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For the just second time ever, the St. Louis Blues and Chicago Blackhawks take their rivalry outdoors for the 2025 NHL Winter Classic.

The news of Jimmy Carter’s passing takes me back to 1976, a year that marked my own passage to adulthood. As the bicentennial year dawned, I took first notice of Carter upon his victory in the Iowa Caucuses. I followed his campaign through my high school graduation and into the summer, when I shuttled in […]

Enforcement begins on Jan. 1, and the highway patrol will conduct a hands-free enforcement project on Jan. 2 along I-55 in Jefferson County.

Need a designated driver? Breakthru Beverage Missouri and Absolut Vodka are partnering up to offer free Lyft rides home.

Rain showers early Tuesday will give way by late morning. Winds become gusty out of the west, bringing colder air back to the bi-state region. Temperatures will fall into the low 40s and hold there the rest of the day. Cloudy with gusty winds through the day.

For years music fans have wondered when Foreigner and Peter Frampton were going to get recognized by the Rock & Roll Hall of Fame, and this year they got their…

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by Eli Hager

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One afternoon in September, parents started arriving for pickup at Title of Liberty Academy, a private Mormon K-8 school in Mesa, Arizona, on the eastern outskirts of Phoenix.

Individually, the moms and dads were called in to speak to the principal. That’s when they were told that the school, still just a few months old, was closing due to financial problems.

There would be no more school at Title of Liberty.

Over the course of that week, more parents were given the news, as well as their options for the remainder of the school year: They could transfer their children to another private or charter school, or they could put them in a microschool that the principal said she’d soon be setting up in her living room. Or there was always homeschooling. Or even public school.

These families had, until this moment, embodied Arizona’s “school choice” ideal. Many of them had been disappointed by their local public schools, which some felt were indoctrinating kids in subjects like race and sex and, of course, were lacking in religious instruction. So they’d shopped for other educational options on the free market, eventually leading them to Title of Liberty.

One mom had even discovered the school by window shopping: It was in the same strip mall as her orthodontist’s office, next to a China Palace, and she’d noticed the flags outside with Church of Jesus Christ of Latter-day Saints imagery. (The school was not formally affiliated with the church.)

An LDS member herself, she was soon ready to start paying tuition to the school from her son’s Empowerment Scholarship Account — a type of school voucher pioneered in Arizona and now spreading in various forms to more than a dozen other states. ESAs give parents an average of over $7,000 a year in taxpayer funds, per child, to spend on any private school, tutoring service or other educational expense of their choice.

A sign for Title of Liberty is still standing. The abandoned school can be seen in the background. (Adriana Zehbrauskas for ProPublica)

Yet Arizona’s ESA program provides zero transparency as to private schools’ financial sustainability or academic performance to help parents make informed school choices.

For instance, the state never informed parents who were new to Title of Liberty and were planning to spend their voucher money there that it had previously been a charter school called ARCHES Academy — which had had its charter revoked last school year due to severe financial issues. Nor that, as a charter, it had a record of dismal academic performance, with just 13% of its students proficient in English and 0% in math in 2023.

When it was a charter (which is a type of public school), these things could be known. There was some oversight. The Arizona State Board for Charter Schools had monitored the school’s finances and academics, unanimously coming to the conclusion that it should be shut down.

Yet just a month after the board’s decision, ARCHES was re-creating itself as a renamed, newly religious private school, simply by pivoting to accept voucher dollars.

In other words, it was closed down by a public governing body but found a way to keep existing and being funded by the public anyway, just without the standards and accountability that would normally come with taxpayer money.

Arizona does no vetting of new voucher schools. Not even if the school or the online school “provider” has already failed, or was founded yesterday, or is operating out of a strip mall or a living room or a garage, or offers just a half hour of instruction per morning. (If you’re an individual tutor in Arizona, all you need in order to register to start accepting voucher cash is a high school diploma.)

There is “nothing” required, said Michelle Edwards, the founder and principal of ARCHES and then of Title of Liberty, in an interview with ProPublica. It was “shocking how little oversight” the state was going to provide of her ESA-funded private school, Edwards said.

Materials and books were left behind by Title of Liberty staff after the school closed. (Adriana Zehbrauskas for ProPublica)

According to charter board members as well as parents and family members of her former students, Edwards is a well-intentioned career educator who cares deeply about children. But she has repeatedly struggled to effectively or sustainably run a school.

She said that when she first transformed her charter school into a private school, she and her team called up “every agency under the sun” asking what standards the new school would have to meet, including in order to accept voucher funds. For example, what about special education students and other vulnerable children — would there be any oversight of how her school taught those kids? Or instructional time — any required number of minutes to spend on reading, writing, math, science?

