After a fight with a Black student in a St. Louis suburb left a white student badly injured in March 2024, Missouri Attorney General Andrew Bailey blamed their school district for unsafe conditions, even though the incident occurred after classes and more than a half-mile from campus.

Bailey seized on the fight as evidence of what he called the Hazelwood School District’s misplaced priorities. He sent a letter to the superintendent demanding documents on the district’s diversity policies and accused leaders of “prioritizing race-based policies over basic student safety.” Bailey argued that the district’s dispute with local police departments over its requirement that officers participate in diversity training — an impasse that resulted in some departments leaving schools without resource officers — had left students vulnerable.

In response, the school board’s attorney said Bailey had misrepresented basic facts: The district employed dozens of security guards at schools where it could not assign resource officers, and even if it did have police officers stationed at the school, those officers would not have handled an after-hours, off-campus fight. Finally, police found no evidence that race played a role in the fight.

The attorney general’s office took no further action.

“He was just trying to get attention,” said school board President Sylvester Taylor II.

The legal skirmish was the kind of publicity-getting move that defined Bailey’s two years and eight months as Missouri’s attorney general before his surprise selection last month by President Donald Trump as a co-deputy director of the FBI, according to experts who study the work of attorneys general.

As Missouri’s top law enforcement officer, Bailey repeatedly waded into fights over diversity, gender, abortion and other hot-button issues, while casting conservatives and Christians as under siege by the “woke” left.

Bailey had pledged at the start of his tenure in early 2023 not to use the state’s open public records law “as an offensive tool” to demand bulk records from school districts in broad investigations — a tactic used by his predecessor, Eric Schmitt, now a U.S. senator. Still, he made frequent use of cease-and-desist letters, warning school districts that their diversity initiatives or handling of gender and sex-education issues violated the law.

Some efforts, like his letter to the Hazelwood School District, amounted to little more than a press release. Others ended in defeat, with judges calling his arguments unpersuasive or “absurd” or, in one case, dismissing them without comment. One lawsuit, against China, ended in a judgment against the country that experts said will likely never be enforced.

Bailey, who was sworn in to the FBI position on Sept. 15, did not respond to messages left with the FBI’s press office and with James Lawson, a longtime friend who managed his attorney general campaign and served in various roles on his staff.

Bailey’s actions as attorney general, according to legal observers, stood apart from the office’s core, nonpolitical duties: defending the state against lawsuits and handling felony criminal appeals. That work, by most accounts, continued as usual.

His Republican predecessors, Schmitt and, before him, Josh Hawley, also used the position to advance conservative causes, wage fights against progressive ones and raise their national profiles.

During his stint as attorney general, Hawley — like Schmitt now in the U.S. Senate — delivered a speech in which he claimed the elimination of social stigmas to premarital sex and contraception during the 1960s had degraded the treatment of women and promoted sex trafficking. And he fought to uphold state restrictions that threatened to shut down Planned Parenthood clinics four years before Missouri’s near-total abortion ban took effect after the U.S. Supreme Court overturned Roe v. Wade in June 2022.

Schmitt was named to succeed Hawley in November 2018. During his four years in office, he defended Christian prayer in public schools and sued several local school districts that had enforced mask requirements during the pandemic.

In 2022, he joined a small group of conservative attorneys general in withdrawing from the National Association of Attorneys General, a bipartisan group that had long coordinated multistate investigations in cases against industries ranging from tobacco to opioids. In a letter posted to the social media platform now known as X, Schmitt joined Texas Attorney General Ken Paxton and Montana Attorney General Austin Knudsen in arguing that NAAG had taken a sharp “leftward shift” and that continued membership was intolerable. Neither Hawley nor Schmitt, through their spokespeople, responded to requests for comment.

Chris Toth, the executive director of NAAG who retired from the organization weeks after the letter became public, said in an interview that the claims in the letter were “completely unsupported by facts.” Republicans, he added, were involved “in every facet of the organization.”

The move reflected a broader shift in how many attorneys general now use their offices — not only to defend their states in court, but to score political points on the national stage. Few have embodied that strategy more than Paxton, who has often been described as focusing on culture war issues as attorney general.

ProPublica and The Texas Tribune have reported how Paxton has transformed the attorney general’s office into an agency that seems less focused on traditional duties like representing other state offices in court to one preoccupied with fighting culture wars. His office has increasingly used the state’s powerful consumer protection laws to investigate organizations whose work conflicts with his political views. At the same, he's started increasingly outsourcing major cases to private law firms.

Paxton’s office has said most of the instances when it declined to represent a state agency were due to practical or legal limits — some agencies chose their own attorneys; others were barred by statute. He’s also argued that certain cases would have required reversing earlier positions or advancing claims he viewed as unconstitutional. He’s defended hiring outside law firms, saying his office lacks the resources to take on powerful industries like tech and pharmaceuticals. Paxton did not respond to a request for comment.

Bailey, though far less prominent nationally, fit squarely within this mold. Before leaving for the FBI, he spoke openly about protecting Missourians from what he called “woke” ideology and lawlessness from the left.

A former U.S. Army officer, he has often framed his mission in combat terms. In a podcast interview this year, he said that while conservative states generally try to limit the power of their attorneys general to “maximize freedom,” blue states have weaponized their offices.

“I mean, Letitia James in New York has every weapon in her arsenal that her general assembly can give her,” he said in the podcast interview. He said she uses them “to mess with people’s lives, to prosecute President Trump, take him to court in civil law to try to seize his assets and undervalue those assets.”

“Missouri is uniquely positioned because we were so recently a blue state,” he said, “so it’s like a retreating army has left the battlefield and dropped their weapons and we’re picking them up and learning how to use them against them.”

A spokesperson for James’ office said that “any weaponization of the justice system should disturb every American” and that it stood behind its litigation against Trump’s business and would continue to stand up for New Yorkers’ rights.

Bailey said in the podcast interview that he supported all efforts to investigate President Joe Biden, his family and his administration, and to uncover what Bailey called the truth behind the COVID-19 vaccine, which he said “seems to not be a vaccine at all.”

Bailey used his office to investigate the nonprofit media watchdog Media Matters for America after it reported that corporate ads were appearing next to extremist content on the social media platform X.

Stephen Miller, a top aide to Trump in his first administration, posted that conservative state attorneys general should investigate; Bailey quickly responded that his team was “looking into the matter.” Weeks later, he issued a “notice of pending investigation” to Media Matters and ordered it to preserve records. He later accused the group of using fraud to solicit donations from Missourians to bully advertisers out of pulling out of X, and demanded internal records and donor information under Missouri’s consumer protection law. In a June 2024 interview with Donald Trump Jr., Bailey described the probe as “a new front in the war against the First Amendment” and tied it directly to the 2024 election, accusing Media Matters of trying to silence conservative voices.

Media Matters sued and a federal judge blocked the investigation as likely retaliatory. In early 2025, Bailey dropped the case in a settlement and said he had not found evidence of financial or other misconduct by Media Matters. The organization did not respond to a request for comment.

When Trump was awaiting sentencing after being convicted in a New York court of falsifying business records to conceal hush money payments to a porn star, Bailey asked the U.S. Supreme Court to lift a gag order on the former president and delay his sentencing until after the 2024 election, arguing the restrictions kept Missouri voters from hearing Trump’s message. The Supreme Court rejected his request in an unsigned one-page order without explanation. A New York judge later postponed the sentencing until after the election, writing that he wanted to avoid the appearance, however unwarranted, of political influence.

Trump could have faced up to four years in prison, but a judge issued an unconditional discharge, leaving his conviction in place but sparing him any penalty or fine. Trump said the conviction was a “very terrible experience” and an embarrassment to New York. He is appealing.

Bailey also fought to keep a woman in prison even after a state court judge declared her innocent. Even after the state Supreme Court ordered her release, Bailey’s office told the prison warden to ignore the court’s order. A state court overseeing the case scolded Bailey’s office in a hearing, saying, “I would suggest you never do that.”

Legal experts and other observers of the office said state attorneys general traditionally didn’t act primarily as partisan warriors. Most were focused on defending the state in court and protecting consumers.

Scott Holste, who served as a spokesperson for Jay Nixon, a moderate Democrat who served as the Missouri attorney general from 1993 to 2009, recalls a starkly different approach from Bailey’s. For example, in late September 2008, the top headlines on Nixon’s website focused on robocall rules, lawsuits over mortgage fraud and consumer tips for students.

“We were stridently apolitical in our news releases and in the way we operated,” Holste said. “Our job was to serve all Missourians, not to make political points.”

In the days before the August 2024 Republican primary, two of the three stories featured on Bailey’s homepage targeted the Biden administration over immigration and protections for LGBTQ+ students. The third highlighted a consumer-fraud prosecution.

To his supporters, Bailey is fulfilling campaign promises — a conservative acting like a conservative, said state Rep. Brian Seitz, a Republican from Branson.

Voters see a leader defending their freedoms by fighting policies such as diversity and equity, which they often equate with racism, and mask mandates, which they view as government overreach, Seitz said. “And,” he added, “we have a populist president who appreciates that.”

Toth, the retired head of the national AGs association, traced the shift in how state attorneys general act to the 1998 multistate settlement with the tobacco industry, when nearly every state joined a landmark deal that required cigarette makers to pay more than $200 billion, curb advertising aimed at children and fund anti-smoking campaigns. It also showed attorneys general how much power they could wield.

Over time, the newfound power has raised the profile of attorney general offices across the country, turning them into a springboard for higher office. That higher profile has fueled politicization.

Democratic attorneys general are no strangers to using their offices to fight political battles. California Attorney General Rob Bonta, for example, has filed numerous lawsuits challenging policies of the Trump administration on immigration, environmental regulations and federal funding. While Bonta maintained these suits were based on the law, critics characterized the coordinated legal action as politically motivated resistance.

Dan Ponder, a political science professor at Drury University in Springfield, Missouri, said that as the state has shifted to the right, the GOP primary, rather than the general election, is now the real contest for statewide office.

He pointed to actions such as Schmitt opposing critical race theory and reviewing public school textbooks. “That would have been unheard of 20 years ago,” Ponder said, “but now you can’t lose because you’re fighting the quote-unquote good fight.”

Peverill Squire, a political science professor at the University of Missouri, said that from the time of Bailey’s appointment to the position in January 2023, he probably had only two audiences. The first were voters he needed to defeat Will Scharf, a candidate already in Trump’s orbit, in the 2024 Republican primary for attorney general.

“And then once he secured his election, then I think his audience was really Trump,” Squire said.

Former Missouri Republican Party Chair John Hancock said voters seemed to reward Bailey’s approach. Bailey got nearly as many votes as Trump and Gov. Mike Kehoe in the 2024 general election — and more than Hawley or any of the Republicans who won the offices of lieutenant governor, treasurer or secretary of state.

“So obviously the work he was doing in that office was supported,” Hancock said. “I don’t take terrible shock when politicians do political things.”

Kehoe has appointed Catherine Hanaway, a former Missouri House speaker and U.S. attorney, to succeed Bailey as attorney general. Hanaway has said she intends to run the office in a different style. She told the Missouri Independent she had more interest in Medicaid fraud, consumer protection and violent crimes.

Her office said she was not available for an interview with ProPublica.

Two days later, a grand jury indicted Sam Page, the St. Louis County executive. Acting as a special prosecutor, Missouri Attorney General Andrew Bailey, a Republican, secured two felony counts of stealing by deceit and two election-law violations.

For Bailey, bringing felony charges against the leader of the state’s biggest blue stronghold added to the resume of a MAGA warrior who had already interviewed for a key position in President Donald Trump’s administration.

Less than three weeks later, Trump tapped Bailey to help run the FBI. He’ll serve as co-deputy director with Dan Bongino, a former Secret Service agent and conservative podcast host. Bailey said he’ll resign as Missouri’s attorney general on Sept. 8 to take the post. A spokesperson said he was not taking questions from the media.

The case against Page was the latest in a string of legal strikes against Democrats by Bailey, bringing the full weight of the state on a political adversary. It wasn’t about bribery or self-dealing. Page, the top elected official in a county with about 1 million residents, wasn’t accused of stealing a dime for himself.

Instead, the charges turned on something mundane: the printing and mailing of flyers weeks before about a measure on the ballot in April — the kind of informational material local governments often send to voters and the sort of action that experts said had never led to criminal charges in Missouri.

The election asked voters to give the County Council the power to fire the county’s department heads and its top attorney. Page spent more than $25,000 of taxpayer money to print and mail flyers to voters outlining the measure. The flyer at issue did not overtly tell voters to vote no, but it listed groups that opposed it, including the police board and NAACP, and it quoted a state judge’s ruling that the ballot language was misleading and unfair. It also suggested that a yes vote would allow directors to be fired for political reasons or in emergencies and that a no vote would maintain stable leadership.

Documents filed in the case against Page also showed that he did not follow a county lawyer’s advice to make some changes to the flyer. Bailey alleged that the flyer crossed the line from providing information, which is legal, to urging a no vote, which he said was an unlawful use of tax dollars — and, in his view, grounds to seek felony charges.

If convicted on the most serious count, Page could face three to 10 years in prison and $10,000 in fines. He could also face removal from office and sanctions against his medical license; he’s an anesthesiologist, though he doesn’t currently practice full time.

“Public officials must follow the law,” Bailey wrote in a news release, “and my Office will work to ensure that they always do.”

The playbook was familiar: Trump has talked about arresting California Gov. Gavin Newsom and New York City mayoral candidate Zohran Mamdani. Federal agents just raided the home of John Bolton, the former national security adviser in the first Trump administration and a prominent Trump critic.

Attorney General Pam Bondi appointed Ed Martin, who had worked as an attorney in Missouri, to head the U.S. Department of Justice’s Weaponization Working Group and to investigate two prominent Democrats, New York Attorney General Letitia James and U.S. Sen. Adam Schiff of California, on allegations of mortgage fraud.

“Bailey really was auditioning for that role, or something like it, and what better way to show loyalty than to do exactly what Trump wants on the federal level, but replicated on the state level,” said Paul Nolette, the director of the Les Aspin Center for Government at Marquette University. “It’s a template for what type of approach Bailey is going to take on the federal level. Political opponents are going to get targeted.”

Bailey has called himself a defender of the rule of law, portraying his high-profile lawsuits and investigations in Missouri as necessary to protect the state from what he has described as illegal or unconstitutional actions by the federal government and abandonment of the rule of law by the left.

Page became county executive in 2019 after a federal corruption case toppled his predecessor, Steve Stenger. Page had led a bipartisan bloc on the County Council against Stenger, who was sentenced to nearly four years in federal prison for a pay-to-play scheme that steered county contracts to political donors. (St. Louis County wraps around — but does not include — the much smaller independent city of St. Louis.)

The cooperative spirit collapsed as Page set St. Louis County on the aggressive end of Missouri’s response to the COVID-19 pandemic, issuing early emergency orders limiting gatherings and indoor dining. That stance put him at odds with state officials who were moving to curb local power.

Despite this and other political battles, Page has twice won countywide elections — first in 2020 to finish Stenger’s term, then in 2022 to a full four-year term. He has said he will decide by the end of the year whether to run again in 2026. He is scheduled to be arraigned on Friday.

“I don’t think I did anything wrong,” he said in brief remarks to local news reporters at a ribbon-cutting for a county road project.

A Page spokesperson referred questions to his lawyer, Jeff Jensen, a former U.S. attorney in Missouri during Trump’s first term. Jensen did not respond to requests for comment.

Many have questioned the legitimacy of the case and whether Bailey’s successor, Catherine Hanaway, will see it through. Hanaway, also a former U.S. attorney, as well as a former speaker of the Missouri House of Representatives, did not respond to questions.

“It certainly seems, based on my reading of it, a stretch,” said Peter Joy, a law professor at Washington University in St. Louis and an expert in legal ethics and trial practice. “It would be an uphill battle for the state to make this charge stick.”

Ken Warren, a political scientist and pollster at Saint Louis University, said the charges were “totally phony” but that “the more outrageous you are, the more you are going to attract the attention of Donald Trump.”

“Let’s say the same thing occurred but the county executive happened to be a Republican,” Warren said. “Would Bailey go after him? Of course not.”

Missouri has become a proving ground of sorts for Trump appointees. Martin — a longtime state GOP insider with a record of stoking controversies — was named the U.S. attorney for Washington, D.C. After it became apparent he couldn’t win Senate confirmation, he was moved to the administration’s pardon office and the Justice Department’s weaponization group.

John Sauer, a former Missouri solicitor general and anti-abortion activist who last year helped bankroll a campaign to defeat Missouri’s abortion rights ballot issue, defended Trump’s claim to presidential immunity before the Supreme Court. Now, as U.S. solicitor general, he serves as the federal government’s top advocate before the Supreme Court.

Will Scharf, who lost a primary bid last year to unseat Bailey, pivoted straight into Trump’s legal inner circle. Then there’s Billy Long. The six-term ex-congressman was confirmed in June as IRS commissioner — despite having once pushed to abolish the agency — amid scrutiny over his ties to questionable tax-credit plans. He was recently ousted and said he will become ambassador to Iceland.

That roster of loyalists is no accident. Over the past two decades, Missouri has moved from being a competitive bellwether state to a deep-red stronghold, with a political environment that rewards the kind of hard-line conservatism and culture-war ethos that Trump prizes.

John Danforth, a Republican who served as Missouri’s attorney general from 1969 to 1976 and then as a U.S. senator until 1995, said the office has shifted dramatically from its core mission. Under him, he said, the job was to represent state agencies, handle every felony appeal, respond to legal opinion requests and manage litigation with a small staff. Asked about a move last year in which Bailey investigated a St. Louis-area school district after a student was beaten during school hours — blaming its diversity policies and removal of resource officers for safety failures — Danforth said, “I wouldn’t have done it.”

As the state has shifted right, many races are effectively decided in the primary. Candidates don’t need to win over most voters, according to political experts and observers — just the small, very political group that shows up for low-turnout, winner-take-all primaries. That favors hard-line candidates.

Nowhere is that change clearer than in the attorney general’s office.

Bailey is a U.S. Army veteran who served two tours in Iraq as an armored cavalry officer. He started his career as an assistant Missouri attorney general, then worked as a prosecutor. He joined the governor’s office as deputy general counsel in 2019 and later served as general counsel to then-Gov. Mike Parson.

His politicization of the attorney general’s office follows a path blazed by two predecessors, Josh Hawley and Eric Schmitt, who each used relatively brief tenures as the state’s attorney general to launch themselves into the U.S. Senate. In Hawley’s case, out-of-state political consultants were embedded in the office from his first weeks on the job, directing taxpayer-funded staff, shaping his policy rollouts and boosting his national profile ahead of his Senate run. Schmitt used the office to wage headline-grabbing legal fights, from suing China over COVID-19 to challenging pandemic restrictions, elevating his profile as he prepared his own Senate campaign.

Neither Hawley nor Schmitt could be reached for comment.

After Schmitt was elected to the Senate in November 2022, Parson announced that he would appoint Bailey to fill the vacancy. That set up a high-profile Republican primary last year against Scharf, a candidate with backing from the conservative establishment. Bailey won 63% of the vote and cruised to an easy general-election victory in November.

Within a week, Bailey was interviewing with Trump for the job of U.S. attorney general in the new administration.

With no Democrats holding statewide office and a GOP supermajority in the legislature, Bailey has turned his fire on Democratic officials in Missouri’s two largest cities. He pressured St. Louis Circuit Attorney Kim Gardner to resign by filing a lawsuit to remove her from office that alleged willful neglect of duty and a failure to prosecute violent crimes, and he recently sought to remove St. Louis Sheriff Alfred Montgomery, accusing him of misconduct. Gardner repeatedly denied any wrongdoing before resigning; later she acknowledged misusing some public funds. Montgomery has denied wrongdoing and has refused to resign.

Kansas City Mayor Quinton Lucas has also been a frequent target: Bailey threatened a Missouri Human Rights Act investigation into Lucas and his staff after a city-run social media account, responding to a speech by the Kansas City Chiefs football player Harrison Butker about women being homemakers, named the suburb where Butker lived. The city deleted the post and apologized. Bailey framed the post as discrimination against Christians.

