess whether the student poses an imminent risk to others. And it is supposed to warn any intended victims of major threats, take precautions to protect them and seek ways to resolve conflict.

Cornell said law enforcement involvement and harsh discipline should be reserved for the most serious cases — the exact opposite of zero-tolerance policies. Tennessee, along with 20 other states, requires threat assessments in schools. But because the state also mandates expulsions and felony charges, many students end up ostracized and isolated rather than getting the ongoing help that experts consider to be one of the greatest strengths of the threat assessment process.

The suggestion that schools and authorities should closely monitor and assist students who make threats may feel counterintuitive, especially with fear and frustration soaring, said Mark Follman, a journalist with Mother Jones and author of the 2022 book “Trigger Points: Inside the Mission to Stop Mass Shootings in America.”

It’s also easy to understand why people want a punitive response to threats, Follman said, but it can make the problem worse. Expelling a student who is potentially dangerous means school officials and others have little ability to monitor them. And, crucially, “you’re also potentially exacerbating their sense of crisis, their grievance, especially if it involves the school,” he said, moving them toward a point of attack instead of away from it.

For his book, Follman interviewed leading experts on threat assessments and embedded with a team at a school district in Oregon. He points out that for the threat assessment process to work, it has to be carried out correctly. “Most, if not all, examples I have seen of stories about threat assessment having negative impact on students and families are cases in which it’s not being done right,” Follman said.

Tennessee school officials carry out threat assessments inconsistently, our story last month found. Some allow police to take the lead in minor incidents, resulting in criminal charges for kids who made threats that school officials themselves did not consider credible.

At least one Tennessee lawmaker is responding to the shooting in Georgia by saying it validates the harsh penalties for students who make threats. Tennessee state Sen. Jon Lundberg, who co-sponsored both punitive Tennessee laws, told the Chattanooga Times Free Press this week, “The legislature is constantly looking at, What else can we do?”

by McKenzie Funk

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.

Seven years ago, Oregon’s biggest natural gas company set out to convince lawmakers and residents that an abundant new source of green energy was out there, just waiting to be tapped.

Renewable natural gas is derived from decomposing organic waste at sites like landfills or dairy farms. It could, in theory, replace fossil natural gas in our pipelines with something far better for the environment.

The company, NW Natural, sent a bow-tied lobbyist to the state capital to talk up renewable natural gas, and it helped write a new law promoting development of the new fuel. The company worked with the Oregon Department of Energy to prepare a statewide inventory of potential resources. And, with more than $1 million in customer money, the company targeted those customers with ads, introducing a slogan that highlighted its commitment to lowering carbon emissions: “Less We Can.”

These and subsequent efforts became a template for NW Natural’s industry peers — and effectively tamped down a growing push by climate activists to phase out gas use in Oregon homes and electrify everything instead.

Seven years on, the utility has not delivered on its clean-energy sales pitch. NW Natural has more retail gas customers than ever. It supplies them little, if any, renewable natural gas. It sells them as much fossil natural gas in an average year as it did before. And it wages steady battles in the courts and in local city halls to keep the gas flowing.

Internal industry documents obtained by ProPublica, coupled with an analysis of regulatory filings and testimony before the state Legislature, reveal how NW Natural pursued an approach that perpetuated its core fossil fuel business while the company painted a picture of going green.

“The story they’re telling us is simply not possible,” said former state Rep. Phil Barnhart, a Democrat who voted for some of the company’s legislation when in office.

“What they’re trying to do,” Barnhart said, “is to prevent being put out of business.”

NW Natural, for its part, says that its renewables goals remain attainable and that it firmly believes in them. But “uncertain support from policy makers and regulators along with ongoing barriers demanded by certain climate advocates” have made the company’s path needlessly difficult, spokesperson David Roy wrote in an email. “It’s baffling how a relatively small but loud group of stakeholders have been in opposition to our many efforts to lower system emissions,” he continued. Roy defended the Less We Can campaign as “providing customers with valuable information.”

The story they’re telling us is simply not possible. … What they’re trying to do is to prevent being put out of business.

—Phil Barnhart, former Oregon state representative

NW Natural operates in a state where residents and their Democratic leaders demand real action on climate change. Unlike many other public utilities, it does not sell electricity in addition to gas; if a home switches from gas ranges and furnaces to electric, the company likely loses that customer.

As it navigates the new climate economy, the utility has followed a course that other companies, especially energy companies, have taken in the face of public pressure: a loud embrace of environmental goals; then a complicated, often unproven solution; then a continuation of the status quo if and when that solution falls short. The company’s actions ensured that even as it has failed to hit its targets on renewables, and as the planet has kept heating up, it has faced few consequences.

An early ad from the Less We Can campaign suggested that Oregonians — and maybe NW Natural itself — could save the world with little in the way of personal sacrifice. It shows the sun emerging from a cloud. “Renewable Natural Gas is on the way home,” it reads. “Change for the better. Without changing a thing.”

Ads from NW Natural’s “Less We Can” campaign, from a 2022 filing with the Oregon Public Utility Commission (Obtained by ProPublica)

The story of NW Natural’s long fight against the movement to phase out gas emerges from a trove of more than 100 insider documents from the Northwest Gas Association, a trade group that includes the company and five of its regional peers. The utility watchdog Energy and Policy Institute obtained the documents — four years’ worth of meeting minutes, strategy papers and PowerPoint presentations from 2017 through 2020 — and recently shared them with ProPublica.

The documents capture a moment when the natural gas industry realized it was becoming a target. Barely a decade before, fossil natural gas had been hailed as a bridge to a low-carbon future. The Obama administration promoted it as a cleaner alternative to coal and diesel, an energy source to rely on until more wind and solar could come online. Until 2010, even the Sierra Club supported it.

But pipelines carrying natural gas leaked more than was first understood, releasing uncombusted methane, a greenhouse gas more than 28 times as harmful as carbon dioxide. And North America’s fracking boom was making fossil natural gas so plentiful and cheap that environmentalists increasingly worried the world would get stuck on this energy bridge forever. Going all-electric, they argued, was the way forward.

The Northwest Gas Association decided it had to confront what internal documents alternately called the “anti-fossil fuel chorus,” “zero fossil fuel paradigm,” “zero carbon threat” or, simply, an “existential challenge.”

Board members met to plan their response one June morning in 2017 at Washington state’s Skamania Lodge, where floor-to-ceiling windows frame the Cascade Mountains and Columbia River Gorge, then again for two days in September at another luxury lodge, Cedarbrook, set on 18 acres of gardens and wetlands outside Seattle.

The gas executives agreed that climate change needed to be addressed but that climate policies in the Northwest should not penalize natural gas utilities or their customers.

They adopted a new strategic plan to push a unified message: Natural gas can be compatible with a low-carbon Northwest economy, thanks in part to emerging concepts like renewable natural gas. (Today, the association and NW Natural say more specifically that policies favoring electric stoves and heat pumps won’t necessarily cut emissions because the region’s strained electrical system relies increasingly on gas-fired power plants.)

To sell the idea of continued gas use, the strategic plan said the industry should adopt a more “assertive advocacy style” that borrows insights from psychological research. People first make value judgments “via intuition and emotion,” the strategic plan noted, not facts. So the association would place “greater emphasis on the heart, in the public battle for the ‘hearts and minds.’”

NW Natural’s representative at the trade association, an executive named Kim Rush (Kim Heiting, at the time), gave her industry colleagues a look inside Less We Can. It was just the kind of play for the heart the strategic plan envisioned.

“It’s a theme line,” Rush’s slideshow, dated July 2017, explained. “A rallying cry. A movement. A coalition with customers. A celebration. A call to action. A clean energy stake-in-the-ground… in 3 words or less.”

NW Natural had already road-tested the new slogan across four focus groups, via a consumer survey with 864 respondents and through television-ad concepts shown to 100 customers and 100 noncustomers. It had readied a new website, www.lesswecan.com, which featured cows and green fields and a FAQ about renewable natural gas.

One of Rush’s slides contained the campaign’s takeaways. Among them: “NW Natural and natural gas have an important, long-term role to play in our energy future”; “NW Natural has a plan, a goal and a running start”; and “Renewable natural gas is an exciting part of that plan.”

The campaign went live in fall 2017. Residents of Portland and other Oregon cities saw Less We Can TV spots, Less We Can YouTube videos, Less We Can newsletters, Less We Can billboards and Less We Can water bottles.

“Can a natural gas company be serious when it says it wants us to use less gas?” one video asked before showing a scene of a couple chopping vegetables together in the kitchen. “Can we really raise our families and lower emissions? Can we heat our homes and fight climate change? Can we expand our economy and use less?”

“Yes,” a narrator answered, as the video cut to an image of free-range cows and hand-drawn arrows pointing to the words “renewable natural gas.”

Stills from a NW Natural Less We Can video ad (Screenshots by ProPublica)

At the time the Less We Can campaign was getting off the ground, not a single public utility in the United States regularly piped renewable natural gas to customers’ homes. The market for such organics-based gas was mainly clean fuels programs for vehicle fleets. Residential use would be pioneering, even experimental.

But if NW Natural’s ads had gotten ahead of reality, the company was already backing legislation that seemed to portend widespread use of the alternative fuel.

It started earlier in 2017 with a bill in the Oregon Legislature that put forward a seemingly straightforward proposition. Oregon would take stock of its every landfill, every dairy farm, every sewage plant and every conceivable pile of woody debris: sites that could emit methane as organic matter broke down. Why not study how much was out there? The bill, a precursor to similar bills in other states, including Washington, sailed through with little opposition.

The ensuing inventory was a rigorous, yearlong process led by the Oregon Department of Energy that produced a 110-page report to the Legislature in September 2018 — which NW Natural quickly turned into a valuable talking point.

The report’s authors found that Oregon’s “technical potential” for renewable natural gas was significant: nearly 50 billion cubic feet. “That’s equivalent to the total amount of natural gas used by all Oregon residential customers today,” read a NW Natural press release. The company would go on to use variations of this phrase on its website, in annual sustainability reports and in statements to lawmakers.

But “technical potential” represents the amount Oregon could produce if money was no obstacle. NW Natural said little about another, more problematic finding: Using currently available technologies and waste streams, the state could produce just 10 billion cubic feet of gas from organic sources.

Barnhart, the former state lawmaker, says the utility’s selective interpretation of the study not only overstated the size of the resource, it left out “the real denominator” by ignoring industrial and commercial gas use. Including those and transportation customers in the equation would put total gas demand in Oregon at three times the figure NW Natural cited; the state’s potential renewable natural gas resources, using current technology, could meet less than 7% of that demand.

“NW Natural has done a very, very good job of saying true things in a way that is grossly misleading,” Barnhart said.

Roy, the company spokesperson, said it was reasonable to call out Oregon’s full theoretical capacity to make the biogas, noting that all renewable energy sources have required innovation to bring them to market. As for focusing on residential use alone, NW Natural said highlighting a single sector was a useful way to “help people understand the magnitude of the resource.”

The company leaned on the state’s most optimistic numbers in early 2019 when it returned to lawmakers with a second, far more expansive bill that was the first of its kind in the country.

The new bill aimed to address another key barrier to NW Natural’s plans for renewable natural gas. Under existing state rules, utilities had to purchase gas for their customers at the lowest available price, and gas made from biomass could be 10 times more expensive than fossil natural gas. But the bill would allow NW Natural to pursue renewable natural gas and recoup the added cost from its customers. It would be able to spend up to 5% of its annual revenues, some $40 million or more, to secure a dedicated supply.

The legislation also set out ambitious but voluntary goals for NW Natural and other large gas utilities: to produce or acquire renewable natural gas equivalent to 5% of deliveries to retail customers by 2024, 10% by 2029 and 30% by 2050.

Renewable Natural Gas Is a Small Fraction of NW Natural's Supply for Retail Customers Sources: NW Natural 2023 Annual Renewable Natural Gas Compliance Report; Oregon Senate Bill 98 (2019); 2022 NW Natural Integrated Resource Plan (Lucas Waldron/ProPublica)

The company sent an executive named Anna Chittum to testify before an Oregon Senate committee, and she cited the inventory almost immediately. “They found about 50 billion cubic feet of potential in the state of Oregon,” she said.

Chittum emphasized that this would be a boon not only for the planet but for Oregon businesses.

“Renewable natural gas is a local resource, first and foremost,” she continued. “We believe that Oregon entities like wastewater treatment plants and landfills, some of the dairies in our region and other companies, as well as our natural gas customers, will directly benefit.”

The bill passed easily and with support from both parties just a day before a partisan meltdown tanked a more controversial piece of climate legislation, an effort to create a California-style carbon cap-and-trade system. The changes called for by cap-and-trade would have been mandatory, unlike those created by the renewable gas legislation. (The company now says it wanted binding targets for renewable gas but “other stakeholders,” whom it declined to name, opposed them.)

On social media, the company’s Kim Rush soon cheered the bill’s success, sharing a photo of Oregon Gov. Kate Brown at a September 2019 signing ceremony, flanked by fellow lawmakers, NW Natural CEO David Anderson and at least three other employees of the company.

“Proud of our state for leading the nation on renewable natural gas development!” Rush wrote. “A vital step in the path toward decarbonizing our pipeline network. #LessWeCan.”

In a post on LinkedIn, Kim Rush of NW Natural shared this photo of a signing ceremony for a landmark 2019 bill allowing her utility to be one of the first in the nation to acquire renewable natural gas for customers. Oregon Gov. Kate Brown, center, posed with legislators and numerous NW Natural representatives. Anna Chittum, in pink, led the company’s renewables effort. (Screenshot by ProPublica)

Despite the victory lap with Oregon’s chief executive, behind the scenes NW Natural and its allies were preparing to quash measures that activist groups and government officials said were needed to reduce the gas industry’s footprint.

For this mission the Northwest Gas Association initially hired Kelly Evans, a public affairs consultant who once ran the successful reelection campaign of Washington Gov. Christine Gregoire. Evans recommended creating a formal coalition with partners outside the gas industry to lobby for continued natural gas use. It would draw in restaurant associations, labor unions, appliance manufacturers, homebuilders and more.

The winner of a million-dollar contract to build just such a coalition and launch a pro-gas campaign across the Northwest was the communications firm Quinn Thomas. It had helped Washington business interests win fights against cap-and-trade and a carbon tax in that state in 2015 and 2016. Now the firm pledged to “defeat policies detrimental to the natural gas industry” once again.

“When the time comes to ‘turn on’ the coalition to combat a specific proposal,” Quinn Thomas wrote in its bid, “we have extensive experience training and deploying spokespeople for public hearings.”

Evans and Quinn Thomas did not respond to ProPublica’s requests for comment.

Northwest cities including Bellingham, Washington, and Eugene, Oregon, were beginning to consider natural gas restrictions. Evans had outlined a messaging plan for such fights, one focused on affordability, reliability and resiliency, on solutions like renewable natural gas, and, most of all, on consumer choice: “There are policies being advanced to limit YOUR choice…” and “people want to take it away,” she wrote when describing the plan.

After activists in Eugene accused NW Natural of overstating Oregon’s potential for renewable natural gas, Rush prepared a letter in 2021 to the city manager repeating the consultant’s talking points — “affordability, reliability and choice” — almost verbatim.

Eugene’s City Council nevertheless passed a partial natural gas ban in early 2023. Three days later, a group formed to collect signatures to revoke the ban, its name another apparent echo of the talking points: “Eugene Residents for Energy Choice.” Belying its grassroots name, the group’s work was bankrolled by $1,014,300 in donations — all but $220 of them from NW Natural. (The council eventually revoked the ban on its own.)

Another fight loomed at the state level. With cap-and-trade dead in the Oregon Legislature, Brown had issued an executive order mandating statewide controls on greenhouse gas emissions. For much of 2020 and 2021, the state prepared new rules to put Brown’s order in action.

The Oregon Public Utility Commission, which determines which costs NW Natural can pass along to consumers, soon began to question whether renewable natural gas was the most economical way for the company to meet the new climate rules. What if money spent on renewable natural gas went instead to home weatherization or more efficient appliances? What if it wasn’t spent on natural gas at all?

NW Natural filed suit against regulations stemming from the governor’s executive order in early 2022, serving as the lead plaintiff. The company noted in a letter to its customers that it was committed to addressing climate change, citing its support for past “landmark” renewable natural gas legislation among other actions. It said its legal challenge to the state’s climate program came only “after exhausting all other options.”

NW Natural’s public messaging around renewable natural gas, meanwhile, remained upbeat. Starting in the summer of 2021, its events team visited at least two dozen street fairs and town festivals across Oregon with what it called the Cowthouse (“think cow + outhouse,” the utility explained): a fake toilet with cow legs sticking out below the door.

Those who approached the Cowthouse were challenged to a riddle: “What do a cow, a toilet and a banana peel have in common?” The answer, “RNG,” for renewable natural gas, was stamped on sugar cookies the company handed out.

As it pitched Oregonians on renewable natural gas, NW Natural had gone all out in emphasizing the vast amounts of rotting matter their state could use to produce it. In the end, the company opted not to use a bit of homegrown waste. It turned instead to other states, especially Nebraska.

Meat and poultry giant Tyson Foods kept two of its biggest beef slaughterhouses there, each week churning through tens of thousands of cows that, in turn, churned out hundreds of thousands of pounds of manure as they awaited their end at the facility.

Cattle pens at Tyson Fresh Meats in Dakota City, Nebraska (Google Maps)

Rotting manure lets off methane. Rotting carcasses let off methane. Rotting garbage lets off methane. The gas is so much worse for the climate than carbon dioxide, ounce for ounce, that capturing a farm or landfill’s uncontrolled methane and purifying it to pipeline quality could, under the right circumstances, offset the harm from emissions it creates when burned.

NW Natural has described renewable natural gas as “carbon neutral” in corporate reports and a “zero-carbon resource” in news releases. But in more recent filings with Oregon regulators, the company estimates that gas from its project in Dakota City, Nebraska, while cleaner than ordinary natural gas, still packs 25% of the climate impact. At the Tyson slaughterhouse in Lexington, Nebraska, it’s 40%.

In an interview, Chittum noted that there is no universal standard to measure how much a renewable natural gas project actually helps the climate. By the standards followed by some state programs, including in California, she said the Tyson projects could possibly be certified as carbon-zero, or even carbon-negative. But it’s expensive to hire someone to do a full accounting, and Oregon doesn’t require NW Natural to prove any benefit — so “we just haven’t spent … the third-party dollars to go calculate all of that,” she said.

Methane from the Tyson operations is captured and piped not to Oregon, but to customers mainly near the two plants. NW Natural counts it as a credit against the fossil natural gas its own customers burn.

For 2023, NW Natural reported renewable natural gas from the Tyson projects, some dairy digesters in Wisconsin, a sewage treatment plant in New York and a food-waste project in Utah.