State agencies, she said, each responded with versions of a question: “Why are you asking us? We don’t do that for private schools.”

“If you’re gonna call yourself a school,” Edwards told ProPublica, “there should be at least some reporting that has to be done about your numbers, about how you’re achieving. … You love the freedom of it, but it was scary.”

This school year, ProPublica has been examining Arizona’s first-of-its-kind “universal” education savings account program. We are doing so both because other states have been modeling their own new ESA initiatives after this one, and also because President-elect Donald Trump has prioritized the issue, most recently by nominating for secretary of education someone whose top priority appears to be expanding school choice efforts nationwide. (And Betsy DeVos, his first education secretary, was and remains a leading school voucher proponent.)

These programs are where the U.S. education system is headed.

In our stories, we’ve reported that Arizona making vouchers available even to the wealthiest parents — many of whom were already paying tuition for their kids to go to private school and didn’t need the government assistance — helped contribute to a state budget meltdown. We’ve also reported that low-income families in the Phoenix area, by contrast, are largely not being helped by vouchers, in part because high-quality private schools don’t exist in their neighborhoods.

But the lack of any transparency or accountability measures in Arizona’s ESA model is perhaps the most important issue for other states to consider as they follow this one’s path, even some school choice supporters say.

“If you’re a private school that gets most of its money now from the public, which has happened in Arizona, at that point there should be accountability for you as there is for public schools,” said Michael J. Petrilli, president of the Thomas B. Fordham Institute, a center-right and pro-voucher education reform think tank. “If the public is paying your bills, I don’t see what the argument is for there not to be.”

To illustrate this double standard: Private school parents can speak at public school board meetings, and they vote in school board elections. But public school parents can’t freely attend, let alone request the minutes of, a private school governing body’s meetings, even if that school is now being funded with taxpayer dollars.

Arizona’s School Transparency Rules Don’t Apply to Private Schools, Even if They Get Public Funding

Public schools include regular neighborhood schools as well as charter schools.

Note: ESL stands for English as a second language.

Defenders of universal voucher programs counter that the goal of American education should be a free market of educational options for families to choose from, unburdened by excessive state regulations and paperwork. The Heritage Foundation, a conservative think tank associated with Trump, has maintained that in such a system, schools would have “a strong incentive to meet the needs of their students since unsatisfied parents can take their children and education dollars elsewhere,” which the group says would create “direct accountability to parents.”

Yet in a truly free market, opponents say, consumers would have information, including about vendors’ past performance, to make purchasing decisions in their own best interests.

And if the product fails and has had a history of similar problems — as Title of Liberty did — there would be recourse, as with “lemon laws” that protect consumers who’ve unknowingly bought a defective car.

Abandoned reading and spelling materials are scattered on the floor of what was once Title of Liberty. (Adriana Zehbrauskas for ProPublica)

Several ESA parents across the Phoenix area said in interviews that they absolutely want educational choice and flexibility, but that they also want the sort of quality assurance that only government can provide. Most said that the Arizona Department of Education should provide at least some information as to the background and credentials of private schools and other educational providers that accept voucher money, and also that the department should do something to protect families from badly unqualified providers.

Rebekah Cross, a mother of five in the northwest Phoenix suburb of Peoria, said that the ESA program, overall, has been “life-changing” for her family; she is also an administrator of multiple Facebook groups of ESA parents. Still, she said, it’s “on you” to check the credentials and the criminal history of every private school founder and provider to whom you’re considering paying your ESA dollars, because in Arizona, “anybody can start a private school, you have no idea.” There are mostly “just rumors to rely on,” she said.

Cross pointed out that many local private schools and other educational vendors have started advertising on Facebook and elsewhere that they are “ESA certified,” even though there’s no state “certification” beyond simply signing up to receive the voucher payments. “There’s no criteria; that’s not a thing,” she said.

“You’re putting your kid in [a school], hoping it’s going to work,” Cross said. “If it closes midyear, you’re kind of screwed.”

Doug Nick, spokesperson for the Arizona Department of Education, responded that state law “makes it clear that we have no authority to oversee private schools,” even ones receiving public dollars.

Regarding publicly funded private schools closing midyear, he said that parents “have the wherewithal” to find another schooling option “regardless of the time of year,” and that the law “does not contemplate the department making recommendations to parents” at all.

Asked if the department knew how much public money had gone to Title of Liberty, Nick responded, “We don’t track that information since there’s no business reason to do so.”

