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The U.S. Department of Labor found widespread noncompliance and violations of federal law in how health plans and insurers cover mental health care, findings that mirror a recent ProPublica investigation.
Health plans, and the companies that administer them, have excluded key behavioral treatments, such as therapies for substance use and autism, and offered inadequate networks of mental health providers, according to a 142-page report released Jan. 17 in conjunction with the Treasury and Health and Human Services departments.
The report, which the agencies are required to file regularly to Congress, also detailed the results of secret shopper surveys of more than 4,300 mental health providers listed in insurance directories and found an “alarming proportion” were “unresponsive or unreachable.” Such error-ridden plans, commonly known as ghost networks, make it harder for patients to get the treatment they need, ProPublica has previously found.
Since 2021, the Labor Department has addressed violations in health plans that serve more than 7 million people, according to the report. The agency has worked to remedy the problems by seeking changes to plan provisions, policies and procedures, as well as working to ensure wrongly denied claims were paid.
But the report acknowledged that while plans and insurers have made some progress, they continue to fall short. For instance, federal officials wrote that insurers were working faster to fix problems in their plans once they had been identified, but officials had not seen sufficient improvement overall.
The report examined the enforcement and implementation of the federal Mental Health Parity and Addiction Equity Act, which requires health insurance plans to provide the same access to mental health care as they do to medical care. Last week, on the same day the report was released, department staff told ProPublica that the agency was investigating issues related to our reporting.
ProPublica has spent the last year investigating how insurers interfere with mental health treatment, including employing aggressive tactics that push therapists out of network; deploying an algorithmic system to limit coverage; creating ghost networks; cutting access to treatment for children with autism; relying on doctors whose judgments have been criticized by courts; and using patients’ progress to justify denials.
The Labor Department regulates insurance plans for about 136 million Americans who receive health coverage through their employers and is responsible for enforcing federal protections around their mental health claims. Federal regulators have struggled to hold insurance companies accountable for improperly denying mental health coverage, in part because of staffing and budgetary constraints.
The agency has asked Congress for additional funding on multiple occasions and, in its most recent congressional report, wrote that the agency is left with one investigator for every 13,900 plans it regulates, a higher workload than in previous years. Some temporary funding runs out in September, and its “full depletion will likely have catastrophic effects” on its enforcement capabilities, according to the report.
Timothy Hauser, a deputy assistant secretary of labor, said in an interview on the day of the report’s release that the agency is investigating the oversight and management of doctors hired by insurance companies who repeatedly deny mental health coverage for patients — and may open additional investigations.
Hauser, who has worked at the agency for more than three decades and is staying on in the new administration, said the agency is probing how insurers use and supervise doctors they rely on to conduct reviews of coverage and whether those doctors review cases in a “fair and dispassionate” way. ProPublica’s reporting raised serious concerns around those issues.
Last month, ProPublica examined how insurance companies, including UnitedHealth Group, Cigna, and Blue Cross and Blue Shield, rely on doctors to make crucial decisions on whether to approve mental health coverage even after courts have criticized their judgment. Judges have ruled that in denying such coverage, insurers violated federal law and acted in ways that were “puzzling,” “disingenuous” and even “dishonest.”
Some insurers and doctors, according to court records, engaged in “selective readings” of the medical evidence, “shut their eyes” to medical opinions that opposed their conclusions, and made critical errors in their reviews that were sometimes contradicted by medical records they had said they read.
Hauser said he could not comment on specific investigations but said that agency officials have discussed the ProPublica story, which he said “will have an impact on the questions we ask” and the “approaches we take.”
At least one investigation in the past has resulted in the removal of a doctor and the outside review organization they worked for, a spokesperson for the Labor Department said previously.
Insurance companies across the country rely on doctors working on their behalf to determine whether the treatment sought by the patients’ own doctors is medically necessary. If they determine it is not, they recommend denying coverage, which can leave patients in crisis and without the treatment they need. In some cases, those decisions have led to fatal consequences.