“It doesn’t matter where the renewable molecule of RNG comes from if reducing emissions is the goal,” NW Natural’s Roy told ProPublica.

NW Natural has notched a series of wins in recent months.

For the fourth year in a row, it was named one of the best gas utilities in the West by the survey company J.D. Power. For the third year in a row, it was named one of the world’s most ethical companies by Ethisphere, a for-profit company that rates other companies’ ethics for a fee.

In late December, the Oregon Court of Appeals ruled in favor of NW Natural in overturning the state climate program that resulted from Brown’s executive order.

In May, NW Natural touted the results of a poll it had commissioned: It said 72% of Oregon voters opposed bans on natural gas in new homes and buildings, a 9-point increase since 2019. “Voters’ attention is more focused on what they believe are pressing concerns, such as homelessness,” a press release said. More than 75% of respondents supported efforts promoting renewable natural gas.

It doesn’t matter where the renewable molecule of RNG comes from if reducing emissions is the goal.

—David Roy, NW Natural spokesperson

But the renewable gas business has not gone as billed.

The company’s data for 2023 showed that even as it harnesses the waste streams of one of the world’s biggest meatpackers — at an anticipated cost of $38 million, if two more planned Tyson projects come online — NW Natural is falling far short of the share of its supply it said would come from the alternative fuel.

In a document filed in August with the Public Utility Commission, the company said it had slowed its procurement and did not expect to hit the goal of 5% it had set for 2024. It blamed “policy and regulatory uncertainty,” particularly the commission’s skepticism of its renewable natural gas plans.

Less We Can is taking on a new meaning.

After years of fanfare about renewable natural gas, what’s its share of NW Natural’s gas supply today?

Less than 1%.

by Justin Elliott, Robert Faturechi and Alex Mierjeski

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Earlier this summer, Devin Nunes, the CEO of Trump Media and a former California congressman, touched down just outside Skopje, the capital of North Macedonia.

He and a small group of other North American executives were there to talk business. But they weren’t there to meet with representatives from another company. A high-ranking official from the Macedonian government greeted them on the tarmac outside their private jet. Then a police escort ferried them from the airport. They were there to meet with the Balkan nation’s newly elected prime minister.

At the time, Prime Minister Hristijan Mickoski, the leader of the country’s conservative nationalist party, offered little in the way of specifics about the meeting’s purpose: “For now, I would not reveal this type of details,” he told local reporters in the Balkans who covered the meeting at the time.

In a recent earnings call, Chris Pavlovski, who accompanied Nunes on the trip and who is the CEO of Rumble, a video streaming company and close partner of Trump Media, revealed that he had discussed a cloud technology services deal with the Macedonian government.

The meeting is the first known instance of the former president’s media company dealing directly with a foreign government — and in this case one that is eager for a future Trump administration’s assistance on a wide range of security, economic and diplomatic issues.

In his public comments, the prime minister boasted about the visiting delegation’s political connections. He described Nunes and another attendee as “two of the closest associates of former president of the United States Donald Trump.”

As Trump runs for a second term, ethics experts have warned that his valuable stake in Trump Media and its Twitter-like platform Truth Social presents opportunities for influence. Advertisers, vendors or investors who have political agendas could use their business relationships with the social media enterprise to seek favorable treatment from a Trump administration.

A Trump Media spokesperson didn’t respond to detailed questions, including about what role the company might play in such an agreement or whether one has been reached.

The spokesperson provided a statement saying only, “The ProPublica geniuses, much to our dismay, have discovered Devin Nunes’ secret plan to reconstitute Alexander the Great’s empire and get Chris Pavlovski named King of Macedon.”

Spokespeople for the Trump campaign, Rumble and the Macedonian prime minister didn’t respond to questions.

Trump’s term in office was marked by concerns that foreign governments sought to curry favor by patronizing his businesses, including his Washington, D.C., hotel. Trump’s businesses had numerous dealings abroad even after his attorney pledged he would not enter into new foreign deals while he was president. If the Macedonian government makes a deal with Trump Media or its partners and Trump is once again elected president, it could be another instance in which his private business interests intersect with U.S. foreign policy.

“They want an in with Trump,” said a U.S. government official who has been involved in Eastern European issues, noting that North Macedonia seeks U.S. support in diplomatic disputes with its neighbors. “We have enormous leverage.”

Nunes, front row right, arrived in North Macedonia by private jet with two other businessmen in Trump’s orbit: Wall Street executive and Trump transition team co-chair Howard Lutnick, far left, and Chris Pavlovski, center, CEO of the video streaming site Rumble. (via the LinkedIn page of Macedonian official Stefan Andonovski)

Trump Media launched just a few years ago, in 2021, but Trump’s nearly 60% stake in the company now represents an important chunk of his personal fortune.

Trump Media’s stock is trading at about a quarter of the high it hit in March soon after it went public, but the company’s value remains around $3 billion, based in part on hype and speculation fueled by Trump fans. The company has little revenue and Truth Social has yet to catch on as a threat to the major social media platforms. Trump’s stake is currently worth around $2 billion. In one week, he will be able to sell his shares for the first time.

Joining Nunes on the July trip were two other figures in Trump’s orbit: Pavlovski, the Rumble CEO, and Howard Lutnick, a Trump donor and Wall Street executive who helped Rumble go public and was recently named the co-chair of Trump’s transition planning team.

Pavlovski, a Canadian whose parents are from North Macedonia, has long been a booster of the country. He also co-founded an IT outsourcing firm that employs software developers in North Macedonia and that has provided services to Trump Media. ProPublica previously reported that Trump Media has contracted with Pavlovski’s outsourcing firm in the country and secured a special visa for a Macedonian coder who is now chief technology officer of the company.

In a quarterly investor call last month, Pavlovski said he met the Macedonian prime minister “multiple times” and that they “discussed the possibility of Rumble Cloud’s direct involvement in their country’s digital transformation.”

“To our delight, Prime Minister Mickoski recently publicly shared his enthusiasm for the possibility of a partnership with Rumble, an exciting sign for all of us at the company,” he added.

Pavlovski compared Rumble’s possible role in North Macedonia to a $500 million tech services deal announced last year between El Salvador and Google.

Trump Media’s business is closely intertwined with Rumble, which provides the former president’s company with ad sale services and cloud services that are “immune to cancel culture.” Rumble also has a deal reported to be worth seven figures with Trump Media board member Donald Trump Jr. for his show “Triggered.”

Trump Media established its headquarters in Sarasota, Florida, a short drive from Rumble’s U.S. headquarters. The companies are so close that Rumble staffers actually worked out of Trump Media’s offices for several months in 2022 while its own office was being renovated, according to a person familiar with the companies.

Scenes from the group’s trip to North Macedonia show the media executives being greeted almost as visiting heads of state, beginning with what Pavlovski described in an Instagram post as a “pretty cool … legit police escort” from the airport.

Nunes met with the Macedonian prime minister in July. It later emerged that Rumble, a close business partner of Trump Media, sought a cloud technology services deal with the Macedonian government. (via the Facebook page of Macedonian Prime Minister Hristijan Mickoski)

Images posted by the Macedonian government, members of the nationalist party that came to power following May elections, show Nunes seated across from the prime minister one day and beside the country’s president the next, meeting under an enormous tile mosaic depicting scenes from Macedonian history. The government minister in charge of “digital transformation” also hinted in a LinkedIn post at potential business dealings, saying that the “investment potential that these world-leading companies offer can revolutionize our digital infrastructure.”

North Macedonia, a landlocked country roughly the size of Vermont with a population smaller than Houston’s, declared independence amid the breakup of Yugoslavia in 1991. It relies on the United States for support, including millions in foreign aid from Washington.

The U.S. has also been one of its most influential diplomatic backers. The country was admitted to NATO in large part due to U.S. support. Its neighbor to the south, Greece, had objected for years to allowing the Balkan nation into the military alliance, asserting it was appropriating classical Greek heritage with its name. The U.S. backed a deal to resolve the dispute in which the Macedonian legislature changed the country’s name in 2019 from Macedonia to North Macedonia.

The U.S. has also been advocating for North Macedonia to be welcomed into the European Union — a process that’s been stalled because of demands from another neighbor, Bulgaria, that North Macedonia has been reluctant to satisfy.

"Everyone in the Balkans wants the Americans on their side,” said Daniel Serwer, a former State Department official and Balkans expert now at Johns Hopkins. From the Macedonian government’s point of view, he said, “You’re much freer to do what you want if you have goodwill from the United States.”

The recent election of Mickoski as prime minister marks a return to power for North Macedonia’s right-leaning nationalist party VMRO-DPMNE. Experts in the region said the party sees Trump as a natural ally and as someone whose support may give them leeway to buck European demands.

Mickoski’s party has been able to rely on Republicans in the U.S. before. In 2017, VMRO members blamed political unrest in the country on the American embassy in Skopje meddling in internal politics and favoring left-leaning groups. The party’s allies successfully lobbied several Republican members of Congress to take up their cause. The lawmakers demanded answers from the State Department, which denied the allegations, then called for an investigation from the Government Accountability Office, which found that aid was properly distributed.

The Balkans have become a focal point of activity in the dealings of former top Trump officials in their years out of office.

Trump’s son-in-law Jared Kushner is pursuing a pair of real estate development deals — one in Albania and one in Serbia — for his new investment firm, which is funded by the governments of Saudi Arabia and other Mideast nations. Both deals have drawn criticism because of the involvement of foreign governments and the perception that helping Kushner’s business could be a way to gain favor in a second Trump administration.

Another former Trump official, Richard Grenell, has been working with Kushner on the Balkans deals, The New York Times reported earlier this year. When Trump was in the White House, Grenell was ambassador to Germany and acting director of national intelligence, as well as a special envoy for Serbia and Kosovo. In the years since, Grenell has become a semi-official envoy for Trump, meeting and seeking to help foreign officials with right-wing parties around the globe.

Last month, just a few weeks after the Trump Media and Rumble executives’ visit to North Macedonia, Grenell arrived in Skopje where he, too, met with the new prime minister. Among the topics discussed was the desire for more foreign capital in the country, in particular the potential for U.S. investment in a massive hydropower project.

There’s no evidence Grenell’s trip was connected to the Trump Media visit. Grenell didn’t respond to questions.

Do you have any information about Trump Media or its partners that we should know? Justin Elliott can be reached by email at justin@propublica.org or by Signal or WhatsApp at 774-826-6240. Robert Faturechi can be reached by email at robert.faturechi@propublica.org and by Signal or WhatsApp at 213-271-7217.

by Byard Duncan, Ryan Gabrielson and Lucas Waldron

This story works best on ProPublica's website, where you can use our free Car Loan Deferment Calculator. You can also read our investigation into Exeter Finance and get in touch with ProPublica reporters to share your own experience.

Have you taken out a car loan and struggled to pay it back? You’re not alone. Borrowers like you owe more than $1.6 trillion in auto debt, and many are falling behind. Your lender might have given you the option to move payments to a later date, also known as a “deferment” or “extension.”

We’ve collected advice from borrowers, consumer finance experts, auto dealers and more to help people make more-informed choices about deferring car payments. Our reporting shows lenders aren’t always up front about how much these deferments will cost you in the long run.

In 2018, one lender got into trouble for allegedly misleading borrowers about them. We found another company, Exeter Finance, using similar extension practices, driving struggling people deeper into debt. These deferments especially affect those with bad credit, who often must pay sky-high interest rates to borrow money.

Exeter Finance responded to our story saying it is “fully committed to transparency in its lending practices” and follows all relevant laws. But in dozens of interviews, people told us they did not understand how much more they would owe after they took deferments. At the end of their terms, some ended up with thousands of dollars in unexpected charges. Some defaulted and lost their cars anyway.

“If I would have known,” said Chassidy Smith, an Exeter borrower living in Georgia who received six extensions in the course of her five-year auto loan, “I probably would have done something different.”

What’s ProPublica? Why should I trust your research?

We (Byard Duncan and Ryan Gabrielson) are reporters at ProPublica, a nonprofit news organization. We write stories that hold powerful institutions accountable. We’ve been reporting on car loans for more than a year. In that time, we reviewed thousands of pages of lawsuits and complaints, and we spoke to dozens of borrowers, consumer finance experts, auto lending specialists, former Exeter Finance employees and more. All of our stories are rigorously fact-checked, nonpartisan and free to read. We do not profit in any way off of tools such as our loan extensions calculator. See our Code of Ethics for more.

The Car Loan Deferment Calculator

To calculate what you could owe at the end of your car loan, all you need is your contract, your monthly statement and the dates that you received deferments. Click here to use the free car loan deferment calculator on ProPublica’s website.

This is a screenshot of the calculator. Click here to use the calculator on ProPublica's website. (Development by Chris Zubak-Skees for ProPublica. Design by Lucas Waldron.) Where to find information about your car loan:

Contract: If you don’t have a hard copy of your auto loan contract, you should be able to download a digital one from your lender’s website.

An excerpt of an Exeter borrower’s contract. (Obtained by ProPublica)

Dates of deferments: This should be the months covered by the deferments. Lenders sometimes send you written notices when they grant you deferments. You can also contact your lender’s customer service team and ask if you don’t remember.

Monthly statement: Our auto loan calculator is most accurate when you use your loan’s interest rate, which can be slightly different from the APR, or annual percentage rate. You’ll sometimes find the true interest rate on your monthly billing statement.

Got more questions? There’s no shame in feeling overwhelmed by the process. Even the experts sympathize.

“Auto transactions are notoriously complex and confusing,” said Rosemary Shahan, president and founder of Consumers for Auto Reliability and Safety, an advocacy organization. “There is nothing in life that prepares you for that transaction. It’s unlike any other transaction you ever enter into.”

Here are answers to some of the most common questions about car loan extensions that came up in our reporting.

Frequently Asked Questions about Car Loan Deferments What is a car loan deferment?

A car loan deferment is when a lender allows you to postpone one or more payments to a later date. Some borrowers said they chose to defer car payments when they faced unexpected expenses, like an illness, hurricane or death in the family. Others simply couldn’t afford their loans. Not all lenders allow you to defer payments, and different lenders have different rules. Some, for example, require you to make a certain number of on-time payments in a row before they will grant you a deferment.

Ask your lender what its specific deferment policies are. Get them in writing if you can.

What’s the difference between a deferment and an extension?

There is no difference. In fact, the Consumer Financial Protection Bureau, a federal watchdog agency, uses the terms interchangeably. “Deferment,” “deferral” and “extension” all mean basically the same thing: You’re pushing one or more loan payments to a later date.

How do car loan deferments work?

To understand what deferments do, you first have to understand how car loan interest is supposed to work.

Most car loans use a “simple interest” formula. This means that although you usually make a car payment once per month, you technically owe a little bit of interest for every single day of the loan. As a result, paying late can cause you to owe more later on.

On the other hand, paying early can reduce your balance faster. Imagine you won the lottery tomorrow and paid off the whole loan immediately. That would save you money because you’d pay a lot less in interest over time.

Let’s say you have a $15,000 loan with a hefty 25% interest rate that you will pay back over 72 months.

If you pay exactly on time, a typical daily simple interest car loan will look like this:

Note: This chart assumes that the borrower always paid on time and did not accrue late fees. (Lucas Waldron/ProPublica)

When you start off, more of your payment will count toward interest than principal (the amount you owe excluding interest) each month. That’s normal. Over time, this dynamic switches: By the loan’s endpoint (also known as its “maturity date”), you’ll pay mostly principal until you owe nothing at all. Then you get the title and own the car outright.

Deferments can change this equation. Let’s say you move a $404 monthly payment to the end of your loan several years from now. If your lender charges interest on the extension, as many do, you will owe more than $404 at the end of the loan: You will have to pay higher interest charges for the rest of the loan, so your remaining payments won’t be enough to eliminate your debt. You will still owe hundreds, or even thousands, of dollars.

Note: This chart assumes that the borrower always paid on time and did not accrue late fees. (Lucas Waldron/ProPublica)

This leaves some people with a “balloon payment” — a large lump sum, due when your loan term ends. These balloon payments caught a lot of Exeter borrowers we spoke to by surprise and caused them financial pain.

Who decides if I can defer a car payment?

It’s important to remember that the company selling you the car is often different from the company that will be collecting the payments. In fact, several experts told us that If you decide to take out a loan, you’re under no obligation to choose financing at the dealership, even if you buy the car there.

If you’re making monthly car payments, there’s a good chance the dealer “assigned” the contract to an auto lender like Exeter Finance (or Santander Consumer USA or Capital One) after you signed on the dotted line. The lender is the entity you’re now paying back — and the one that might grant you a deferment.

Will deferred car payments cost me money?

Deferments can cost you more money in the long run, but the exact amount is not always obvious to borrowers. As mentioned above, deferments provide a temporary break from monthly payments. But if interest continues to accrue during that reprieve, you will end up paying higher interest charges and then owing more in a lump sum at the end. For Exeter borrowers who received multiple extensions, the final payment totaled thousands of dollars.

Should I take a deferment on my car loan?

Consumer finance experts told us it depends on several factors. Overall, you should think about it in terms of your broader financial health.

“It’s not just the cost of the monthly payment — it’s all of this other stuff,” said Dara Duguay, CEO of the nonprofit Credit Builders Alliance. “Can you afford gas? If — and especially if — gas is going to fluctuate up and down?”

“It’s tempting to just say, ‘Oh yeah, let’s just add it to the end,’” said John Van Alst, director of the National Consumer Law Center’s Working Cars for Working Families project. But “if the numbers weren’t working before — unless something’s changed — there’s a real chance the numbers aren’t going to work as you continue to go forward.”

Some borrowers told us they regretted their decisions to accept deferments. Some didn’t. But nearly everyone we spoke to wished they’d had more information.

“I would have tried to make arrangements” like making extra payments, said Natosha Smith, an Exeter borrower living in Georgia whose eight car loan extensions led to a balloon balance of roughly $6,000. “I honestly did not understand the full complexity of the situation.”

What questions should I ask before taking a deferment?

If you’re considering deferring a car payment, experts say you need to get as much information about the cost as possible.

Pamela Foohey, a University of Georgia law professor who studies subprime lending, said lenders would ideally give borrowers a table explaining what they will owe each month until the end of the loan. She said the table should lay out “exactly what is going to be paid, broken down by principal and interest.”

Foohey also recommended asking for:

• Your new loan maturity date.

• An explanation of any fees or penalties.

• Any changes to your monthly payment amount.

• A breakdown of what will be going to principal versus interest for all future payments.

Get familiar with your other financial obligations, too, said Barry Coleman, vice president of program management and education at the National Foundation for Credit Counseling. Ask yourself: Will I have to skimp on necessities to stay in the car? Is the deferment to cure a one-off problem, or am I postponing payment because the car wasn’t affordable in the first place?