Last year, Lucas suggested the city could benefit from asylum-seeking immigrants joining the local workforce, then clarified that he meant immigrants who were in the U.S. legally. Bailey — who had sued the Biden administration over what he called an “illegal” parole program for migrants from Cuba, Haiti, Nicaragua and Venezuela — accused Lucas of trying to involve Missouri businesses in a “fundamentally unlawful program.” He posted a letter on the social media platform X calling Lucas’ comments “wildly irresponsible” and said he was “putting him on notice that it is a Class D felony to knowingly transport an illegal alien in the State of Missouri.”

Lucas responded in a statement then that Bailey’s letter was “a political campaign press release with no legal effect.”

“It’s not effective lawyering,” Lucas said in a recent interview. “It’s a whole new branch of lawyering that I, as a lawyer, didn’t grow up knowing, which is: If you get a story out, who cares if you drag people through the mud?”

Bailey, on the other hand, has stepped up to defend Republican allies. His office intervened to defend three GOP state senators who were sued for false light and invasion of privacy after wrongly identifying a Kansas man as the shooter at a Super Bowl parade honoring Kansas City’s NFL team — and falsely calling him an undocumented immigrant.

Two of the senators called the lawsuits frivolous, while Bailey has argued the posts were protected by legislative immunity, as the senators were acting in their official capacity.

Lawsuits against two of the officials, who are represented by the Missouri deputy solicitor general, a high-ranking lawyer in the attorney general’s office, remain pending in federal court.

Fearing mass firings, or worse, retaliation by the people they helped prosecute, a group of agents scrambled to enlist a legal team who could stop the administration in court. Norm Eisen, a prominent ethics lawyer now leading dozens of lawsuits against the Trump administration, agreed within hours to represent the agents pro bono, along with Mark Zaid, a veteran whistleblower attorney. For more firepower, the two approached the giant Chicago-based law firm Winston & Strawn, which has a history of providing free representation to people and organizations that squared off against Trump’s first administration.

But Winston declined to represent the FBI agents, three people with knowledge of the matter said. It was one of several cases Winston turned down in quick succession, they added, that would have pitted the firm against an openly retributive president.

Some of the country’s largest law firms have declined to represent clients challenging the Trump administration, more than a dozen attorneys and nonprofit leaders told ProPublica, while others have sought to avoid any clients that Trump might perceive as his enemies. That includes both clients willing to pay the firms’ steep rates, and those who receive free representation. Big Law firms are also refusing to take on legal work involving environmental protections, LGBTQ+ rights and police accountability or to represent elected Democrats and federal workers purged in Trump’s war on the “deep state.” Advocacy groups say this is beginning to hamper their efforts to challenge the Trump administration.

Their fears intensified after Trump signed a battery of executive orders aimed at punishing top firms over old associations with his adversaries. But as the Winston episode shows, Big Law began to back away from some clients almost the minute he returned to power. The country’s top firms remain deeply wary, even though the president has lost all four initial court challenges to those executive orders.

“The President’s Policy is working as designed,” said a lawsuit the American Bar Association filed against the administration in June. “Even as federal judges have ruled over and over that the Law Firm Orders are plainly unconstitutional, law firms that once proudly contributed thousands of hours of pro bono work to a host of causes — including causes championed by the ABA — have withdrawn from such work because it is disfavored by the Administration.”

The bar association itself has struggled to find representation, the lawsuit said. One unnamed firm, which has represented the association since the 1980s in lawsuits related to ABA’s accreditation of law schools, “is no longer willing to represent the ABA in any litigation against or potentially adverse to the Administration and its policies.” Sidley Austin, the sixth-ranked corporate firm by revenue in the world, has represented the ABA in at least five lawsuits over its accreditation practices since 1989.

The ABA and Susman Godfrey, which is representing the association in its lawsuit against the administration, declined to comment. Winston, Sidley and the White House did not respond to questions sent in writing.

Trump’s grievances with Big Law stem partly from its role in blocking his first-term agenda. In his executive order targeting Jenner & Block, a firm with close ties to the Democratic Party that fought Trump on transgender rights and immigration, he assailed the firm for allegedly “abus[ing] its pro bono practice to engage in activities that undermine justice.” Another firm, WilmerHale, was where former Special Counsel Robert Mueller worked before and after leading the Russian interference investigation.

The executive orders barred attorneys working for the firms from entering federal buildings where they represent clients, terminated the firms’ government contracts, revoked partners’ security clearances and required government contractors to disclose if they work with the targeted firms. Perkins Coie, one of Trump’s first targets, began to lose business “within hours,” its suit said. The judge who halted the executive order against WilmerHale wrote that the firm “faces crippling losses and its very survival is at stake.”

“I just think that the law firms have to behave themselves,” Trump said at a press conference in late March.

Nine corporate law firms behaved themselves in the form of reaching public settlements with Trump. The deals require them to provide $940 million in total of pro bono support for Trump-approved causes. There has been no public indication of the White House calling on them to perform specific work, and Trump has not released any new executive orders against firms since April.

Yet organizations that challenge the government are still feeling the chill.

“There’s been a real, noticeable shift,” said Lauren Bonds, the executive director of the National Police Accountability Project, a national nonprofit that brings lawsuits over alleged police abuse and was a frequent pro bono client of Big Law.

In November, as soon as Trump won reelection, a top firm that was helping NPAP develop a lawsuit against a city’s police force abruptly stopped attending all planning calls, Bonds said. Later, the firm became one of the nine that struck a deal with Trump, after which the firm half-heartedly told Bonds, she said, that it would reconsider the case in the future. Bonds declined to identify the firm.

Activist nonprofits have long relied on free representation because they typically lack the resources to mount major lawsuits on their own. Civil rights cases in particular are complex undertakings usually lasting years. Many call for hundreds of hours spent deposing witnesses and performing research, as well as upfront costs of tens of thousands of dollars. Big Law, with its deep ranks of attorneys and paying clients to subsidize their volunteer work, is in a unique position to help. In exchange, the work burnishes the firm’s reputation and serves as a draw for idealistic young associates.

“I know that [cases] have been shot down that in Trump Administration 1, firms would crawl over each other to get our name at the top of the case so that we could get the New York Times headline,” said a Big Law partner whose firm has not been one of Trump’s targets. “That’s the environment. What’s become radioactive has grown from a very small number of things to anything this administration and Trump might notice and get angry about.”

Jill Collen Jefferson, the president and founder of Julian, a small nonprofit that investigates civil rights violations, has felt the chill too.

Three years ago, Julian partnered with the elite law firm Wachtell, Lipton, Rosen & Katz, the country’s No. 1 corporate firm most years by per-partner revenue, to bring lawsuits against the town of Lexington, Mississippi, and its police force for racial discrimination.

“It wasn’t hard at all to get help,” she recalled. George Floyd’s death had raised public support for police accountability, and the details Julian was exposing in Lexington were especially grim. The police chief was secretly recorded promising to cover for a fellow officer if he killed someone “in cold blood.” A DOJ investigation released in 2024 found Lexington police operated in “a system where officers can relentlessly violate the law.” (The town’s board fired the chief, Sam Dobbins, over the recording. In a court filing, Dobbins said he was not guilty of “any actionable conduct” and denied Julian’s characterization of the recording, asserting that “the recording speaks for itself.” Julian’s litigation is still ongoing.)

Since January, when Trump began gutting police accountability measures, Jefferson’s efforts to recruit pro bono help have yielded almost no commitments. The official explanation many firms offer is that they lack the capacity to help, she said, though lawyers at those firms have privately told her that was false. Wachtell did not respond to a request for comment.

Jefferson now doubts Julian’s ability to bring a police abuse lawsuit it had planned to file before the statute of limitations expires this month.

“It’s been a nightmare,” she said. “People don’t want to stand up, and because of that, people are suffering.”

NPAP ultimately joined forces with another civil rights organization to salvage the case after its co-counsel disappeared from planning calls last November. But the suit will be “less robust” without the firepower of a major law firm, Bonds said. And NPAP’s capacity to file future suits is in question. Civil rights attorneys in NPAP’s network have developed novel legal theories for challenging arrests by Immigration and Customs Enforcement under state constitutions, but they lack enough outside partnerships.

“There are cases that aren’t being brought at a time when civil rights abuses are maybe at the highest they’ve been in modern times,” Bonds said.

Big Law was often in the vanguard of fighting Trump’s first administration. After he signed the 2017 travel ban affecting several predominantly Muslim countries, partners from Kirkland & Ellis and Davis Polk rushed alongside hundreds of other lawyers to international airports to help travelers stuck in limbo. Kirkland teamed up with the LGBTQ+ legal advocacy organization Lambda Legal to challenge Trump’s transgender military ban.

Now, Davis Polk is among the many firms that are avoiding pro bono immigration cases, The New York Times reported. Kirkland, by some measures the top moneymaker in Big Law, entered a deal with Trump to provide $125 million in pro bono work, and the firm is notably absent from Lambda’s nearly identical challenge to Trump’s reinstated ban on transgender military service members. Kirkland and Davis Polk did not respond to requests for comment.

Winston & Strawn’s annual pro bono reports show how its focus — or at least, its language — has changed. The firm’s 2023 impact report highlighted its advocacy on behalf of a transgender competitive marathoner. “I am also pleased to report that Winston dedicated 30% of our pro bono hours to racial justice and equity matters in 2023,” nearly double its share in 2020, wrote Angela Smedley, the pro bono committee chair. The 2024 report, published after Trump’s reelection, contained zero mentions of “equity” and spotlighted attorneys who helped small nonprofits navigate “complex mergers and business challenges.”

Eisen and Zaid, the lawyers representing the FBI agents, themselves became the target of a presidential memorandum in March that revoked their access to classified material. Both have aggravated Trump for years. Zaid represented a whistleblower who helped bring about Trump’s first impeachment.

Zaid sued to restore his security clearance in May, in a case that is ongoing. His lawyer, Abbe Lowell, is a high-profile defense attorney who left Winston this spring in order to form his own firm. Lowell said his goal is to represent those “unlawfully and inappropriately targeted.” New York Attorney General Letitia James, who won a fraud judgment against Trump and is now a target of his DOJ, was one of his first clients.

“The Administration’s attempt at retribution against Mark for doing his job — representing whistleblowers without regard to politics — is as illegal as its similar efforts against law firms that have been enjoined in every case,” Lowell wrote in an email to ProPublica.

Good-government groups and small and mid-sized law firms have stepped into the breach, helping to file hundreds of lawsuits against the Trump administration. And the four firms that sued Trump over his executive orders are devoting thousands of pro bono hours to others challenging the administration. Perkins Coie, for example, has replaced Kirkland as Lambda Legal’s partner in challenging Trump’s transgender military ban.

But until they build up the capacity to fully replace Big Law, Bonds said, some of the administration’s legally dubious actions will go unchallenged.

“There’s a financial resources piece that we’re really missing when we can’t engage a firm,” Bonds said. “Even if there’s a big case and we feel really confident about it, we’ll just have to pass on it.”

These consumers — along with hundreds of others — reached out to their congressional representatives for help in the past 12 months.

“I have been unable to pay my rent, utilities, personal bills, student loans, or my credit card. I have been unable to buy groceries or put gas in my car,” wrote the New Yorker, who contacted Rep. Nicole Malliotakis’ office.

Records show their representatives — all Republicans — referred them to the Consumer Financial Protection Bureau, the watchdog agency formed in the wake of the Great Recession to shield Americans from unfair or abusive business practices. All three consumers got relief, according to agency data.

Then the lawmakers — along with nearly every other Republican in Congress — voted to slash the agency’s funding by nearly half as part of President Donald Trump’s signature legislative package, the One Big Beautiful Bill Act, a step toward the administration’s goal of gutting the agency.

Republicans have long been critical of the CFPB, accusing it of imposing unreasonable burdens on businesses. Already, the CFPB under Trump has dropped a number of cases and frozen investigations into dozens of companies.

Yet the agency has historically benefited consumers across the political spectrum, securing around $20 billion in relief through its enforcement actions.

Data obtained by ProPublica through a public records request shows that many of the same Republican members of Congress who have targeted the CFPB for cuts have collectively routed thousands of constituent complaints to the agency.

Rep. Darrell Issa of California and Rep. Rob Wittman of Virginia, for example, voted to reduce the CFPB’s budget. Yet each of their offices has referred more than 100 constituents to the CFPB for help, among the most of any House members. The office of Sen. John Cornyn of Texas, who also voted for the CFPB cuts, has routed more than 800 constituent complaints to the agency, the most of any current lawmaker from either party, ProPublica found.

A spokesperson for Issa said in an email that most of his office’s referrals to the agency “occurred several years ago” and reflected “a conventional way” to handle constituents’ consumer issues.

Wittman and Cornyn didn’t respond to questions from ProPublica about the disconnect between their offices’ use of the CFPB’s services and their votes to cut it. Neither did New Jersey Rep. Chris Smith, whose office fielded the defrauded service member’s complaint, or Malliotakis, who was approached by the New York business owner, or Rep. Rick Allen, whose office directed the Georgia chemotherapy patient to the agency.

Overall, members of Congress have steered nearly 24,000 complaints to the CFPB since it opened its doors in 2011. Roughly 10,000 of those were referred by the offices of current and former Republican lawmakers, ProPublica found.

“This is how members of Congress from both parties get help for the people who live in their districts,” said Erie Meyer, the CFPB’s former chief technologist, who left the agency in February. The agency has a particular mandate to help service members and seniors, she noted. “This is how, if a service member is getting screwed on an auto loan, this is the only place they can go.”

Sen. Richard Blumenthal, D-Conn., has referred more than 200 constituents to CFPB since its creation. In a statement to ProPublica, he accused Republicans in Congress of “pursuing senseless cuts that will undermine their own ability to protect their constituents, who will be left in the lurch when they fall victim to scams or deceptive and unfair business practices.”

“Republicans have made clear that they stand on the side of big businesses — not consumers,” he added. “Their irresponsible pursuit of dismantling the CFPB will have far-reaching and long-lasting consequences.”

An Irreplaceable System

In recent years, the CFPB’s public database shows the number of complaints has exploded, from around 280,000 in 2019 to more than 2.7 million last year.

Complaints have grown across many categories, including credit cards and debt collection. Last year, most of the complaints filed, over 2.3 million, were about mistakes or other problems involving credit reporting agencies, and more than half of them resulted in relief, CFPB data shows.

“These credit score formulas govern so many factors of your life. It’s not just your ability to get a loan, it’s your ability to secure housing or qualify for a job,” said Adam Rust, director of financial services at the Consumer Federation of America. “It’s important that you can resolve something, but it’s difficult to do it on your own.”

Once a complaint is submitted, it is routed to the company, which has 15 days to respond. Companies can request an additional 45 days to reach a final resolution.

Many consumers end up getting nonmonetary relief, such as fixes to erroneous credit reports or an end to harassment by debt collectors, but some get financial help as well. More than $300 million has been returned to Americans through the complaint system, including $90 million just last year.

Normally, staff at the CFPB monitor the complaints to identify systemic issues and escalate complaints involving consumers who are at immediate risk of foreclosure, although that didn’t happen for a few weeks this year when the agency’s acting director halted its work.

The CFPB also shares complaint information with other federal agencies, states and localities to help them protect consumers. No other government or private entity has the capacity to effectively handle the volume of complaints that the CFPB does, experts and current and former employees say.

States often have limited resources for consumer protection efforts. Many states — including some conservative ones that supported a lawsuit challenging the constitutionality of the CFPB’s structure — steer consumers to the agency on their websites, providing links to it.

In legal filings opposing the Trump administration’s steps to effectively shut down the CFPB, 23 Democratic attorneys general noted that their states collectively have referred thousands of complaints to the agency and that its services can’t be replaced by state-level operations.

“In the CFPB’s absence, consumers will be left without critical resources,” they wrote.

The complaint system has also lessened the burden on congressional offices, which can route constituent problems to an agency dedicated to, and expert in, addressing consumer issues. Yet that hasn’t stopped Republicans from pursuing dramatic cuts to the agency.

The CFPB receives its funding from the Federal Reserve instead of annual appropriations bills. The structure is meant to safeguard the agency’s independence, though critics say this makes the agency less accountable, giving elected officials less power over its operations.

Initially, Republicans pressed for extreme cuts to the CFPB as part of Trump’s legislative package. House members approved a 70% cut. The Senate Banking Committee attempted to go even further, zeroing out the agency’s funding entirely.

Ultimately, the final version of the bill signed into law by Trump on July 4 cut the CFPB’s budget by around 46%, reducing the agency’s funding cap — the maximum amount it can request from the Federal Reserve — from $823 million to $446 million for this fiscal year. The agency requested $729 million last fiscal year.

The offices of lawmakers who voted for the bill have referred about 3,400 complaints to the agency, running the gamut of consumer problems — from crushing debt to mortgage issues to financial scams, ProPublica’s data analysis shows. (In some of these cases, consumers also took complaints to the CFPB themselves in addition to reaching out to their representatives. Consumers’ names aren’t disclosed in the data.)

Their constituents are sometimes desperate: “I’m about to be homeless because of this,” wrote a Florida resident whose bank account was frozen.

Others have expressed frustration at getting the runaround from a company. “I’ve spent countless hours on hold trying to speak with a representative, only to be met with silence or outdated instructions to send letters,” wrote one Virginian in a complaint about their bank.

In a statement after the CFPB funding cut passed, the chair of the Senate Banking Committee, Tim Scott, R-S.C., applauded the measure for saving taxpayer money but insisted it would not affect the agency’s mandatory functions, which include handling complaints.

Consumer experts as well as current and former CFPB employees, however, said the cuts will likely hinder the agency’s effectiveness.

“I think the whole process is at risk,” said Ruth Susswein, director of consumer protection at the nonprofit advocacy group Consumer Action. “If you starve the system, it cannot provide the benefits that it now offers.”

Signs of Strain

The Trump administration’s initial efforts to unilaterally hobble the CFPB give a hint of what may lie ahead for the complaint system.

In February, acting Director Russell Vought issued a stop-work order to all CFPB employees and canceled a slew of contracts, including for antivirus software that scanned files attached to consumer complaints.

The actions largely froze the complaint system for about a week. More than 70,000 complaints were submitted, but most were not sent to companies for their response during that period, data shows.

Although some issues were later fixed, the work stoppage spawned a backlog of more than 16,000 complaints that required manual review, according to court records from a lawsuit filed by the union that represents CFPB employees. About 75 complaints from consumers at risk of imminent foreclosure, which would normally be escalated to CFPB staff, weren’t acted upon.

In late March, U.S. District Judge Amy Berman Jackson ordered the CFPB to end the work stoppage, reverse contract terminations and reinstate probationary employees who were fired. However, an appeals court allowed layoffs to proceed, triggering a frenzied effort by the administration to cut about 90% of the CFPB’s staff.

The layoffs included the vast majority of the roughly 130-member team that manages the complaint system as well as nearly every staffer in legally mandated offices focused on service members and seniors.

The CFPB has fielded over 440,000 complaints from current and former service members and their families since 2011, according to CFPB data, more than 100,000 of which have resulted in relief.

The CFPB did not respond to multiple requests for comment. In a court declaration, Mark Paoletta, the CFPB’s chief legal officer, said that the agency’s leadership had “been assessing how the agency can fulfill its statutory duties as a smaller, more efficient operation. In making this assessment, leadership discovered vast waste in the agency’s size.”

Paoletta also said the agency would have a “much more limited vision for enforcement and supervision activities, focused on protecting service members and veterans, and addressing actual tangible consumer harm and intentional discrimination.”

In April, Jackson issued an order blocking the firings made at the CFPB after the appeals court decision. The administration has appealed Jackson’s ruling.

Lawsuits won’t protect the CFPB or its complaint apparatus from the cuts included in the recently passed spending bill, current and former agency employees pointed out.

These changes are likely to hit home with consumers no matter which party they favor, said Lauren Saunders, associate director of the National Consumer Law Center, which is a plaintiff in the union’s lawsuit.

“Republicans don’t want to be abused by big corporations that ignore them any more than Democrats do,” she said.