“It’s supposed to be done with impartiality and without having been structured in such a way as to incentivize the physicians to favor denying claims as opposed to granting claims,” Hauser said. “Similarly, the physicians and the providers should not be selected because of their propensity to to deny claims.”
United, Cigna and Blue Cross and Blue Shield did not immediately respond to requests for comment but in the past have said they employ licensed physicians to conduct reviews and work to ensure the doctors issue appropriate coverage decisions. The companies have said they conduct regular audits of doctors’ decisions, provide mentorship and coaching opportunities and are committed to providing access to safe, effective and quality care to patients.
Hauser said he was struck by the story of Emily Dwyer, who was featured in a ProPublica article that examined the role of company psychiatrists. She was 15 and suffered from severe anorexia — she arrived at a residential treatment center wearing her 8-year-old sister’s jeans — when United Healthcare denied her coverage.
United argued that three separate doctors had reviewed her case. The Dwyers sued and lost, but appealed to the 5th U.S. Circuit Court of Appeals, which reversed that decision and ruled unanimously in favor of the family. In a harshly critical opinion, the judges wrote that the denial letters issued by the three doctors were “not supported by the underlying medical evidence.” In fact, the court found, they were “contradicted by the record.”
Dwyer, who was pleased to learn of the agency’s investigation, said she hopes it results in “substantive action.”
“I never would have thought that our story would be part of that,” she said. “I think it’s incredible that the Department of Labor is paying attention to this issue and is investigating the insurance doctors. But I also hope they look beyond the actions of the individual doctors to deeper issues of the way insurance companies operate more systematically.”
This article was produced for ProPublica’s Local Reporting Network in partnership with the North Dakota Monitor. Sign up for Dispatches to get stories like this one as soon as they are published.
During Doug Burgum’s two terms as North Dakota governor, the state repeatedly sued the U.S. Department of the Interior, attempting to rip up rules that govern federal lands in his state and across the country.
Now, Burgum is poised to oversee that same department as President Donald Trump’s nominee for secretary of the interior. Those lawsuits and a host of others the state launched against the federal government, some of which are ongoing, reveal the worldview he’ll bring to a department that touches nearly every aspect of life in the West. Its agencies oversee water policy, operate the national parks, lease resources to industries including oil and ranching, provide services across Indian Country and manage more land than any person or corporation in the nation.
During his confirmation hearing last week before the Senate Committee on Energy and Natural Resources, Burgum portrayed the Interior Department as key to geopolitical power struggles. On energy policy, he said that growing consistently available types of energy production — namely nuclear and climate-warming coal, oil and gas — is a matter of national security; he claimed that greenhouse gas emissions can be mitigated with carbon capture technology that’s unproven at scale; and he argued that renewable energy is too highly subsidized and threatens the electrical grid.
The committee advanced his nomination to the full Senate on Thursday.
The North Dakota Monitor and ProPublica reviewed the nearly 40 lawsuits in which the state was a named plaintiff against the federal government at the time Burgum left the governor’s office. In addition, the review included friend of the court briefs the state filed to the Supreme Court and Burgum’s financial disclosures and public testimony. Many of the nearly 40 suits were cases North Dakota filed or signed onto with other Republican-led states, although the state brought a handful independently. Five of the cases were lodged against the Interior Department.
Burgum is a relative newcomer to politics who initially made his fortune when he sold his software company. But the cases and disclosures highlight his deep ties to the oil and gas industry, which have aided his political rise. The records also put on display his sympathy for Western states that chafe at what they believe is overreach by the Interior Department and that attack federal land management.
Notably, the litigation includes a case aimed at undoing the Interior Department’s hallmark Public Lands Rule that designated the conservation of public lands as a use equal in importance to natural resource exploitation and made smaller changes such as clarifying how the government measures landscape health. Additionally, North Dakota filed a case to roll back the agency’s rule intended to limit the amount of methane that oil companies could release, a practice that wastes a valuable resource and contributes to climate change. North Dakota also cosigned a brief in support of a controversial, although ultimately futile, attempt by Utah to dismantle the broader federal public lands system.