“Do a budget,” Coleman advised. “Know what your expenses are and whether or not an extension is necessary. Maybe you’re able to make some adjustments in other parts of your budget, where you don’t have to get this extension.”

Will deferring a car payment hurt my credit?

In most cases, deferments do not negatively affect your credit score. This is because they are not the same as late payments. Instead, they represent a mutual agreement between you and your lender. But be aware that you can hurt your credit by failing to restart payments when they become due again — or by failing to pay off your balloon balance.

I can’t make my car payment. What can I do besides deferring a payment?

You may have options. Experts we spoke to said the first thing to do is call your lender. Different banks have different repayment policies, and trying to adjust your agreement proactively is often a good bet.

“View the extension offer as the beginning of a negotiation,” Foohey said. “It is not the thing that you absolutely have to take.”

The CFPB also lays out a few options to avoid deferring a car payment:

• Ask to change the date your payment is due each month. For some people, paying off a car loan consistently is all about timing. If it’s more convenient for you to be billed right after you receive a paycheck, tell your lender that. Ask if they can change your due date to better match the rhythm of your income.

• Request a payment plan. Rather than extend your loan, some lenders will allow you to pay a smaller monthly payment for a while, then increase your bill totals later to balance things out. If you choose to do this, make sure to ask your lender for a written breakdown of how the payment plan will work and how it would change the interest charges.

• Refinance your loan. Refinancing means looking for a bank that will buy the debt from your auto lender and continue working with you at a lower interest rate. Working out an arrangement like this can bring down both your monthly payment and the total amount you’ll owe in the long term. But be aware that refinancing often requires a steady payment history or good credit.

There are also lots of credit counseling nonprofits across the U.S. that can help advise you.

• The Credit Builders Alliance has more than 600 members and a handy map to find one near you.

• The National Foundation for Credit Counseling is the country’s oldest nonprofit “dedicated to improving people’s financial wellbeing.”

What should I do if I can’t afford to pay back interest on my deferment?

If you’ve made a lot of on-time payments in a row, there’s a chance you’ve improved your credit score along the way. In that case, consumer finance experts say it’s worth reaching out to a bank or credit union to see if they might refinance your loan.

Not everyone can do this, though. Once the true cost of car loan deferments became clear to some of the borrowers we interviewed, they saw no choice but to let their car be repossessed. Repossessions and late payments hurt your credit score, and damaged credit can keep you from getting a low interest rate on your next car loan.

One silver lining: If you surrender your car, it’s possible you won’t end up owing the total remainder of the loan. That’s because after a lender auctions it off, they’re usually required to charge you only the difference between what you owe and what they got at auction. But beware: If your loan remainder was bigger than the car’s actual value, there’s a chance you could still owe a sizable chunk of change after this.

I think my lender didn’t give me information they were supposed to. Is there anything I can do?

First, you can try to work something out with them. According to CFPB, “Companies can usually answer questions unique to your situation and more specific to the products and services they offer. Keep all the documents, messages, voicemails, and records of your interactions with the dealer or lender.”

If that doesn’t work, you have the right to file a complaint to state and federal regulators.

• The CFPB accepts complaints here.

• You can use this database to find your attorney general’s contact information. In addition to fielding complaints, your attorney general can sometimes help answer questions about your state’s car loan laws.

• If you’d like to find an attorney with affordable fees, CFPB maintains a state-by-state list of them here.

• CFPB also has a searchable “know your rights” database that answers lots of questions about car loans.

• Finally, if you want to understand the federal laws that apply to your car loan, the National Automobile Dealers Association has an easy-to-understand primer.

AAuto contracts often include class-action lawsuit waivers and arbitration provisions. These can make it hard for people to sue lenders.

For this reason, a lot of recent legal action against auto lenders has come from the CFPB and state attorneys general. When those agencies sue a company, it can sometimes result in a monetary settlement for people harmed. It can also wipe away borrowers’ debt and prevent their cars from getting repossessed.

Common Car Loan Terms

Amortization: The process of reducing a debt through regular payments.

Amount financed: The amount of money you've borrowed.

Amount of payments: What you'll owe each time a payment is due.

Annual percentage rate: The cost of your loan, including interest rate and fees. It's usually expressed as a percentage.

Balloon payment: A one-time, lump sum charge including any money you still owe on principal or fees, due at your loan's maturity date. This is typically the result of extensions and late payments.

Debt-to-income ratio: The amount of money you owe for housing, credit card and all other loan payments divided by the amount of money you make each month (before taxes). 

Down payment: The up-front payment you put down when you buy your car. The more you can put down, the cheaper your loan will be in the long run.

Extension/deferment: A postponement of one or more payments on your car loan.

Finance charge: The total dollar amount of interest you'll owe if you make every payment on time.

Interest: The cost of borrowing money. This is usually a percentage of the unpaid debt that accumulates on a daily, monthly or annual basis.

Loan term: The amount of time it will take to completely pay off your loan. Usually measured in months: 48-, 60- and 72-month terms are common.

Loan-to-value ratio: The amount you borrowed to purchase the car divided by the car's current value.

Negative equity: When the amount you owe to your lender exceeds the value of your car. This is also called being "upside-down" or "underwater" on your loan.

Number of payments: This usually equals the number of months your loan will last. Occasionally, car loan payments are due every two weeks. You can make sure by checking for the term "monthly" under "When Payments Are Due" in your Truth-in-Lending Disclosures. 

Principal: The total dollar amount you borrowed, and have not yet repaid, before interest is calculated. If you bought a car for cash, you'd be paying just the principal.

Refinancing: The process of taking out a new loan — sometimes with your current lender, sometimes with a new one — to pay for your existing one. People often refinance to get more favorable terms, like a lower APR.

Repossession: When a lender seizes your vehicle because you've missed several payments, typically the equivalent of four months. Lenders have different rights of repossession in different states.

Total of payments: The combination of the amount of money you borrowed and what you'll owe in interest on the loan.

Total sale price: The total of payments plus the down payment you made.

Help ProPublica Investigate the World of Subprime Car Loans

More and more people are struggling to pay back loans on their used cars. Our journalists want to hear from the people who know the industry best. Click here to get in touch with ProPublica reporters.

Development by Chris Zubak-Skees. Research by Sophia Kovatch.

by Ryan Gabrielson and Byard Duncan

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This story is part of a partnership with Scripps News.

Jessica Patterson tensed as she tore open the letter from Exeter Finance. “This notice is being sent to you concerning your default,” the company wrote.

She didn’t need to keep reading to know she was in trouble.

It was January 2018. Seven months earlier, she’d borrowed $14,786.07 to purchase a silver Kia Rio. The interest rate was sky high — 25.17% — and the $402 monthly payment was more than a quarter of her take-home pay. But she needed the car to keep her job and support her three young children. For months she had skimped on groceries, eaten at soup kitchens and even skipped Christmas gifts to pay the car loan. But most of the time it wasn’t enough, and now Exeter was threatening to seize the Kia.

Panicked, she dialed the number in the letter. Can we work something out, Patterson asked.

Exeter’s response came easily, she recalled. It offered to extend her loan.

The company would simply move the December and January payments to the end of her five-year payment schedule, the representative told her, adding two months to the loan’s term. “It was instant relief,” Patterson said.

The extension seemed to be a courtesy from Exeter in a time of need. In fact, the company’s disclosures at the time stated “Extension fee: $0.00.”

The pause in payments, however, was anything but free. What Patterson didn’t know, and what she said Exeter didn’t tell her, was that every penny of her next five payments would go to the interest that built up during the reprieve. That meant she didn’t pay down the original loan balance at all during that time.

While the extension allowed her to keep her car, it added about $2,000 in new interest charges, which the lender did not clearly disclose.

Jessica Patterson at home with her husband and four kids in Olathe, Kansas (Greg Kahn, special to ProPublica)

Patterson’s experience with Exeter was not unusual. A ProPublica investigation has found that it’s an integral part of how the company runs its business.

Exeter is one of the largest auto lenders in the nation, specializing in high-interest loans to people with histories of not paying bills or defaulting on debt, a practice known as subprime lending. The company, which has more than 500,000 active loans and a partnership agreement with CarMax, the country’s largest used car retailer, casts itself as a provider of second chances. “We’re here to help,” it says on its website. In reality, Exeter’s practices often do the opposite.

When the company allows a borrower to skip payments, it typically adds thousands of dollars in new interest charges to the customer’s debt. Dozens of customers told ProPublica that Exeter didn’t tell them about the added costs.

When it’s time to make their final payment, many are faced with a huge bill, which they often can’t afford to pay.

Click here to find out how much used car loan extensions could cost with our free calculator tool.

At that point, Exeter often repossesses a car and sends the bill to a debt collector, regulatory records show. In some cases, the company makes more money on loans that default than on ones in which borrowers pay on time, ProPublica found.

Critics, including some former employees, say the company’s practices are predatory. “I really hated extensions once I found out what they did to people,” said Tyhara Ross, who worked at Exeter for nearly nine years. “You think you’re getting something for nothing, and you’re not.”

Exeter’s top executives declined to be interviewed for this story, and the company did not answer detailed written questions. Instead, it issued a statement that said it’s “fully committed to transparency in its lending practices” and “has no reason to mislead customers.”

“Exeter’s mission is to enable Americans who otherwise may not be able to access financing the opportunity to own their own vehicle so they can go to work and take care of their families,” the company said. “We take that mission seriously as well as our commitment to our customers.”

It’s difficult to track just how many extensions Exeter gives out; the company is not required to report detailed numbers. But publicly available data shows they’re fundamental to Exeter’s business model. Lenders often describe extensions in the context of financial emergencies, like when a borrower loses their job, or national crises, like the COVID-19 pandemic. Exeter hands them out “like candy,” according to three former employees who worked in the company’s collections operation.

To examine Exeter’s practices and their effect on borrowers, ProPublica analyzed data on more than 10 million auto loans included in bonds issued in the past five years.

At first blush, Exeter’s portfolio looks dire: A majority of its loans — more than 200,000 — are at least three payments behind schedule — a degree of delinquency that is roughly twice that of any other subprime lender in the data. Many companies would be preparing to count those loans as losses, send them to a collection agency and repossess the cars.

But Exeter has turned what would otherwise be a financial crisis into a profit center. Each time the company grants an extension, it resets the clock and reclassifies the loan as being on schedule. ProPublica found that Exeter has done this as many as 12 times over the course of a 72-month loan, with borrowers continuing to make payments in hopes of catching up. Regulatory records show many customers paid the equivalent of the full loan or more, only to see their cars repossessed.

Federal law prohibits lenders from engaging in “unfair, deceptive or abusive acts,” and the chief enforcer of that law, the Consumer Financial Protection Bureau, took action against Santander Consumer USA, the nation’s largest subprime lender, in 2018 for practices similar to Exeter’s, such as offering loan extensions without clearly disclosing the financial impacts. CFPB forced Santander to pay nearly $12 million in restitution and penalties. But the agency hasn’t taken enforcement action against Exeter. Meanwhile, annual complaints to the CFPB about the company have grown threefold in the past five years, with nearly 900 in 2023.

Extensions that hide the consequences from borrowers “are taking a loan that is not working and ensuring that it’s just not going to work for a little longer,” said Pamela Foohey, a University of Georgia law professor who has written extensively about subprime lending.

Exeter said it made “voluntary revisions” in 2019 “to the way it communicates about extensions to ensure customers are fully informed on the costs,” notably in the scripts its agents use when talking to borrowers. It also said it created a dedicated team that year to handle extensions “with a focus on transparency to customers.”

“Customers are told clearly that interest will continue to accrue during an extension and are given the true cost of the interest accrual so that customers can make a decision on whether to choose an extension,” the company said.

But none of the customers that ProPublica spoke to said that was what they experienced. In fact, more than 20 borrowers told us they were not provided a dollar amount of what their extensions would cost before they agreed to them. “I just felt like that was so wrong,” said Natosha Smith, a former Exeter borrower living in Georgia.

She received eight extensions over the course of her loan. Each time, Smith said, an Exeter employee explained that it added additional months to the end of her loan term. Smith said she expected to pay a little extra interest, something akin to her $425 monthly payment. Instead, the cost was more than 10 times that.

“You guys have gotten double what this vehicle is worth, and you still want to take another $6,000 from me?” Smith said of Exeter. “I was appalled. I couldn’t believe it.”

When asked why it did not provide Smith and others with the exact cost of their extensions, Exeter amended its statement, saying, “Customers who request an extension are given the option before accepting the extension to immediately speak with an agent who can provide the cost of the interest that will accrue during the extension period. Some customers choose not to be transferred to an agent to receive the explanation.”

Neither Smith nor other borrowers could recall being given this option.

Loans With Extensions Result in Inflated Final Payments

The monthly payment for a 72-month, $15,000 loan with a 25% interest rate is $404. But with two extensions early in the loan, the borrower’s final payment will be more than six times higher.

Note: These charts assume that the borrower always paid on time and did not accrue late fees. (Lucas Waldron/ProPublica) Targeting Struggling Buyers

Exeter has always specialized in the subprime market. But in the late 2010s, the company went after customers with poor credit more aggressively than it had in the past. It accepted borrowers with even lower credit scores, lent them more money — as much as $50,000 per loan — and gave them longer to repay it. Some agreed to schedules stretching longer than six years, making the loans more costly.

“We’re not your father’s Exeter Finance,” the company proclaimed in a 2019 blog post aimed at wooing new business from dealerships.

It also increased its prices.

ProPublica’s analysis shows that Exeter charges the highest interest rates of any lender in the publicly available data. Since 2020, the average interest rate for an Exeter car loan jumped from 19% to nearly 22%, regulatory records show.

Exeter Charged Higher Interest Rates Than Other Subprime Lenders

Rates for borrowers with the lowest credit scores were nearly 30%.

Note: Each circle represents the mean interest rate for all loans by that lender at that credit score between 2019 and 2023. Circles are generated only when the lender made at least 50 loans to borrowers with that credit score. The chart displays only lenders with at least half as many subprime loans as Exeter. Source: ProPublica analysis of U.S. Securities and Exchange Commission and Finsight.com data. (Lucas Waldron/ProPublica)

Exeter’s loan volume exploded, bond data shows. And as borrowers got into trouble, the lender’s collections workers were rewarded with bonuses for getting loans out of delinquency, according to three former employees. Extensions were a common tool to accomplish that. Exeter denied the allegation, saying, “customer service agents are not incentivized or rewarded with compensation related to granting extensions.”

Either way, Exeter financial records show the number of loans with five or more extensions rocketed 80% between 2016 and 2018.

The company attributed part of a more recent uptick in extensions to the COVID-19 relief bill that Congress passed during the pandemic in 2020, saying the legislation “encouraged compassion from lenders.”

That “compassion,” however, led to confusion and anger among borrowers who began filing complaints with state attorneys general. ProPublica examined nearly 200 of them and found the most common problems involved how much of their payments went to interest and why they still owed so much.

The company has drawn the scrutiny of regulators in at least three states. In 2019, the attorneys general of Massachusetts and Delaware settled lawsuits against Exeter alleging it had violated consumer protection laws. The company said the settlements had nothing to do with extensions and contained no admission of illegality. The Georgia attorney general’s office confirmed it is now investigating Exeter, though it declined to provide more detail. Exeter declined to comment on the investigation.

The CFPB declined to answer questions about Exeter’s practices and its oversight of the company. Chris Kukla, a CFPB program manager supervising the auto finance industry, said that in general “it’s important for everybody to understand what’s going on in the transaction.”

“All the information should be shared," he added.

For years, Exeter failed to provide specific information in its written notices. They did not explain that a borrower’s next payments would first be applied to the interest from extensions, which would delay repayment of the original loan balance, known as the principal. These omissions were identical to those that federal regulators had targeted in their case against Santander years earlier, according to three consumer finance experts who reviewed them.

The company said it updated those disclosures in late 2021 but declined to provide copies or details about the changes.

Notices sent to borrowers earlier this year, reviewed by ProPublica, said that an extension would increase the borrowers’ interest charges as well as the amount of their final payment. However, the notices did not include the actual dollar amount. If borrowers wanted to know more, the letter directed them to call a toll-free number.

One employee said that lack of disclosure was intentional.

“The object was for the agent to keep the customer in the car no matter what,” said Ross, the former Exeter employee who worked with borrowers struggling to make their payments. “That’s the end game. Because as long as that customer stays in that car, guess what? They are getting that interest. And the interest brings them more money.”

Lender of Last Resort

A faded Carmax plate on the front of Patterson’s car (Greg Kahn, special to ProPublica)

Jessica Patterson encountered Exeter like tens of thousands of consumers do each year: via CarMax, which uses Exeter to make loans when borrowers don’t qualify for CarMax’s in-house financing.

In the spring of 2017, Patterson sat at a circular table in her local CarMax just outside Kansas City, Kansas, with $200 in her pocket. Around her was an open sales room nearly as deep and wide as a football field.

A salesperson had shown her a Kia Rio with low mileage and zero frills. At $15,000, it was “the best that I could do for what I had,” Patterson recalled.

As a receptionist at a hearing aid sales center, she made $12 an hour, below the federal poverty line. She’d just moved her family out of a domestic violence shelter and into a basement apartment of their own. Their life felt fragile.

Like most subprime customers, her credit history was rife with unpaid bills. The debts were mostly from her ex-husband, she said.

The CarMax employee said she had good news, though: Exeter would lend Patterson the full amount needed to buy the Kia. Then the employee read the loan terms aloud. A six-year loan. A 25.17% interest rate. ​​A monthly payment of $402.63. That would be a quarter of Patterson’s take-home pay, almost twice what consumer finance experts recommend.

She asked whether there were cheaper offers. None of the other companies were willing to give Patterson a loan, said the employee, who turned her computer monitor so Patterson could see. “Exeter was the only one there,” she said. According to rating agency reports, CarMax is the single largest source of Exeter’s business — responsible for some 50,000 loans per year.

Patterson agreed to the terms. To get to work and get her kids to school, she needed a car. Turning down the loan felt like giving up.

Exeter contacted her employer and landlord to confirm the details in her application. It knew how much money Patterson would get in her upcoming paychecks, how much would automatically go out and how little room for error she had.

For its part, CarMax said it is not involved with the loans Exeter and other lenders sell to its customers and declined to answer specific questions about its partnership with Exeter.

“Each of CarMax’s finance sources performs its own underwriting, servicing, and collection activity,” the dealership chain said in a written statement. “CarMax cannot speak to details about how our finance sources manage repossessions or extend financing.”

Truth in Lending?

The top of Patterson’s contract had a box detailing just how much she would pay over six years — a requirement of the federal Truth in Lending Act. It said she’d pay Exeter more than $14,000 in interest, almost as much as she would pay for the Kia itself.