NOW READ: There's a very simple reason why Trump will never release the Epstein files

The week before President Donald Trump unveiled bruising new tariffs that sent the stock market plummeting, a key official in the agency that shapes his administration’s trade policy sold off as much as $30,000 of stock.

Two days before that so-called “Liberation Day” announcement on April 2, a State Department official sold as much as $50,000 in stock, then bought a similar investment as prices fell.

And just before Trump made another significant tariff announcement, a White House lawyer sold shares in nine companies, records show.

More than a dozen high-ranking executive branch officials and congressional aides have made well-timed trades since Trump took office in January, most of them selling stock before the market plunged amid fears that Trump’s tariffs would set off a global trade war, according to a ProPublica review of disclosures across the government.

All of the trades came shortly before a significant government announcement or development that could influence stock prices. Some who sold individual stocks or broader market funds used their earnings to buy investments that are generally less risky, such as bonds or treasuries. Others appear to have kept their money in cash. In one case unrelated to tariffs, records show that a congressional aide bought stock in two mining companies shortly before a key Senate committee approved a bill written by his boss that would help the firms.

Using nonpublic information learned at work to trade securities could violate the law. But even if such actions aren’t influenced by insider knowledge, ethics experts warn that trading stock while the federal government’s actions move markets can create the appearance of impropriety. The recent trades by government officials, they said, underscore that there should be tighter rules on how, or if, federal employees can trade securities.

“The executive branch is routinely engaged in activities that will move the market,” said Tyler Gellasch, who, as a congressional aide, helped write the law on insider trading by government officials and now runs a nonprofit focused on transparency and ethics in capital markets. “I don’t think members of Congress and executive branch officials should be trading securities. To the extent they have investment holdings, it should be managed by someone else outside their purview. The temptation to put their own personal self-interest ahead of their duties to the country is just too high.”

There is no evidence that the trades by government officials identified by ProPublica were informed by nonpublic information. Still, when government officials trade stock at opportune times, Gellasch said, even if it was based on luck and not inside information, it undermines trust in government and the markets

“It then becomes a thing where our markets look rigged,” he said.

In response to questions from ProPublica, the officials who made the trades either said they had no insider information that would help them time their decisions or did not respond to questions about the transactions.

Questions about trades based on nonpublic information have swirled around Congress for years and began anew after Trump’s tariffs announcements led to wild swings in the market. Lawmakers’ trades are automatically posted online and, after multiple congressional stock-trading scandals, are widely scrutinized as soon as they become public.

But less attention is paid to the trades of executive branch employees and congressional aides whose work could give them access to confidential information likely to influence markets once made public.

Last week, ProPublica reported that Attorney General Pam Bondi sold between $1 million and $5 million worth of shares of Trump Media, the president’s social media company, on April 2. After the market closed that day, Trump unveiled his “Liberation Day” tariffs, sending the market reeling. Bondi’s ethics agreement required her to sell by early May, but why she sold on that date is unclear. She has yet to answer questions about the trades, and the Justice Department did not respond to requests for comment.

Earlier this week, ProPublica reported that Sean Duffy, Trump’s transportation secretary, sold shares in almost three dozen companies on Feb. 11, two days before Trump announced plans to institute wide-ranging “reciprocal” tariffs. A Transportation Department spokesperson said Duffy’s account manager made the trades and that Duffy had no input on the timing.

Using insider government information to buy or sell securities could violate the Stop Trading on Congressional Knowledge, or STOCK, Act. But no cases have ever been brought under the law, and some legal experts have doubts it would hold up to scrutiny from the courts, which in recent years have generally narrowed what constitutes illegal insider trading.

Thousands of government employees are required to file disclosure forms if they sell or buy securities worth more than $1,000. In many cases, the records are available only in person in Washington, D.C., or through a records request. The documents do not include exact amounts bought or sold but instead provide a broad range for the totals of each transaction.

ProPublica examined hundreds of records for trades shortly before major tariff announcements or other key government decisions. Trump, of course, repeatedly said on the campaign trail that he intended to institute dramatic tariffs on foreign imports. But during the first weeks of his term, investors were not panic selling, seeming to assume that his campaign promises were bluster. Several tariff announcements by Trump early on shook the markets, but it wasn’t until he detailed his new tariffs on April 2 that stocks dived.

Among those who sold securities before one of Trump’s main tariff announcements was Tobias Dorsey. Dorsey, a lawyer in the executive branch since the Obama administration, was named acting general counsel for the White House’s Office of Administration in January, when Trump was inaugurated. The division provides a range of services, including research and legal counseling across the president’s staff, including the Office of the United States Trade Representative, which helps craft trade policy. In his LinkedIn bio, Dorsey describes his duties since 2022 as giving “expert advice on a wide range of legal and policy matters to help White House officials achieve their policy goals.”

On Feb. 25 and 26, disclosure records show, Dorsey unloaded shares of an index fund and nine companies, including cleaning products manufacturer Clorox and engineering firm Emerson Electric. The total dollar figure for the sales was between $12,000 and $180,000. (He purchased one stock, defense contractor Palantir, which was selling for a bargain after recently plummeting on news of Pentagon budget cuts.)

At the time of Dorsey’s trades, investors were still largely in denial that Trump was going to go through with the massive tariffs he had promised during the campaign. But the next morning, Trump posted on social media that significant tariffs on Mexico and Canada “will, indeed, go into effect, as scheduled” in several days, and that “China will likewise be charged an additional 10% Tariff on that date.”

The S&P 500, a stock index that tracks a wide swath of the market, fell almost 2% that day alone and ultimately dropped nearly 18% in six weeks.

In an interview, Dorsey said the sale was made by his wife from an account belonging to her. He said she decided to sell around $20,000 worth of shares so they could make tuition payments and that he had no nonpublic information on the impending tariff announcements. The kind of work he does as a career employee, he said, focuses not on public policy, but on how the White House operates, including personnel, workplace technology, contracts and records issues.

“I’m not advising Stephen Miller or Peter Navarro,” he said, referring to top policy advisers to the president. “I’m advising the people running the campus. … I don’t have access to any sensitive political information.”

Another well-timed set of transactions was made by Marshall Stallings, the director of intergovernmental affairs and public engagement for Trump’s Trade Representative. The office helps shape the White House’s trade policy and negotiates trade deals with foreign governments.

On March 25 and 27, Stallings sold between $2,000 and $30,000 of stock in retail giant Target and mining company Freeport-McMoRan. The sales appear to have been an abrupt U-turn. He had purchased the shares less than a week earlier. Days after Stallings’ sales, Trump unveiled his most dramatic tariffs. Target stock fell 17%. Freeport-McMoRan fell 25%.

Stallings and the Trade Representative’s office did not respond to multiple requests for comment.

A longtime State Department official, Stephanie Syptak-Ramnath, who until April was ambassador to Peru, also appeared to make a bet against the stock market. On March 24 and 25, she sold between $255,000 and $650,000 in stocks, and bought between $265,000 and $650,000 in bond and treasury funds (along with $50,000 to $100,000 in stocks). Then, on March 31, two days before Trump’s “Liberation Day” announcement, she sold between $15,000 and $50,000 of a broad-based stock fund. When the market started to plummet, she bought back the same dollar range in another stock fund. Syptak-Ramnath said she did not have any information about the administration's decisions beyond what was publicly available. The trades, she said, were “undertaken as a result of family obligations” and in “response to a changing economy.”

A second longtime State Department official, Gautam Rana, who is now ambassador to Slovakia, sold between $830,000 and $1.7 million worth of stock on March 19, a week before Trump declared new tariffs on cars and two weeks before his “Liberation Day” announcement. The shares he sold were largely broad-based index funds. Rana declined to comment for this story.

Virginia Canter, a former government ethics lawyer, said executive branch employees who don’t have nonpublic information and want to trade stock should consult with ethics officials before doing so, thereby allowing an independent third party to assess their actions.

“If you trade and you don’t seek advice in advance, you kind of do it at your own risk, and if you’re asked about it, you have to hope there aren’t factors that make someone question your motivations,” Canter said. “If you seek ethics official advice, you have some cover.”

Executive branch employees are barred from taking government actions that would narrowly benefit them personally, and some are required to sell stock in companies and industries they have purview over in their jobs. But like members of Congress, they are allowed to trade securities.

Since Trump’s tariff announcements and walkbacks began causing fluctuations in the market, questions have been raised about whether anyone has profited off advance notice of the moves. After Trump unexpectedly rolled back some of his tariffs in early April, causing stocks to surge, Rep. Alexandria Ocasio-Cortez warned on social media that “any member of Congress who purchased stocks in the last 48 hours should probably disclose that now.”

Rep. Marjorie Taylor Greene bought between $21,000 and $315,000 of stock the day before and the day of the announcement. The Georgia Republican has not said what motivated the trades but in the past said a financial adviser manages her investments without her input.

ProPublica’s review of disclosures also found trades by congressional aides that took place before the market tumbled.

Michael Platt, a veteran Republican staffer who served in the Commerce Department during Trump’s first term and now works for the House committee that handles administrative matters for the chamber, restructured his portfolio in March. An account under his wife’s name sold off between $96,000 and $390,000 in mostly American companies, and purchased at least $45,000 in foreign stocks and at least $15,000 in an American and Canadian energy index fund. Some stock forecasters considered international markets a relatively safe haven if Trump went through with his tariffs. Platt did not respond to requests for comment.

Stephanie Trifone, a Senate Judiciary Committee aide, sold stock in mid-March and bought at least $50,000 in treasuries. A spokesperson for the committee’s Democratic minority said Trifone had no nonpublic information about the tariffs and her trades were conducted by a financial adviser without her input. Kevin Wheeler, a staffer for the Senate Appropriations Committee, made a similar move. In late February, he and his spouse offloaded between $18,000 and $270,000 in funds composed almost entirely of stocks and bought between $50,000 and $225,000 in bonds. A spokesperson for the Appropriation Committee’s Republican majority said Wheeler had no nonpublic information about Trump’s tariff plans and that a financial planner made the trades after advising Wheeler to take a more conservative approach with his portfolio.

Another staffer, Ryan White, chief of staff to Sen. James Risch, R-Idaho, bought shares worth between $2,000 and $30,000 in two precious metals mining companies two days before Trump’s “Liberation Day” announcement. He continued buying more shares in the companies, Hecla Mining and Coeur Mining, in the following days.

Precious metals can be a safe haven during a bear market turn, but those stocks, like the rest of the market, declined after Trump’s tariff announcements.

Two days after White’s last purchase in April of the mining companies’ shares, however, the firms got some good news. A bill White’s boss introduced to make it easier for mining companies like Hecla and Coeur to operate on public lands was approved by a Senate committee, an important step in passing a bill. (White added to his Hecla shares earlier this month and sold his stake in Coeur.)

White told ProPublica that “all required reporting and ethics rules were followed.” Any suggestion that the committee passing the bill played a role in his stock purchases “is a stretch and patently false,” he said, adding that the legislation “has not become law and even if it does, would take decades to have any appreciable impact.”

When the federal courts first blocked the Trump administration’s funding freeze, Jessyca Leach was cautiously optimistic.

For days, the pause had prevented her from accessing the money she needs for her Phoenix health clinic to serve thousands of at-risk people, most of them poor and many of them members of the LGBTQ+ community. Things had gotten so bad that she had to lay off three employees and cut the salaries of her leadership team, including her own.

So when the funding started to flow again last week, days after the court orders, Leach hoped her ordeal would be over. It wasn’t.

Her federal dollars were accompanied by an ominous note from the payment processing arm of the U.S. Department of Health and Human Services. Citing “Executive Orders regarding potentially unallowable grant payments,” the agency said that it would continue “taking additional measures to process payments” and that its reviews “will result in delays and/or rejections of payments.”

“If it’s not there,” Leach said of the federal money that covers the salaries for 40% of her staff, “things get really bad, really fast.”

The notice Leach received was one of several indications over the past week that the Trump administration is not backing down in its fight to slash spending and dramatically reshape the federal government, despite multiple court orders explicitly restraining the president’s sweeping executive actions. In some cases, to get around the judges’ rulings, the administration has cited a memo that it says is not subject to the existing orders. In others, it denied funding to organizations because their granting agencies are not defendants in one of the ongoing legal challenges. In others still, it has withheld funds by citing the agencies’ own judgment, not the president’s directives.

That argument in particular has been met with skepticism by one of the federal judges hearing lawsuits over the administration’s spending freeze. U.S. District Judge Loren AliKhan wrote in a Feb. 3 temporary restraining order that “the court is not persuaded that the continuing freezes are solely due to independent agency action” and that “both logic and record evidence point to the opposite conclusion.”

Nevertheless, the administration is pressing the same argument in a separate case brought by a coalition of 23 state attorneys general, who assert that the government continues to effectively pause spending in defiance of the court’s rulings. The administration denied that claim in a filing on Sunday, arguing that it is making “good-faith, diligent efforts to comply with the injunction” and that to the extent the court doesn’t agree with the government’s interpretation of the order, it should clarify “the intended scope of its temporary restraining order.”

On Monday, the judge overseeing that case, John J. McConnell Jr., did just that, ruling that the Trump administration had violated his restraining order by keeping funds frozen. He wrote that the government’s “broad categorical and sweeping freeze of federal funds” was “likely unconstitutional” and that it must immediately restore funding across the board, unless it could show the court “a specific instance where they are acting in compliance with this order but otherwise withholding funds due to specific authority.”

The Constitution gives Congress the power to tax and spend, but legal experts say the Trump administration’s actions set the stage for major challenges to that authority — and the well-established limits on the chief executive’s power to unilaterally cut off money that Congress has appropriated to groups he disagrees with. Many of the cuts are related to climate and diversity programs.

Past presidential administrations have tried to exert more control over spending, and President Richard Nixon took the fight to withhold funding to the U.S. Supreme Court. But his administration argued, unsuccessfully, on statutory grounds. No administration has found a constitutional argument compelling enough to bring to the U.S. Supreme Court, said David Super, constitutional law professor at Georgetown Law.

“The only hope the administration will have is someone will recognize the heretofore unrecognized power of the president to withhold money on their own,” Super said.

David Cole, a former legal director for the American Civil Liberties Union who also teaches at Georgetown Law, agreed, saying the president already has the means to pursue changes to federal spending, including majorities in both houses of Congress. “If he disagrees with the law that Congress has enacted, including an appropriation, he can urge Congress to amend the law,” Cole said. “Ideological disagreement with a law is not a justification for refusing to execute that law.”

Still, the Trump administration seems to be girding for potentially thousands of contract disputes. Super, however, said contract law is clear there too: both parties to the contract are bound to its terms.

“No contract I’ve seen has terms that allow a contractor to be dumped because someone doesn’t like their ideology,” Super said.

Neither the White House nor the Department of Health and Human Services responded to requests for comment for this story. But on Sunday, Vice President JD Vance telegraphed on social media the administration’s view on the series of court rulings blocking executive actions in the first three weeks of Trump’s presidency. “Judges aren’t allowed to control the executive’s legitimate power,” he wrote on X.

The legal battle kicked off after the Office of Management and Budget issued a two-page memo on Jan. 27 that required all agencies to identify and pause funding to programs that didn’t comply with executive orders Trump issued on his first day in office, “including, but not limited to, financial assistance for foreign aid, nongovernmental organizations, DEI, woke gender ideology, and the green new deal.”

That prompted two lawsuits — one filed in Washington, D.C., by a group of nonprofits and another in Rhode Island by states. Budget officials withdrew that OMB memo two days later. But the White House’s top spokesperson announced the following day that the executive orders would continue “in full force and effect, and will be rigorously implemented.”

Judges in both cases have temporarily blocked the administration from withholding spending based on the executive orders and the since-rescinded OMB memo.

In its notice to agencies about the rulings, though, government lawyers told leaders that they were still free to pause federal grants. In that document, the Department of Justice wrote that while federal officials couldn’t “pause, freeze, impede, block, cancel, or terminate” obligated money based on the administration’s January directives, agencies “remain free to exercise their own discretion under their ‘authorizing statutes, regulations, and terms,’ including any exercise of discretion to pause certain funding.”

It’s unclear how the administration will respond to Monday’s court order to unfreeze federal funding. But the resulting confusion caused by the various executive actions and court rulings may be the goal of the administration’s rapid-fire directives and its evolving justifications for withholding funds even after the judicial intervention, experts said. In the absence of clarity, groups that rely on federal funding could be forced to scale back or suspend operations.

“There are policy decisions that are being made by simply stirring all this up and creating uncertainty and confusion,” said Don Kettl, a professor emeritus and former dean in the School of Public Policy at the University of Maryland.

That’s what’s happening at the Walker Basin Conservancy, an environmental nonprofit that is relying on federal grants to restore a shrinking lake in rural Nevada.

“On the same day, I will have conversations with different people, often in the same office, who have different understandings,” said Peter Stanton, the group’s CEO. “It’s just a mess.”

The conservancy needs the money for restoration work on public lands in the basin, work that creates local jobs. But in a phone call on Wednesday with the Department of Interior agency that oversees the group’s grants, Stanton said he was told he would get no money from awards that involve funds from two laws that were passed by Congress while Joe Biden was president: the Bipartisan Infrastructure Law and the Inflation Reduction Act. The Interior Department did not respond to ProPublica’s request for comment.

The confusion is influencing big spending decisions that need to be made soon, such as hiring a seasonal workforce. “There will be an inflection point where the chaos and lack of clarity itself begin to drive those decisions,” he said.

Injecting even more uncertainty into the mix, Trump can issue executive orders “faster than opponents can file suits to stop them or courts can decide the cases,” Kettl said.

On Thursday, Trump did just that, issuing another order that directs agency heads to review grants to nongovernmental organizations, many of which, the order said, “are engaged in actions that actively undermine the security, prosperity, and safety of the American people.”

Legal observers say these moves should not have come as a surprise.

Four years ago, on the last day of Trump’s first presidency, Russell Vought and Mark Paoletta, who then, as now, served as top budget officials, wrote in a 14-page letter to a congressional committee that a 1974 law asserting Congress’ powers over the purse was “an albatross around a President’s neck.” In another part of the letter, they said that the president “must be permitted to take time to consider how to best execute” spending federal dollars and that “if that requires a temporary pause in spending, it must be permitted.”

The extent and breadth of the administration’s efforts to control domestic spending appropriated by Congress is still unclear. In affidavits filed late Friday night, officials from across the country detailed the scope and disruption at the state level.

In New York, a top accounting official wrote that, as of Wednesday, the state could not access money that low-income people use to buy groceries, a block grant for maternal and child health services and nearly $6 million in education funding. In New Mexico, the official who heads services for the elderly and disabled adults said further spending pauses could force them to stop delivering hot meals.

Individual grantees who received far smaller sums were no less concerned as they struggled to get clear answers from the government.

Soon after Trump issued his executive orders, Hally Strevey emailed her grant officers at the Bureau of Reclamation about the $600,000 in grants her organization had been awarded under the Biden-era Bipartisan Infrastructure Law to restore a section of the Poudre River in Colorado to prevent future floods. “Since your agreement is already in place and awarded, you should actually be fine,” one wrote back on Jan. 23, “and this current situation will not impact your ability to draw down funding.” Four days later, she wrote again, pasting a link to a Washington Post story detailing the budget memo that called for a sweeping freeze of federal funds and asked, “Is our funding still safe given this latest news?”

An official confirmed receipt of that email but didn’t answer her question. Unable to access her money, she emailed the help desk of the federal grant payment system on Wednesday, after the court rulings, and finally learned the truth: “the grants are suspended.” The next day, her federal grant officer responded, citing another budget memo, which was not at issue in either of the cases challenging the administration’s spending pauses. Pursuant to that document, all funding related to the Bipartisan Infrastructure Law and the Inflation Reduction Act “has been paused,” the official wrote.

“Even though I was anticipating it, deep down you’re like, that’ll never happen,” Strevey said. “And then it did.”

The Bureau of Reclamation did not respond to a request for comment.

Jillian Blanchard, vice president of climate change and environmental justice at Lawyers for Good Government, said that by freezing the grants, the Trump administration had broken a binding contract. “It is illegal to pause legally obligated funds for policy reasons without congressional approval, which is what is happening,” she said.