The main entrance of the now-shuttered Title of Liberty. Its founder previously ran a failed charter school, ARCHES Academy. (Adriana Zehbrauskas for ProPublica)

Edwards, the Title of Liberty founder, first had the idea for her own school more than a decade ago. She’d long been an educator; she even ran a tutoring business in high school, she told me. At the beginning of her career, she taught Head Start and kindergarten in public and charter schools.

Through that experience and also seeing her own six kids not always having their individual needs met in Arizona’s K-12 system, she came to the conclusion that “to try to teach every child the same is ridiculous.”

Edwards began pitching the state charter board on a concept for a school that would meld principles of hands-on learning, borrowed from the Boy Scouts of America, with a proposal that students be grouped by learning level — “novice,” “apprentice” and so on — rather than into standard grade levels.

The board ultimately allowed her to open this school, ARCHES, in 2018. But it kept a close eye on her finances, in no small part to try to prevent a damaging outcome for students like a midyear closure. While giving her room to innovate, which is a chief goal of charter schools, the board monitored her enrollment numbers and staffing.

As it turned out, Edwards had persistent problems not just with low state test scores but also with unsustainably low enrollment, which would later plague Title of Liberty.

In our interview, she attributed those issues to the transience of many students during the pandemic and post-pandemic period as well as her business managers not being as experienced “as they probably should have been.”

This March, the charter board issued a notice of its intent to revoke ARCHES’ charter contract — a rare, serious move, according to ProPublica’s interviews with board members. (Edwards later reached an agreement with the board to surrender the charter.)

At that hearing, one of the board members commented to Edwards that “I love the fact that you have, you know, ideas and plans and things. … [But] I’m concerned about the kids. I’m concerned about the staff. I’m concerned about the families.”

Another added: “Don’t let that take away personally, on your end, the value of your intent.”

She didn’t. Edwards wanted to keep helping kids, she told me, including several ARCHES students whose families decided to stick with her.

She had the private school idea almost immediately. A post appeared on ARCHES’ Facebook page: “Hey parents! Interested in joining us next year at Title of Liberty Academy?” This was accompanied by an invitation to an “ESA workshop” to help them fill out voucher applications.

Meanwhile, Jason Mow, an ARCHES board member who was helping with its transition to Title of Liberty, tried to recruit new students: “Get your kids out of the government run schools,” he posted, adding, somewhat paradoxically: “The state ESA program will pay for tuition!!!!”

At one point, a parent asked him whether — if state money was going to be funding the school — it would be required to take part in state testing.

“As a private school using ESA, we have a great deal of latitude and not mandated to,” Mow answered.

He also said, “This is how we save the Republic.”

A banner found folded on the floor of the vacated Title of Liberty reads “Students can learn — no excuses!” (Eli Hager/ProPublica)

This last comment was part of a larger move that Edwards’ school was making: not just from charter to private and from some public accountability to none, but also from secular to religious with a right-wing bent, which was fully allowed even though it would be bankrolled by taxpayers. So, where ARCHES had touted an “American Revolutionary Classical Holistic Educational System,” Title of Liberty would simply be a “private faith-based school focused on the values of The Church of Jesus Christ of Latter-day Saints.”

Meanwhile, Edwards had already been planning to move the school into a new space: a series of storefronts in a strip mall that another charter school had previously occupied.

Over the summer, largely through sheer force of personality, she enrolled about two dozen students.

But Title of Liberty was ultimately even more disorganized than ARCHES had been. For one, Edwards told me, “We didn’t yet have [enough] students enrolled to be able to afford teachers. … But we had to have teachers in order to be able to get students.” She ended up hiring mostly her own family members, both for teaching positions and to do much of the school’s financial paperwork.

She also blamed difficulties with the ESA process, like some parents being told that they hadn’t submitted their email addresses or signatures in the right format. She made clear that none of this involved the state actually scrutinizing her school; still, she wasn’t able to obtain ESA funding as quickly as she had expected to.

The landlord, waiting on unpaid rent, finally asked Edwards to pack up the school and leave. According to one of the property managers, “She just left the space for us to deal with this shit,” which he said amounted to six large dumpsters’ worth.

Edwards responded that she couldn’t afford moving vehicles or storage space for all of those desks, bookshelves, books and files. She said that she’d provided the landlord with information about another school that could have moved in and used the furniture and supplies. (A representative of the owner of the building said that they were done with questionably funded schools by that point, and that they gave Edwards time to clear out.)

“It all depends on how you define success,” Edwards told me. “I feel like the time that our kids had with us was valuable and they learned a lot and took a lot with them from that.”