While it would be tight, Patterson thought she could budget for the loan.

Within months, though, she fell behind. In January 2018, Patterson took her first two extensions. She used the time to reorder her finances so she could resume payments.

To save on food, she drove her family to free church dinners every Wednesday and Thursday night. Donations from a nearby food bank allowed them to keep grocery bills at a bare minimum.

Patterson sent payments to Exeter for February and March. But by late spring, she was in trouble again, resorting to sending a few hundred dollars at a time. By the fall, she was on the verge of default.

She called the lender’s collections department and asked for a third extension. The lender granted it over the phone without question, Patterson said.

Exeter agents could see the exact cost of the added interest on their screens during calls like this, but they did not share it with borrowers, said Clair Groves, who worked in Exeter’s collections department in 2019. The company does not include specific price information in the scripts it requires agents to read when giving an extension, Groves said, and urges them to finish calls in less than three minutes, leaving little time to provide more information.

Exeter did not respond to questions about Patterson’s account or Groves’ statements.

Extension practices like Exeter’s, experts say, undermine the utility of the Truth in Lending law, which aimed to eliminate financial surprises for consumers.

“If you can manipulate the payment schedule in such a way that makes the original disclosures meaningless, that’s a huge problem,” said Erin Witte, consumer protection director at the Consumer Federation of America.

For Patterson, the true cost of the extensions would become clear only after she remarried two and a half years later. Her new husband, Andrew Patterson, had found the Exeter loan odd. He had bought a more expensive car from the same dealership, but because he qualified for a loan from CarMax directly, his monthly payments were far lower. He decided to take a closer look.

The numbers on her statements were staggering, he said. Even when she made payments consistently, so much money went to interest that she barely made a dent in the original debt. If they made the 20 remaining payments, there was still no way they’d be able to pay off the car.

Using her loan statements, ProPublica calculated that Patterson had paid Exeter $17,097 over three years. About 80% of that had gone to interest, leaving her with more than $11,000 in debt.

“Just let them repo it,” Andrew told his wife.

The lender seized the Kia in the fall of 2021 and auctioned it off for $13,800. Exeter collected more from Patterson’s failed loan than it would have if she’d paid on schedule.

Patterson’s new husband, Andrew, helped her get out of the Exeter loan by letting the company repossess the vehicle. (Greg Kahn, special to ProPublica) A Giant Bill, Then Repossession

ProPublica’s analysis found that nearly a quarter of Exeter loans from 2020 and 2021 — more than 65,000 — ended like Patterson’s did, with borrowers stopping repayment early.

For people who take extensions and make it to the end of their loan, a large final payment typically awaits.

That news was crushing for Don Weaver, a disabled veteran living in Louisiana. In 2015, Exeter lent him $15,607.29 to buy a 7-year-old GMC Envoy. Over the next seven years, the company granted him 12 extensions by phone, Weaver said. Each time, the agent assured him he was “current,” he recalled.

The extensions had helped him navigate choppy economic waters, he said. He lived off VA disability payments, and unexpected expenses like a busted lawn mower or worn-down brake pads often made his $393.14 monthly payment difficult.

In September 2022, after Weaver had paid Exeter $29,125 — $819 more than his loan contract outlined — the company told him he still owed more than $9,000.

“I couldn’t get heads or tails about how much of that was actual payments and how much of that was fees,” Weaver said.

When he couldn’t pay, Exeter repossessed the Envoy, and today, a collections company is pursuing him for the $5,800.73 he still owes.

Don Weaver, at his home in Baton Rouge, Louisiana, with the car he bought after Exeter repossessed his previous one (Greg Kahn, special to ProPublica)

Although their loan outcomes were different, both Weaver and Patterson felt certain that local authorities should know about their experiences. Exeter “has a huge role in allegedly financing unfair, subprime auto loans,” Patterson wrote to Kansas Attorney General Derek Schmidt in November 2021. “They are a predatory company.”

Weaver’s complaint was strikingly similar, citing the settlements Exeter had entered into with Massachusetts and Delaware: “They had to pay millions back to consumers due to predatory practices,” he wrote to Louisiana Attorney General Jeff Landry. “I am wondering if that is happening to me.”

Kansas simply forwarded Patterson’s complaint to Exeter, which responded with a letter claiming that all the contract terms were properly disclosed; five extensions were granted “at Jessica’s request.” Months after it repossessed her Kia, Exeter added, it stopped pursuing her, “as a courtesy,” for the $51.63 she still owed.

Louisiana regulators didn’t press Exeter in Weaver’s case, either. After receiving a similar explanation from the lender, the attorney general’s office ended its inquiry, encouraging Weaver to hire a lawyer if Exeter’s response “does not result in a satisfactory outcome for you.”

The attorney general’s office confirmed that it did not investigate Weaver’s case. Landry, who is now governor of Louisiana, did not respond to requests for comment. The Kansas attorney general’s office also declined to comment.

In the fall of 2022, even with the bill collector after him, Weaver still needed a car. So, he headed to a nearby CarMax to start the process over. When the employee ran his information, he was told that Exeter had approved him for another loan.

“You’re telling me you got to charge me this extra interest and all this because I’m a bad risk,” Weaver said, “but you’re willing to risk it again?”

This time, he declined the offer.

Help ProPublica Investigate the World of Subprime Car Loans

Disclosure: The private equity firm Warburg Pincus owns a controlling stake in Exeter. Mark Colodny, one of the firm’s managing directors, is a member of ProPublica’s board.

Jeff Ernsthausen and Mollie Simon of ProPublica and Carrie Cochran and Patrick Terpstra of Scripps News contributed reporting.

by Eric Umansky

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

The New York Police Department has tossed out hundreds of civilian complaints about police misconduct this year without looking at the evidence.

The cases were fully investigated and substantiated by the city’s police oversight agency, the Civilian Complaint Review Board, and sent to the NYPD for disciplinary action. They included officers wrongfully searching vehicles and homes, as well as using excessive force against New Yorkers.

In one instance, an officer punched a man in the groin, the oversight agency found. In another, an officer unjustifiably tackled a young man, and then another officer wrongly stopped and searched him, according to the CCRB.

The incident involving the young man was one of dozens of stop-and-frisk complaints the NYPD dismissed without review this year — a significant development given that the department is still under federal monitoring that a court imposed more than a decade ago over the controversial tactic.

The practice of killing cases without review began three years ago as a way to cope with escalating caseloads that were approaching a deadline for discipline. But ProPublica found it has become more frequent under Police Commissioner Edward Caban.

The commissioner may not be in his position for long. He is under pressure to resign after his phone was seized in a federal corruption investigation. He has also faced criticism for failing to hold officers accountable for misconduct.

Since he took office last July, the NYPD has ended without review more than 500 incidents, about half the cases the oversight board referred to it, according to an analysis of board data. That rate has climbed to nearly 60% this year. Under Caban’s predecessor, Keechant Sewell, the department faced roughly the same number of cases, but about 40% were tossed without review. (Neither Caban nor Sewell responded to requests for comment.)

The tactic is part of a broader pattern under Caban, who has repeatedly used the powers of his office to intervene in misconduct cases brought by the oversight agency. This summer, ProPublica and The New York Times detailed how the commissioner has used an authority known as “retention” to short-circuit some of the most serious cases, which otherwise would face public disciplinary trials.

In those instances, Caban and his staff reviewed the cases and “retained” the ones they believed the CCRB erred on, often ordering little to no discipline. Some episodes, like officers using chokeholds and beating protesters with batons, were so serious the board concluded the police had likely committed crimes.

With lower-profile matters, the board investigates and makes recommendations directly to the NYPD, which then decides what to do. The department has a policy of not reviewing most cases that arrive within three months — or 60 business days — of the statute of limitations for discipline.

“This is highly problematic and deeply troubling,” said City Council member Alexa Avilés, who has sponsored police reform legislation. “What the department is saying is that there’s not enough time, so they’re not going to do anything at all. They’re using the statute of limitations to avoid accountability.”

The NYPD does not disclose to the public or to the civilians who complained of abuse that it has terminated such cases. ProPublica obtained data on the practice from the CCRB.

In response to questions, the department issued a statement defending its policy, saying that “every case and officer is entitled to due process,” and that the CCRB had not given it enough time in these cases under the statute, which requires charges to be filed or discipline given within 18 months of an incident.

“The suggestion that the CCRB may take 486 days to review a case, but the Department may not take 60, reflects a lack of appreciation for the thorough effort, analysis, and diligent investigation these matters require,” the statement said.

When the CCRB sends a case to the NYPD, it hands over a full investigation, complete with evidence such as body-camera footage and a report summarizing its findings. NYPD lawyers then review the files.

“It’s irresponsible for the Department, and a disservice to its officers and to the people of the city of New York for the NYPD to claim it needs more than 60 days to review every case it receives from CCRB,” said the Rev. Fred Davie, who chaired the oversight board until two years ago. “Simply ignoring substantiated incidents of misconduct is truly untenable and indefensible.”

The CCRB did have a history of handling cases slowly, but that was due in large part to the NYPD withholding evidence from civilian investigators, a 2020 investigation by ProPublica found.

After police shot and killed a Bronx man in his own apartment in 2019, the department refused to share the body-camera footage with the oversight board for more than a year and a half. The delay prevented the CCRB from filing charges against the officers within the statute of limitations. (The department has since pledged to hand over body-camera footage within 90 days of a request from the board.)

This year, Caban announced that he would not impose any discipline in the killing. He approved an NYPD judge’s ruling that the oversight board had acted too late.

“The CCRB is not perfect, but its goal is clearly accountability,” said Chris Dunn, legal director of the New York Civil Liberties Union. “The NYPD clearly does not have that goal. When a problem arises, the department’s default solution is to kill the case.”

The NYPD can act on cases that have little time left until the deadline. CCRB data shows the department has done so more than 600 times over the past three years.

Advocates for reform said they were particularly troubled by the revelation that, under Caban, the NYPD has killed dozens of civilians’ complaints about stop-and-frisks without review. The NYPD was ordered in 2013 by a federal judge to end a pattern of discriminatory and illegal behavior around the practice, where officers stop, question and frisk residents without reasonable suspicion.

“This is an end run,” said Shira Scheindlin, the former federal judge who issued the ruling that led to the federal consent decree.

Scheindlin told ProPublica the NYPD’s refusal to even review many stop-and-frisk cases shows the department is policing with impunity. “Accountability was the whole point of my decision,” she said. “Now they’re saying we can still do what we want on the street. That there will be no consequences for bad decisions.”

Since Eric Adams, a former police officer, became mayor, stop-and-frisks have climbed to their highest level in nearly a decade. And a federal monitor has found a continuing pattern of unconstitutional and undocumented stops. An earlier report from the federal monitor noted that the NYPD “failed to impose meaningful discipline” after the CCRB found misconduct. The monitor said the NYPD “must provide more deference” to agency investigations.

Adams, who struck a law-and-order image as mayor, has had a tense relationship with the CCRB, and he recently forced out its chair after she criticized the department’s response to board investigations. His administration also froze hiring at the agency.

The agency has said that because of understaffing it has had to close more than 700 cases of alleged misconduct this year without investigating them.

“What I would ask of City Hall, City Council and the police commissioner is whether this is really what they want to tell people in their communities — that citizens’ complaints will be thwarted by these technical and bureaucratic measures,” Davie said.

In response to ProPublica’s reporting this year, City Council members have called for the police commissioner to be stripped of the power of retention. Advocacy groups, like Black Lives Matter Greater New York, have called for Caban’s resignation. And still others, like LatinoJustice, have filed a lawsuit challenging the department’s practices around misconduct cases. (The NYPD did not respond to requests for comment about the lawmakers’ calls or the lawsuit.)

The mayor’s office pushed back against criticism.

“Mayor Adams has spent his career fighting for both public safety and police reform, and that’s why he and Commissioner Caban have been clear that they expect a Police Department that is professional, impartial, and just,” a spokesperson said in a statement. “The police commissioner and NYPD leadership continue to work diligently to ensure New Yorkers are both safe and policed fairly.”

So far this year, the department has killed more than 430 police misconduct cases without review, far more than it did in all of last year.

by Tim Golden

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From the start of U.S. investigations into the terrorist attacks of Sept. 11, 2001, the question of whether the Saudi government might have been involved has hovered over the case.

The FBI, after the most extensive criminal probe in its history, concluded that a low-level Saudi official who helped the first two hijackers in California met them by chance and aided them unwittingly. The CIA said it saw no evidence of a higher-level Saudi role. The bipartisan 9/11 commission adopted those findings. A small FBI team continued to dig into the question, turning up information that raised doubts about some of those conclusions.

But now, 23 years after the attacks, new evidence has emerged to suggest more strongly than ever that at least two Saudi officials deliberately assisted the first Qaida hijackers when they arrived in the United States in January 2000.

Whether the Saudis knew the men were terrorists remains unclear. But the new information shows that both officials worked with Saudi and other religious figures who had ties to al-Qaida and other extremist groups.

Most of the evidence has been gathered in a long-running federal lawsuit against the Saudi government by survivors of the attacks and relatives of those who died. That lawsuit has reached a critical moment, with a judge in New York preparing to rule on a Saudi motion to dismiss the case.

Already, though, information put forward in the plaintiffs’ case — which includes videos, telephone records and other documents that were collected soon after the attacks but were never shared with key investigators — argues for a fundamental reassessment of the Saudi government’s possible involvement with the hijackers.

The court files also raise questions about whether the FBI and CIA, which repeatedly dismissed the significance of Saudi links to the hijackers, mishandled or deliberately downplayed evidence of the kingdom’s possible complicity in the attacks that killed 2,977 people and injured thousands more.

“Why is this information coming out now?” asked retired FBI agent Daniel Gonzalez, who pursued the Saudi connections for almost 15 years. “We should have had all of this three or four weeks after 9/11.”

Saudi officials have long denied any involvement in the plot, emphasizing that they were at war with al-Qaida well before 2001.

They have also leaned on earlier U.S. assessments, especially the one-page summary of a joint FBI-CIA report that was publicly released by the Bush administration in 2005. That summary said there was no evidence that “the Saudi Government or members of the Saudi royal family knowingly provided support” for the attacks.

Pages of the report that were declassified in 2022 are more critical of the Saudi role, describing extensive Saudi funding for Islamic charities linked to al-Qaida and the reluctance of senior Saudi officials to cooperate with U.S. counterterrorism efforts.

The plaintiffs’ account still leaves significant gaps in the story of how two known al-Qaida operatives, Nawaf al-Hazmi and Khalid al-Mihdhar, avoided CIA surveillance overseas, flew into Los Angeles under their own names and then — despite speaking no English and ostensibly knowing no one — settled in Southern California to start preparing for the attacks.

Still, the lawsuit has exposed layers of contradictions and deceit in the Saudi government’s portrayal of Omar al-Bayoumi, a middle-aged Saudi graduate student in San Diego who was the central figure in the hijackers’ support network.

Almost immediately after the 9/11 attacks, FBI agents identified Bayoumi as having helped the two young Saudis rent an apartment, set up a bank account and take care of other needs. Bayoumi, then 42, was arrested on Sept. 21, 2001, in Birmingham, England, where he had moved to continue graduate studies in business. Scotland Yard terrorism investigators questioned him for a week in London as two FBI agents monitored the sessions.

Bayoumi dissembled from the start, newly released transcripts of the interrogations show. He said he barely remembered the two Qaida operatives, having met them by chance in a halal cafe in the Los Angeles suburb of Culver City, after he stopped at the Saudi Consulate to renew his passport. The evidence shows he actually renewed his passport the day before the encounter in the cafe, one of many indications that his meeting with the hijackers was planned.

After pressure from Saudi diplomats, Bayoumi was freed by the British authorities without being charged. U.S. officials did not try to have him extradited.

Two years later, in Saudi Arabia, Bayoumi sat for interviews with the FBI and the 9/11 commission that were overseen by Saudi intelligence officials. Again, he insisted that he was just being hospitable to the hijackers. He knew nothing of their plans, he said, and was opposed to violent jihad.

Gonzalez and other FBI agents were dubious. Though Bayoumi was supposedly a student, he did almost no studying. He was far more active in setting up a Saudi-funded mosque in San Diego and spreading money around the Muslim community. (The Saudi government paid him surreptitiously through an aviation-services company in Houston.)

FBI officials in Washington accepted the Saudi depiction of Bayoumi as an amiable, somewhat bumbling government accountant trying to improve his skills, and as a devout but moderate Muslim — and not a spy. The lead agent on the FBI team that investigated him, Jacqueline Maguire, told the 9/11 commission that by “all indications,” Bayoumi’s connection with the hijackers had been the result of “a random encounter” at the cafe.

The 9/11 commission accepted that assessment. The commission’s investigators noted Bayoumi’s “obliging and gregarious” manner in interviews and called him “an unlikely candidate for clandestine involvement with Islamist extremists.” The panel found “no credible evidence that he believed in violent extremism or knowingly aided extremist groups.”

But in 2017, the FBI concluded that Bayoumi was, in fact, a Saudi spy — although it kept that finding secret until 2022, after President Joe Biden ordered agencies to declassify more documents from the 9/11 files.

A page from an exhibit submitted by the plaintiffs in a long-running lawsuit against the Saudi government over the role it may have played in the 9/11 attacks. The exhibit contains screenshots from a video by a Saudi official, Omar al-Bayoumi, who toured Washington, D.C., in 1999. (Obtained by ProPublica from the U.S. District Court of the Southern District of New York)

Exactly whom in the Saudi government Bayoumi was working for remains unclear. FBI reports describe him as a “cooptee,” or part-time agent, of the Saudi intelligence service, but say he reported to the kingdom’s powerful former ambassador to Washington, Prince Bandar bin Sultan. (Lawyers for the Saudi government have continued to repeat Bayoumi’s earlier denials that he ever had “any assignment” for Saudi intelligence.)

Another layer of Bayoumi’s hidden identity has emerged from documents, videotapes and other materials that were seized from his home and office at the time of his arrest in England. The plaintiffs had sought that information from the Justice Department for years but received almost nothing until the British authorities began sharing their copies of the material in 2023.

Although Saudi officials insist that Bayoumi merely volunteered at a local mosque, the British evidence points to his deeper collaboration with the Ministry of Islamic Affairs. The Saudi royals had established the ministry in 1993 as part of a governing pact with the powerful clergy. In return for political support, they gave the clerics effective control over domestic religious matters and funded their efforts to spread their fundamentalist Wahhabi brand of Islam overseas.

From the start of the FBI’s 9/11 investigation, agents pored over a short excerpt of a videotape recorded at a party that Bayoumi hosted for some two dozen Muslim men in February 2000, soon after Hazmi and Mihdhar arrived in San Diego.