The administration has not always stated policy reasons though. Instead, in some cases, it has blamed the grinding machinery of government bureaucracy.

On Thursday, for example, a Department of Justice lawyer denied the administration was not abiding by the court’s rulings in one of the two cases challenging the government’s spending freezes, this one brought by a coalition of state attorneys general. He told an attorney representing Oregon that the Environmental Protection Agency was “working through the process of unsuspending grants, which is taking some time given the nature of the process.”

In another email, the same official wrote to a lawyer for New York that the delays in releasing funds to the state were not examples of the administration’s obstinance but were instead “very likely related to” the federal Payment Management System’s “ongoing process of working through the unusually large number of payment requests they received.”

In a filing, the lawyer explained the cause of the “operational delay,” writing that in the four days after OMB issued the spending freeze memo that kicked off the litigation, so many grantees tried to draw down funds — in many cases for their full grant balance — that the payment system automatically flagged 7,000 of them as unusual, prompting further review. As of Sunday, the lawyer wrote, the backlog was fewer than 600 requests.

Paxton had traveled to be with Trump for what he described on social media as a “sham of a trial” and a “travesty of justice.” Trump was facing 34 counts of falsifying records in the case, which focused on hush money paid to porn star Stormy Daniels during the 2016 presidential campaign to keep her from disclosing their sexual relationship.

“It’s just sad that we’re at this place in our country where the left uses the court system not to promote justice, not to enforce the rule of law, but to try to take out political opponents, and that’s exactly what they’re doing to him,” Paxton said on a conservative podcast at the time.

“They’ve done it to me.”

A year earlier, the Republican-led Texas House of Representatives voted to impeach Paxton over allegations, made by senior officials in his office, that he had misused his position to help a political donor. Trump was not physically by Paxton’s side but weighed in repeatedly on social media, calling the process unfair and warning lawmakers that they would have to contend with him if they persisted.

When the Texas Senate in September 2023 acquitted Paxton of the impeachment charges against him, Trump claimed credit. “Yes, it is true that my intervention through TRUTH SOCIAL saved Texas Attorney General Ken Paxton from going down at the hands of Democrats and some Republicans …” Trump posted on the social media platform he founded.

The acquittal, however, did not wholly absolve Paxton of the allegations brought by his former employees. The FBI has been investigating the same accusations since at least November 2020. And come Monday, when Trump is inaugurated for his second term, that investigation will be in the hands of his Department of Justice.

Paxton and Trump have forged a friendship over the years, one that has been cemented in their shared political and legal struggles and their willingness to come to each other’s aid at times of upheaval. Both have been the subjects of federal investigations, have been impeached by lawmakers and have faced lawsuits related to questions about their conduct.

“If there’s one thing both guys share in common, people have been after them for a while in a big way. They’ve been under the gun. They’ve shared duress in a political setting,” said Bill Miller, a longtime Austin lobbyist and Paxton friend. “They’ve both been through the wringer, if you will. And I think there’s a kinship there.”

Neither Trump nor Paxton responded to requests for comment or to written questions. Both men have repeatedly denied any wrongdoing, claiming that they have been the targets of witch hunts by their political enemies, including fellow Republicans.

Their relationship is so cozy that Trump said he’d consider naming Paxton as his U.S. attorney general pick. He ultimately chose another political ally, former Florida Attorney General Pam Bondi.

Although Trump did not select Paxton, the two men will get yet another opportunity to have each other’s backs now that he has returned to office, both when it comes to the federal investigation into Paxton and pushing forward the president’s agenda.

Before and during Trump’s first term, Paxton filed multiple lawsuits challenging policies passed under former President Barack Obama. He then aggressively pursued cases against President Joe Biden’s administration after Trump lost reelection. Such lawsuits included efforts to stop vaccine mandates, to expedite the deportation of migrants and to block federal protections for transgender workers.

Trump has supported Paxton over and over, not only as the Texas politician sought reelection but also as he faced various political and legal scandals. The president-elect’s promises to exert more control over the Justice Department, which has traditionally operated with greater independence from the White House, could mark an end to the long-running investigation into Paxton, several attorneys said.

Justice Department and FBI officials declined to comment on the story and the status of the investigation, but as recently as August, a former attorney general staffer testified before a grand jury about the case, Bloomberg Law reported. Paxton also referenced the FBI’s four-year investigation of him during a speech in late December without mentioning any resolution on the case. The fact that Paxton hasn’t been indicted could signal that investigators don’t have a smoking gun, one political science professor told ProPublica and The Texas Tribune, but a former federal prosecutor said cases can take years and still result in charges being filed.

“As far as I’m aware, this is pretty unprecedented, this level of alliance and association between those two figures,” said Matthew Wilson, a political science professor at Southern Methodist University in Dallas.

“Don’t Count Me Out”

In 2020, when then-U.S. Attorney General William Barr found no evidence to support Trump’s claims that voter fraud turned the election results in his opponent’s favor, Paxton emerged to take up the argument.

He became the first state attorney general to challenge Biden’s win in court, claiming in a December 2020 lawsuit that the increased use of mail ballots in four battleground states had resulted in voter fraud and cost Trump the election.

Trump eagerly supported the move on social media, writing, “We will be INTERVENING in the Texas (plus many other states) case. This is the big one. Our Country needs a victory!”

The U.S. Supreme Court declined to take the case, ruling that Texas had no legal interest in how other states conduct their elections. Trump, however, didn’t forget Paxton’s loyalty.

He offered Paxton his full-throated endorsement during the 2022 primary race for attorney general against then-Texas Land Commissioner George P. Bush. His decision to back Paxton, who was under federal criminal investigation at the time and had been indicted on state securities fraud charges, was a major blow to Bush, the grandson and nephew of two former Republican presidents. Bush had endorsed Trump for president even though Trump defeated his father, former Florida Gov. Jeb Bush, in the Republican primary and repeatedly disparaged his family.

Trump properties in Florida and New Jersey served as locations for at least two Paxton campaign fundraisers over the course of that campaign. And at a rally in Robstown in South Texas, Trump repeated debunked claims that the election was stolen and said he wished Paxton had been with him at the White House at the time. “He would’ve figured out that voter fraud in two minutes,” Trump said.

While Paxton pursued reelection, FBI agents executed a search warrant at Trump’s Mar-a-Lago resort as part of an investigation into how his administration handled thousands of government documents, many of them classified. Paxton led 10 other Republican state attorneys general in intervening in court on Trump’s behalf, arguing in a legal filing that the Biden administration could not be trusted to act properly in the case.

Paxton won another term in office in November 2022, but the celebration was short-lived. Six months later, the Texas House of Representatives considered impeaching him over misconduct allegations including bribery, abuse of office and obstruction related to his dealings with Nate Paul, a real estate developer and political donor. Paxton has denied any wrongdoing.

Hours before the House voted on whether to impeach Paxton, Trump weighed in on social media.

“I love Texas, won it twice in landslides, and watched as many other friends, including Ken Paxton, came along with me,” he wrote on his social media platform Truth Social. “Hopefully Republicans in the Texas House will agree that this is a very unfair process that should not be allowed to happen or proceed — I will fight you if it does. It is the Radical Left Democrats, RINOS, and Criminals that never stop. ELECTION INTERFERENCE! Free Ken Paxton, let them wait for the next election!”

Despite Trump’s threat, the House voted 121-23 in May 2023 to impeach Paxton. The Senate then held a trial that September to determine Paxton’s fate. “Who would replace Paxton, one of the TOUGHEST & BEST Attorney Generals in the Country?” Trump posted before the Senate acquitted Paxton.

Trump is among the few people who understand what it’s like to be under the kind of scrutiny Paxton has faced and how to survive it, Miller said.

“There is that quality [they share] of, ‘Don’t count me out,’” he said. “‘If you’re counting me out, you’re making a mistake.’”

On Monday, Trump will become the first president also to be a convicted felon. A jury found Trump guilty on all counts of falsifying records in the hush money case. A judge, however, ruled that he will not serve jail time in light of his election to the nation’s highest office.

Trump has repeatedly decried the case, as well as the Justice Department’s investigations that resulted in him being charged in June 2023 with withholding classified documents and later with conspiring to overturn the 2020 election by knowingly pushing lies that the race was stolen. Jack Smith, the special counsel who led the DOJ investigations, dropped both cases after Trump’s reelection. A Justice Department policy forbids prosecutions against sitting presidents, but in a DOJ report about the 2020 election released days before the inauguration, Smith asserted that his investigators had enough evidence to convict Trump had the case gone to trial.

Not only have Paxton and Trump supported each other through turmoil that could have affected their political ambitions, they have taken similar tacks against those who have crossed them.

After surviving his impeachment trial in 2023, Paxton promised revenge against Republicans who did not stand by him. He had help from Trump, who last year endorsed a challenger to Republican Texas House Speaker Dade Phelan, calling Paxton’s impeachment “fraudulent” and an “absolute embarrassment.” Phelan, who has defended the House’s decision to impeach Paxton, won reelection but resigned from his speaker post.

For his part, Trump has tried a legal strategy that Paxton has employed many times, using consumer protection laws to go after perceived political adversaries. In October, Trump sued CBS News over a “60 Minutes” interview with Vice President Kamala Harris, saying the news organization’s edits “misled” the public. Instead of accusing CBS of defamation, which is harder to prove, his lawsuit argues that the media company violated Texas’ consumer protection act, which is supposed to protect people from fraud. The case is ongoing. In moving to dismiss the case, CBS’ attorneys have said the Texas law was designed to safeguard people from deceptive business practices, “not to police editorial decisions made by news organizations with which one disagrees.” (Marc Fuller, one of the CBS attorneys, is representing ProPublica and the Tribune in an unrelated business disparagement case.)

The move indicates a broader, more aggressive approach that the Justice Department may pursue under the Trump administration, said Paul Nolette, director of the Les Aspin Center for Government at Marquette University, who researches attorneys general.

“It’s a signal to me that, yes, the federal DOJ is going to follow the path of Paxton, and perhaps some other like-minded Republican AGs who have been using their office to also go after perceived enemies,” Nolette said.

Cleaning House

On Dec. 21, six weeks after Trump won reelection, Paxton stepped onstage in a Phoenix convention center at the AmericaFest conference, hosted by the conservative organization Turning Point USA.

The event followed Trump’s comeback win. It also represented a triumphant moment for Paxton: He’d not only survived impeachment, but prosecutors agreed earlier in the year to drop long-standing state securities fraud charges against him if he paid about $270,000 in restitution and performed community service.

But Paxton spent much of his 15-minute speech ticking off the grievances about what he claimed had been attacks on him throughout his career, including impeachment by “supposed Republicans” and the FBI case.

He praised Trump’s selection of Bondi to run the DOJ. It was time to clean house in a federal agency that had become focused on “political witch hunts and taking out people that they disagree with,” Paxton said.

Before taking office, Trump threatened to fire and punish those within the Justice Department who were involved in investigations that targeted him. FBI director Christopher Wray, a Republican whom Trump appointed during his first term in office, announced in December that he would resign after the president-elect signaled that he planned to fire him. After facing similar threats, Smith, the special prosecutor who led the DOJ investigations, stepped down this month.

In his speech, Paxton made no mention of the agency’s investigations into Trump, nor did he connect the DOJ to his own case. But a Justice Department that Trump oversees with a heavy-handed approach could benefit the embattled attorney general, several attorneys told ProPublica and the Tribune.

Trump could choose to pardon Paxton before the case is officially concluded. He used pardons during his first presidency, including issuing one to his longtime strategist Steve Bannon and to Charles Kushner, his son-in-law’s father. He’s been vocal about his plans to pardon many of the Jan. 6 rioters on his first day in office.

More concerning, however, is if Trump takes the unusual approach of personally intervening in the federal investigation, something presidents have historically avoided because it is not a political branch of government, said Mike Golden, who directs the Advocacy Program at the University of Texas School of Law.

Any Trump involvement would be more problematic because it would happen behind closed doors, while a pardon is public, Golden said.

“If the president pressures the Department of Justice to drop an investigation, a meritorious investigation against a political ally, that weakens the overall strength of the system of justice in the way a one-off pardon really doesn’t,” Golden said.

Michael McCrum, a former federal prosecutor in Texas who did not work on the Paxton case, said “we’d be fools to think that Mr. Paxton’s relationship with the Trump folks and Mr. Trump personally wouldn’t play some factor in it.”

“I think that the case is going to die on the vine,” McCrum said.

Miller, Paxton’s friend, agreed.

“I would expect his troubles are behind him.”

This spring, the Justice Department announced a major victory against a drug firm that manufactured billions of opioid painkillers. Endo Health Solutions, the agency said, would face $1.5 billion in fines and forfeitures and plead guilty to a corporate criminal charge.

Prosecutors said the massive fine would hold accountable a suburban Philadelphia company that profited by “misrepresenting the safety of their opioid products and using reckless marketing tactics to increase sales.”

But in the end, federal prosecutors offered far friendlier terms than those trumpeted by the agency.

Endo would not have to pay the $1.5 billion in criminal penalties, which was already a deep discount from the billions federal officials said Endo owed for dodging taxes and driving up Medicare costs.

In what amounted to a liability fire sale by the Justice Department, the company’s woes with the federal government would all be resolved by a $200 million payment.

In sentencing Endo in federal court in May, Judge Linda Parker wondered how the amount paid to the U.S. could be so low.

“I don’t understand. I really don’t understand,” Parker said. “I just don’t understand how it went from $1 billion to $200 million.”

Federal prosecutor Benjamin Cornfeld explained: Endo was broke.

“The reality is that there are limited funds available because the debtors were in bankruptcy,” Cornfeld said.

But a fuller explanation, drawn from corporate filings, interviews, and criminal court and bankruptcy records, shows how the DOJ, after years of aggressively prosecuting opioid companies, delayed for a decade a winning criminal case against Endo. In the intervening years, Endo vastly expanded its narcotic-pill empire before executing a corporate escape plan.

Codenamed Project Zed, the plan allowed Endo to restructure its debt to retain control of the company and hand out $95 million in executive bonuses before seeking protection in bankruptcy. The result for U.S. taxpayers: Endo paid a tiny fraction — three pennies on the dollar — of the $7 billion that officials said it owed the U.S. government, including $4 billion in taxes.

Endo is not a household name. But by 2018, a year when 15,000 Americans overdosed and died on prescription painkillers, Endo and the firms it purchased had sold 33 billion opioid pills over two decades, almost three times the number sold by Purdue Pharma, the Sackler family’s OxyContin powerhouse.

Though federal prosecutors first learned about Endo’s criminal behavior in a 2013 whistleblower suit, they dropped their investigation, even as they doggedly pursued Purdue. By the time DOJ prosecutors revived the allegations against Endo early this year, the company was bankrupt.

Hundreds of lawyers, paralegals and financial advisers litigated Endo’s bankruptcy, billing more than $350 million. Some lawyers charged more than $2,000 an hour. Paul Leake, Endo’s lead attorney, said in a court filing that the bankruptcy plan “extinguished” Endo’s liabilities for “a fraction of the debtors’ total criminal and civil exposure.”

Individual opioid victims didn’t fare as well. They got just $40 million from Endo — a sum that works out to about $1,000 per victim. In comparison, people hurt by bankrupt Purdue, the poster firm for the U.S. painkiller trauma, were to share up to $750 million. Purdue victims are to receive sums ranging from $3,500 to $48,000.

Margo Siminovitch, an attorney representing opioid victims, was the fiercest critic of the plan. At the bankruptcy’s last major hearing, she told the judge that lawyers in the case earned hourly rates that “exceed what an opioid victim who’s had their life devastated is going to get.”

Endo “came with a strategy purposely intended to reduce payments to opioid victims,” Siminovitch said in an interview. “All of the [Endo] opioid victims were burned by this process, in that they were going to get virtually nothing.”

Profiting From Pain Management

Spun out of DuPont Merck in 1997, Endo — the name is Greek for “inside” — set out to make money “in the changing landscape of pain management,” and for 20 years it did just that.

The company started with Percocet: It upped the per-pill opioid dosage and whipped up sales through promotions and a contest among salespeople where BMW corporate cars were the prize. Revenue soared.

Endo’s next big bet was Opana ER, an extended-release painkiller that won the Food and Drug Administration’s approval in 2006. Opana ER became its flagship opioid, Endo’s answer to Purdue’s OxyContin. Endo launched the brand with a $48 million marketing campaign and began, in a phrase Endo used internally, “hyper-targeting” heavy opioid prescribers.

To ease deep-seated concerns over opioid addiction, Endo also linked up with other pharma companies to try to reshape the public image of prescription narcotics. The firm poured millions into advocacy front groups, notably the American Pain Foundation, which contended doctors feared opioids “because they mistakenly think their patients will become addicted.” The foundation shut down the day a Senate committee announced it was probing the industry groups.

Larry Romaine, Endo’s senior vice president for sales, told subordinates in a 2012 voicemail that salespeople had to be “laser focused” on selling Opana ER. “If we have reps out there, I don’t care who they are, that can’t sell Opana ER clinically, they can’t be with Endo. OK?” he said.

His voicemail and other material from inside Endo, including emails, became public court records in lawsuits filed against the company.

Endo declined to comment for this story and would not respond to detailed questions sent to the firm. Former Endo employees, including those whose communications were entered into court records and are cited in this story, did not return emails and phone calls seeking comment.

In an email sent in 2009, Endo sales manager Bret Anderson wrote to his team, referencing requirements to identify and cut off doctors who prescribed suspiciously high volumes of opioid drugs, with a warning that if too many doctors were flagged it could hurt business. “I also consider the rule: ‘if you are not aware of any major issues, it is probably not a problem.’”

At Endo’s headquarters, Linda Kitlinski oversaw Endo’s education programs for doctors for 16 years. In 2009 she sent an email to her husband documenting her concerns that “Endo’s senior leadership” was pressuring her to improperly use her program as a sales tool. Soon after she raised these issues internally, her boss called her into his office and warned her that she had nearly been fired because she was “an impediment to the business.” She needed to stop “playing policeman.”

When Endo salespeople alerted bosses to dangerous doctors, lawsuit testimony revealed that the company, unlike other manufacturers, never reported those suspicions to the Drug Enforcement Administration. Those reports were required by law.

In Alabama, Endo sales reps made 1,200 visits to a Mobile clinic where two doctors wrote “thousands of Opana ER prescriptions after Endo knew the clinic to be engaged in abuse,” the government said this year in its criminal case against Endo. Prosecutors said the clinic had a crowded waiting room with intoxicated customers, armed guards and medical staff “abusing controlled substances on-site.”

In Knoxville, Tennessee, where Endo sold more Opana ER pills than in New York City, Los Angeles and Chicago combined, a sales rep reported to supervisors that one doctor had “patients waiting in the parking lot in lounge chairs,” and “it is just a matter of time before the DEA closes him down.”

In Pittsburgh, more than 100 pharmacies refused to fill prescriptions for a reckless doctor, yet Endo continued to supply him. He was the nation’s largest Opana ER prescriber, according to an Endo email.

Doctors in those clinics were eventually sentenced to prison.

Separately, records show that of Endo’s 20 biggest Opana ER prescribers in the Medicare program in 2016, four clinic operators would later be convicted of running multimillion-dollar pill mills. A fifth would lose her medical license for dangerous prescribing.

As it became clear that opioids were causing a health crisis, Endo came up with a response. It engineered a new, purportedly safer pill with a hard outer shell to make it more difficult to extract the active opioid, branding it as Opana ER “with Intac Technology.”

But there was a big problem: The FDA found the retooled drug to be no safer than the old version. For three years, the agency warned Endo that the pill could be “readily prepared for injection” — an even riskier high than snorting because of the danger of sharing needles.

Within Endo, Bob Barto, the vice president for regulatory affairs, warned in a 2010 email against using the Intac slogan “because we don’t have any data to demonstrate that the technology conveys any benefit to the patient.”

Endo leaders didn’t drop the marketing approach. In the new drug’s slogan, the company said the pills were “designed to be crush resistant,” stopping short of saying they actually were crush resistant.