While some of the cases mirror his party’s long-running push to support the oil and gas industry over other considerations, including conservation, the litigation over public lands represents a more extreme view: that federal regulation of much of the country’s land and water needs to be severely curtailed.
Burgum did not respond to requests for comment but made clear many of his positions in public statements. A spokesperson did not answer a question on whether Burgum would recuse himself from matters pertaining to the cases his state filed.
While the state’s attorney general handled the lawsuits, Burgum emphatically supported them, urging state lawmakers last spring to fully fund the legal fights. He also cited the litigation during his confirmation hearing to assure Republican lawmakers that he would increase oil and gas leasing on public lands.
While speaking to North Dakota lawmakers about federal actions, Burgum characterized the Biden administration’s environmental policies as “misguided rules and regulations proposed often by overzealous bureaucrats.” The rules, he said, pose “an existential threat to the energy and ag sectors, our economy and our way of life.”
Burgum is considered less controversial than some other Trump nominees and is expected to gain Senate approval in the days ahead. Outdoor recreation groups and multiple tribes publicly supported his nomination, and he was lauded at his confirmation hearing by Republican as well as some Democratic senators. “If anybody is the pick of the litter, it’s got to be this man,” said Sen. Jim Justice, a Republican of West Virginia, another key fossil fuel-producing state.
Conservation groups, meanwhile, decried Burgum as an anti-public lands zealot who does oil companies’ bidding. Among them is Michael Carroll, who runs the Wilderness Society’s Bureau of Land Management campaign.
“If you’re not a reality TV star or under investigation for ethics violations or misconduct, you’re considered a normal nominee,” Carroll said of Trump’s picks. But, he continued, that obscures how Burgum and a Republican sweep of the federal government present a threat to public lands that’s “as extreme as we’ve seen. Period. Full stop.”
Donald Trump, then the Republican presidential nominee, talks with Burgum during the Republican National Convention in July. (Tom Williams/CQ-Roll Call, Inc/Getty Images) “Giveaways of Federal Public Lands”The federal government manages significant portions of the West. Most of that comes through the Interior Department’s Bureau of Land Management, which oversees an area more than five times the size of North Dakota. As a result, public lands management is a local flashpoint.
North Dakota has had a particularly contentious relationship with the federal government over its management of public lands that intermingle with parcels owned by the state or private citizens.
Lynn Helms was the state’s top oil regulator for more than 25 years before retiring last year, and he witnessed constant conflict over how federal agencies wanted to manage land in the state. “From the time I took this office until the day I walked away, there has always been at least one federal resource management plan or leasing plan under development and in controversy,” he told the North Dakota Monitor and ProPublica.
Two titanic legal fights will shape the future of federal land management. North Dakota is not a named plaintiff in the cases, but the state and Burgum have made known their opposition to federal authority in both.
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Last August, Utah sued the United States, asking the Supreme Court to rule that the federal government’s oversight of 18.5 million acres of public land in the state was unconstitutional. Utah, in its founding documents, forswore any unappropriated public lands to the federal government. Still, legal scholars and environmentalists worried a conservative Supreme Court might remove land management responsibilities from the federal government, which is widely seen as more favorable to conservation than Republican-led states are.
“Few issues are as fundamentally important to a State as control of its land,” a coalition that included North Dakota wrote in support of Utah’s case in a friend of the court brief during Burgum’s tenure.
Carroll, of the Wilderness Society, said that North Dakota siding with Utah was cause for concern about Burgum leading the Interior Department. “Supporting that lawsuit suggests that he’d be willing to support large-scale sell-off or giveaways of federal public lands, which, for most of us who live in the West and are concerned about the future of those public lands, is a very extreme position,” he said.
The Supreme Court in mid-January declined to take up the case, but Utah pledged to keep fighting. Burgum expressed sympathy for the state during his confirmation hearing, agreeing with Sen. Mike Lee, a Utah Republican and champion of the anti-federal movement, who said that Western states feel like “floating islands within a sea of federal land.”