It was another coincidence, Bayoumi claimed, that he held the event in the hijackers’ apartment. The two young Saudis had nothing really to do with the gathering, he said, but he needed to keep his wife and other women in his own apartment, sequestered from male guests according to conservative Muslim custom.

The FBI did not share a full copy of the VHS recording with either its own field agents or the 9/11 families, who sought it repeatedly. (An FBI spokesperson declined to comment on the bureau’s handling of the Bayoumi evidence.) But the full recording was provided to the plaintiffs by the British police last December.

The longer version casts Bayoumi’s gathering in a different light. Although the nominal guest of honor is a visiting Saudi cleric, the two hijackers are carefully introduced to the other guests and are seemingly at the center of the proceedings.

After identifying many of the party guests for the first time, the plaintiffs’ lawyers were able to document that many went on to play significant roles in the hijackers’ support network, helping them set up internet and telephone service, sign up for English classes and buy a used car.

“Bayoumi hand-picked these individuals because he knew and assessed that they were well-suited to provide the Al Qaeda operatives with important forms of support,” the lawyers wrote of the party guests.

Another videotape taken from Bayoumi’s Birmingham home is even more at odds with the image he conveyed to the FBI and the 9/11 commission. The video follows Bayoumi as he tours Washington, D.C., with two visiting Saudi clerics early in the summer of 1999.

Lawyers for the Saudi government called the recording an innocent souvenir — “a tourist video that includes footage of artwork, flowerbeds, and a squirrel on the White House lawn.” But the plaintiffs’ lawyers posit a more ominous purpose, especially as Bayoumi focuses on his main subject: an extensive presentation of the Capitol building, which is shown from a series of vantage points and in relation to other Washington landmarks.

“We greet you, the esteemed brothers, and we welcome you from Washington,” Bayoumi says on the video. Later, standing before the camera, he reports as “Omar al-Bayoumi from Capitol Hill, the Capitol building.”

The footage shows the Capitol from various angles, noting architectural features, entrances and the movement of security guards. Bayoumi sprinkles his narration with religious language and refers to a “plan.”

“Bayoumi’s video footage and his narration are not that of a tourist,” the plaintiffs contend in one court document, citing the analysis of a former FBI expert. The video, they add, “bears the hallmarks of terror planning operations identified by law enforcement and counterterrorism investigators in operational videos seized from terror groups including Al Qaeda.”

Lawyers for the Saudi government dismissed this conclusion as preposterous.

But the video’s timing is noteworthy. According to the 9/11 commission report, Osama bin Laden and other al-Qaida leaders began discussing their “planes operation” in the spring of 1999. Although they disagreed on which U.S. landmarks to strike, the report states, “all of them wanted to hit the Capitol.”

The two Saudi clerics who joined Bayoumi on the trip, Adel al-Sadhan and Mutaeb al-Sudairy, were so-called propagators — emissaries of the Islamic Affairs ministry sent to proselytize abroad. U.S. investigators later linked them to a handful of Islamist militants.

Another page from the plaintiffs’ exhibit shows two Saudi religious officials, Mutaeb al-Sudairy and Adel al-Sadhan, during a trip in the Washington, D.C., area with Bayoumi early in the summer of 1999. (Obtained by ProPublica from the U.S. District Court of the Southern District of New York)

Most notably, Sudairy, whom Bayoumi describes as the emir, or leader, of the Washington trip, spent several months living in Columbia, Missouri, with Ziyad Khaleel, a Palestinian-American al-Qaida member who delivered a satellite phone to bin Laden in Afghanistan in 1998. The Qaida leader used the phone to coordinate the deadly bombings of U.S. embassies in Kenya and Tanzania, FBI officials have said.

Sudairy and Sadhan, who had diplomatic status, had previously visited California, working with Bayoumi and staying at a small San Diego guesthouse where the hijackers later lived. Many new details of their travels were revealed in the British documents. The two Saudis had previously denied even knowing Bayoumi, one of many false claims in depositions coordinated by the Saudi government.

The new evidence also shows that Sadhan and Sudairy worked with the other key Saudi official linked to the hijackers, the cleric Fahad al-Thumairy. According to one FBI source, it was Thumairy, the 32-year-old imam of a prominent Saudi mosque in Culver City, who received the hijackers when they arrived on Jan. 15, 2000, and arranged for their temporary housing and other needs.

Thumairy, a Ministry of Islamic Affairs official who was also assigned to the Saudi consulate, insisted he had no memory of Hazmi and Mihdhar, although the three were seen together by several FBI informants. Thumairy also denied knowing Bayoumi, despite telephone records that show at least five dozen calls between them. Thumairy’s diplomatic visa was withdrawn by the State Department in 2003 because of his suspected involvement with terrorist activity.

In an extensive analysis of telephone records produced by the FBI and the British authorities, the plaintiffs also documented what they called patterns of coordination involving Bayoumi, Thumairy and other Saudi officials. (Lawyers for the Saudi government said the calls were about mundane religious matters.)

Two weeks before the hijackers’ arrival, for example, the records show calls among Bayoumi, Thumairy and the Islamic Affairs director at the Saudi Embassy in Washington. Bayoumi and Thumairy also made a number of calls around that time to a noted Yemeni American cleric, Anwar al-Awlaki, who later emerged as an important Qaida leader in Yemen.

It has long been known that Awlaki, who was killed by a U.S. drone strike in 2011, had some contact with Hazmi and Mihdhar in San Diego and met two other 9/11 hijackers after moving to a mosque in Falls Church, Virginia. But many FBI investigators believed he was radicalized well after 9/11 and may not have known the hijackers’ plans.

New evidence filed in the court case points to a more significant relationship. Awlaki appears to have met Hazmi and Mihdhar as soon as they arrived in San Diego. He joined Bayoumi in helping them rent an apartment and set up bank accounts, and he was seen by others to have served as a trusted spiritual advisor.

Awlaki’s worldview “matched quite closely to al-Qaida’s at the time,” said Alexander Meleagrou-Hitchens, a biographer of Awlaki who served as an expert for the plaintiffs. “The new information now becoming public, on top of what we already know about his teachings and associations, makes it reasonable to conclude that Awlaki knew the hijackers were part of the al-Qaeda network.”

by Pamela Colloff

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The Nashville, Tennessee, medical examiner who determined 24 years ago that Russell and Kaye Maze’s young son, Alex, was the victim of homicide — a finding that helped persuade a jury to send Russell to prison for life — now says he was wrong.

“I recant my trial testimony that Bryan Maze suffered from shaken baby syndrome,” Dr. Bruce Levy stated in a sworn affidavit, which used the child’s legal name. “If called to testify now, I would assert Bryan Maze’s brain, at the time of his death, showed no indication, to a reasonable degree of medical certainty, of prior trauma or abuse. Instead, the residual brain lesions viewed at autopsy more likely than not resulted from a natural disease process.”

Levy went on to state that he would now classify the child’s manner of death as “natural.”

In July, the Maze case was the subject of an in-depth article by ProPublica and The New York Times Magazine, which examined new scientific evidence that suggested Alex died not from shaking but an undiagnosed, underlying condition. That evidence first came to light when the Nashville district attorney’s office, through its conviction-review unit, began reinvestigating the case in 2023. The ProPublica-Times story explored the challenges in overturning convictions, even when prosecutors themselves determine that the underlying evidence no longer stands up to scrutiny.

Russell Maze stood trial twice. He was convicted before Alex’s death of aggravated child abuse and after Alex’s death of murder. He is currently serving a life sentence.

Levy’s affidavit, which was filed on Monday with the Tennessee Court of Criminal Appeals, marks a watershed moment in the Maze case. Because his trial testimony directly contributed to Russell’s conviction, Levy’s recantation will be hard for the courts to ignore. Whether this is enough to persuade the courts to set aside Russell’s conviction remains to be seen. But it offers a lifeline to a defendant whose chances of relief dramatically narrowed in May when a lower-court judge, after hearing two days of testimony from multiple experts who found no evidence that Alex had been shaken, nevertheless concluded, “The court does not find an injustice nor that the petitioner is actually innocent based on new scientific evidence.”

The affidavit also creates a highly unusual situation: Now both the DA’s office and the original medical examiner agree that the crime for which Russell was convicted never occurred.

At both of Russell’s trials, prosecutors presented evidence that they said showed Alex was a victim of shaken baby syndrome. The diagnosing doctor, Suzanne Starling, told jurors that internal bleeding around Alex’s brain and eyes indicated that he endured a ferocious act of violence by shaking. “You would be appalled at what this looked like,” she testified at Russell’s first trial. So forceful was the shaking, she added, that “children who fall from three or four floors onto concrete will get a similar brain injury.”

But in the years since the infant was rushed to the emergency room, shaken baby syndrome has come under increasing scrutiny. A growing body of research has demonstrated that the triad of symptoms doctors traditionally used to diagnose the syndrome — brain swelling and bleeding around the brain and behind the eyes — are not necessarily produced by shaking; a range of natural and accidental causes can generate the same symptoms.

“If called to testify today,” Levy stated in his affidavit, “I would refute the previous testimony of Dr. Suzanne Starling that Bryan Maze was definitely a victim of shaken baby syndrome and that there was no other explanation for his condition.”

Before reaching his new conclusion, Levy reviewed the original medical examiner’s file, which included his 2000 autopsy report, photos and slides. He also studied medical records that the CRU provided him this summer. Those records gave essential context about the health challenges that Alex faced before his father called 911 on May 3, 1999, to report that the 5-week-old had stopped breathing.

The records documented Alex’s first five weeks of life, which included 13 days in a neonatal intensive care unit, and health problems that spurred his parents to seek medical attention seven different times in the three weeks that followed. Levy also examined Kaye’s obstetric records, which documented her troubled pregnancy and Alex’s preterm birth.

“I do not believe many of these records were previously provided for my review,” Levy, who was the Nashville medical examiner for 13 years, wrote in the affidavit.

Levy also reviewed reports written by experts in the fields of pathology, radiology and neonatology, who reexamined the evidence in the case last year as part of the CRU’s probe.

Those experts testified at a hearing in March before Judge Steve Dozier, who had overseen Russell’s previous two trials. “Every single medical expert, using current science, confirms that Russell and Kaye Maze are actually innocent of the crimes for which they were convicted,” Nashville DA Glenn Funk told the judge. “It is my duty as district attorney to ask the court to vacate these convictions.”

At that hearing, Dozier pointedly asked about Levy, who — along with Starling, the diagnosing doctor — was not called to testify by the CRU. Its director, Sunny Eaton, and assistant DA Anna Hamilton chose to call medical experts who did not have a record to protect and who could approach the case with fresh eyes.

During the hearing, Dr. Darinka Mileusnic-Polchan, the chief medical examiner in Knox and Anderson counties, criticized Levy’s original work in the case. “He was a good pathologist,” she said, but she thought he had been “too busy to really dedicate enough time to study this case thoroughly.”

Dozier, who sometimes interrupted witnesses during the hearing with provocative questions, said pointedly, “You’re not busy?”

Mileusnic-Polchan explained that for forensic pathologists who are saddled with heavy workloads, “sometimes the easiest thing is just to copy and paste” previous medical conclusions. She suggested that if Levy had the opportunity to look at the case anew, and took more time with the evidence, that he would see what she saw. “I am almost certain if I were to bring Dr. Levy here and just kind of slow him down —”

“There is no way you can say that,” Dozier said. “Really?”

“I — I think that any pathologist looking at the brain slides —”

Dozier was skeptical of the notion that Levy would take a different stance. “He’s going to admit he was wrong?” the judge asked dismissively.

After two days of testimony and a forceful closing argument from Eaton — “The state got this wrong,” she told the judge — Dozier did not find that there was enough evidence to set aside Russell’s conviction.

Levy, Starling and Dozier did not respond to an emailed request for comment.

The CRU subsequently reached out to Levy and asked him to review the record, including Alex’s full medical history and Kaye’s obstetrics record. Levy could have upheld his previous position or written a more measured reappraisal. Instead, after reviewing all the evidence, he unequivocally rejected his original findings and testimony.

When Levy memorialized his conclusions in his affidavit, the CRU informed Jason Gichner of the Tennessee Innocence Project, who is representing Russell, and Melissa Dix and Daniel Horwitz, who are representing Kaye.

(Kaye, who was not home with her husband when their son became unresponsive in 1999, was charged with aggravated assault. After she was told that having an open criminal case would make it harder for her to regain custody of her son, she took an Alford plea to a reduced felony charge — a plea that allows defendants to accept punishment while maintaining their innocence. Kaye has asked that her conviction be vacated. Her appeal has been consolidated with her husband’s and will move through the courts with his.)

Levy’s affidavit comes as the Tennessee Court of Criminal Appeals considers whether Dozier was correct, this May, in finding that there was not enough new evidence to set aside Russell’s conviction.

Levy came to Nashville in 1997 to reform a medical examiner’s office that was plagued by backlogs and scandal, and he was praised for restoring integrity to the office. He also became the state’s chief medical examiner. But he lost both jobs after he was arrested in Mississippi in 2010 on a felony marijuana possession charge, for which he entered a pretrial diversion program. He subsequently pleaded guilty to a misconduct charge in Nashville after investigators found that some of the marijuana came from evidence bags from the medical examiner’s office. Levy is currently a professor of pathology and informatics at Geisinger Commonwealth School of Medicine in Scranton, Pennsylvania.

The Tennessee Court of Criminal Appeals must now decide whether to remand the case back to the trial court, where Levy’s new findings would be presented and entered into evidence. Dozier would then have to weigh whether all of the evidence taken together — both the experts’ testimony from the March hearing and Levy’s new conclusions — is sufficient to vacate Russell’s conviction.

In the meantime, Russell remains at Trousdale Turner Correctional Center, a long-troubled prison run by private contractor CoreCivic. Last month, the U.S. Department of Justice launched a civil rights investigation that it said “will examine whether Tennessee protects those incarcerated at Trousdale Turner from harm, including physical violence and sexual abuse.”

“The safety and dignity of every person in our care is a top priority,” CoreCivic spokesperson Steven Owen said in a statement in August. “We take this matter very seriously and are committed to working closely with both TDOC and USDOJ officials to address areas of concern.”

by Hannah Bassett, Arizona Center for Investigative Reporting, and Mary Hudetz, ProPublica, photography by Adriana Zehbrauskas, special to ProPublica

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Before her fifth birthday, Rainy had experienced a lifetime of trauma. As an infant, she witnessed violence at home before child welfare authorities intervened and her parents were incarcerated. Night terrors followed. Then, she endured the death of her great uncle who had taken on the role of dad.

She didn’t speak until she was nearly 5. Any separation from her great aunt-turned-adoptive mother, Lisa Enas, triggered panic attacks, and reminders of her great uncle’s death left her nearly inconsolable.

With counseling, however, Rainy, now age 7, with a long, thick braid and a bright smile, grew more joyful and independent. She could hold conversations and spend time away from Enas without panicking. She was selected for her school’s gifted and talented program. Home life on the Gila River Indian Community in Arizona, where her bedroom walls were lined with stuffed animals and family photos, steadied.

But that progress came to a halt last October, after a spiraling Medicaid scandal that targeted thousands of Native Americans exploded into public view.

Arizona officials announced they were investigating a massive fraud scheme in which people had been lured into fake substance abuse treatment programs, where providers exorbitantly billed Medicaid for treatments they did not deliver. Some were alleged to have kidnapped patients and held them against their will. The fraud has cost the state as much as $2.5 billion since 2019, state officials said.

In response, the Arizona Health Care Cost Containment System, or AHCCCS, terminated contracts with scores of facilities as authorities investigated them. The agency also swiftly suspended Medicaid reimbursements to hundreds of other providers that it accused mostly of overbilling or paperwork errors. Among those suspended was Desert Rain Behavioral Health Services, the Tempe provider that was treating Rainy and 260 other patients, all insured by the state Medicaid agency’s American Indian Health Program.

AHCCCS accused Desert Rain of overbilling and failing to have the license needed to treat children — allegations that the clinic would eventually resolve, but not before its ability to care for patients was disrupted.

When AHCCCS launched its investigation, officials said their top priority was the safety of patients like Rainy. Yet even as the agency says it considered whether people would lose behavioral health services before it took action, its efforts left hundreds without treatment or counseling, the Arizona Center for Investigative Reporting and ProPublica have found.

The agency told the very behavioral health providers it accused of fraud that it was their responsibility to ensure patients continued to receive treatment, despite halting their reimbursements. Some closed. Others scaled back services or paid out of their own pocket while they challenged the allegations against them.

For patients, the state established a hotline to connect them to treatment, housing or transportation back to their communities. But it too has fallen short in addressing the fallout from the crisis.

AHCCCS said it had no record of what happened to the majority of the hotline’s 11,400 callers, largely because after six months it stopped tracking outcomes for people who did not stay in a hotel at the state’s expense. Of 4,100 people who received temporary lodging after calling the hotline, the state said only about 150 requested referrals to behavioral health centers. According to call data obtained by the news organizations, more than 575 ended up unsheltered, increasing their chances of relapse or even death.

In an interview, Marcus Johnson, AHCCCS’ deputy director of community engagement and regulatory affairs, said AHCCCS conducted outreach to make sure patients knew about the hotline. Yet advocates say far more people were unaware of the hotline or could not call it because they did not have phones.

“There’s always opportunity for us as an agency to improve,” Johnson said. “But like I said, we’ve done a great amount of outreach to try to get the word out as much as possible, not only to victims and our members, but also to all of the providers.”

Enas, Rainy’s adoptive mother, said no one ever told her about it as she struggled to find counseling for her daughter. (AZCIR and ProPublica are identifying Rainy, who does not share a last name with Enas, by her nickname to protect her privacy.)

Enas braids Rainy’s hair at the family home on the Gila River Indian Community.

Thirty behavioral health providers that AHCCCS has accused of fraud since the spring of 2023 have been cleared to again receive Medicaid reimbursements, though the agency cautioned providers that it could pursue further actions against them amid ongoing investigations. Most reached settlement agreements or proposed corrective action plans, according to records provided to the news organizations by AHCCCS.

Desert Rain, however, was among a handful of providers that did not have to compensate the state or rectify their practice, according to documents. After a four-month suspension, Desert Rain was informed in a February letter that it could resume receiving payments from the state because it had addressed the accusations.

AZCIR and ProPublica spoke to six of the 30 facilities that had their suspensions lifted. The suspensions, delayed payments and enhanced billing requirements resulting from the state crackdown have jeopardized their ability to stay in business, they said. Almost everyone who operated behavioral health facilities and spoke to the news organizations asked to remain anonymous out of concern they would be targeted by AHCCCS for criticizing the agency.

AHCCCS has maintained that its actions were necessary and appropriate to ensure bad actors could no longer exploit Medicaid. It also told the news organizations that it is always willing to help patients find providers.