In early 2012, William Best, an Endo executive who dealt with regulators, emailed internally to say he was comfortable with promoting Opana as designed to be safe. While acknowledging that the language might provoke FDA disapproval, Best wrote, “it is likely to be a warning letter.”

As the company began selling its new formulation, the firm declared in marketing material: “At Endo, we are doing our part to limit abuse.”

Warning Signs for Endo

In 2013, a whistleblower emerged from the Endo salesforce. Her name was Loretta Reed.

A veteran in the pharma industry, Reed had worked for Endo for seven years when she filed a lawsuit in Philadelphia federal court alleging that top executives were intent on selling the updated version of Opana ER as safer, despite the FDA’s rejection of that claim. The 50-year-old’s job was to market Endo’s pain drugs to doctors in the Atlantic City, New Jersey, area.

Endo leaders distributed marketing gimmicks, notably kits with samples of Opana ER’s new hard covering, Reed disclosed. Salespeople deployed the kits, she said in the suit, to demonstrate the toughness of the pills, pounding samples with hammers and microwaving them — the kinds of misleading tactics cited later as part of Endo’s guilty plea.

But while hammering and microwaving demonstrated the new pill’s exterior strength, it left doctors uninformed about the other ways the narcotic active ingredient, oxymorphone, could be extracted by abusers, including by cutting, chewing, grinding and heating the pills for injection.

Endo’s marketing was “purposely designed to fraudulently manipulate prescribing physicians,” Reed’s suit charged. She said the company’s management misled the sales force about the FDA’s concerns.

Indeed, Endo’s own research, provided to the FDA in 2016, showed that many users switched to shooting up when abusing the product.

In 2017, a senior medical adviser with the Centers for Disease Control and Prevention investigated the role Opana ER had played in an HIV outbreak in Indiana after doctors diagnosed 135 people with the disease, all of them tightly concentrated in a rural county. Narcotics users had extracted the oxymorphone from Opana ER and shot it up, with many sharing needles.

In his report, the CDC investigator quoted a drug user as saying that once Opana ER added its hard cover, “You had to cook them. … It pretty much forced me to have to inject really.”

Said another: “I couldn’t find any [original] Opanas or other pain medicine to snort. It became almost non-existent. So I was turned on to shooting up. So that’s pretty much how that went down.”

Reed’s allegations of mislabeling were strikingly similar to those made by an Endo salesperson eight years earlier. In a 2005 federal lawsuit, sales rep Peggy Ryan had reported that top executives had relentlessly pushed the sales force to sell the nonopioid shingles drug Lidoderm off-label for everything from sore backs to carpal tunnel. Ryan declined to comment for this story.

Federal prosecutors had embraced Ryan’s suit, using her to gather evidence. Ryan wore a wire for the FBI for two years. The criminal investigation advanced slowly, but in early 2014, Endo admitted it had illegally misbranded Lidoderm. It paid a $192 million fine and signed a “corporate integrity agreement” promising to improve its ethics. The deal permitted it to keep doing business with Medicare, despite a law mandating that criminal pharma firms be cut off.

As for new whistleblower Reed’s allegations involving Endo’s leading narcotic painkiller — a far more dangerous drug than Lidoderm — the Justice Department took them seriously at first. Federal officials put together a task force of prosecutors and FDA investigators.

By the fall of 2014, eight months after charging Endo over Lidoderm, prosecutors had decided to end their probe regarding Opana ER, Philadelphia court documents show. That led Reed to withdraw the case in 2015. Prosecutors would not discuss their reasons for dropping the Opana ER investigation.

The Justice Department did not answer questions in detail for this article, but in a statement it praised the deal it finally reached with Endo this year that “secured a victory for American taxpayers and other stakeholders.”

Reed’s lawsuit aside, Endo still saw promise in opioids. New chief executive Rajiv De Silva, who took charge in 2013, executed an ambitious acquisition strategy, taking on debt to buy Par Pharmaceuticals, a maker of generic opioids that was churning out billions of pills a year, for $8 billion.

The timing was terrible. After Endo’s expensive wager on Par, the national conversation over opioids darkened. Tens of thousands had overdosed and social costs exploded. Cities and counties across the nation, linking up with aggressive personal-injury law firms, sued opioid players at every rung of the business, from pillmakers to distributors to pharmacies to doctors. More than 40 state attorneys general joined together to demand compensation from opioid firms.

In 2017, the FDA held two days of emotional public hearings on Opana ER that laid bare its dangers.

Not long after, the agency asked Endo to take Opana ER with Intac Technology off the market, a first in modern times for an approved opioid. If Endo didn’t remove the drug, the FDA said it would. Endo complied. By then, Endo had made $543 million in profits over six years selling the painkiller.

In 2018, federal prosecutors subpoenaed opioid-related records from Endo. After the FBI contacted Reed, now living in Florida, about the allegations made in her withdrawn Philadelphia case, her lawyer, Eric Young, refiled the whistleblower suit in Florida. But it would be another five years before federal prosecutors would bring criminal charges against Endo.

Launching Project Zed

As the feds delayed, Endo acted.

Facing a growing wave of lawsuits, Endo spent heavily on legal fees — ultimately paying $345 million. Its fierce legal strategy generated its own controversy as Endo’s leading defense firm, Arnold & Porter, faced repeated allegations that it wasn’t fighting fair.

One New York state prosecutor in a civil trial accused the law firm of “concealing vast troves of smoking-gun evidence proving Endo’s grave misconduct.”

In California, a judge barred testimony from former Endo senior director Kitlinski after Arnold & Porter and other defense law firms did not turn over her 2009 memo.

In Tennessee, the legal hardball became a debacle for both Endo and Arnold & Porter. A judge there held them in contempt and found that they had engaged in “a coordinated strategy” to deprive opponents of information. The judge demanded that Arnold & Porter apologize to the court and that its attorneys take an ethics refresher class.

Arnold & Porter declined to comment, but referred reporters to previous statements. The firm said at the time it had acted in good faith and regretted that any document had been produced late. It said its lawyers had worked hard to locate and turn over all relevant documents and had even offered to pay for additional depositions to go over issues raised in any belatedly revealed material.

Endo turned to another big law firm, Skadden Arps in New York, to deal with a declining business and potential bankruptcy. From Endo’s perspective, the lawyering here proved more successful. Skadden Arps helped develop a plan that Endo confidentially codenamed Project Zed.

When companies declare bankruptcy, all the businesses and people who are owed money file proofs of claims to be paid. These creditors are divided into groups, and those with the strongest legal claims are placed in higher tiers for payment — and thus are more likely to recover funds.

Distressed companies have gotten aggressive with rearranging debt so that some creditors may leapfrog others through a process called “uptiering.”

Endo completed sweeping uptiering transactions in 2019 and 2020, putting liens on assets and replacing unsecured debt with secured debt. Endo said its uptiering under Project Zed gave the firm time to seek settlements for opioid lawsuits by extending debt deadlines.

But the uptiering also shrank the funds available to deal with Endo’s opioid liability. State attorneys general initially sought $3.3 billion from Endo for its role in the epidemic, according to bankruptcy court records. They lost bargaining power, though, as the business declined and Endo uptiered debt. Before Endo filed for bankruptcy, the state prosecutors settled for $274 million.

In total — including pre-bankruptcy lawsuit settlements with a few individual states and payments to private organizations and victims — Endo paid about $635 million for the ravages of the opioid crisis.

In their deal, the Sacklers and Purdue agreed to pay $6 billion in compensation, with most of the money going to state and local governments. Teva and Allergan, pharmaceutical companies that merged their generic opioid businesses, are to pay $6.5 billion.

Mallinckrodt, the nation’s biggest opioid pill maker, agreed to pay $1.7 billion in opioids damages in 2022 in its first bankruptcy. It filed a second bankruptcy last year and cut its payment to $700 million.

In the Endo bankruptcy, lawyers for opioid victims and other unsecured creditors labeled Project Zed a scheme to wall off assets, alleging it amounted to fraud. Endo denied the fraud allegations.

“It’s all the more unfortunate,” attorneys for opioid victims and unsecured creditors said in court filings, “that the victims of Endo’s conduct in this should also be the victims of the opioid crisis from which Endo profited handsomely.”

In interviews, legal experts called uptiering a dangerous trend. Opioid victims are “kind of like sitting ducks,” Berkeley Law professor Kenneth Ayotte said. Opioid victims, he said, “don’t have contracts to protect themselves against these transactions.”

As it failed to pull out of a financial tailspin, Endo accelerated bonuses to about two dozen executives. Records show a total of $95 million was paid in less than a year.

Four days after the last bonus round of $22 million was paid to chief executive Blaise Coleman and his three top lieutenants, Endo filed its bankruptcy petition in federal court in New York. The total Endo paid its top bosses dwarfed the controversial $7 million in pre-bankruptcy bonuses granted to a handful of Purdue executives.

The bonuses immediately came under fire from a federal bankruptcy watchdog, opioid victims and many creditors. The critics told U.S. Bankruptcy Court Judge James Garrity Jr. that the payouts violated a law, championed by then-Sen. Ted Kennedy, D.-Mass., nearly 20 years ago after scandals involving windfalls paid to executives of bankrupt firms, most notably Enron.

In interviews, professors who specialize in bankruptcy said that the bonuses appeared to be an end run around Kennedy’s reforms. “It looks like pre-petition theft,” said Gregory Germain, a widely published bankruptcy expert at the University of Syracuse.

Skadden lawyer Lisa Laukitis defended the bonuses in a bankruptcy hearing. “These are not windfall payments that were made to line the pockets of executives on the eve of the filing,” she said.

The bankruptcy went on for months. Hedge funds and other investors — led by GoldenTree Asset Management, a New York firm that specializes in buying distressed debt — agreed to use their secured debt to buy Endo out of bankruptcy. In negotiations to take ownership, the group sweetened the deal by increasing the payments going to individual opioid victims and other unsecured creditors. As part of the deal, the critics dropped their complaints about Project Zed and the bonuses.

Garrity, the judge in New York, confirmed Endo’s bankruptcy plan in March. Federal prosecutors, engaged in a parallel criminal investigation of Endo, had reached their own deal. All that remained was for Parker, the judge in the criminal court in Michigan, to approve the intertwined deals.

Winners and Losers

On the afternoon of May 2 in Detroit, federal prosecutors and Endo’s defense lawyer explained to Parker how the financial penalty facing Endo had dwindled to $200 million.

Along with the criminal fine, a final “global resolution” signed by U.S. officials and Endo wiped out virtually all of the potential $4 billion IRS bill. The agreement also mostly erased claims of another $1.5 billion for false health care billing and Medicare costs generated by the opioid crisis.

Endo’s attorney, Carole Rendon, a former U.S. attorney from Cleveland, blamed the misconduct at the firm on a “very small number” of rogue salespeople.

She told the judge the company had cleaned up its act, including firing its 375-member opioid sales staff back in 2016. The firm at one point had called them “pain solution brand ambassadors.”

A near-defunct Endo subsidiary pleaded guilty to a misdemeanor, allowing the parent company to again sidestep a law barring convicted firms from doing business with federal health care programs. No Endo executives or employees were criminally charged in the case. Endo is still selling Percocet and other opioids that bring in 7% of its revenue.

With the bankruptcy case closed, law firms and financial advisers won big. Skadden Arps billed for the labor of nearly 350 lawyers and paralegals. Its total fees: $114 million.

Two law firms, Akin Gump and Cooley LLP, represented painkiller victims. In total, the lawyers and other advisers for victims are set to receive $48 million — more than the $40 million Endo’s individual opioid victims are to share in a court-approved trust.

Reed, the Endo opioids whistleblower, received a reward of about $1.9 million.

Stockholders got wiped out. More than 3,000 victims’ lawsuits were ended.

And Endo continues to reward its veteran and new top executives, setting aside more than $80 million in a stock pool for them, board members and other “key employees.” It gave former CEO Coleman a $6.1 million parachute when he resigned in August.

Individual victims still need to be compensated. If the number of individual victims holds steady, arithmetic shows they might each receive about $1,000 after administrative costs from the court-approved trust. Under the $750 million Purdue plan, the largest checks, for $48,000, were to go to family members who lost someone to a fatal overdose.

The Rappold family has filed for compensation. They lost Nicholas Rappold, 21, a kosher deli waiter and community college student. He was found slumped in his car in 2010, dead from an overdose. Rappold received various prescriptions, including for Percocet, from Dr. Stan Li in the weeks leading up to his death, according to court records from Li’s criminal trial. Li banked thousands in cash from selling painkillers at his New York City clinic to customers who lined up around the block.

Nicholas’ mother, Margaret, faulted the way Endo and other firms marketed to Li. The doctor died in prison while serving a 10-year sentence for manslaughter in the fatal overdoses of her son and a 37-year-old former stockbroker.

“Just to get sales, they don’t care what they sell,” said Margaret Rappold, 75, who works at a school cafeteria. “Whether it’s good for you or not good for you.”

While she says money would never make up for the loss of her boy, it could defray her expenses, including her son’s $14,000 funeral.

So far, the Rappolds and other families have found collecting difficult. They have had to deal with paperwork filled with legalese and footnotes, a short deadline for seeking money, an application website that didn’t work — and, most significantly, rules that barred thousands of victims from getting help.

Emily Walden, a Kentucky woman whose son, T.J. Walden, died at age 21 on a camping trip after taking Opana given him by a friend, followed the Endo saga closely until she realized that the trust will only help if victims had a doctor’s prescription for an Endo narcotic.

“These prescriptions were not falling off trucks,” Walden said. “They marketed these drugs inappropriately and wrongly and flooded the streets. They did nothing about it because money was number one.”

Some 90,000 individual victims initially filed opioid claims against Endo. Already, two-thirds of them have dropped out.

There was a time when Sharelle Menard thought her son would never be able to speak. She couldn’t soothe Benji when he cried, couldn’t read him books he could follow, couldn’t take him out in public. “The screaming, and screaming, and screaming,” she said. “He would get so frustrated because he couldn’t communicate.”

Benji was nearly 3 when he was diagnosed with severe autism and soon after started a specialized therapy to help him develop basic skills. After two years in treatment, his murmuring gave way to small words, with “bubbles” among the first. To celebrate, Menard powered up a bubble machine she found at the dollar store, and for hours, they watched the iridescent orbs drift over their porch.

Menard, who is raising Benji alone in south-central Louisiana, began to picture a future for her son that diverged from the stories she’d heard about some kids with similar diagnoses, who grew up still unable to manage their frustrations and had to live in nursing homes or institutions.

But now, she’s worried again.

The insurer that has been paying for her son’s therapy, UnitedHealthcare, has begun — to the befuddlement of his clinical team — denying him the hours they say he requires to maintain his progress. Inside the insurance conglomerate, the nation’s largest and most profitable, the slashing of care to children like Benji does have a reason, though it has little to do with their needs. It is part of a secret internal cost-cutting campaign that targets a growing financial burden for the company: the treatment of thousands of children with autism across the country.

ProPublica has obtained what is effectively the company’s strategic playbook, developed by Optum, the division that manages mental health benefits for United. In internal reports, the company acknowledges that the therapy, called applied behavior analysis, is the “evidence-based gold standard treatment for those with medically necessary needs.” But the company’s costs have climbed as the number of children diagnosed with autism has ballooned; experts say greater awareness and improved screening have contributed to a fourfold increase in the past two decades — from 1 in 150 to 1 in 36.

So Optum is “pursuing market-specific action plans” to limit children’s access to the treatment, the reports said.

“Key opportunities” are outlined in bullets in the documents. While acknowledging some areas have “very long waitlists” for the therapy, the company said it aims to “prevent new providers from joining the network” and “terminate” existing ones, including “cost outliers.” If an insurer drops a provider from its network, patients may have to find a new clinician that accepts their insurance or pay up to tens of thousands of dollars a year out of pocket for the therapy. The company has calculated that, in some states, this reduction could impact more than two-fifths of its ABA therapy provider groups in network and up to 19% of its patients in therapy.

The strategy targets kids covered through the company’s state-contracted Medicaid plans, funded by the government for the nation’s poorest and most vulnerable patients. To manage Medicaid benefits, states often pay private insurers a fixed amount of funds per patient, regardless of the frequency or intensity of services used. When companies spend less than the allotted payment, they are typically allowed to keep some or all of what remains, which federal investigators and experts acknowledge may be incentivizing insurers to limit care.

United administers Medicaid plans or benefits in about two dozen states and for more than 6 million people, including nearly 10,000 children with autism spectrum disorder. Optum expects to spend about $290 million for ABA therapy within its Medicaid plans this year, and it anticipates the need increasing, documents show. The number of its Medicaid patients accessing the specialized therapy has increased by about 20% over the past year, with expenses rising about $75 million year-on-year.

So Optum — whose parent company, UnitedHealth Group, earned $22 billion in net profits last year — is “heavily investing” in its plan to save millions by limiting access to such care.

In addition to culling providers from its network, the company is scrutinizing the medical necessity of the therapy for individual patients with “rigorous” clinical reviews, which can lead to denials of covered treatment. Optum has developed an “approach to authorizing less units than requested,” the records state.

Mental health and autism experts and advocates reviewed ProPublica’s findings and expressed outrage over the company’s strategy. Karen Fessel, whose Mental Health and Autism Insurance Project helps families access care, called the tactics “unconscionable and immoral.”

“They’re denying access to treatment and shrinking a network at a time when they clearly know that there is an urgent need,” she said.

United and Optum declined a request ProPublica made more than a month ago for an on-the-record interview about their coverage of behavioral health care. They have not answered questions emailed 11 days ago, citing the Dec. 4 killing of UnitedHealthcare’s CEO as the reason. In an email, a spokesperson said “we are in mourning” and could not engage with a “non-urgent story during this incredibly difficult moment in time.” Offered an additional day or two, the company would not agree to a deadline for comment.

Benji, who is now 10, requires 33 hours of weekly therapy to be able to progress, his therapists have concluded. They have documented the consequences of having even a few hours less: toppled furniture, scratched-up classroom aides, a kid in unremitting tears, unable to learn. But in a letter to Menard, Optum said it was refusing to pay for the full hours, stating that her son had been in therapy for too long and was not showing enough progress to ultimately graduate from it.

“Your child still has a lot of difficulty with all autism-related needs,” Optum wrote. “Your child still needs help, but it does not appear that your child will improve enough to end ABA.”

The response confounded experts who spoke with ProPublica, who said such an approach misunderstands the long-term nature of his condition. “Challenges that often come with autism shouldn’t be looked at like an injury that you’re going to get better from quickly and then the treatment can stop,” said Christa Stevens, who directs state government affairs for the advocacy group Autism Speaks. “Treatment may still be medically necessary even if it’s for skill maintenance or the prevention of regression.”

The company’s denial also appears to contrast with recent professional guidelines for the therapy — which are cited as a reference in Optum’s own clinical criteria — that state “there is no specific limit on the duration of a course of treatment.”

The appropriate duration of treatment, according to those standards and experts interviewed by ProPublica, should be based on the patients’ needs, as evaluated by the clinicians working directly with the patients.

“This is a very blunt instrument to chase after excessive costs,” said Tim Clement, the vice president of federal government affairs at the nonprofit group Mental Health America.

Several advocates told ProPublica the company’s strategy is legally questionable.

The federal mental health parity law requires insurers to provide the same access to mental health and physical care. As ProPublica recently reported, United has gotten in trouble in the past for targeting therapy coverage in a way that violates the law; while denying the allegations, it agreed to a multimillion-dollar settlement. It continues to use arbitrary and one-size-fits-all thresholds to scrutinize its therapy claims, ProPublica previously found.

It would raise legal questions if the company restricted ABA more stringently than comparable physical care, the advocates said.

“Medicaid managed care organizations are subject to the parity act,” said Deborah Steinberg, a senior health policy attorney with the nonprofit advocacy group Legal Action Center. The company may be violating Medicaid regulations, she said, which require managed care organizations to maintain networks sufficient to provide covered services to all enrollees.

Last year, the federal government formally affirmed that ABA therapy is a protected benefit, and it recently investigated health plans for entirely excluding its coverage; legislators have passed laws in every state requiring insurance companies to pay for it.