“We did try to hold to a super high standard,” she added, noting that there’s no one at the state level checking on all the other private schools out there that might not care to meet that standard.

Michelle Edwards, Title of Liberty’s founder, said that she couldn’t afford moving vehicles or storage space for all of her school’s desks, bookshelves, books and files, and that she had believed another school might be moving in. (Adriana Zehbrauskas for ProPublica)

Calls for school transparency and accountability used to be a feature of the center-right education reform movement. No Child Left Behind, one of President George W. Bush’s signature legislative achievements, mandated that public school students in certain grades undergo standardized testing in core subjects, on the grounds that schools should have to prove that they’re educating kids up to state standards and, if they’re not, to improve or else risk losing funding.

That testing was often rote, providing incomplete information as to the varied lives of students and pressuring many teachers to “teach to the test,” critics alleged. But it did offer a window into school performance — which, in turn, gave the voucher movement ammunition to criticize failing public schools.

Still, early voucher efforts too included basic transparency and accountability measures. When vouchers were first proposed in Arizona, for instance, a state task force said that “private schools must also participate in the same accountability process as public schools in order to qualify for state funding.” Louisiana’s voucher program, similarly, required participating private schools to administer state student achievement tests just like public schools did.

But voucher advocates changed course between 2017 and 2020. By that time, several academic studies had found that larger voucher programs had produced severe declines in student performance, especially in math.

Asked about a set of particularly negative findings out of Louisiana, DeVos, Trump’s secretary of education, blamed the state’s voucher program for being “not very well conceived.” Part of the problem was that it was overregulated, she and other advocates said.

In the years since, fully unregulated universal ESA programs have become the favored program design of many school choice supporters.

The result is a situation in which, on the one hand, the Arizona Department of Education annually publishes detailed report cards on all public schools in the state, including charter schools. You can look up any Arizona public school’s overall letter grade (ARCHES had a D when it was still a charter school); the academic performance and progress of that school’s students, including by demographic categories; the experience levels of its teachers, and so on.

On the other hand, Arizona private schools receiving public funding have to do no public reporting at all. If they want, they can self-report their enrollment and performance numbers to be published on websites like Niche.com, but they are free to exaggerate.

In other words, it’s not that this newer ESA model has been a clear academic success or failure. It’s just that the public, and more specifically parents, can’t know.

Not all states keep information as hidden as Arizona. At least five, for example, require schools that accept voucher money to be accredited or to provide evidence that they don’t have financial troubles.

Yet even these minimal efforts at transparency and accountability have been opposed by big-money voucher supporters.

Walmart heir Jim Walton, for instance, gave $500,000 this year to defeat a proposed Arkansas state constitutional amendment that would have required private schools receiving state funds to meet the same educational standards that public schools do. At the Ohio Legislature, provisions of a proposed bill that would’ve made voucher schools submit an annual report showing how they’re using state funding were recently removed under pressure from voucher advocates.

And in Arizona, Republicans in the Legislature have opposed every effort by Democratic Gov. Katie Hobbs to increase oversight of private schools that receive ESA money — except for one reform: They decided that such schools must fingerprint their teachers.

But the new law doesn’t require the ESA schools to run those fingerprints through any database or to use them in any way.

A hallway separates abandoned classrooms at Title of Liberty. A ProPublica reporter and a photographer went inside the space this month. (Adriana Zehbrauskas for ProPublica)

About a month ago, I asked parents if they could still pay Title of Liberty from their taxpayer-funded voucher accounts. I was curious not because I thought Edwards was collecting voucher money for a closed school but because it remained listed in ClassWallet, the Arizona Department of Education’s privately owned payment interface for ESA schools and vendors.

One mom sent me screenshots showing that she could indeed still pay the shuttered school from her ESA account, though she would need to produce an invoice.

What’s more, when she’d clicked on it in ClassWallet, “ARCHES Academy” was what had popped up — the name of the failed charter school that was repurposed into Title of Liberty.

The school, whatever it was called, was still open, as far as the state of Arizona was concerned. (It was only disabled in ClassWallet after recent inquiries from ProPublica.)

Title of Liberty was still an active vendor in ClassWallet, where Arizona parents can use their voucher money to pay private school tuition, long after the school had closed. The website also conflated Title of Liberty with its failed predecessor, ARCHES.

Wanting to make triple-sure that I wasn’t missing something, I drove over to the strip mall a few weeks ago to see if anything was still going on there.

What I found inside was a scene of school choice in its endstage. A sort of zombie voucher school, with dozens or possibly hundreds of books and papers scattered across the floor. Student records, containing confidential information, had been left out. There was food in the cafeteria area, molding.