Desert Rain owner Alexis James said that since the clinic was cleared, the state has largely denied or not processed its claims for patients insured by the American Indian Health Program. As a result, she is unable to serve her former patients. She said she is concerned many people from the Gila River Indian Community — and other Indigenous communities — have gone months without treatment because so many facilities have shut down or are not accepting new American Indian Health Program patients due to financial uncertainty.

“There are no providers available to see these clients who are higher risk, who are suicidal, who are high trauma,” James said. “What makes me so angry is it’s not anyone but the Indigenous population.”

Enas said she recognizes the state had to stem the widespread fraud but regrets it came at such a high cost. Rainy regressed without counseling, while Enas unsuccessfully sought help from AHCCCS and the local hospital.

The grief Rainy was learning to manage now overwhelms her more frequently. On a recent afternoon, within a matter of minutes, Rainy turned from chattering happily about her school day to sobbing as she looked over a favorite photo collage of her late adoptive father.

Enas comforts Rainy.

“I miss him so much,” Rainy cried. “Why did he have to die when I was 3?”

Enas held Rainy until the wave of sadness eventually passed. When they sat down at the dinner table, where Rainy announced she was joining the school color guard, Enas looked on with a mixture of pride, exhaustion and worry.

“I need to know, who is gonna actually help me?” Enas said. “Who’s going to actually listen to me? Who’s going to help my child? Because I’m fighting for her.”

A Crisis Goes Undetected

As early as 2020, state data showed a spike in billings for behavioral health care covered by the American Indian Health Program.

AHCCCS’ contracts with managed care organizations, like Mercy Care and UnitedHealthcare, use fixed rates for Medicaid reimbursement. But the American Indian Health Program — available only to American Indians and Alaska Natives — was different. Federal requirements led AHCCCS to structure the program under a “fee-for-service” model, which allowed health clinics and other providers to set their own rates and directly bill the agency. It also broadened access in areas not served by the network of insurance companies for a population that has historically faced significant barriers to health care. But it left the program vulnerable to fraud, experts say, much like other fee-for-service plans offered at the federal level.

“It was a claims shop,” AHCCCS’ Johnson said, noting the plan lacked safeguards used by managed care organizations to prevent waste, fraud and abuse.

One behavioral health clinic collected more than $200,000 a day on average through the American Indian Health Program, according to an audit of AHCCCS. The flood of cash spurred predatory recruitment of new Native American patients from across the country just as the federal government’s COVID-19 public health emergency allowed Medicaid programs to relax enrollment and screening requirements.

Will Humble, a former director of the Arizona Department of Health Services, said AHCCCS’ failure to monitor its management of Medicaid billing and reimbursements allowed the American Indian Health Program to “completely detonate.”

A view of neighbors’ houses from Enas and Rainy’s family home on the Gila River Indian Community

Reva Stewart, a community advocate in Phoenix who is Navajo, was, in the fall of 2022, among the first to sound the alarm on social media about providers’ recruitment efforts in the city and on reservations. For months, she had observed white vans pull up to city parks in search of new patients. She learned fraudulent providers were also sending vans to reservations across Arizona, New Mexico and Montana in search of patients.

Newly elected Gov. Katie Hobbs announced an initial wave of provider suspensions in May 2023. As the agency continued reviewing billing records for irregularities, more followed. Community members, patients and employees of licensed behavioral health providers had alerted authorities to the suspected fraud, said AHCCCS Director Carmen Heredia.

When suspended providers ignored the agency’s calls to ensure ongoing care, the agency said it sent demand letters and threatened legal action. AHCCCS has not pursued any provider for failing to transition patients’ care, saying it hasn’t needed to take that step.

“When our legal office has reached out to providers in this situation, they have complied,” Johnson said. “They have worked with us to transition care for their members.”

Thousands Call Asking for Help

State housing officials warned AHCCCS leadership nearly a year before it began suspending providers that reforms could trigger a surge in homelessness, according to emails reviewed by AZCIR and ProPublica. Indeed, many people faced homelessness as the state suspended behavioral health payments because some unscrupulous providers had housed patients just so they could bill for them, advocates say.

Patients in the roughly 25 suspended facilities outside the Phoenix area had few options for assistance once AHCCCS took action; the state hotline’s offer of temporary housing was limited to three hotels in the metro area.

Stewart said the state’s response has been inadequate for such a massive crisis that has rendered people homeless. She and other advocates, organized under the name Stolen People, Stolen Benefits, regularly traverse the Phoenix metro area with meals and sanitary kits to assist unhoused people who haven’t been helped. Many contact her directly.

Raquel Moody, who is from the Fort Apache Reservation in northeastern Arizona, recounted how at the height of the crisis she bounced from one fraudulent treatment home to the next. She had achieved sobriety in the past, before relapsing, and such treatment programs had helped her, including Another Level of Community Service, which served people just released from prison. (Another Level of Community Service is one of the 30 behavioral health providers that had its suspension lifted by AHCCCS after a monthslong investigation.)

From December 2022 to the end of 2023, Moody spent time in more than a half-dozen programs in the Phoenix area that promised, but never provided, treatment. Soon after arriving at each new facility, she realized legitimate treatment classes would not be offered. When she spoke up about it, the operators would kick her out.

Not only was there no treatment, she said, but lax operators made it more challenging to get sober. The owners of one facility downplayed her complaint that alcohol was being consumed in the house, claiming the drinking wasn’t harming other residents. They asked her to leave. Once, providers left her for days in an unfurnished home with nothing to do, which she described as a nightmare scenario for someone trying to overcome addiction.

“Some of us, we were looking for the right programs,” she said. “But during this whole scheme and everything, it was really hard. It was really hard to get sober.”

After the final home she was in was suspended in December 2023, no one from the state stepped in to help, she said.

She’s now in recovery and conducts homeless outreach with Stewart.

Desert Rain owner Alexis James “I’m Still Being Punished and Not Paid”

Following Desert Rain’s suspension in September 2023, James, the clinic’s owner, said she continued serving patients for as long as she could.

The clinic was roughly two years into treating Rainy, who had been diagnosed with prolonged grief, anxiety, attention-deficit/hyperactivity disorder and obsessive-compulsive disorder. It was a two-hour round trip to each appointment, but her progress made the drives worth it, Enas said.

Desert Rain, which opened 13 years ago, was one of several clinics that AHCCCS accused of treating children without the necessary state health department license. The Medicaid agency also said the treatment center had billed for some patients after their deaths and overbilled for certain mental health assessments and rehabilitation services.

As she fought the allegations, James laid off all but three of her 35 employees and coordinated with Gila River case managers to transfer most of the facility’s 260 patients to other providers. Many of the patients found that nearby facilities were also facing fraud allegations from the state and couldn’t treat them. James offered limited services at no cost to roughly half a dozen high-need clients, including Rainy.

Nearly every provider who spoke with AZCIR and ProPublica and had resolved their fraud allegations said they tried to serve clients for as long as they could without Medicaid reimbursements. James said she almost went bankrupt. She drew on personal funds to cover Medicaid patients’ treatment and took out high-interest loans that left her in financial peril.

State records show James cleared the allegations by providing evidence of an active license to work with kids and documentation explaining the handful of claims that were inadvertently submitted after a patient’s death during the height of the COVID-19 pandemic, when it often took days for word of a patient’s passing to reach outside the reservation’s hospital.

The agency also imposed a moratorium on new provider enrollments and enacted administrative reforms that included capping reimbursement rates for intensive outpatient treatment, and fingerprinting and background checks for more behavioral health providers under contract with AHCCCS. The agency also adopted more stringent billing procedures and revamped its process for reviewing claims.

Since the agency implemented the reforms, spending on American Indian Health Program services has declined by two-thirds, according to data released by AHCCCS in July.

“While there is still work to be done, this data reflects that our efforts to combat fraud are working,” Heredia said in a news release. “We have transformed AHCCCS into a new agency that puts our members first, and always strives to get them the help they need.”

This abrupt decrease in payments to providers also reflects the inability of patients like Rainy to get treatment.

In February, AHCCCS paid Desert Rain more than $140,000 for care provided prior to the suspension. But the agency has not reimbursed the clinic for any services billed under the American Indian Health Program since its reinstatement, according to James.

“I’m still being punished and not paid,” James said. “Essentially, we’re still suspended.”

Records reviewed by AZCIR and ProPublica showed that AHCCCS repeatedly pressed the facility to submit additional documentation required for claims to be approved. The agency also arranged a meeting to discuss the billing process. AHCCCS did not respond to questions about the agency’s billing decisions.

In a survey of 229 providers by the Arizona Behavioral Health Providers Association, an industry trade group, half of respondents reported anonymously this spring that they were close to shutting down due to issues with AHCCCS since the spring of 2023, including delayed reimbursements. Another 20% reported they had either already closed or were filing for bankruptcy. The data was presented to AHCCCS earlier this year.

Lynn Janson, a co-founder and CEO of the treatment center Milestone Recovery, described to lawmakers this year how a suspension had threatened the business she and her husband opened in 2021 with help from their daughter, a licensed clinician. Janson’s son had struggled with a methamphetamine addiction, she said, and it had been difficult to find a treatment program that would help him address childhood trauma that fueled his drug use. She opened the business to fill that void for others.

“My husband and I decided to move forward by creating a space focused on treating the trauma that is the root cause” of addiction, she said. “Fraud was never a motivating factor for us to enter this field.”

This spring, the state lifted Milestone’s suspension.

Twenty providers, not including Milestone, have filed notices of claim — precursors to lawsuits — against AHCCCS and state officials for wrongful suspension or termination. Four families have sued the Medicaid agency since April over the deaths of their loved ones while they were in the care of treatment centers. The state has denied culpability, saying state agencies, including AHCCCS, responded appropriately to past concerns about patient safety based on the information they had. AHCCCS declined to comment about the lawsuits.

Rainy plays on the trampoline at her family home. “It’s Like She’s Never Even Been to Counseling”

In April, James paused Rainy’s therapy altogether. She could no longer afford to provide counseling without reimbursement.

When AHCCCS learned that James was no longer providing care to Rainy, the agency sent a message reminding her that agency policy prohibits providers from turning away patients based on their enrollment in the American Indian Health Program. James replied, saying that she and her staff wanted to accept new patient referrals but couldn’t without payment. She never heard back.

To stay in business, James began accepting patients insured by plans other than the American Indian Health Program. Claims were promptly reviewed and reimbursed, James said, including by other Medicaid plans. Only AHCCCS’ American Indian Health Program has not reimbursed her claims.

The transition to working with patients outside of the Gila River community was bittersweet, James said, especially knowing that many of her former patients like Rainy were still searching for reliable treatment. “When I hear about the constant need that is still going on out there, it’s just really frustrating,” she said.

Enas said it has been painful to watch Rainy’s grief and trauma resurface over the past 10 months. She has tried her best to help Rainy process her emotions but said she isn’t equipped to address her daughter’s behavioral health challenges on her own.

“It’s like she’s never even been to counseling,” she said.

Rainy’s night terrors returned, with recurring dreams of her adoptive father dying. She continued to excel at school, but her teachers noticed worsening mood swings. On a visit to her adoptive father’s grave to bring him offerings of flowers and home-cooked food, Rainy lay by his headstone for hours, until dark. Unwilling to leave, Rainy cried and asked Enas how she could die so she could be with him again.

Rainy places solar lamps on the grave of her adoptive father on the Gila River Indian Community.

Enas tried everything she could think of to find care for her daughter. She contacted lawmakers, AHCCCS officials, health care administrators, school caseworkers and providers.

At one point, a patient advocate with the Gila River hospital in Sacaton, on the reservation, encouraged Enas to disenroll Rainy from the American Indian Health Program. The idea was that by switching to insurance provided by managed care organizations, Enas and Rainy would avoid issues related to AHCCCS’ handling of the insurance plan.

But changing her daughter’s insurance would be tedious and have broader repercussions. Enas would have to find a new allergist and primary care doctor because those providers, based on the reservation, accept only the American Indian Health Program. Switching back and forth also was not feasible when a single afternoon could involve juggling appointments or calls with multiple health care providers.

“We shouldn’t have to switch our plans so that way our kids can get the service that they need. That’s not right,” she said.

Enas and Rainy’s search has led back to where it began: Desert Rain. Recent income from privately insured patients has given James enough cushion to resume providing some services for free. In mid-August, Rainy returned for grief counseling sessions with James. Rainy’s other mental health disorders remain largely untreated.

Desert Rain is the best place for Rainy, Enas said, but she doesn’t know how long the treatment will last.

“Alexis is going to carry her for a little bit, and then she’s going to have to drop her again, because she’s not getting paid,” said Enas.

“How can AHCCCS do this to these kids, do this to my child?”

by Maya Miller and Annie Waldman

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

The Biden administration announced on Monday that it has finalized new regulations to strengthen protections for mental health care coverage and hold insurance companies accountable for unlawfully denying it.

The rules update the Mental Health Parity and Addiction Equity Act, which was passed in 2008, requiring health insurance plans to provide the same access to mental health care as medical care. The new provisions will force health insurance plans to collect and report more robust data on how they limit and deny mental health claims. If disparities exist between mental and medical care, insurers will need to lay out how they are attempting to address these gaps.

“Mental health care is health care. But for far too many Americans, critical care and treatments are out of reach,” President Joe Biden said in a press release announcing the final rules. “There is no reason that breaking your arm should be treated differently than having a mental health condition.”

The updated rules seek to address a problem captured in numerous studies and reports and examined in a new level of detail in a recent ProPublica investigation.

Although nearly all Americans have health insurance, millions still can't access mental health care. ProPublica found that insurance companies have interfered with patient care, deployed aggressive audits and set reimbursement rates so low that providers felt they had no choice but to quit insurance networks. Our reporting also documented how consequences can be fatal when patients can’t find therapists or mental health treatment.

Federal regulators have struggled to police insurance companies. Nearly all of the recent reports that the Department of Labor has collected from insurers and health plans have lacked enough detail to determine companies’ compliance with the law, the department reported to Congress last year. Some states have passed laws to close those gaps in information, but we found mental health protections often depend on where one lives.

The new rules require insurers to collect and turn over outcomes data, like denial rates, to measure how often patients access care. The companies will have to disclose details on insurance networks, which may include how regularly patients go out of network for mental health treatment and how reimbursement rates are calculated for mental health providers.

The rules also clarify that patients have the right to access this data and require insurers and health plans to furnish records within 30 days of a request.

Republican U.S. Rep. Virginia Foxx, R-N.C., who chairs the Committee on Education and the Workforce, said the rules are too burdensome. “These rules do nothing to improve mental health care access and instead put paperwork over patients,” she said in an emailed statement.

But former U.S. Rep. Patrick J. Kennedy, who sponsored the 2008 parity bill and co-founded the mental health advocacy nonprofit The Kennedy Forum, said the new rules will protect access for patients. “This is an opportunity for consumers to finally have a seat at the table,” he told ProPublica.

The law applies to 175 million people who have private health insurance. Under the new rules, these protections will also cover people with health insurance through state and local governments, about 120,000 additional Americans.

The finalized regulations came after a yearlong review process, in which three departments — Treasury, Health and Human Services, and Labor — collected thousands of public comments. The departments had initially published proposed rules in August 2023. Some of the provisions will go into effect on Jan. 1, said Lisa Gomez, the assistant secretary of employee benefits security at the Department of Labor.

“People living with mental health conditions and substance use disorders continue to face greater barriers,” she said. “That’s not fair, it’s not right and it’s against the law.”

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

by Lisa Song

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

Most of the products in the typical kitchen use plastics that are virtually impossible to recycle.

The film that acts as a lid on Dole Sunshine fruit bowls, the rings securing jars of McCormick dried herbs, the straws attached to Juicy Juice boxes, the bags that hold Cheez-Its and Cheerios — they’re all destined for the dumpster.

Now a trade group representing those brands and hundreds more is pressuring regulators to make plastic appear more environmentally friendly, a proposal experts say could worsen a crisis that is flooding the planet and our bodies with the toxic material.

The Consumer Brands Association believes companies should be able to stamp “recyclable” on products that are technically “capable” of being recycled, even if they’re all but guaranteed to end up in a landfill. As ProPublica previously reported, the group argued for a looser definition of “recyclable” in written comments to the Federal Trade Commission as the agency revises the Green Guides — guidelines for advertising products with sustainable attributes.

The association’s board of directors includes officials from some of the world’s richest companies, such as PepsiCo, Procter & Gamble, Coca-Cola, Land O’Lakes, Keurig Dr Pepper, Hormel Foods Corporation, Molson Coors Beverage Company, Campbell Soup, Kellanova, Mondelez International, Conagra Brands, J.M. Smucker and Clorox.

Some of the companies own brands that project health, wellness and sustainability. That includes General Mills, owner of Annie’s macaroni and cheese; The Honest Co., whose soaps and baby wipes line the shelves at Whole Foods; and Colgate-Palmolive, which owns the natural deodorant Tom’s of Maine.

ProPublica contacted the 51 companies on the association’s board of directors to ask if they agreed with the trade group’s definition of “recyclable.” Most did not respond. None said they disagreed with the definition. Nine companies referred ProPublica back to the association.

“The makers of America’s household brands are committed to creating a more circular economy which is why the industry has set sustainability goals and invested in consumer education tools” with “detailed recycling instructions,” Joseph Aquilina, the association’s vice president and deputy general counsel, wrote in an email.

The Green Guides are meant to increase consumer trust in sustainable products. Though these guidelines are not laws, they serve as a national reference for companies and other government agencies for how to define terms like “compostable,” “nontoxic” and “recyclable.” The Federal Trade Commission is revising the guides for the first time since 2012.

Most of the plastic we encounter is functionally not recyclable. It’s too expensive or technically difficult to deal with the health risks posed by the dyes and flame retardants found in many products. Collecting, sorting, storing and shipping the plastic for reprocessing often costs much more than plowing it into a landfill. Though some newer technologies have pushed the boundaries of what’s possible, these plastic-recycling techniques are inefficient and exist in such limited quantities that experts say they can’t be relied upon. The reality is, only 5% of Americans’ discarded plastic gets recycled. And while soda bottles and milk jugs can be turned into new products, other common forms of plastic, like flimsy candy wrappers and chip bags, are destined for trash heaps and oceans, where they can linger for centuries without breaking down.

The current Green Guides allow companies to label products and packaging as “recyclable” if at least 60% of Americans have access to facilities that will take the material. As written, the guidelines don’t specify whether it’s enough for the facilities to simply collect and sort the items or if there needs to be a reasonable expectation that the material will be made into something new.

“The Green Guides have long set forth that items labeled as ‘recyclable’ are those which are capable of being recycled,” Aquilina, the association vice president, told ProPublica. “Any characterization suggesting Consumer Brands is pushing for a ‘looser definition’ is false.”