“Yes, this therapy can be expensive,” said Dan Unumb, an attorney and president of the Autism Legal Resource Center. “But solving the problem by denying kids access to medically necessary care is a terrible solution.”

“What Happens if We Withdraw the Care?”

Benji was making progress about three years ago.

For more than 33 hours a week in the specialized therapy, his clinicians broke down the learning process into basic steps, using repetition and positive reinforcement to affirm behaviors. The state’s Medicaid contractor, UnitedHealthcare, covered the bill.

Researchers have found that about a quarter of kids diagnosed with autism are severely affected; these children are often minimally or non-speaking or require extensive assistance for basic daily needs. “Things a lot of people take for granted,” said Menard. While experts continue to debate which therapies are most effective and appropriate for these kids, ABA is one of the most widely recommended.

By 7, Benji had accumulated a few dozen words, and his aggressive, prolonged tantrums had grown less frequent, allowing his mother to take him grocery shopping and to mass on Sundays. It was time for him to go to school, she thought.

Menard enrolled him in their public school district, St. Martin Parish. He attended Breaux Bridge Primary twice a week in a special education classroom and continued therapy the other days. Menard urged the district to allow a therapeutic technician to shadow him in school, but it refused. (The district declined to respond to ProPublica’s questions, citing privacy restrictions.)

With the diminished hours of treatment, Benji grew increasingly disruptive. “It was a disaster,” said Menard. He snapped a swing in gym class and struggled to sit still during lessons. When teachers tried to give him instructions, he hit them. His speech plateaued and eventually regressed.

Menard, who cleans pools for a living, grew to fear the moment her phone rang. School employees, unable to soothe Benji’s tantrums, frequently called her to take him home. One morning last spring, they told her Benji had lashed out when an aide tried to persuade him to work, aggressively poking their hand with a pencil. He hadn’t broken the skin, but after a dozen incidents, the situation was becoming unsalvageable. The district made her sign a behavioral contract, his second in two years: If Benji didn’t behave, he could be suspended or expelled.

Menard felt she had no choice but to withdraw Benji. She enrolled him full time in a home-study program run by his therapy group, Aspire Behavioral Health Center in Lafayette, which costs about $10,000 a year in tuition, a substantial portion of her paycheck. That was in addition to the therapy cost, which his insurance still covered.

Benji’s clinicians determined he needed direct support for most of the day and told Optum they wanted him to scale up his therapy from 24 hours a week to 33. They expected the insurer would approve the request; after all, it was less than what was previously covered and only nine hours more than it was currently paying for.

But Optum denied the increase in a letter to Menard this past May. “Your child has been in ABA for six years,” the insurer wrote. “After six years, more progress would be expected.”

The response disturbed Whitney Newton, Benji’s behavior analyst and a clinical director at Aspire; it didn’t seem rooted in the established medical standards for the treatment. She’d seen firsthand how critical the therapy had been to his growth. “We know what he needs. It’s in our scope of practice and it’s our right as the provider to determine that,” she said. “They’re cutting and denying an unethical amount.”

The center’s founder, psychologist Joslyn McCoy, has grown accustomed to battling insurers. Her practice serves about 160 patients between the ages of 2 and 19 across five centers, and many have Medicaid coverage. In 2022, Louisiana expanded its Medicaid parameters, allowing parents with higher incomes to access coverage for children with complex medical needs.

“What I’m seeing is that children now have this ticket to access this care, but then once they go to try to access it, it’s being denied,” she said.

Nearly two years ago, Optum selected her center for a payment integrity audit, demanding to inspect its clinical and billing records. After her team turned over thousands of pages of documentation, Optum conducted a separate in-person quality review.

Internal company records show Optum is targeting ABA providers for scrutiny based on how much they invoice and how many services they provide. Groups like McCoy’s can be be flagged for patterns that providers told ProPublica are are typical in the delivery of ABA therapy: billing on weekends or holidays, serving multiple family members in one practice, having long clinician or patient days, providing an “above average delivery” of services, or abruptly increasing or decreasing the number of patients or claims.

McCoy said that a company executive who visited her office for the quality review told her that she approved of the center’s work and thought Aspire should expand across the state.

But Optum has continued to challenge her patients’ individual therapy claims.

When her team received the denial for Benji’s care, McCoy set out to gather hard evidence to demonstrate the necessity of his treatment. “It’s what we call a reversal to baseline, where we will withdraw the treatment for a short period of time,” McCoy said. “The reason is to demonstrate what happens because we’re curious, too: What happens if we withdraw the care?”

Much of the therapy is driven by positive reinforcement; for example, if Benji pays attention and engages in his academic exercises, he can take a break to play on his iPad. But the reward is contingent on him not hitting anyone for at least 10 minutes at a time. During the experiment, the clinicians took away the possibility of his reward, and without an incentive, they had limited leverage to manage his behavior.

At first, Benji lightly hit the staff, they said, as though testing the limits. But when there was no response to his behavior, it began to escalate. He tossed chairs and flipped tables. He pushed Newton into a bookshelf, which collapsed to the ground. He hit walls and windows, eventually turning his fists on his aide. They stopped the experiment early, both for his safety and theirs.

Once they resumed the interventions, Benji was able to calm down.

Newton drafted a report, including line charts that quantified his behavior with and without the interventions and photographs of her team’s injuries. She faxed it to Optum, asking the company to reconsider the denial.

The insurer did not change its decision.

“The Need Is Not Going Away”

Last month, inside a cubicle decorated with posters of Minions and Mario Brothers, a behavior technician placed a laminated card with an image of a sneaker in front of Benji.

“What is this?” she asked him.

Benji paused, rubbing the edge of his baseball cap and pursing his lips. “Sh,” he said, stuck on the consonant.

“Shoes, that’s right,” the technician responded. She pulled out another card, showing a slice topped with white frosting. “Is this cake?”

“No,” Benji said.

“Is this cake?” she repeated, before adding, “yes.”

“Yes,” echoed Benji, but her correction appeared to frustrate him. He hit the technician on the leg, softly but with determination.

“We’ll let it go,” she warned with a sugared voice, “but hands to self, OK?”

After 10 minutes, a timer beeped. It was time for Benji’s reward, getting to hear a reggaeton hit by Daddy Yankee. “It’s a big reinforcer here,” Newton said.

Even though Optum denied the additional hours of treatment, Benji has continued to receive them. “We’re giving the hours even if they were not approved,” McCoy said. “We don’t think it would be safe for him to do what the insurance is saying.”

Next month, a state administrative law judge will hear an appeal for the additional hours. If the request is approved, Benji’s clinicians will be paid for the six months of services that they’ve provided without reimbursement.

Even if that happens, their battle with the insurer will go back to square one. Each insurance authorization typically lasts for only six months, and soon after the hearing date, the clinicians will have to request coverage for his treatment again.

They will be doing so at a time when internal records show Optum has deployed more than 90 “care advocates” to question clinicians about the medical necessity of their patients’ ABA treatment, using “quality initiatives to decrease overutilization and cost.”

Optum is focusing on states whose Medicaid plans yield the highest costs for ABA therapy, including Arizona, Nebraska, Tennessee, Virginia, New Jersey, Indiana and Louisiana, where Menard and her son live. ProPublica reached out to the state Medicaid programs with questions about their oversight of United’s practices. Arizona’s Medicaid agency told ProPublica that all managed care organizations, including United, are required to provide timely services within their networks, and that the agency has been closely monitoring ABA networks. (Read its full response.) No other state Medicaid agencies responded to ProPublica’s questions.

Autism experts said such a strategy may not only be harmful to children, it could also ultimately be more expensive for states, as children age and require more intensive services, like residential or nursing care.

“If these kids get the intervention they need as children, then there will be tremendous cost savings over the course of their lives,” said Lorri Unumb, an attorney and CEO of the Council of Autism Service Providers.

Menard worries about what will happen to her son’s hard-fought gains if he can’t get the level of therapy he needs. And even if the additional nine hours are approved, she fears that with the next authorization, they could face a more drastic denial that could be challenging to overturn.

“This motivation and momentum — when you lose that,” she said, “it’s so hard to get it back.” She doesn’t believe that Benji needs to be fixed or cured or changed from who he is. She just hopes the therapy helps him to be better able to advocate for himself and, ultimately, be safe. “There’s nothing else that I’ve known to work,” she said.

McCoy resents being put in the position of scaling back care that her patient needs because an insurer is refusing to pay. “It puts us in a tough place, because we don’t want to discontinue therapy of our client who’s not ready,” she said.

When such denials become common, it disincentivizes clinicians from working with insurance companies, she said, and can ultimately drive clinics into the ground. “The patients can’t afford it,” she said, “so eventually the private provider goes out of business.”

But even if children like Benji get pushed out of treatment, there is no shortage of children seeking care. McCoy’s center currently has a waitlist of about 260 children.

That list may likely expand. Internal documents show Optum is aiming to exclude from its network about 40% of Louisiana groups that offer ABA therapy. About 1 in 5 children whose treatment is covered by the company's Medicaid plan in the state could lose access to care.

“If the insurance company wants to deny all of our clients, we’re going to replace them,” she said. “The need is not going away.”

The night the EMTs carried Elizabeth Nakagawa from her home, bleeding and in pain, the tarp they’d wrapped her in reminded her of a body bag.

Nakagawa, 39, is a Coast Guard commander: stoic, methodical, an engineer by trade. But as they maneuvered her past her young daughters’ bedroom, down the narrow steps and into the ambulance, she felt a stab of fear. She might never see her girls again.

Then came a blast of anger. She’d been treated for a miscarriage before. She knew her life never should have been in danger.

Earlier that day, April 3, 2023, Nakagawa had been scheduled to have a surgical procedure called a D&C, or dilation and curettage, to remove fetal tissue after losing a very wanted pregnancy. But that morning, she was told the surgery had been canceled because Tricare, the military’s health insurance plan, refused to pay for it.

While her doctor appealed, Nakagawa waited. Then the cramps and bleeding began.

In recent months, ProPublica and other media outlets have told the stories of women who died or nearly died when state abortion restrictions imposed after the Supreme Court’s 2022 Dobbs decision impeded them from getting critical care.

But long before Roe v. Wade was overturned, military service members and their families have faced strict limits on abortion services, which are commonly used to resolve miscarriages.

Under a decades-old federal law, the military is prohibited from paying for abortions except in cases of rape, incest or to save the life of the mother. This applies even to service members based in states where abortion is legal; Nakagawa lives in Sonoma County, California.

There’s also no exception for catastrophic or fatal fetal anomalies. In such cases, service members either have to pay out of pocket for abortions or carry to term fetuses that won’t survive outside the womb.

Tricare does allow abortions in cases like Nakagawa’s, in which the fetus has no heartbeat. But even then, some doctors who treat military service members say that Tricare requires more documentation and takes longer to approve these procedures than other insurers, putting women at risk.

“There definitely have been cases where our Tricare patients have required emergency services, emergency D&C procedures, blood transfusions, things that have been critical to lifesaving care because their procedure had yet to occur,” said Dr. Lauren Robertson, an OB-GYN who has served military members and their spouses in San Diego for more than a decade.

“It just feels very unnecessary.”

Since the Dobbs decision, abortion care for service members seems to be coming under heightened scrutiny, said retired Rear Adm. Dana Thomas, who was until recently the Coast Guard’s chief medical officer and advocated for Nakagawa.

“Trust me, post Roe v. Wade, I’m sure people felt there was much more of a spotlight,” Thomas said. “I think they were more guarded after June of ’22.”

After being rushed to the emergency room, Nakagawa hemorrhaged for four more hours before doctors performed the surgery Tricare had refused to authorize. Later, Tricare and Defense Department officials would all agree that Nakagawa should have been treated as her doctor recommended, and she said they told her they’d taken steps to prevent future mistakes.

But her experience, which doctors say nearly cost Nakagawa her life, laid bare the challenges service members have long faced in obtaining reproductive health care. And it raises questions about whether the Supreme Court’s ruling has created a chilling effect that has further complicated access to these procedures.

Officials at the Defense Health Agency, which runs the military health system, including Tricare, did not respond to specific questions from ProPublica, but they provided a statement saying its policies haven’t budged.

“There have not been any changes to Tricare coverage or documentation requirements for medically necessary care of D&Cs following the Supreme Court’s Dobbs decision,” the statement said. “Medically necessary care was, and continues to be, covered.”

The agency declined to answer questions about Nakagawa, saying that “as a matter of practice” it doesn’t discuss individual beneficiaries’ care. (ProPublica is involved in an unrelated public records lawsuit with the DHA.)

As a senior officer, Nakagawa felt duty-bound to press for answers about what happened to her.

“The abortion policy, in theory, is supposed to protect life, and in my case it did the opposite,” Nakagawa said. “It almost led to my children not having a mother.”

After the Supreme Court upended Roe, the Biden administration took steps to reassure service members that their access to reproductive health care would remain unaffected by a wave of state abortion bans.

An October 2022 memo from Defense Secretary Lloyd Austin pledged to facilitate leave for service members seeking abortions that were not covered by Tricare, and to pay for travel if care wasn’t available nearby. It also emphasized that these procedures would be “consistent with applicable federal law.”

The statute barring the Defense Department from paying for most abortions goes back to 1985 and mirrors language in what’s called the Hyde Amendment. Named for its author, Henry Hyde, a Republican representative from Illinois, Congress has attached the amendment to spending bills since the late 1970s to prohibit the use of federal funds on abortion.

With Congress in control of military spending, abortion care is highly politicized, said Kyleanne Hunter, a Marine Corps combat veteran and senior political scientist at RAND Corp. “There’s been a lot of backlash and a lot of scrutiny and a lot of congressional disapproval as to how the DOD has engaged with abortion care, D&C care and the like.”

About 9.5 million people, including active-duty service members and their families as well as military retirees and their dependents, rely on Tricare for health services. Women make up a growing portion of the active-duty force, more than 17%. They also leave the military at higher rates. Research by RAND and others suggests the military’s reproductive health policies may make it harder to recruit and retain them.

Dr. Toni Marengo, a former Navy OB-GYN, said she left the service in part because she felt unable to provide patients with appropriate care. Many of them only discovered how sharply Tricare’s policies curtailed access to procedures like D&Cs when they needed them.

“It was like living in a pre-Roe world,” said Marengo, now chief medical officer at Planned Parenthood of the Pacific Southwest.

The effects have been felt for decades. In 1994, Maureen Griffin and her then-husband, a captain in the Air National Guard, ended her pregnancy after learning their baby had anencephaly, a fatal birth defect. They found out the military considered her induced labor an abortion when she got a phone call from a bill collector for the hospital seeking thousands of dollars in reimbursement for the procedure.

“I said: ‘We have full coverage. My husband’s in the military.’ And they said, ‘They don’t pay for abortions,’” Griffin recalled. “We were completely blindsided. I mean, no one called it an abortion. It was a horrible tragedy.”

Griffin, then known as Maureen Britell, was so outraged that she sued the Defense Department, winning a judgment in federal district court in 2002. Two years later, an appeals court reversed the decision, upholding the Defense Department’s refusal to cover abortions in such circumstances.

Twenty-five years after Griffin’s pregnancy, Samantha Babcock spent the equivalent of seven paychecks to fly home from her husband’s Air Force base in Okinawa, Japan, for an abortion Tricare wouldn’t cover.

She was five months pregnant when doctors told her that her fetus had multiple abnormalities and wasn’t viable.

The grief was crushing. Then she found out that, by law, the military couldn’t perform or pay for a surgery called a D&E, or dilation and evacuation, which her military doctors agreed was the safest option. She and her family paid $14,000 — most of it for plane tickets — with help from a GoFundMe so that she could go home to Portland, Oregon, to get the procedure.

She still can’t believe such a step was necessary.

“I assumed Tricare had my best interest at heart,” she said. “If the condition was fatal, why wouldn’t they help me?”

Babcock said her specialist told her that the military would pay to transfer her temporarily to Hawaii for more testing. They also offered to move her family to a location where they would have access to specialty care for the baby in the unlikely chance she survived outside of the womb.

For Babcock, that was untenable. “I did not want to keep growing a baby that wouldn’t live,” she said.

In August 2022, Thomas, the Coast Guard’s chief medical officer, was galvanized into action when a service member sought help to end her pregnancy after receiving a diagnosis similar to Babcock’s.

Doctors had recommended that, like Babcock, she have a D&E. Because the fetus still had a heartbeat, Tricare would not approve the procedure.

Thomas called Tricare daily trying to find a solution, then elevated the case to leaders at the DHA, which sets policy for the health plan. “We have to do something,” she told them.

Tricare stuck to its denial even after the service member’s doctor appended a note explain­ing that continuing the pregnancy would endanger the patient’s life.

That was the first case Thomas had taken on after Dobbs.

The second was Nakagawa’s.

Nakagawa and her husband, Matt, met a couple years after earning engineering degrees from the Coast Guard Academy in the mid-2000s. Their path to a family was long and bittersweet. In 2015, they suffered a miscarriage. A year later, their first daughter was born. Then came a second miscarriage, followed by the birth of a healthy girl.

For the next three years, they tried for another child. Then Nakagawa got pregnant in 2021, only to learn at 10 weeks there was no fetal heartbeat. She waited, hoping to miscarry naturally, then tried abortion pills.

When a follow-up exam showed she hadn’t passed all the fetal tissue, her OB-GYN scheduled a D&C. The procedure was approved by Tricare, and she had the surgery soon afterward.

By early 2023, Nakagawa had risen to become chief of engineering at the Coast Guard’s training center in Petaluma, California, and her husband had left the service and was supporting her as a stay-at-home dad. They were thrilled to learn she was pregnant, only to have their joy turn to devastation when two ultrasounds showed that once again, her fetus had no heartbeat.

This time, since abortion pills hadn’t worked in 2021, Nakagawa and her OB-GYN agreed the best course would be to schedule a D&C as soon as possible. Her doctor’s office scheduled the procedure for Monday, April 3, and requested approval in advance, or prior authorization, from Tricare.

Then, five hours before the procedure was scheduled to begin, the office told Nakagawa the surgery was canceled — Tricare had refused to cover it.

In its denial letter, Health Net Federal Services, the contractor that administered claims for Tricare’s western region, said the services requested were “not a covered benefit.”

The insurer’s letter also said it had requested additional information from Nakagawa’s doctor, but that the information had not been sent. (Health Net declined to answer questions from ProPublica about Nakagawa even though she waived her right to privacy.)

Her doctor maintains that wasn’t the case. She declined to be identified, citing concerns about safety.

“Tricare has always been difficult to work with for coverage of women’s health care — they require records more than other insurances — this often creates a delay in care,” the doctor said via text.

The office staff appealed the denial, telling Nakagawa they’d provided documentation of the ultrasounds showing no fetal heartbeat. The staff also told her a Tricare medical director wasn’t available to review it that day and that it might take an additional three to five days to get a response.

Nakagawa called Tricare for answers herself, only to be told her options were to wait or pay out of pocket — not only for the surgery but for any follow-up care, including mental health counseling.

“It was surreal. I was angry and shaking,” Nakagawa said. She couldn’t understand why Tricare had approved her D&C in 2021 under similar circumstances, then denied the same care two years later.

Overwhelmed by emotion, she climbed into bed and cried herself to sleep.

At about 5 p.m., her doctor provided a prescription for abortion pills as a backup plan. But before Nakagawa could pick it up, she started to miscarry.

The first signs were mild cramping and spotting. Soon after, the fetus passed. Nakagawa yelled for her husband and sobbed. They consoled themselves with the thought that they’d made it through the hardest part.

“At least this is over,” Nakagawa recalled saying. “At least God’s giving us a break for once.”

Then the hemorrhaging started — fist-sized clots of blood that soaked through sanitary pads in minutes. Nakagawa lay in the fetal position on towels, in so much pain she couldn’t sit up.

Around 9 p.m., her husband called the doctor, who recommended they go to the emergency room.

At the hospital, she was given fluids, a clotting drug and a transfusion, but her bleeding continued.

After four hours, doctors decided her condition was critical and they needed to intervene. They performed a D&C to remove the remaining tissue.