Under quotes from the Book of Mormon painted on the walls and a banner proclaiming that Title of Liberty would strive to be a “celestial stronghold of learing [sic],” a document was sitting on a table. It offered guidance for parents on how to select the right school for their little ones, including this line: “You might be surprised how many schools are just flying by the seat of their pants.”

And on top of a file cabinet next to that was a stack of postcard-sized flyers that had been printed off at Walmart, reading, “Sign up your student for ESA.”

Help ProPublica Report on Education

Mollie Simon contributed research.

Co-editor Robert Kuttner’s Best of 2024

Writing fellow Luke Goldstein’s Best of 2024

by Maya Miller and Duaa Eldeib

This article discusses suicide.

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Geneva Moore’s therapist pulled out her spiral notebook. At the top of the page, she jotted down the date, Jan. 30, 2024, Moore’s initials and the name of the doctor from the insurance company to whom she’d be making her case.

She had only one chance to persuade him, and by extension Blue Cross and Blue Shield of Texas, to continue covering intensive outpatient care for Moore, a patient she had come to know well over the past few months.

The therapist, who spoke on the condition of anonymity out of fear of retaliation from insurers, spent the next three hours cramming, as if she were studying for a big exam. She combed through Moore’s weekly suicide and depression assessments, group therapy notes and write-ups from their past few sessions together.

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

• Call the National Suicide Prevention Lifeline: 988
• Text the Crisis Text Line from anywhere in the U.S. to reach a crisis counselor: 741741

She filled two pages with her notes: Moore had suicidal thoughts almost every day and a plan for how she would take her own life. Even though she expressed a desire to stop cutting her wrists, she still did as often as three times a week to feel the release of pain. She only had a small group of family and friends to offer support. And she was just beginning to deal with her grief and trauma over sexual and emotional abuse, but she had no healthy coping skills.

Less than two weeks earlier, the therapist’s supervisor had struck out with another BCBS doctor. During that call, the insurance company psychiatrist concluded Moore had shown enough improvement that she no longer needed intensive treatment. “You have made progress,” the denial letter from BCBS Texas read.

Moore’s denial letter from Blue Cross and Blue Shield of Texas contradicts many of her therapist’s assessments. (Obtained and highlighted by ProPublica)

When the therapist finally got on the phone with a second insurance company doctor, she spoke as fast as she could to get across as many of her points as possible.

“The biggest concern was the abnormal thoughts — the suicidal ideation, self-harm urges — and extensive trauma history,” the therapist recalled in an interview with ProPublica. “I was really trying to emphasize that those urges were present, and they were consistent.”

She told the company doctor that if Moore could continue on her treatment plan, she would likely be able to leave the program in 10 weeks. If not, her recovery could be derailed.

The doctor wasn’t convinced. He told the therapist that he would be upholding the initial denial. Internal notes from the BCBS Texas doctors say that Moore exhibited “an absence of suicidal thoughts,” her symptoms had “stabilized” and she could “participate in a lower level of care.”

The call lasted just seven minutes.

Moore was sitting in her car during her lunch break when her therapist called to give her the news. She was shocked and had to pull herself together to resume her shift as a technician at a veterinary clinic.

“The fact that it was effective immediately,” Moore said later, “I think that was the hardest blow of it all.”

After BCBS Texas denied Moore’s treatment, her therapist, pictured here, urged the company to reconsider. (Ilana Panich-Linsman, special to ProPublica)

Many Americans must rely on insurers when they or family members are in need of higher-touch mental health treatment, such as intensive outpatient programs or round-the-clock care in a residential facility. The costs are high, and the stakes for patients often are, too. In 2019 alone, the U.S. spent more than $106.5 billion treating adults with mental illness, of which private insurance paid about a third. One 2024 study found that the average quoted cost for a month at a residential addiction treatment facility for adolescents was more than $26,000.

Health insurers frequently review patients’ progress to see if they can be moved down to a lower — and almost always cheaper — level of care. That can cut both ways. They sometimes cite a lack of progress as a reason to deny coverage, labeling patients’ conditions as chronic and asserting that they have reached their baseline level of functioning. And if they make progress, which would normally be celebrated, insurers have used that against patients to argue they no longer need the care being provided.

Their doctors are left to walk a tightrope trying to convince insurers that patients are making enough progress to stay in treatment as long as they actually need it, but not so much that the companies prematurely cut them off from care. And when insurers demand that providers spend their time justifying care, it takes them away from their patients.