Meanwhile, Republicans and industry groups also have their sights set on the 118-year-old Antiquities Act, which gives the president authority to create national monuments to protect areas of cultural, historical or scientific significance. Using the act, former President Joe Biden set aside more land and water for conservation than any previous president.
Burgum’s stance on the act is key, as the Interior Department typically handles details of these monuments, including where their borders are drawn.
During his confirmation hearing, Burgum said the Antiquities Act should be used for limited “Indiana Jones-type archeological protections,” not the sweeping landscapes that recent Democratic presidents have protected. While various tribes supported the use of the Antiquities Act in recent years, Burgum suggested monument designations have hurt tribes.
In western North Dakota, tribal representatives, conservation groups and others have pushed for a monument — which they’ve suggested calling Maah Daah Hey National Monument — to preserve 140,000 acres considered sacred by members of the Mandan, Hidatsa and Arikara Nation and other nearby Indigenous cultures. Burgum has expressed concern that such a designation would impede oil and gas drilling. And while he boasted at his confirmation hearing about conservation wins in his home state — such as creating the North Dakota Office of Outdoor Recreation — he didn’t mention the monument proposal.
In addition to legal challenges against the Interior Department, North Dakota is part of 14 lawsuits against the Environmental Protection Agency and at least five cases that challenge environmental or climate-related regulations against other federal agencies.
One of those cases, led by Iowa and North Dakota, seeks to roll back updates to Biden-era rules concerning the implementation of the National Environmental Policy Act, one of the nation’s core environmental laws. The legal battle will have sweeping implications for the government’s environmental permitting process, influencing major construction projects across the country, including those aimed at building infrastructure to meet the ongoing surge in electricity demand.
Pump jacks in Williston, North Dakota. The state is one of the country’s top oil and gas producers. (Daniel Acker/Bloomberg/Getty Images) “Blatant Conflicts With the Oil Industry”In North Dakota’s litigation and Burgum’s record, one idea stands out for how often it is repeated: the opinion that the federal government impedes oil and gas drilling. The state, one of the country’s top oil and gas producers, has consistently pushed for more drilling on public lands. Burgum has been cheerleading the industry for years.
Shortly before completing his term in mid-December, Burgum appealed a Bureau of Land Management land-use plan for the state, saying it hindered oil and gas development by barring oil, gas and coal leasing on several hundred thousand acres of federal mineral rights. (The agency denied Burgum’s appeal and finalized the plan.)
Under Burgum, North Dakota also sued the Bureau of Land Management over the agency’s handling of mineral lease sales, a system that allows companies to drill for and profit off publicly owned natural resources and that Helms labeled as “badly broken.” In the lawsuit, which is ongoing, the state argued the bureau neglected its duty to host quarterly lease sales under the Mineral Leasing Act. (A federal judge has ordered the bureau to address this issue.)
Environmental groups worry that Burgum’s ties to the oil industry influence his oversight of fossil fuels. Trump also picked Burgum to run the nascent National Energy Council, which will focus on boosting energy production.
His relationship with oil magnate Harold Hamm, the richest man in Oklahoma and a pioneer in hydraulic fracturing and horizontal drilling technology, has been well-documented.
Hamm pledged $50 million to the Theodore Roosevelt Presidential Library, a favored project for Burgum. When Burgum ran for president before dropping out and supporting Trump, he received nearly $500,000 in campaign contributions from oil and gas interests, about half of which came via a PAC sponsored by Continental Resources, which Hamm founded. Burgum also has acknowledged that he attended an April 2024 meeting at Mar-a-Lago that Hamm helped organize for oil executives to meet with Trump and pledge financial support for his campaign.
Burgum’s financial disclosure reports reveal a personal fortune spread across software companies, real estate ventures and farmland. He also listed royalties from oil and gas leases involving Hess Corporation, Kodiak Oil & Gas Corp. and Continental Resources.