But the association seemed to disregard what the FTC said in a separate document released alongside the guides, which states that a truthful recyclable claim means that “a substantial majority of consumers or communities have access to facilities that will actually recycle, not accept and ultimately discard, the product.”

In its comments to the FTC, the association pushed back on that idea. The U.S. recycling system is decentralized, and manufacturers have no control over economic factors that might lead a recycler to change its mind about how it handles a certain type of plastic, the association wrote, adding that it was unrealistic to force brands to predict which products will be “ultimately recycled.”

The association represents sellers and will naturally seek more flexibility in its positions, Jef Richards, a professor of advertising and public relations at Michigan State University, said in an email. The “problem with defining ‘recyclable’ as anything that MIGHT be recycled is that I seriously doubt that’s how consumers define it.”

When consumer expectations fail to match what the advertiser is saying, “consumers are being deceived,” he added.

That deception has concrete impacts: Plastic bags that mistakenly end up at recycling centers can gum up machinery, start fires and contaminate bales of paper, which then can’t be recycled. The problem could get worse if the FTC listens to the Consumer Brands Association and allows companies to market plastic bags as “recyclable.”

Annie’s mac and cheese is one of the brands under the association’s umbrella that has a reputation for health and sustainability. Unlike most pasta companies, Annie’s avoids using plastic film to create windows in its pasta boxes. The brand also sells cheese crackers packaged in plastic that is clearly labeled as nonrecyclable, with a diagonal slash through the triangular “chasing arrows” symbol. Its parent company, General Mills, however, has promoted store drop-off recycling programs for one of its granola bar brands, Nature Valley. A Bloomberg News investigation found these programs have a spotty record, with much of the plastic ending up at landfills. The CEO of General Mills is a member of the association’s executive committee. Earlier this year, the investment firm Green Century filed a shareholder resolution asking General Mills to investigate how it could reduce its use of plastic packaging. The resolution also suggested that the company assess the effectiveness of drop-off recycling programs.

The Honest Co. similarly cultivates a sustainable reputation, including by avoiding two particularly problematic types of plastic in its packaging. Its website provides instructions on how to dispose of plastic packaging; product pages tell consumers to disassemble and rinse out containers and to “check with your local municipality for recyclability acceptance.” Tom’s of Maine uses similar language in fine print on its “first-of-its-kind recyclable toothpaste tube.” The tubes show the familiar chasing arrows recycling symbol accompanied by the words, “Once empty, replace cap and recycle.” Small letters on the edge of the tube read, “Your community may not yet accept tubes for recycling. Check locally.”

But regulators have warned that “check locally” caveats are vague. The Environmental Protection Agency told the FTC last year that the warning “has little value in assessing recyclability” and said companies should use clearer instructions to reduce “wishcycling” — tossing things into a curbside bin with the faint hope that they will get recycled. A group of state attorneys general suggested using more aggressive language: “NOT ROUTINELY RECYCLED — Please check with your local jurisdiction.”

“We’re proud of the leading role we’ve played in transforming tube packaging,” Rob Robinson, a marketing executive at Tom’s of Maine, said in an email. A “check locally” caveat appears on the toothpaste tube, the outer carton and the company website, he said.

Miriam Holsinger, co-president of Minnesota-based Eureka Recycling, said not every sorting center has the right equipment or staff training to recycle these tubes. “Until all toothpaste tubes are recyclable, it’s just not something that you can easily do.”

General Mills, The Honest Co. and Colgate-Palmolive didn’t return requests for comment.

Here’s a list of all the consumer packaged-goods companies with a membership on the Consumer Brands Association’s board of directors, listed alongside some of the brands that they own. The companies in bold responded to ProPublica’s inquiry by directing us back to the association. The others did not comment.

Abbott Nutrition (Ensure, Pedialyte, Similac)

B&G Foods Inc. (Crisco, Green Giant frozen foods, Cream of Wheat)

BellRing Brands Inc. (PowerBar, Premier Protein)

Bush Brothers & Co. (Bush’s baked beans and bean dip)

Campbell Soup Co. (Goldfish crackers, Kettle and Cape Cod potato chips)

Church & Dwight Co. Inc. (Arm & Hammer laundry detergent, Feline Pine cat litter)

The Clorox Co. (Clorox bleach, Pine-Sol, Burt’s Bees)

The Coca-Cola Co. (Dasani, Minute Maid, Schweppes, Sprite)

Colgate-Palmolive Co. (Colgate toothpaste, Softsoap, Tom’s of Maine)

Conagra Brands Inc. (Healthy Choice, Swiss Miss, Reddi-wip)

Danone (Danone and Oikos yogurts, Silk soy milk)

Del Monte Foods Inc. (College Inn broths, Del Monte fruit cups)

Dole Sunshine (Dole Whip, Dole fruit bowl snacks)

Ferrara (Jelly Belly, SweeTarts, Laffy Taffy, Nerds)

Ferrero USA Inc. (Nutella, Butterfinger, Crunch, Keebler, Famous Amos)

Flowers Foods Inc. (Nature’s Own, Dave’s Killer Bread, Wonder bread)

Freshpet (dog and cat food)

General Mills Inc. (Annie’s, Bisquick, Cheerios, Chex Mix, Nature Valley, Yoplait)

Georgia-Pacific LLC (Dixie cups and plates, Quilted Northern, Brawny)

Hain Celestial Group (Celestial Seasonings, Terra chips, Alba Botanica)

Harvest Hill Beverage Co. (SunnyD, Juicy Juice)

Henkel Corp. (Dial soap, Snuggle fabric softener)

The Honest Co. (Honest branded skin care, hair care and products for babies)

Hormel Foods Corp. (Skippy, Planters peanuts)

Idahoan Foods LLC (Idahoan packaged mashed potatoes)

J&J Snack Foods Corporation (Icee, Dippin’ Dots)

The J.M. Smucker Co. (Jif, Twinkies, Smucker’s jam)

Kellanova (Cheez-It, Eggo, Pringles)

Keurig Dr Pepper (Keurig coffee, 7UP, Canada Dry)

Land O’Lakes Inc. (Land O’Lakes butter, cheese and eggs)

McCall Farms (Veg-All, Princella)

McCormick & Co. Inc. (McCormick herbs and spices, Billy Bee honey)

Milo’s Tea Co. Inc. (Milo’s iced teas)

Molson Coors Beverage Co. (Blue Moon, Coors, Keystone Light)

Mondelez International Inc. (Clif, Oreo, Ritz)

Moody Dunbar Inc. (Dunbar’s canned vegetables, Nature’s Pride)

Morgan Foods Inc. (soups, beans, broths and sauces)

Nestle (Blue Bottle Coffee, Gerber, KitKat, Purina)

Nissin Foods (Cup Noodles, Top Ramen)

Ocean Spray Cranberries Inc. (juices and drinks)

PepsiCo Inc. (Aquafina, Doritos, Lipton, Quaker)

Post Holdings Inc. (Honey Bunches of Oats, Pebbles)

The Procter & Gamble Co. (Charmin, Tide, Gillette, Herbal Essences)

Reckitt (Enfamil, Lysol, Airborne)

Rich Products Corp. (Carvel, Coffee Rich)

Ripple Foods (dairy-free milks and protein shakes)

Sargento Foods (cheese and packaged snacks)

Schwan’s Co. (Tony’s, Mrs. Smith’s)

Tillamook County Creamery Association (cheese, ice cream, frozen meals)

Utz Brands Inc. (Utz and Boulder Canyon potato chips)

WK Kellogg Co. (Frosted Flakes, Froot Loops, Raisin Bran)

Do You Have Experience in or With the Plastics Industry? Tell Us About It.

by Max Blau, illustrations by Vanessa Saba, special to ProPublica

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

This article contains descriptions of mental illness, alcohol addiction and suicidal ideation.

Early one morning in February 2023, before the sun rose over Phoenix, Ravi Coutinho went on a walk and, for a brief moment, thought about hurling his body in front of a moving bus. He had been feeling increasingly alone and depressed; anxious and unlovable; no longer sure if he was built for this world.

Several hours later, Ravi swiped open his iPhone and dialed the toll-free number on the back of his Ambetter insurance card. After navigating the automated voice system, he was routed to a friendly, fast-talking customer service rep with a slight foreign accent. His name was Giovanni.

“How can I help you today?” Giovanni asked.

“Hi, I am trying to find a psychiatric care provider,” Ravi said.

“So, you are looking for a primary care provider?” Giovanni asked.

“No,” Ravi replied, seeming confused. Ravi tried to clearly repeat himself. “Psy-chi-at-ric.”

“Psychiatric, all right, so, sure, I can definitely help you with that,” Giovanni said. “By the way, it is your first time calling in regards to this concern?”

Listen to this exchange.

Ravi paused. It was actually the sixth attempt to get someone, anyone, at Ambetter to give him or his mother the name of a therapist who accepted his insurance plan and could see him. Despite repeatedly searching the Ambetter portal and calling customer service, all they had turned up so far, he told Giovanni, were the names of two psychologists. One no longer took his insurance. The other, inexplicably, tested patients for Alzheimer’s disease and dementia and didn’t practice therapy at all.

“I’m a little concerned about all this,” Ravi said.

This had not been part of the plan Ravi had hatched a few months earlier to save his own life. Diagnosed with depression and anxiety, and living in the heart of Austin, Texas’ boisterous Sixth Street bar district, the 36-year-old former college golfer had become reliant on a dangerous form of self-medication.

His heavy drinking had cost him his marriage and was on the verge of destroying his liver and his livelihood. His therapist back in Texas had helped him understand how his mental illnesses were contributing to his addiction and vice versa. She had coached him through attempts to get sober.

He wanted to save his business, which sold dream vacations to golfers eager to play the world’s legendary courses. He wanted to fall in love again, even have a kid. He couldn’t do that when he was drinking a fifth of a gallon of liquor — the equivalent of nearly 17 shots — on any given day.

Ravi with a golf tournament trophy and playing a course in Scotland

When all else had failed, he and his therapist had discussed a radical move — relocating to the city where he’d spent his final years of high school. Phoenix symbolized a happier and healthier phase. They agreed that for the idea to work, he needed to find a new therapist there as quickly as possible and line up care in advance.

Ravi felt relieved when he signed up for an insurance plan right before the move. Ambetter wasn’t as well known as Blue Cross Blue Shield or UnitedHealthcare. But it was the most popular option on HealthCare.gov, the federal health insurance marketplace, covering more than 2 million people across the country. For $379 a month, his plan appeared to have a robust network of providers.

Frustrating phone calls like this one began to confirm for Ravi what countless customers — and even Arizona regulators — had already discovered: Appearances could be deceiving.

After misunderstanding Ravi’s request for a therapist, Giovanni pulled up an internal directory and told Ravi that he had found someone who could help him.

It was a psychiatrist who specialized in treating the elderly. This was strange, considering that Giovanni had asked Ravi to verify that he was born in 1986. “I mean, geriatric psychiatry is not …” Ravi responded, “I mean … I wouldn’t qualify for that.”

Listen to this exchange.

Annoyed but polite, Ravi asked Giovanni to email the provider list on the rep’s computer. He figured that having the list, which he was legally entitled to, would speed up the process of finding help.

But Giovanni said that he couldn’t email the list. The company that ran Ambetter would have to mail it.

“What do you mean, mail?” Ravi asked. “Like physically mail it?”

Listen to this exchange.

Ravi let out a deep, despondent sigh and asked how long that would take.

Seven to 10 business days to process, Giovanni responded, in addition to whatever time it would take for the list to be delivered. Ravi couldn’t help but laugh at the absurdity.

“Nothing personal,” he told Giovanni. “But that’s not going to work.

“So I’m just gonna have to figure it out.”

Listen to this exchange.

This baffling inability to find help had tainted Ravi’s fresh start.

In the weeks before the call with Giovanni, Ravi had scrolled through Ambetter’s website, examining the portal of providers through his thick-rimmed glasses. He called one after the next, hoping to make an appointment as quickly as possible.

Of course, it was unreasonable to expect every therapist in Ambetter’s network to be able to accept him, especially in a state with an alarming shortage of them. But he couldn’t even find a primary care doctor who could see him within six weeks and refill his dwindling supply of antidepressants and antianxiety meds.

Days before he was supposed to move to Phoenix, he texted friends about his difficulties in finding care:

“Therapists have been 0-4.”

“Called ten places and nothing.”

“The insurance portal doesn’t know shit.”

Ravi didn’t know it, but he, like millions of Americans, was trapped in a “ghost network.” As some of those people have discovered, the providers listed in an insurer’s network have either retired or died. Many other providers have stopped accepting insurance — often because the companies made it excessively difficult for them to do so. Some just aren’t taking new patients. Insurers are often slow to remove them from directories, if they do so at all. It adds up to a bait and switch by insurance companies that leads customers to believe there are more options for care than actually exist.

Ambetter’s parent company, Centene, has been accused numerous times of presiding over ghost networks. One of the 25 largest corporations in America, Centene brings in more revenue than Disney, FedEx or PepsiCo, but it is less known because its hundreds of subsidiaries use different names. In addition to insuring the largest number of marketplace customers, it’s the biggest player in Medicaid managed care and a giant in Medicare Advantage, insurance for seniors that’s offered by private companies instead of the federal government.

ProPublica reached out to Centene and the subsidiary that oversaw Ravi’s plan more than two dozen times and sent them both a detailed list of questions. None of their media representatives responded.

In 2022, Illinois’ insurance director fined another subsidiary more than $1 million for mental health-related violations including providing customers with an outdated, inaccurate provider directory. The subsidiary “admitted in writing that they are not following Illinois statute” for updating the directory, according to a report from the state’s Insurance Department.

In a federal lawsuit filed in Illinois that same year, Ambetter customers alleged that Centene companies “intentionally and knowingly misrepresented” the number of in-network providers by publishing inaccurate directories. Centene lawyers wrote in a court filing that the company “denies that it made any misrepresentations to consumers.” The case is ongoing.

And in 2021, San Diego’s city attorney sued several Centene subsidiaries for “publishing and advertising provider information they know to be false and misleading” — over a quarter of those subsidiaries’ in-network psychiatrists were unable to see new patients, the complaint said. The city is appealing after a judge sided with Centene on technical grounds.

Even the subsidiary responsible for Ravi’s plan had gotten in trouble. Regulators with the Arizona Department of Insurance and Financial Institutions found in 2021 that Health Net of Arizona had failed to maintain accurate provider directories. The regulators did not fine Health Net of Arizona, which promised to address that violation. When ProPublica asked if the company had made those fixes, the department said in a statement that such information was considered “confidential.”

These were exactly the type of failures that Ravi’s mother, Barbara Webber, confronted as the head of an advocacy group that lobbied for greater health care access in New Mexico. From her Albuquerque apartment more than 300 miles away from her son’s new, 12th-floor studio, she listened to Ravi vent about how hard it was to find a therapist in Phoenix.

Ravi was Barbara’s only child, and they had always been close. In the seven years since Ravi’s dad died, they’d grown even closer. They talked on the phone nearly every day. Barbara was used to supporting Ravi from afar, ordering him healthy delivery dinners, reminding him to drink enough water and urging him to call crisis hotlines amid panic attacks. But when Ravi crashed at her apartment while waiting to move to Phoenix, she saw more of his struggles up close. At one point, she called 911 when she feared for his life.

Ravi with his mother, Barbara Webber, on a hike in Arizona in March 2023 and on a childhood trip with her to Lake Tahoe

Despite her desire and ability to help him, Ravi didn’t want to stay with his mom for any longer than necessary. He didn’t want to feel like a teenager again.

Barbara understood her son’s desire for independence, and when he first encountered insurance barriers, she drew from her expertise and coached him through ways to try to get past them. But by the middle of February, a few days after Ravi settled into his new place, there was no good news about his mental health care. She felt the need to step in.

So, she called Ambetter to try to get better information than what Ravi was looking at online. But Khem Padilla, a customer service rep who seemed to be working at a call center overseas, couldn’t help her find that information. She then asked Padilla to send referrals to therapists.

When Padilla followed up, he only sent phone numbers for mental health institutes, including one that exclusively served patients with autism. “I wish that everything will work together for you,” Padilla wrote in an email to Barbara and Ravi on what happened to be Valentine’s Day, “and [don’t] forget that you are Loved.”

Loneliness is one of the strongest forces for triggering a relapse in someone addicted to alcohol, and Ravi’s early days in Phoenix provided a dangerous dose.

His old friends were often busy with work and family. He hadn’t found his way to a new Alcoholics Anonymous group yet. And he struggled to find matches on dating apps. (“Phoenix Tinder is a wasteland,” he told one friend.) His only consistent companion was Finn, a half-Great Pyrenees with a thick coat of fluffy white hair, whom he took on long walks around the city. “His unconditional love brings me so much joy,” he’d told his mom.

Alone in his apartment with Finn, vodka within reach, Ravi felt guilty about calling his loved ones for help. Even though his mom and his friends would pick up the phone at just about any hour, Ravi hated the idea of bothering them.

But he couldn’t resist after he hung up with Giovanni, the customer service rep. That afternoon, Feb. 22, he fired off a frustrated text message to his mom.

“How is it this hard?!” Ravi seethed.

Barbara’s next move was to reach out to a member of her nonprofit board who happened to work for a Centene company. The board member helped pull strings in late February to get Ravi a care manager, a person who works for the insurer to help patients navigate access to providers. But not even his new care manager, Breona Smith, a licensed professional counselor based in Arizona, could connect him to a therapist.

She spent 16 minutes calling in-network providers to check if they could see him. Four couldn’t. One could. Instead of calling more, she sent along a single therapy referral. When Ravi called that office, the staff had to verify if they accepted Ambetter. But Ravi never heard back.

Smith did get him a referral for a psychiatric nurse practitioner who could refill his meds; he first saw him one month into his move. Ravi hoped that the office might be able to refer him to a therapist, but none of the three providers it ultimately passed along took Ambetter. One of them had stopped taking insurance a decade ago; another had only ever seen patients willing to pay cash.

Without therapy, Ravi’s descent took on a momentum of its own.

One day, he drank himself to sleep and woke up with a pillow full of blood from his nose. On another, he white-knuckled a version of do-it-yourself detox that caused violent vomiting.

A close friend from high school, David Stanfield, was watching it all unfold. Ravi had always made David feel like they could pick up where they’d last left things. But this new withdrawn person, who would break into a sweat on a crisp night in the 60s, was a far cry from the guy he once knew.

Ravi was beginning to remind David of his brother-in-law, who had died of a drug overdose a few years earlier. So when Ravi sent a series of distressing texts, indicating that he had relapsed, David and another friend staged an intervention and took Ravi to the hospital.