“The issues that we grapple with are in the real world,” said Dr. Robert Trestman, the chair of psychiatry and behavioral medicine at the Virginia Tech Carilion School of Medicine and chair of the American Psychiatric Association’s Council on Healthcare Systems and Financing. “People are sicker with more complex conditions.”

Mental health care can be particularly prone to these progress-based denials. While certain tests reveal when cancer cells are no longer present and X-rays show when bones have healed, psychiatrists say they have to determine whether someone has returned to a certain level of functioning before they can end or change their treatment. That can be particularly tricky when dealing with mental illness, which can be fluid, with a patient improving slightly one day only to worsen the next.

Though there is no way to know how often coverage gets cut off mid-treatment, ProPublica has found scores of lawsuits over the past decade in which judges have sharply criticized insurance companies for citing a patient’s improvement to deny mental health coverage. In a number of those cases, federal courts ruled that the insurance companies had broken a federal law designed to provide protections for people who get health insurance through their jobs.

Reporters reviewed thousands of pages of court documents and interviewed more than 50 insiders, lawyers, patients and providers. Over and over, people said these denials can lead to real — sometimes devastating — harm. An official at an Illinois facility with intensive mental health programs said that this past year, two patients who left before their clinicians felt they were ready due to insurance denials had attempted suicide.

Dr. Eric Plakun, a Massachusetts psychiatrist with more than 40 years of experience in residential and intensive outpatient programs, and a former board member of the American Psychiatric Association, said the “proprietary standards” insurers use as a basis for denying coverage often simply stabilize patients in crisis and “shortcut real treatment.”

Plakun offered an analogy: If someone’s house is on fire, he said, putting out the fire doesn’t restore the house. “I got a hole in the roof, and the windows have been smashed in, and all the furniture is charred, and nothing’s working electrically,” he said. “How do we achieve recovery? How do we get back to living in that home?”

Unable to pay the $350-a-day out-of-pocket cost for additional intensive outpatient treatment, Moore left her program within a week of BCBS Texas’ denial. The insurer would only cover outpatient talk therapy.

During her final day at the program, records show, Moore’s suicidal thoughts and intent to carry them out had escalated from a 7 to a 10 on a 1-to-10 scale. She was barely eating or sleeping.

A few hours after the session, Moore drove herself to a hospital and was admitted to the emergency room, accelerating a downward spiral that would eventually cost the insurer tens of thousands of dollars, more than the cost of the treatment she initially requested.

Moore’s wrists still show scars from where she was cutting herself. (Ilana Panich-Linsman, special to ProPublica) How Insurers Justify Denials

Buried in the denial letters that insurance companies send patients are a variety of expressions that convey the same idea: Improvement is a reason to deny coverage.

“You are better.” “Your child has made progress.” “You have improved.”

In one instance, a doctor working for Regence Blue Cross and Blue Shield of Oregon wrote that a patient who had been diagnosed with major depression was “sufficiently stable,” even as her own doctors wrote that she “continued to display a pattern of severe impairment” and needed round-the-clock care. A judge ruled that “a preponderance of the evidence” demonstrated that the teen’s continued residential treatment was medically necessary. The insurer said it can’t comment on the case because it ended with a confidential settlement.

In another, a doctor working for UnitedHealth Group wrote in 2019 that a teenage girl with a history of major depression who had been hospitalized after trying to take her own life by overdosing “was doing better.” The insurer denied ongoing coverage at a residential treatment facility. A judge ruled that the insurer’s determination “lacked any reasoning or citations” from the girl’s medical records and found that the insurer violated federal law. United did not comment on this case but previously argued that the girl no longer had “concerning medical issues” and didn’t need treatment in a 24-hour monitored setting.

To justify denials, the insurers cite guidelines that they use to determine how well a patient is doing and, ultimately, whether to continue paying for care. Companies, including United, have said these guidelines are independent, widely accepted and evidence-based.

Insurers most often turn to two sets: MCG (formerly known as Milliman Care Guidelines), developed by a division of the multibillion-dollar media and information company Hearst, and InterQual, produced by a unit of UnitedHealth’s mental health division, Optum. Insurers have also used guidelines they have developed themselves.

MCG Health did not respond to multiple requests for comment. A spokesperson for the Optum division that works on the InterQual guidelines said that the criteria “is a collection of established scientific evidence and medical practice intended for use as a first level screening tool” and “helps to move patients safely and efficiently through the continuum of care.”

A separate spokesperson for Optum also said the company’s “priority is ensuring the people we serve receive safe and effective care for their individual needs.” A Regence spokesperson said that the company does “not make coverage decisions based on cost or length of stay,” and that its “number one priority is to ensure our members have access to the care they need when they need it.”