In his required ethics agreement to become secretary of the interior, Burgum committed to resign from several companies, divest from energy-related holdings and work with agency ethics officials to avoid conflicts, including those tied to his home state. He also testified at his confirmation hearing that he had no outstanding conflicts of interest.
“Doug Burgum’s blatant conflicts with the oil industry cast doubt on his ability to fairly manage our public lands,” said Tony Carrk, executive director of government ethics watchdog Accountable.US.
“He Wants to Cut Tape So That the Benefits Actually Get to the Tribes”Among its many mandates, the Interior Department is tasked with fulfilling the United States’ trust responsibility to 574 federally recognized sovereign tribes. This includes providing schools and health care, representing tribes as they negotiate water rights settlements and liaising between tribes and the federal bureaucracy.
Burgum has had good relationships with tribal leaders in North Dakota. He partnered with tribes to pass tax-sharing agreements, was the first North Dakota governor to permanently display tribal nations’ flags outside his office and created an annual conference to bring together leaders of tribal and state governments.
Burgum also found common ground with a local tribe seeking to expand oil and gas drilling. “He wants to cut tape so that the benefits actually get to the tribes,” said Chairman Mark Fox of the Mandan, Hidatsa and Arikara Nation, who hopes to see more wells drilled on the Fort Berthold Reservation.
Fox said that he stays in touch with the former governor and that Burgum has asked him for input on issues affecting Indian Country, although he declined to share specifics.
“The No. 1 priority in discussion is: How do we enhance our opportunity to develop our trust resources of oil and gas?” Fox said.
But the state, under Burgum’s leadership, has also taken opposing positions on major issues to tribes, both inside and outside its boundaries.
When Burgum assumed the governorship in December 2016, a monthslong protest was raging against construction of the Dakota Access Pipeline, which transports oil from North Dakota to Illinois. Thousands of protesters joined with the Standing Rock Sioux Tribe, who assert that the pipeline infringes on its tribal sovereignty, disrupts sacred cultural sites and poses an environmental hazard.
Burgum supports the project.
Burgum appeared at a 2017 news conference to discuss protests over the Dakota Access Pipeline. (Stephen Yang/Getty Images)North Dakota sued the federal government over claims that the Army Corps of Engineers should have done more to quell the demonstrations, leaving state and local law enforcement and first responders to step in at a cost of $38 million. During the case, which went to trial in early 2024 and is yet unresolved, Burgum also criticized other agencies, including the Interior Department, alleging they sided with protesters.
“It’s dangerous in our country where politics on either side — either party, either direction, whatever — can somehow inject themselves in a permitting process,” Burgum said, according to court records.
The difference between Burgum’s views and that of many tribes around the country is especially stark on conservation.
The state became a co-defendant in December in a separate lawsuit the Standing Rock Sioux Tribe brought against the Army Corps of Engineers calling for the pipeline to be shuttered. Parties to the litigation have filed briefs, and the case is ongoing.
And the state and some tribes are at odds over the Bureau of Land Management’s Public Lands Rule, which clarified the role of a land designation called “areas of critical environmental concern.” A central purpose of the designation is to protect “rare or sensitive archeological resources and religious or cultural resources important to Native Americans.” Various tribes support the rule, but North Dakota is suing to halt it.
Despite those disagreements, tribal leaders in North Dakota said they respect Burgum, and several credited him with rebuilding relations. Standing Rock Sioux Tribe Chairwoman Janet Alkire said Burgum has a strong grasp of issues facing Indian Country, while Fox said Burgum has been willing to work with tribal leaders.
As Burgum takes the reins at the Interior Department, Monte Mills, director of the Native American Law Center at the University of Washington School of Law, said he is watching how Burgum will work with tribes that favor conservation over natural resource extraction.
It remains to be seen if keeping the federal government’s commitments to Indian Country are a priority for Burgum, Mills said, or whether tribal issues are “only really taken up where they align with other priorities of the administration.”
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