Nakagawa’s recovery took more than a week. Lying on her couch, unable to walk, she was determined to ensure other service women would get the care she was denied. Taking a risk, she banged out a long email to Thomas, who had a reputation for being approachable.

“I feel compelled to report a traumatic experience I went through that will undoubtedly impact more women in the CG and DOD if the TRICARE policy is not changed,” the email began. “The summary is that I nearly lost my life last week due largely to a TRICARE policy regarding miscarriages and abortions.”

Thomas connected Nakagawa to the Defense Health Agency’s chief medical officer, Dr. Paul Cordts, who called her personally a month after her emergency surgery.

Nakagawa said that Cordts seemed apologetic and even angry on her behalf. “This shouldn’t have happened to you,” she recalled him saying, adding that he’d get to the bottom of what went wrong. (Cordts didn’t respond to emails from ProPublica.)

Two days later, a new record appeared in Nakagawa’s Tricare file: a letter approving the scheduled D&C she’d never received and no longer needed. “Please contact the provider to schedule your appointment(s),” it said.

Cordts also arranged for Col. John Verghese, Tricare’s chief of clinical oversight and integration, to look into her case. Nakagawa said she had two calls with Verghese, who looped in a senior official at Health Net, the Tricare contractor that had dealt with the request to cover her D&C.

In one, she said, Verghese acknowledged Tricare had become more conservative in reviewing requests for D&Cs, requiring more documentation to justify approving these procedures. (Verghese, who has retired, declined to answer questions from ProPublica about the case.)

He admitted that until her case, Tricare hadn’t understood that delaying or denying care could put women at risk, she said. This infuriated Nakagawa.

“I just said, ‘Well, maybe you didn’t realize there would be physical negative consequences, but you had to know there would be mental and emotional consequences to making women carry around their [dead] fetuses’” after a miscarriage.

Verghese quickly apologized, she said.

On the final call, Nakagawa said that Verghese and the Health Net official told her that from now on, they would no longer require doctors to submit proof of no fetal heart tones to get approvals for D&Cs and would speed up reviews of appeals.

In its statement to ProPublica, the DHA maintained that Tricare’s coverage and documentation requirements for D&Cs have not changed.

Nakagawa is one of few women in senior leadership within Coast Guard civil engineering. She remains committed to serving in the military. But she worries about the impact the Defense Department’s reproductive health policies could have on service members and their spouses and daughters. Junior members especially might be less able to advocate for themselves, she said.

“At the very least, this policy will likely encourage women, like myself, to work for a company that has insurance that will cover these procedures,” she said, “At the worst, it will lead to service members or their dependents losing their lives.”

This didn’t happen during the Trump administration, which separated more than 4,000 migrant children from their families under its controversial “zero tolerance” policy. Marina was separated from her baby in April of this year. The 40-year-old former restaurant manager came to the U.S.-Mexico border with her husband, mother-in-law and child to seek asylum. More than eight months later, she and her mother-in-law remain in federal immigration custody in Louisiana. Her husband is detained at a different Louisiana immigration facility. And Aleksandra is over a thousand miles away, being cared for by strangers in foster care in California.

Aleksandra is one of around 300 children the Biden administration has separated from their parents or legal guardians this year, according to two government sources who asked not to be identified because they hadn’t been authorized to speak about the separations. Most of the cases involved families crossing the southwestern border, the sources said. These numbers haven’t previously been reported.

Similarly, 298 children were separated from their parents in 2023, according to a government report to Congress published on Tuesday, even as overall migrant crossings have declined. According to the report, the average amount of time children separated between April 2018 and October 2024 have spent in federal custody before being released to a sponsor is 75 days.

The Department of Homeland Security, Customs and Border Protection, and Immigration and Customs Enforcement did not respond to multiple requests for comment on the numbers or on Marina’s case.

Those officials who did speak about the separations did so on the condition they not be identified. They said the current separations are not similar — in either character or scale — to what was happening during the Trump administration. Its zero tolerance policy directed authorities to detain and criminally prosecute all immigrants caught illegally crossing the border and to separate them from their children if they were travelling together. Biden administration officials say they have only separated families for reasons according to longstanding immigration practices, including when they have concerns about the parents or the safety of the children. Some of those concerns are related to suspicions about abuse, criminal histories or threats to national security.

The administration reports the numbers of separations to Congress and to lawyers at the American Civil Liberties Union who have been charged with providing oversight. However, those reports give few details about the reasons for the separations, especially in cases where parents have been flagged for national security reasons. Around 80 of the children separated between December 2023 and November 2024 were in that category, one of the government sources said, and some 50 of those were Russian, like Aleksandra. The second source said at least 10 of the Russian children who were separated this year are still in government custody.

In cases involving national security, the government can withhold its rationale even from the families themselves, making it hard for them and their lawyers to contest the separations or mount a defense. And some advocates have been reluctant to talk publicly about the current separations, much less call out President Joe Biden’s administration, as they press for the government to resolve their clients’ cases and fear the incoming Trump administration could apply the same standards more broadly to separate more families in the future.

Family separations at the border did not begin with the zero tolerance policy and didn’t end when it was lifted, said Talia Inlender, deputy director of the Center for Immigration Law and Policy at the University of California, Los Angeles School of Law, which wrote a report on family separations going back to the Obama years and before. She said that while Trump’s policy was unprecedented because of how expansive it was, the scant information that the government provides about separations at the border has been common practice across administrations.

“I think the lack of transparency creates a lack of accountability,” she said, “and that is by design.”

“Where there is room left for agency discretion,” Inlender said, “that’s really where we need to make sure that there are eyes on what is happening, so that these exceptions, or these grey areas, don’t become the rule.”

During telephone interviews with Marina and her husband, conducted through a translator, the couple said they hoped by breaking the silence on their case, they might get answers about why they were separated from their daughter and get her back. They asked to be identified only by their first names because of their pending deportation cases.

Marina said that she and her husband Maksim, who worked as a supplies manager at a construction company, had met at a restaurant where Marina worked in Moscow. They married in 2021 and tried for years to have a child before Alexsandra was born.

Maksim said he started going to antigovernment protests in support of opposition leader Alexei Navalny and later against Russia’s invasion of Ukraine. According to an affidavit Marina gave as part of her asylum case, she said Maksim had been detained, questioned and on one occasion beaten up by police after protests. ProPublica could not independently corroborate the accounts of his political activity. They both said Marina wasn’t involved in the protests and had asked him to stop attending them. Eventually the family decided to leave the country, fearing government reprisals.

After researching the best routes into the U.S. online, they said they bought tickets to Dubai, Mexico City and Tijuana, which sits on the border with California. Once in Tijuana, Marina said they waited for six months for an appointment after using a U.S. government app known as CBP One to apply for permission to approach the border and ask for asylum. They were finally granted a slot and allowed to cross in mid-April.

But instead of being released to pursue their asylum claim, Marina said she and Aleksandra were held in a cold cell at a Border Patrol detention facility. She said she was given only formula and vegetable purees for Aleksandra. She smashed up bread from her own sandwiches to give her daughter extra food. At the time Aleksandra was learning to walk and was always moving around; she had just started to talk.

Then, after several days, Marina said she and her baby were surrounded by border officials who told her the adults would be detained and Aleksandra would be taken away. She said one of the agents handed her a note that read: “CBP has made this decision for the following reason: You are being taken into custody for presenting a public safety or national security risk.”

Recalling the desperation she felt upon seeing the note, Marina wrote: “Why would that be? I didn’t even have an interview!!!”

She said she became catatonic after a Border Patrol agent took her daughter by the hand and led her away.

“I thought I died at that moment.”

Her experience might sound familiar to anyone who followed the news about the thousands of separations carried out by the Trump administration. Its zero tolerance policy first began as a pilot program in 2017, but the administration denied its existence until spring 2018. Even then, authorities refused to make public the details of how the policy was being implemented, including where the children were being held, how many of them were in custody, or even how the separations were conducted.

In June of 2018, ProPublica obtained audio that had been recorded in a Border Patrol facility of wailing children who had been separated from their parents. Among them was a 6-year-old girl, pleading to make a phone call to her aunt. That audio triggered a bipartisan outcry that led the administration to announce the end of the policy 48 hours later. And a federal lawsuit brought by the ACLU forced the administration to reunify the children in its custody with their families.

That reunification effort continued even after Trump left office. Biden, who called zero tolerance a “a moral and national shame,” formed a task force to finish the reunifications shortly after taking office. It found that some parents had been deported without their children and remained separated years later. Biden promised going forward that his administration would not separate children from their parents “except in the most extreme circumstances where a separation is clearly necessary for the safety and well-being of the child or is required by law.”

Biden’s Justice Department negotiated a settlement with the ACLU allowing it to disperse assistance to the families that had been harmed by zero tolerance. Under the terms of the deal, signed last December, future family separations were only allowed in “limited” circumstances, including when parents are deemed a threat to the child, have an outstanding arrest warrant or need to be hospitalized.

The settlement also said separations were allowed when government officials found parents or legal guardians could pose “a public safety or national security risk to the United States,” including people suspected of terrorism or espionage. But in those cases the agreement says that the government is not required to provide documentation of the reason for its decision if it would mean disclosing sensitive information.

Such cases could include instances when migrants’ names come up on an international watch list, said a third government official, who, like the others, spoke on the condition of anonymity. In June of this year, the U.S. Treasury Department sanctioned two Uzbeks and one Russian national for alleged links to an ISIS-linked human smuggling network that the State Department said facilitated travelers coming to the United States.

“If they are looking into cases more deeply and then people are let go after they found out the information they had was not correct,” the official said, “it’s still pretty difficult to say we shouldn’t go ahead and make those checks if we need to pay extra security attention in these cases.” Sometimes, the official said, authorities are able to quickly resolve any security concerns and reunite the families.

Advocates do not disagree that sometimes separations are warranted, said Lee Gelernt, an ACLU attorney and the lead lawyer in the family separation lawsuit. And they said they understand the sensitivity of sharing information that could put the country at risk.

However, when asked whether the Russian cases highlight the potential pitfalls of the agreement the ACLU made with the administration, Gelernt said that the government “cannot create a loophole and place everything in the black box of national security.”

He added that if the exceptions become “an excuse to circumvent the bar on separations, we will return to court.”

With Biden leaving office soon, it’s the incoming Trump administration that most worries the advocates. Trump made stopping border crossings and mass deportations a centerpiece of his campaign and says they are part of his Day 1 plans for when he takes office, but when asked several times in an interview over the weekend if he would revive the zero tolerance policy, he said: “We’ll send the whole family, very humanely, back to the country where they came. That way the family’s not separated.”

Inlender wasn’t convinced that Trump wouldn’t ramp up family separations. “With any loopholes that exist in policies, any loopholes that exist in the settlement agreements, I think there is always a danger when you have an incoming administration that has already both shown itself willing, and in some cases able, to inflict cruelty to separate families, that they will use any tools at their disposal,” Inlender said.

The children who were separated from their parents for national security reasons in the past year came from a range of countries, including Romania, Turkey, Ukraine, Lebanon, Iran, Kyrgyzstan, Armenia, Colombia and Venezuela, the two government sources said. The majority, however, came from Russia. In fact, only one Russian child separated from their parents this year was listed as being separated for a reason other than national security, they said.

None of the officials interviewed could say whether Russian families had been flagged for special scrutiny. The 50 Russian children separated last year represent a very small share of the overall Russian border crossings. According to CBP data for the 2024 fiscal year, which began last October and ended in September, 7,137 Russian families crossed the southwestern border, almost all of them through legal ports of entry like Marina’s family.

The secrecy surrounding Marina’s case has meant the government has not told her or her lawyer any more specific reason for her detention and prolonged separation from Aleksandra. Marina’s New York-based attorney, Elena Denevich, said in an email that while she has filed a series of parole requests for Marina since May, “the requests were denied based on unspecified ‘national security concerns.’” Denevich said DHS “has provided no evidence or explanation to substantiate this allegation.”

The Office of Refugee Resettlement, which is part of the Department of Health and Human Services and oversees migrant children, said it could not comment on individual cases and referred questions about enforcement to DHS. ORR, which earlier this month had only published data on family separations through January 2024 on its website, updated its site with nine new reports from February through October this week.

In addition to interviews, Marina shared her four-page handwritten account of the separation after translating it herself into English using a tablet provided to her in detention. ProPublica reviewed court documents and spoke to Maksim’s stepfather, who crossed the border months earlier but was released to pursue an asylum claim.

Marina’s family has joined a class-action lawsuit brought by more than 150 detained Russian-speaking asylum seekers against the government claiming they are systematically being denied parole by ICE because of their nationalities. Maksim’s stepfather says he has been working nonstop as a long-haul truck driver to pay for legal fees as he fights for the release of his family. ICE said it could not comment on pending litigation.

After their separation, Marina, stuck in detention, said she had to wait three months before she was finally allowed to speak with her daughter on the phone in July. Beginning in August, they were allowed weekly video calls. Because the family Aleksandra is staying with doesn’t speak Russian, Marina has asked them to put on Russian YouTube videos from time to time so her daughter can listen to people speaking her native language. She says Aleksandra looks healthy and like she is being well taken care of, surrounded by toys and wearing new clothes. She is grateful for the foster family, who points to the screen and says “mama” when they talk to remind her who her mother is, but she breaks down crying when talking about how the separation has affected her.

“I’m just trying to take care of myself because my little daughter needs a healthy mom. But because she is so little, I feel really bad. I am starting to fall apart, both mentally and physically,” Marina said from detention. She said she is having trouble sleeping and experiencing a series of worsening health problems.

Not knowing the reason behind their family’s separation is agonizing.

“I don’t have the slightest clue why they did this to us.”

For most working Americans, paying their share of the taxes that fund Medicare is an unavoidable fact of life. It’s so automatic for many workers that they may not even realize it takes a bite out of every paycheck. In theory, everyone is required to contribute to the country’s health insurance program for seniors, no matter how poor or rich, from cashiers to CEOs.

Not on Wall Street. There, some of the most powerful people in finance found a way to opt out.

The trove of tax records behind ProPublica’s “Secret IRS Files” series contains plenty of examples of billionaire financiers who avoided Medicare tax despite earning huge amounts from their companies. In 2016, Steve Cohen, the owner of the New York Mets, paid $0. So did Stephen Schwarzman, head of the investment behemoth Blackstone. Bill Ackman, the headline-grabbing hedge fund manager, was able to shield almost all his income from the tax.

How do they do it? Business owners, like any self-employed person, whether they’re a freelance Uber driver or a hedge fund manager, have the responsibility to declare their self-employment earnings on their tax returns. Indeed, the vast majority of small-business owners have no choice but to do so and pay the same taxes that wage earners pay, including Medicare.

But high-priced tax advisers, wielding a once-obscure bit of the tax code, found a way to make that obligation vanish. By carefully channeling profits through a company in a way that invokes that obscure provision, even a Steve Cohen, with a tax return showing he received hundreds of millions in profits from his hedge fund, can exempt that income from Medicare tax.

The three billionaires contacted for this article said they followed the law as written. They also pointed to the fact that they paid substantial income tax, which for them carries a much higher rate. Medicare tax is 2.9% for most people and 3.8% for high earners.

But these maneuvers by the rich hasten Medicare’s future crisis. Sometime in the 2030s, the program’s trust fund is due to run dry. Closing the loophole, along with eliminating other ways around the tax for wealthy business owners, could raise more than $250 billion over 10 years for Medicare, according to recent government estimates.

Over the past three years, ProPublica has mined the tax records of the rich to detail the many ways they avoid taxes. We’ve focused on basic structural features of the U.S. system that advantage them. We’ve uncovered maneuvers of questionable legality that seem to have escaped the notice of the IRS. The Medicare tax loophole occupies a gray area. The IRS definitely knows about it, but it’s unclear if the agency will be able to stop it.

The potential of the loophole first surfaced in the 1990s, and the IRS soon expressed the view that active business owners shouldn’t be allowed to exploit it. It was only in recent years, however, that the agency got tough. Today, the IRS continues to battle what it considers a serious abuse, waging a rare, long-shot campaign to prevent some of the nation’s wealthiest citizens from using the loophole.

The story of how America’s richest financiers avoid paying Medicare tax gives unique insight into the peculiar, messy way taxes work in the U.S. No one set out to create the loophole when it first entered the tax code in 1977. But a series of seemingly unrelated policy changes, together with a revolution in how American businesses are structured, conspired to deliver a major tax advantage to the wealthy. On Capitol Hill, interest groups have successfully defended that advantage, branding any effort to close the loophole as a tax hike on Main Street businesses.

Approaching its 50th birthday, the loophole, for now, lives on.

Fixing One Problem, Creating Another

Over the 2010s, years of budget cuts sliced deep into the IRS’ enforcement muscle. Audits, especially those of the wealthy and corporations, plummeted. In response, agency leaders decided to conduct a kind of triage and focus the IRS’ dwindling might on the most pressing and addressable problems. Among the agency’s early priorities was to curb the widespread use of the Medicare tax loophole.

Beginning in 2018, the agency began hunting for business owners who, in its view, were abusing the law. It launched over 80 audits aimed at hedge funds, private equity firms, consultancies and similar businesses. Cohen’s firm was just the sort of thing the agency was looking for.

Before Cohen became popular as the approachable, gap-toothed, sweater-wearing Mets-fan-in-chief, he was a controversial figure on Wall Street, the inspiration for the legal-risk-taking hedge fund lead character in the Showtime series “Billions.” Cohen made his fortune through his original hedge fund, SAC Capital, known for rapid-fire trades with a remarkable track record. In 2013, SAC pleaded guilty to five criminal counts of securities and wire fraud, agreeing to pay $1.8 billion in penalties and effectively shut itself down. Cohen was not personally charged. Turning the page, he soon formed a new hedge fund, Point72.

The IRS’ audit of Point72 focused on one thing: how the profits had flowed to Cohen. In 2015, his firm earned $125 million from clients, and the money was routed to him through Point72 Asset Management LP.

Those last two letters, which stand for limited partnership, were Cohen’s key to accessing the loophole.

For most of the last century, before hedge funds and private equity firms dominated Wall Street, limited partnerships played a very specific role. They allowed investors, as limited partners, to buy into a business — often oil drilling or real estate development — without the usual risks of ownership like being pursued for the business’s debts.

But by the 1970s, creative uses of limited partnerships proliferated. One variety caught Congress’ attention. Government employees were covered by public pensions and thus were not eligible for Social Security, but brokerages were pitching these employees on limited partnerships as a way around that. The government workers could buy a small share of a business and receive self-employment income that qualified them for future Social Security benefits.

The scheme was condemned by both parties. After all, Social Security was meant to reward people’s labor, not their investments. Only income earned by someone actively running a business should count toward Social Security.

The solution, Congress decided, was to exclude most income earned by limited partners. It wouldn’t count toward self-employment income and, as a result, wouldn’t be subject to self-employment tax, which goes to Social Security and Medicare. As part of a major 1977 Social Security reform bill, this soon became the law.

It seemed like an easy fix. At the time, limited partners were, as a rule, passive investors. The line between the two types of partners that made up a limited partnership was real: General partners ran the business, and limited partners didn’t.

“Limited partners were historically forbidden under state law from getting too involved in the business,” said Susan Hamill, professor of law at the University of Alabama. “If they got involved at all, they would simply be treated as general partners, and the liability shield would be stripped away from them.”

Lawmakers assumed things would continue as they’d always been. They didn’t. The 1977 law, it turned out, had passed at the dawn of a new age, one where limited liability became standard for business owners, not a special condition with strings attached.

A new business structure, the limited liability company, exploded in popularity in the ’90s. LLCs limited the legal liability of all owners regardless of their role. Limited partnerships morphed into something that functioned similarly. After the change, the fact that someone was a limited partner said nothing about what they did for the business. They could be the CEO or a passive investor. It became common for owners to serve as both limited and general partners.

In this new world, the 1977 law was no longer a narrow exclusion. It was a broad grant of tax avoidance to anyone with a canny tax adviser.

Point72 Asset Management LP was part of the trend.