In interviews, several current and former insurance employees from multiple companies said that they were required to prioritize the proprietary guidelines their company used, even if their own clinical judgment pointed in the opposite direction.

“It’s very hard when you come up against all these rules that are kind of setting you up to fail the patient,” said Brittainy Lindsey, a licensed mental health counselor who worked at the Anthem subsidiary Beacon and at Humana for a total of six years before leaving the industry in 2022. In her role, Lindsey said, she would suggest approving or denying coverage, which — for the latter — required a staff doctor’s sign-off. She is now a mental health consultant for behavioral health businesses and clinicians.

A spokesperson for Elevance Health, formerly known as Anthem, said Lindsey’s “recollection is inaccurate, both in terms of the processes that were in place when she was a Beacon employee, and how we operate today.” The spokesperson said “clinical judgment by a physician — which Ms. Lindsey was not — always takes precedence over guidelines.”

In an emailed statement, a Humana spokesperson said the company’s clinician reviewers “are essential to evaluating the facts and circumstances of each case.” But, the spokesperson said, “having objective criteria is also important to provide checks and balances and consistently comply with” federal requirements.

The guidelines are a pillar of the health insurance system known as utilization management, which paves the way for coverage denials. The process involves reviewing patients’ cases against relevant criteria every handful of days or so to assess if the company will continue paying for treatment, requiring providers and patients to repeatedly defend the need for ongoing care.

Federal judges have criticized insurance company doctors for using such guidelines in cases where they were not actually relevant to the treatment being requested or for “solely” basing their decisions on them.

Wit v. United Behavioral Health, a class-action lawsuit involving a subsidiary of UnitedHealth, has become one of the most consequential mental health cases of this century. In that case, a federal judge in California concluded that a number of United’s in-house guidelines did not adhere to generally accepted standards of care. The judge found that the guidelines allowed the company to wrongly deny coverage for certain mental health and substance use services the moment patients’ immediate problems improved. He ruled that the insurer would need to change its practices. United appealed the ruling on grounds other than the court’s findings about the defects in its guidelines, and a panel of judges partially upheld the decision. The case has been sent back to the district court for further proceedings.

Largely in response to the Wit case, nine states have passed laws requiring health insurers to use guidelines that align with the leading standards of mental health care, like those developed by nonprofit professional organizations.

Cigna has said that it “has chosen not to adopt private, proprietary medical necessity criteria” like MCG. But, according to a review of lawsuits, denial letters have continued to reference MCG. One federal judge in Utah called out the company, writing that Cigna doctors “reviewed the claims under medical necessity guidelines it had disavowed.” Cigna did not respond to specific questions about this.

Timothy Stock, one of the BCBS doctors who denied Moore’s request to cover ongoing care, had cited MCG guidelines when determining she had improved enough — something judges noted he had done before. In 2016, Stock upheld a decision on appeal to deny continued coverage for a teenage girl who was in residential treatment for major depression, post-traumatic stress disorder and anxiety. Pointing to the guidelines, Stock concluded she had shown enough improvement.

The patient’s family sued the insurer, alleging it had wrongly denied coverage. Blue Cross and Blue Shield of Illinois argued that there was evidence that showed the patient had been improving. But, a federal judge found the insurer misstated its significance. The judge partially ruled in the family’s favor, zeroing in on Stock and another BCBS doctor’s use of improvement to recommend denying additional care.

“The mere incidence of some improvement does not mean treatment was no longer medically necessary,” the Illinois judge wrote.

In another case, BCBS Illinois denied coverage for a girl with a long history of mental illness just a few weeks into her stay at a residential treatment facility, noting that she was “making progressive improvements.” Stock upheld the denial after an appeal.

Less than two weeks after Stock’s decision, court records show, she cut herself on the arm and leg with a broken light bulb. The insurer defended the company’s reasoning by noting that the girl “consistently denied suicidal ideation,” but a judge wrote that medical records show the girl was “not forthcoming” with her doctors about her behaviors. The judge ruled against the insurer, writing that Stock and another BCBS doctor “unreasonably ignored the weight of the medical evidence” showing that the girl required residential treatment.

Stock declined to comment. A spokesperson for BCBS said the company’s doctors who review requests for mental health coverage are board certified psychiatrists with multiple years of practice experience. The spokesperson added that the psychiatrists review all information received “from the provider, program and members to ensure members are receiving benefits for the right care, at the right place and at the right time.”

The BCBS spokesperson did not address specific questions related to Moore or Stock. The spokesperson said that the examples ProPublica asked about “are not indicative of the experience of the vast majority of our members,” and that it is committed to providing “access to quality, cost-effective physical and behavioral health care.”