But Ravi resisted rehab that didn’t come with therapy. He wondered what good another detox would do if it didn’t help him combat the root causes of his addiction. He was also worried that it would get in the way of his ability to work; Ravi was still booking some golf vacations through his business and figured he would have to surrender his phone during a rehab stay.

Instead, Ravi sated his withdrawals by feeding his body more alcohol, giving way to a March whirlwind of blackouts, massive hangovers and despondent texts to friends. When Ravi showed up to a baseball game looking pale and disheveled, a friend’s young son turned to his dad and asked: Is Ravi OK?

By early April, almost two months had passed since Barbara’s first call to Ambetter alerting them that Ravi was having trouble finding a therapist. Ambetter was obligated by state law to provide one outside of its network if Ravi couldn’t find one in a “timely manner” — which, in Arizona, meant within 60 days.

Within that span, its own records showed, he’d wound up in the emergency room seeking treatment for alcohol withdrawal and called a crisis line after he had thought about ending his life. Yet despite 21 calls with Ravi and Barbara, adding up to five hours and 14 minutes, the insurer’s staff had not lined up a single therapy appointment.

Ravi with his dog, Finn, in March 2023

Smith called Ravi four times over two weeks, right as his mental health crisis worsened. When he didn’t respond, she closed his case on April 7. Smith did not respond to multiple requests for comment or to questions about what information she tried to share with Ravi on these calls.

As Ravi’s attempts to find a therapist slowed down, his descent accelerated.

There was the episode at a Phoenix Suns game when paramedics had to treat him for severe dehydration after he downed a bottle of vodka.

There was the time he left the dog food container open and Finn got extremely sick from eating a week’s worth of food.

As Ravi crossed into his fourth month in Phoenix, he sat alone in his parked Kia Forte, surrounded by nothing but the lonely quiet, and screamed at the top of his lungs.

Barbara didn’t expect to spend Mother’s Day with Ravi. But after he told his uncle that he was having visions again of jumping in front of a speeding bus, she boarded a last-minute flight to Phoenix and settled into his couch where she could watch him as he slept.

On the morning of May 13, she was roused by his flailing limbs. He was having a seizure. Paramedics rushed Ravi to the hospital, the second time in the past month and fourth since the year began. Doctors gave him benzodiazepines, Valium and Librium, to treat the seizures and anxiety caused by his alcohol withdrawal. “Mom,” Ravi told Barbara, “I don’t want to die.”

One kind of treatment suggested by hospital staff, an intensive outpatient program, seemed the best fit. It would allow Ravi access to his phone for his business purposes. But neither Ravi nor Barbara could get a list of in-network programs from Ambetter, nor could they find them in the portal.

As Ravi called every program he could locate in metro Phoenix, and failed to find a single one that took his insurance, Barbara decided to pester her board member again. (The board member did not respond to multiple requests for comment.)

A few days later, someone with Centene provided the names of two in-network programs out of the dozens in Arizona. Only one offered the individual therapy Ravi was looking for.

That Friday, May 19, Barbara rode with Ravi to Scottsdale, where the intake staff at Pinnacle Peak Recovery drug-tested him. He tested positive for the benzodiazepines the hospital staff had administered following his seizure. Treatment programs sometimes restrict patients who test positive for those drugs because of the liability, experts told ProPublica. Pinnacle Peak Recovery’s staff urged Ravi to come back the following week. Barbara flew home, hopeful that Ravi would be admitted. (Pinnacle Peak Recovery did not respond to multiple requests for comment.)

On Monday morning, Ravi wrote the date, May 22, on a sheet of paper. He tore it out of a notebook, held it up to the side of his face and took a selfie with it. It was a way of marking time as well as a milestone: the first day of his newfound, hopefully permanent sobriety.

Ravi took a selfie on May 22, 2023, to mark the first day of his new sobriety. (Courtesy of Barbara Webber)

When he returned to Pinnacle Peak, however, he tested positive again. The second rejection hurt more than the first. Three days later, Ravi went back a third time; the drugs were still in his system. “I don’t know what else to do,” he told Barbara over the phone. “I am screwed.”

The answer of what else could be done was, unbeknownst to Ravi, buried in the fine print of his own insurance policy. Ambetter’s contract promised to find an out-of-network treatment program and make it available to Ravi, so long as Ambetter’s own employees decided that it was in his “best interest.”

Even though Barbara hadn’t read the fine print either, she had a sense that Ambetter could do more to help Ravi. So she pulled up the number of the last Centene employee she’d spoken with.

In a text message, Barbara expressed concern that the window to get Ravi help was closing. She was certain that, without more medical support ahead of admission to a treatment program, Ravi was bound to relapse. If that happened, Barbara pleaded, there was a good chance that he would have another seizure. She warned that he might even die.

Barbara awaited word on what to do next. She got no response.

The following morning, May 27, she drafted a message to Ravi. She described her visceral memory of his recent seizure — waking to the sound of his screams, pounding on his chest after his heartbeat briefly stopped, calling 911, uncertain if he would survive. “Those few minutes are seared into my soul and will go with me til the end of my days,” she wrote.

Barbara also wrote that she wanted nothing more than for Ravi to be around for the rest of her years. She promised to support him no matter what. If he kept going, he could find peace with Finn and find someone to love. But he had to keep going — not for her, not for Finn, not for his friends, not for anyone else. “I love you,” she wrote, “but you must love yourself.”

She hit send. Ravi didn’t reply right away, which was unusual.

An hour passed, then another. As the afternoon gave way to evening, Barbara called three times, unable to reach him. She tried to reach Phoenix’s 911 dispatch but couldn’t get through.

Not knowing what else to do, Barbara called David, whom Ravi had asked to be his local emergency contact.

David had grown deeply frustrated with Ravi for not getting the care he needed. And he was worried for his friend. He agreed to call 911.

A police dispatcher sent an officer to knock on Ravi’s door. The officer could hear Finn barking from the other side. When no one answered, the officer called David, letting him know that the police couldn’t enter the apartment without the building’s security guard, who wasn’t around right then.

Unsatisfied, David and his fiancée, Aly Knauer, drove over to Ravi’s. A security guard, who had just gotten back from his rounds, was reluctant to let them into the apartment at first. But after David and Aly explained the urgency, the guard relented. They headed up to the 12th floor and turned the corner toward Ravi’s apartment.

When the guard unlocked the door, Finn squeezed past and darted out. As Aly grabbed Finn, David peered inside, calling out his friend’s name. Four empty vodka bottles were strewn across the apartment. The Murphy bed was folded up against the wall. No one seemed to be there.

David glanced toward the window that frames the Phoenix skyline and felt a sense of relief. His friend might still be alive.

When he turned to leave, he looked again at the bed. He realized it was slightly ajar. As he leaned closer, to see why the bed hadn’t fully locked into place, David spotted something jutting out from the gap between the mattress and the wall: a lifeless foot.

About the Reporting

This story was pieced together from more than 1,000 pages of Ravi’s medical records and insurance files; audio recordings of Ambetter customer service calls; police reports and photos; court filings from three states; reports from insurance regulators; Ravi’s texts, phone logs, social media messages and emails; and more than 25 hours of interviews with people who knew Ravi best.

It was also guided by a lengthy chronology of key events that Barbara had compiled in the months after her son’s death. One thing she couldn’t bring herself to do: read the autopsy report. She asked her sister to summarize the findings, which ProPublica obtained and reviewed. Ravi’s death was ruled an accident, likely due to complications from excessive drinking.

ProPublica sent a detailed account of Ravi’s attempts to get help to 12 legal, insurance and mental health experts. They independently identified a variety of problems, including Ambetter’s provider directory inaccuracies, its network inadequacy and its customer service shortcomings.

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

by Max Blau

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It’s hard to know if your health insurance plan is as good as advertised. You pay a monthly premium to access a network of health providers. But call the numbers in your provider directory, and you’re bound to find ones who can’t — or won’t — see you.

These errors are at the heart of a ghost network. Some providers have moved, retired or even died; others left insurance networks because of low pay and intense scrutiny. Even though these providers no longer accept your insurance, their names may remain in the directory. When that happens, policyholders are left to believe that the plan has more options than actually exist.

“Any inaccuracy constitutes a ghost network,” said Abigail Burman, a consumer protection attorney who studies provider directory errors. “This is basic information. It needs to be right.”

Insurers’ failures to correct these errors have led to dire consequences for people seeking mental health care, as demonstrated by a recent ProPublica investigation of one man’s months of struggle to access treatment. Because of the widespread nature of ghost networks, some policyholders are more likely to pay out-of-network costs and face a greater chance of treatment delays — if they get treatment at all.

ProPublica spoke with experts, clinicians and advocates to understand the challenges posed by provider directory errors. They all suggested specific ways for policyholders to navigate a ghost network.

How much do insurers know about the errors in their directories? And what are they required to do about it?

Insurers have acknowledged the problem and in some cases have vowed to address it. AHIP, a national association of health insurers, said in a 2023 statement to the U.S. Senate Committee on Finance that insurers update provider directories through “regular phone calls, emails, online reminders, and in-person visits.” However, AHIP wrote that insurers can’t always quickly fix errors because providers sometimes fail to keep their own professional information up to date. (AHIP declined ProPublica’s request for an interview.)

But Dr. Robert Trestman, a Virginia psychiatrist who testified about ghost networks to the same committee, told ProPublica that insurers are able to track “every detail of finance” around things such as billing and coding. Because of that, he said, insurers’ failures “to set up a system for keeping track of who is in network or not is on them.”

But insurers haven’t had to make it a priority. Simon Haeder, a Texas A&M University professor who studies ghost networks, said that insurers have “very little incentive” to closely monitor directories. Unless tougher regulations are passed, he said, policyholders will continue to struggle with directories full of “inconsistent, outdated or incomplete data.”

For years, it has fallen to academic researchers and secret shopper surveys to reveal the pervasiveness of these errors. Lawmakers have passed bills and called for further reforms. In spite of that, the errors still plague policyholders.

I’m shopping for a plan. How do I know if it is as good as advertised?

Do your homework. In the absence of the insurer making it a priority to update its directory, the task of checking its accuracy falls to you. You can head to the website of the insurer whose health plan you’re interested in buying. Find the provider portal. Since an insurer may offer different networks for each plan, experts suggest double-checking that you’re only searching for providers available in the network that you want.

If you already have a provider, type in their name to see if that person is listed in-network. If you don’t have one, find a provider that’s listed as being in network and taking new patients, and who seems to meet your needs. From there, experts encourage reaching out directly to the provider to verify that both of those things are true.

“Verify, verify, verify,” said Dr. Jane Zhu, an associate professor at Oregon Health & Science University’s medical school who studies ghost networks. “Accuracy in behavioral health provider directories is akin to a coin flip.”

I already have a health plan. What should I do?

Don’t worry if you’ve paid for a plan or have one through your employer. There are other ways to minimize the perils of provider directory errors.

But experts say that you’ll need to arm yourself with some facts.

Track down your “Evidence of Coverage.” The document, which is typically about 100 pages long, outlines what your insurer must do to fulfill its contractual obligations. For instance, if you can’t access an in-network mental health provider within a certain period of time, the insurer may be on the hook for tracking down an out-of-network provider.

From there, you can call the insurer to find out if it handles your mental health benefits or if it has outsourced management of them. If those benefits are “carved out” from your plan, you may have to seek answers about provider directory errors from that subcontractor. (Should you encounter any errors in your directory, this information could come in handy.)

Experts say that by getting these answers, you’ll be able to better fight for your rights.

What should I do if I encounter provider directory errors?

Health care experts warn that you’re likely to encounter errors in your provider directory. They advise not to become discouraged when you do.

David Lloyd, chief policy officer with the mental health advocacy group Inseparable, suggests taking notes of the calls to providers. Did they answer the phone? Did they say they accept your plan? Do they see new patients? You can write all your notes down in this handy worksheet created by Cover My Mental Health, an Illinois-based consumer advocacy group. Take photos of the directory errors, too.

How many calls should I be expected to make?

Some policyholders have called at least 50 supposedly in-network providers in pursuit of an appointment. But experts say you shouldn’t have to contact that many. Burman suggests making a “reasonable effort.” To her, that means making five to 10 calls to providers listed in-network.

She and others note that if you’re in distress because of your mental health, you don’t have to call on your own.

“Ask a friend or family member for assistance and to help advocate for you,” said Wendell Potter, a former Cigna vice president who is now a consumer advocate.

None of my calls secured an appointment. What should I do now?

If you’ve made that reasonable effort and haven’t managed to lock down a provider, experts recommend making another call to your insurer. Inform the customer service rep that you couldn’t make an appointment with a listed provider despite multiple attempts. Request that the rep schedule an appointment for you. Then ask for the rep’s email address and put the request in writing — and ask the rep to reply the same way.

Meiram Bendat, a lawyer and psychotherapist in California, suggests reminding insurers that they “must share in the responsibility of identifying timely and geographically accessible providers.” The exact regulations depend on where you live and the kind of plan you have, so some research may be required before the call. In some instances, you can ask for a care manager and the insurer will assign an employee who can help secure a mental health appointment.

“Set the expectation that the customer service rep needs to solve this problem,” said Joe Feldman, founder of Cover My Mental Health.

If the rep doesn’t connect you with a provider, health insurance experts recommend asking the rep to file an administrative grievance. Persistence is key, Burman said. Be assertive. Demand the grievance be addressed — or escalated to a manager who will resolve your concern.

“Don’t feel like you’re the problem,” Burman said. “They are the problem for engaging in deceptive practices.”

My ghost network grievance hasn’t been resolved. Now what?

While waiting for your insurer to act, health insurance experts also encourage reaching out to your insurance regulator.

Finding that regulator can be a tricky task given America’s complex patchwork of insurance regulations. You’ll need to determine which government agency oversees your insurer. While more research is required to see who will be able help, experts point to the following agencies as a starting point:

1. If you purchased a plan from your state’s Health Insurance Marketplace, or have a fully insured plan through your private employer, you can get in touch with your state’s insurance department.
2. If you have a Medicaid plan, you can contact your state’s Medicaid agency.
3. If you are enrolled in Medicare, you can reach out to the Centers for Medicare & Medicaid Services.
4. If you have a self-funded plan from your private employer or a health and welfare benefit plan from your union, you can try the U.S. Department of Labor’s Employee Benefits Security Administration.

Once you find the right agency, experts suggest that you prepare your complaint. You don’t have to write a new one from scratch. Gather information from your grievance, along with any other new developments, and submit that to the regulator.

Is there anything else I can do?

Yes, there are a few other ways. Whatever approach you take, Potter urges you to make noise, as if you are “a relentless squeaky wheel.”

If you are covered through an employer’s health plan, see if your human resources department can help talk to the insurer.

Or contact the constituency service offices of your federal and state elected lawmakers. They might be able to directly reach out, too.

Depending on where you live, there may even be legal services or consumer advocacy agencies that can help out as well.

“As a consumer, your superpower is not going away,” Burman said. “Your strongest weapon, in the face of a company that wants you to go away, is to not go away.”

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

by Jennifer Smith Richards and Jodi S. Cohen

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An Illinois school district that had the nation’s highest student arrest rate has agreed to change its disciplinary practices and provide help to those who missed class time while being punished.

The agreement with the U.S. Department of Education will end a federal civil rights investigation into the Four Rivers Special Education District that was launched following a 2022 ProPublica and Chicago Tribune investigation that found the district turned to police with stunning frequency to discipline students with disabilities.

Under the deal, students who were referred to police or sent to a “crisis room” multiple times during the past three academic years could be eligible for services including tutoring, counseling or remedial education.

Four Rivers operates one public school: the Garrison School, in west-central Illinois, for students in an eight-county area of the state who have severe emotional and behavioral disabilities; some also have autism or ADHD.

In announcing the agreement on Thursday, the Education Department’s Office for Civil Rights said it found that despite claiming to be a “supportive” school, Garrison routinely sent students to police for noncriminal conduct that could have been related to their disabilities — something explicitly prohibited by federal law.

In the 2021-22 school year, investigators found that students were sent to police 96 times — more than the total number of students enrolled that year — for reasons including “noncompliance,” “disruption,” “inappropriate language” and violating a phone policy. Students also “spent extensive time out of the classroom” even when police weren’t involved; one student was sent to a “crisis room” 143 times in one school year and spent four hours and 20 minutes there one day.

Under the agreement, Garrison employees should no longer call police for behaviors that a specialized school like Garrison “should be fully equipped to manage,” Assistant Secretary for Civil Rights Catherine E. Lhamon said in a written statement.

By Dec. 20, the school must meet about students who were sent to police or to the school’s seclusion room during the past three school years to determine whether they should be given additional services for what they missed and the harm they suffered. Those services would have to be provided within six months of the meeting, according to the agreement.

Four Rivers Director Tracey Fair did not comment on the agreement or respond to questions from ProPublica about plans to help students going forward. She previously told the Tribune and ProPublica that administrators call police only when students are being physically aggressive or in response to “ongoing” misbehavior. Fair signed the civil-rights agreement on Tuesday.

The agreement also requires the district to develop new policies governing when to use its crisis rooms — described by the Education Department as two bare rooms with cinderblock walls and tile floors — and provide those to the agency within 30 days. Additionally, the district will need to keep detailed documentation every time students are sent to police and provide training to all staff, including on when the use of law enforcement or a crisis room could violate federal law.

The ProPublica-Tribune investigation found school administrators had called the police to report student misbehavior every other school day, on average, for years. When police were brought to the school, staff members then regularly pressed charges against the students — some as young as 9.

Officers typically handcuffed students and took them to the Jacksonville police station, where they were fingerprinted, photographed and placed in a holding cell. The local newspaper in Jacksonville then printed a brief description of the arrest in its police blotter.

(Jacksonville Journal-Courier)

During the 2017-18 school year, half of all Garrison students were arrested. No school district in the country that year had a higher student arrest rate, according to federal data.

Olga Pribyl, who oversees the special-education law division of Equip for Equality, called the agreement “a wake-up call” that the school should be focused on training staff to help students avoid crisis situations. The group is the federally appointed watchdog for people with disabilities in Illinois.

“They should’ve been complying with the law, that’s the bottom line, and they weren’t,” she said. She said that, at a minimum, all students who were sent to police or put in the seclusion room should be offered counseling.

“There’s trauma involved whenever these types of restrictive practices are used on students and especially if they’re used frequently,” Pribyl said.

A mother named Lena, who pulled two of her children from Garrison, said she won’t seek help from the school even though her sons would be eligible under the new agreement. One of her sons was arrested at school.

“For people who are going to go there in the future or going there now, that’s great,” Lena said. (ProPublica and the Tribune are not including her last name to protect the privacy of her children.) “But for the kids whose lives have been altered completely, that doesn’t do any good.

“You are asking somebody to take their kid back to the place that harmed them.”