A Lifelong Struggle

A former contemporary dancer with a bright smile and infectious laugh, Moore’s love of animals is eclipsed only by her affinity for plants. She moved from Indiana to Austin, Texas, about six years ago and started as a receptionist at a clinic before working her way up to technician.

Moore’s depression has been a constant in her life. It began as a child, when, she said, she was sexually and emotionally abused. She was able to manage as she grew up, getting through high school and attending Indiana University. But, she said, she fell back into a deep sadness after she learned in 2022 that the church she found comfort in as a college student turned out to be what she and others deemed a cult. In September of last year, she began an intensive outpatient program, which included multiple group and individual therapy sessions every week.

Moore, 32, had spent much of the past eight months in treatment for severe depression, post-traumatic stress disorder and anxiety when BCBS said it would no longer pay for the program in January.

The denial had come to her without warning.

“I was starting to get to the point where I did have some hope, and I was like, maybe I can see an actual end to this,” Moore said. “And it was just cut off prematurely.”

At the Austin emergency room where she drove herself after her treatment stopped, her heart raced. She was given medication as a sedative for her anxiety. According to hospital records she provided to ProPublica, Moore’s symptoms were brought on after “insurance said they would no longer pay.”

A hospital social worker frantically tried to get her back into the intensive outpatient program.

“That’s the sad thing,” said Kandyce Walker, the program’s director of nursing and chief operating officer, who initially argued Moore’s case with BCBS Texas. “To have her go from doing a little bit better to ‘I’m going to kill myself.’ It is so frustrating, and it’s heartbreaking.”

After the denial and her brief admission to the hospital emergency department in January, Moore began slicing her wrists more frequently, sometimes twice a day. She began to down six to seven glasses of wine a night.

“I really had thought and hoped that with the amount of work I’d put in, that I at least would have had some fumes to run on,” she said.

She felt embarrassed when she realized she had nothing to show for months of treatment. The skills she’d just begun to practice seemed to disappear under the weight of her despair. She considered going into debt to cover the cost of ongoing treatment but began to think that she’d rather end her life.

“In my mind,” she said, “that was the most practical thing to do.”

Whenever the thought crossed her mind — and it usually did multiple times a day — she remembered that she had promised her therapist that she wouldn’t.

Moore’s therapist encouraged her to continue calling BCBS Texas to try to restore coverage for more intensive treatment. In late February, about five weeks after Stock’s denial, records show that the company approved a request that sent her back to the same facility and at the same level of care as before.

But by that time, her condition had deteriorated so severely that it wasn’t enough.

Eight days later, Moore was admitted to a psychiatric hospital about half an hour from Austin. Medical records paint a harrowing picture of her condition. She had a plan to overdose and the medicine to do it. The doctor wrote that she required monitoring and had “substantial ongoing suicidality.” The denial continued to torment her. She told her doctor that her condition worsened after “insurance stopped covering” her treatment.

Her few weeks stay at the psychiatric hospital cost $38,945.06. The remaining 10 weeks of treatment at the intensive outpatient program — the treatment BCBS denied — would have cost about $10,000.

Bracelets and a watch cover Moore’s scars from cutting herself. (Ilana Panich-Linsman, special to ProPublica)

Moore was discharged from the hospital in March and went back into the program Stock had initially said she no longer needed.

It marked the third time she was admitted to the intensive outpatient program.

A few months later, as Moore picked at her lunch, her oversized glasses sliding down the bridge of her nose every so often, she wrestled with another painful realization. Had the BCBS doctors not issued the denial, she probably would have completed her treatment by now.

“I was really looking forward to that,” Moore said softly. As she spoke, she played with the thick stack of bracelets hiding the scars on her wrists.

A few weeks later, that small facility closed in part because of delays and denials from insurance companies, according to staff and billing records. Moore found herself calling around to treatment facilities to see which ones would accept her insurance. She finally found one, but in October, her depression had become so severe that she needed to be stepped up to a higher level of care.

Moore was able to get a leave of absence from work to attend treatment, which she worried would affect the promotion she had been working toward. To tide her over until she could go back to work, she used up the money her mother sent for her 30th birthday.

She smiles less than she did even a few months ago. When her roommates ask her to hang out downstairs, she usually declines. She has taken some steps forward, though. She stopped drinking and cutting her wrists, allowing scar tissue to cover her wounds.

But she’s still grieving what the denial took from her.

“I believed I could get better,” she said recently, her voice shaking. “With just a little more time, I could discharge, and I could live life finally.”

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

Kirsten Berg contributed research.

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