To take advantage of the loophole, Cohen needed to channel his firm’s profits through a limited partner before the money reached him.

One obstacle, it might seem, was that Cohen was one person. How could he partner with himself? That part was simple. A partnership requires at least two partners, but they can be companies or people. Cohen created two business entities, each wholly owned by him. One became the limited partner, the other the general partner.

Over 2015 and 2016, Point72 Asset Management earned $344 million in profits; 99.98% of that went to the limited partner and was declared exempt from Medicare tax. While those profits were subject to the 40% income tax rate (as much as $136 million in tax), Cohen’s returns showed $0 in self-employment income both years, helping him avoid up to $11 million in Medicare tax.

The IRS audited those returns and determined that the full $344 million was self-employment income. Last year, Point72 challenged that finding in court in a case that continues to this day. A spokesperson for Cohen declined to comment, citing the ongoing litigation.

“A Nasty Little Tax Increase”

Almost as soon as LLCs began their rapid spread, IRS officials recognized the possibility of widespread avoidance of self-employment tax. The problem became more urgent after 1993. Since its beginning, Medicare tax had, like Social Security, been capped. But Congress, in need of more revenues to support Medicare, eliminated the cap. Suddenly, avoiding Medicare tax might save a business owner millions of dollars instead of, in 1993, under $4,000.

In 1997, the IRS proposed a rule that would dictate how the 1977 law should be interpreted. A limited partner would mean essentially what it had meant back in 1977, when the term described passive investors. People who worked more than 500 hours (about three months) annually for the business could not be a limited partner under Section 1402(a)(13), the loophole’s place in the tax code.

IRS rule proposals are usually soporific affairs closely watched only by tax practitioners. But in early April 1997, fax machines in Republican congressional offices spat out a message that ended this rule’s obscurity.

The IRS was about “to slip through a nasty little tax increase on America’s partnerships,” the memo read. It was from Steve Forbes, the millionaire magazine publisher and 1996 Republican presidential candidate. He’d centered his self-funded campaign around the idea of a “flat tax,” under which he promised “the IRS would be RIP.” Now he was rallying his party against what he called a “stealth tax increase.”

His message reached Rush Limbaugh, the conservative radio host, who was then at the height of his influence. Soon after Limbaugh mentioned Forbes’ faxed memo on his nationally syndicated show, Speaker of the House Newt Gingrich, a Georgia Republican, called in.

Congress would “intervene directly,” Gingrich promised. “And as you yourself pointed out earlier, we didn’t get elected to raise taxes. We got elected to lower taxes and simplify them and to end the IRS as we know it,” he said.

“Now, folks, that is fast action,” Limbaugh boasted.

A coalition of powerful trade groups hurriedly formed to pressure Congress to follow through on Gingrich’s vow. The rule change would raise taxes by more than $1 billion over the following decade, they estimated, and must be stopped.

The coalition represented businesses that were both small and decidedly not small (among the members were the U.S. Chamber of Commerce and the Securities Industry Association). But their message emphasized the rule’s impact on the “small business community.”

In fact, most small-business owners already paid Medicare and Social Security taxes. Then, as now, the most common form of small business was the simple sole proprietorship, taxspeak for a business with a single, human owner.

By July, the coalition had prevailed. A short provision of a major bill, the Taxpayer Relief Act of 1997, forbade the IRS from issuing any new rule “with respect to the definition of a limited partner” in the next year.

The IRS had been roundly rebuffed. It would be almost two decades before the agency would seriously consider trying again.

In the meantime, the options for business owners to skirt Medicare tax multiplied. New forms of partnerships arose, and the subchapter S corporation, which offered its own loophole around Medicare tax, emerged as an even more popular vehicle. The breadth of the tax avoidance meant that opposition to closing those loopholes would be even fiercer the next time there was a major threat.

“100% Political Fear”

In early 2010, President Barack Obama’s administration and a Democratic Congress were struggling to pass the Affordable Care Act when they hit on a way to help fund it. The proposal boiled down to an expansion of Medicare tax. Whereas before it had only applied to income from work, now, for high earners, it would extend to investment income like dividends and capital gains. The rate would also go from 2.9% to 3.8%.

But, while new forms of income would now be subject to the tax, the proposal intentionally left huge gaps. It wouldn’t touch the ability of business owners to use loopholes to avoid Medicare tax and would even limit their exposure to the new tax on investment income.

Why create a new, complicated tax that favored some forms of income over others, asked Jason Furman, then a member of Obama’s National Economic Council. In a meeting with Obama and his advisers, Furman advocated for a simple, uniform version of the tax that would also close the loophole, he said. The president agreed on the merits, Furman said. But arousing the opposition of the business lobby could endanger the whole bill. It wasn’t worth the risk. “It was 100% political fear,” Furman said.

A monumental health care reform effort like the ACA was already controversial, and members of Congress were looking to get it passed, said Robert Andrews, a former New Jersey Democratic representative and lead negotiator on the bill. They chose the funding option “with the least political risk,” he said.

“This was an ugly compromise, and I think we knew it was an ugly compromise and worth it for the greater good,” Furman said.

Pushing Around the Edges

As the years passed and no legislative fix came, the IRS vacillated on what to do about the limited partner loophole. The Treasury Department decides which tax regulations to pursue, and under the Bush and then the Obama administration, there wasn’t appetite for another bruising fight over a new rule. At the same time, IRS officials decided they couldn’t ignore what they viewed as widespread abuse of Section 1402(a)(13).

They decided on a middle path, said Curt Wilson, who in 2008 became the senior IRS attorney overseeing partnership issues. “We looked for places where we could push around the edges, so to speak,” he said.

This wasn’t a crusade. But in audits, when the opportunity presented itself, the agency cracked down on what it saw as abuse of the loophole. Agents focused on some of the newer forms of partnerships that had sprouted since 1977. LLCs were the prime target.

“We were looking at hedge funds, private equity firms, things like that where there were big dollars,” Wilson said. The goal was to make a splash with a precedent-setting case.

Landing that big case proved elusive. Instead of fighting it out in court, taxpayers were content to privately settle the audits with the IRS’ appeals division, Wilson said. The IRS did its best to send a message, releasing an advisory letter in 2014 to a hedge fund that said the fund’s LLC members didn’t qualify as limited partners. But that wasn’t a binding rule, and it fell short of a headline-grabbing court decision.

What’s more, the IRS risked playing Whac-A-Mole. Even if the agency succeeded in dissuading taxpayers from using the loophole with LLCs, business owners could simply register their business as a limited partnership instead. As the granddaddy of partnerships with limited liability, the LP, the original limited partnership, offered taxpayers the strongest claim for invoking the loophole.

ProPublica’s database of IRS data includes the tax returns of thousands of wealthy business owners through 2018. These titans of capitalism, despite huge flows of ordinary income, often reported remarkably little self-employment income in the 2010s. The LP appears to have been their favored variety of partnership.

In 2017, Bill Ackman earned $413 million in income through an LP operated by the hedge fund he manages, Pershing Square, famous for taking activist stances in companies. As was typical in other years, Ackman reported self-employment income of $4.7 million, a small fraction of his total business earnings. The difference meant he paid $142,000 in self-employment tax instead of more than $13 million.

In a statement, a spokesperson said: “Mr. Ackman has followed the advice of his tax advisors whose interpretation of the law has been the industry standard since 1977. Should the law change, Mr. Ackman will of course adjust his tax payments accordingly.”

In 2018, at least $143 million flowed via a Blackstone LP to Stephen Schwarzman, the firm’s CEO. As in years past, he exempted the income from Medicare tax. Schwarzman, who sits atop an investment firm with over $1 trillion in assets, reported no self-employment income at all in five of the seven years between 2012 and 2018.

“Mr. Schwarzman is one of the largest individual taxpayers in the country and fully complies with all tax rules,” a spokesperson said.

Attacking Head-On

The IRS’ announcement of its audit campaign in 2018 meant the agency would stop pushing around the edges and unleash a frontal assault: Its audits would target not just the newer form of partnerships but also LPs.

This time, after years of audits and appeals within the IRS, the agency finally got its splashy court case. Many taxpayers chose to settle, but Cohen’s partnership and at least five others took their cases to tax court, the first in 2022. All argued they were following the law.

Soroban Capital, a hedge fund, was audited after converting to an LP from an LLC. Demonstrating the gulf between owners and employees, Soroban’s three partners collected $142 million in income over the two years of the audit, while paying a total of $74 million in salaries and wages (subject to Medicare tax) to the fund’s staff.

Soroban’s founder, Eric Mandelblatt, was once an employee. His compensation from Goldman Sachs cost him $128,000 in Medicare tax one year, according to ProPublica’s IRS database. After he started his own hedge fund and began earning tens of millions more, his Medicare tax bill never exceeded a third of that, the records show. Soroban did not respond to requests for comment.

In 2023, the IRS won a major tax court decision against Soroban. The “limited partner exception of I.R.C. § 1402(a)(13) does not apply to a partner who is limited in name only,” the court said, because Congress had only intended to “exclude earnings from a mere investment.” A “functional analysis,” the court said, was needed to determine whether a partner was really “limited.”

With the Soroban decision, the loophole entered a new stage in its history. It’s the most serious challenge since 1997 when, protected by Congress, the loophole emerged not only unscathed but stronger. This time, it’s up to the federal judges who will be reviewing appeals of the tax court’s rulings in the IRS’ cases.

One of the audit targets, Sirius Solutions, a consultancy, has already sought a more sympathetic venue than the U.S. Tax Court. Last summer, it turned to the 5th U.S. Circuit Court of Appeals, known for its conservative bent. Industry groups representing the hedge fund and real estate industry have filed amicus briefs. Tax law experts told ProPublica they are skeptical the IRS’ position will ultimately prevail.

Still, amid this uncertainty, the Treasury Department and IRS last year announced plans to start work on a regulation for Section 1402(a)(13). It’s a process that could take years if it isn’t halted by the incoming administration. If a new rule is finally released, it might again face a hostile Congress. It would also be subject to challenge in the courts.

As has always been the case, the simplest solution is for Congress to change the law. Democrats will keep trying, said a former senior congressional aide, especially when they propose some new expensive initiative and need ways to pay for it.

Including a fix for the Medicare tax loopholes is “a beautiful pay-for,” he said. “It’s real money, and there are not a lot of options sitting around that are this obvious and relatively straightforward technically.”

The last attempt came a couple years ago, when Democrats needed to cover the cost of their $2.4 trillion climate bill. Build Back Better, as it was initially called, passed the House with a provision similar to Furman’s gap-plugging tax. The proposal was estimated to raise $252 billion over 10 years.

But the bill stalled in the Senate, where Democrats needed every vote. In the summer of 2022, negotiations suddenly approached consensus on a new, slimmer bill, soon dubbed the Inflation Reduction Act. The gap-plugging tax was part of the mix.

As they had 25 years before, business groups quickly rallied. Several dozen trade groups co-signed a letter to congressional leaders. The National Federation of Independent Business launched radio ads. “Now Congress is considering a brand-new tax on West Virginia small businesses, an additional tax wrongly characterized as the closing of a loophole,” ran one ad targeting Sen. Joe Manchin, one of the two key swing votes.

When a deal was finally announced on the bill, the proposal was gone. There had been other, less politically dangerous options to raise revenue.

Last month a major shareholder of a publicly traded company took to social media to complain that people — perhaps short sellers — were spreading lies that could hurt his firm’s stock price.

“There are fake, untrue, and probably illegal rumors,” the post read. “I hereby request that the people who have set off these fake rumors or statements, and who may have done so in the past, be immediately investigated by the appropriate authorities.”

The Securities and Exchange Commission doesn’t typically take its marching orders from shareholders on social media. But in this case, the poster was Donald Trump, who’s just weeks away from being inaugurated and gaining the power to appoint the head of the SEC.

When Trump takes office in January, a president will for the first time be the majority owner of a publicly traded company, Trump Media, which runs Truth Social. Former SEC officials are concerned about how Trump could try to use the agency to go after the foes of his company, which accounts for more than half his fortune. They also worry that the agency isn’t up for the job of taking on Trump Media should it run afoul of securities laws.

Cases involving public companies with aggressive lawyers are difficult “even if you don’t have conflicts of interest and concerns about pissing someone important off,” a current employee in the SEC’s enforcement division said. “I don’t think anyone would explicitly say, ‘Don’t do it,’ but they’d just be like, ‘I could do another case.’”

In Trump Media’s short history, it has had a combative relationship with the SEC, though it has never been charged with wrongdoing by the agency.

In 2022 as Trump Media was seeking to go public, which it did through a merger with an already traded company, it threatened to sue the SEC because of what it called “inexcusable obstruction” and “obvious conflicts of interest among SEC officials and clear indications of political bias.” CEO Devin Nunes posted on the platform, “NO MORE BS!” The company never sued.

The following year, the company that took Trump Media public settled fraud charges with the SEC for $18 million after the agency found it made misrepresentations in its filings. The SEC also brought insider trading charges against several people who invested in the deal.

Other, previously unreported issues have raised alarms inside the company that Trump Media could be violating securities laws by misleading investors, according to a person with knowledge of the company.

The company has long reported in its disclosure filings that it does not track basic performance numbers for Truth Social.

In its securities filings, the company says it “does not currently, and may never, collect, monitor or report certain key operating metrics used by companies in similar industries,” such as the number of active users and ad views. It has always been a puzzling claim — akin to a TV network choosing not to track ratings. Other publicly traded social media companies do track and report such fundamental measures of success for their platforms.

But according to interviews and records reviewed by ProPublica, the company does track the numbers, and the active user count is a tiny fraction of its competitors’. ProPublica reviewed images of an internal Truth Social employee dashboard from 2022 showing the company monitored the number of active users. Internal communications from this year show the practice continued.

The SEC investigates those types of discrepancies, experts said. Securities laws prohibit companies from knowingly misleading investors about information deemed to be significant to the company’s share price.

In a statement, Trump Media accused ProPublica of “willfully misrepresenting TMTG’s public filings and the content of stolen information” and relying on “unreliable individuals with known axes to grind.” The statement also alleged ProPublica was “conspiring with others to engage in market manipulations and fraud, and we will bring evidence of this malfeasance to the relevant local, state, and federal officials.” The company did not respond to a request to explain what was “misrepresented.”

While current and former SEC officials doubt the SEC will aggressively regulate Trump Media, the company is relatively small. The agency’s oversight of companies owned by Trump associates will also be fraught and could have broader market implications. Elon Musk’s Tesla, for example, is more than one hundred times the size of Trump Media. Musk has for years fought bitterly with the SEC. He settled a securities fraud case with the agency and later declared that, “Something is broken with SEC oversight.” After Musk became one of Trump’s most important financial backers, Trump appointed him to lead a commission to target government spending it deems wasteful.

Securities experts warned that if the SEC fails to aggressively regulate companies connected to the president or his allies, it could have disastrous consequences.

“If political power buys the power to defraud, that’s a problem, not just for our politics but for our markets. American companies have an easier time getting capital because there is faith in the way the American capital markets are regulated,” said Howard Fischer, an SEC trial lawyer during Trump’s first term.

Created after the stock market crash of 1929, the SEC is part of the executive branch but operates independently of the White House. Presidents appoint the agency’s chair, who leads a five-member commission that includes members of both parties. The agency’s nearly 5,000 employees report to that commission as they do the work of regulating the securities industry.

“How much impact is the president supposed to have on the SEC's day-to-day operations? The answer is none,” said Allison Herren Lee, a former Democratic SEC commissioner appointed during the first Trump administration.

The line between the SEC and the president on enforcement actions has been crossed before. President Richard Nixon’s aides pressured the SEC’s general counsel, G. Bradford Cook, to remove a reference to a financier’s illegal contribution to the Nixon campaign from an SEC complaint against the executive. Nixon then installed Cook as the SEC’s chair. But after the meetings with Nixon’s aides were revealed, Cook resigned as chair, saying “the effectiveness of the agency might be impaired” because of the perception of undue influence.

If Trump tries to make enforcement demands of the SEC, as he did in his Truth Social post calling for an investigation of short sellers, SEC officials would face a choice: either ignore the president and risk his wrath, or follow his orders and undermine their independence. Former SEC officials interviewed by ProPublica predicted a middle path, in which the agency would not seriously investigate baseless claims against the company’s foes but would claim it was doing so to satisfy him.

The co-director of the SEC’s enforcement division during Trump’s first term told ProPublica he knew of no instances of Trump getting involved in enforcement decisions during his first term.

“We didn’t have issues of political interference,” said Steven Peikin, who is now in private practice. “We investigated some significant political figures.”

The Trump-era SEC investigated former Rep. Chris Collins, a Republican Trump ally from New York, who pleaded guilty to insider trading. Trump later pardoned him. The agency also investigated former Republican North Carolina Sen. Richard Burr for insider trading after the coronavirus stock market crash. (Burr said the case was ultimately dropped.)

Still, during his first term, Trump did not shy away from asking the SEC to consider specific regulatory changes. In 2018, for example, he tweeted that after speaking with “some of the world’s top business leaders,” he had asked the agency to consider allowing companies to stop filing quarterly reports and move to twice-a-year reporting.

“This was highly unusual,” Lee, the former SEC commissioner, told ProPublica.

Trump’s SEC chair at the time, Jay Clayton, said the agency was looking into “the frequency of reporting,” before rejecting the idea months later.

Though Clayton was generally popular among the SEC’s staff, his chumminess with Trump, including multiple rounds of golf together, did raise concerns about his independence.

In 2020, Clayton was asked during a House hearing if he ever discussed SEC matters with Trump during their golf outings. “There are no conversations that I’ve had that make me in any way — in any way — uncomfortable with my independence,” he testified.

While the SEC investigates possible civil violations of securities law, it is up to the FBI and Department of Justice to pursue criminal cases. Trump’s selections to lead both those agencies in his second term have ties to his social media company: Kash Patel, the FBI pick, is on the Trump Media board. Pam Bondi, selected to be attorney general, was identified in an April filing as owning a stake in the company worth more than $4 million at current prices. It’s not clear if she still owns the shares. (Bondi did not respond to a request seeking comment.)

If federal authorities shy away from scrutinizing Trump Media, securities experts said the void could be filled by state authorities, who Trump has no authority over.

“I wouldn’t be surprised if we saw blue state securities regulators opening investigations,” said Andrew Jennings, a law professor who teaches securities regulation at Emory University.

New York’s attorney general has already entered the fray. Letitia James’ office is examining an emergency loan provided to Trump Media before it went public from a trust connected to a bank in the Caribbean, according to records and a source with knowledge of the probe.

Last month, the Financial Times reported that Trump Media is in talks to buy a crypto trading venue called Bakkt. If that deal is consummated, it would be Trump’s second crypto venture following the September launch of a Trump-affiliated token by a company called World Liberty Financial.

Trump’s crypto investments create yet another area of potential conflict of interest with the SEC, whose current Democratic chair, Gary Gensler, led an enforcement campaign against the crypto market, which he described as rife with fraud and scams.

On Wednesday, Trump announced his nominee to chair the SEC: Paul Atkins, a Bush-era SEC commissioner who has spent the last seven years as co-chair of a crypto advocacy group.

Deregulating crypto was a theme of Trump’s campaign, with Trump telling a crypto conference over the summer: “The rules will be written by people who love your industry, not hate your industry.”

One month after Missouri voters approved a constitutional amendment guaranteeing the right to abortion, Republican lawmakers in the deeply red state are already working to overturn it — or at least undermine it.

One measure would ask voters to amend the state constitution to define life as beginning at conception, declaring that embryos are people with rights to life, liberty and the pursuit of happiness.

The result would be to classify abortion as an unlawful killing.

Another proposal, aimed at repealing the abortion rights amendment, would ask voters to ban gender transition procedures for minors, tying the two issues together, despite the fact that the amendment did not address gender surgery and gender-affirming care for transgender children is already illegal in Missouri.

Other proposed amendments include stricter abortion limits, such as restricting access to cases of rape, incest, medical emergencies and fetal anomalies. These measures would impose additional requirements, such as mandating that rape survivors file police reports to obtain an abortion.

GOP lawmakers have also introduced a measure to raise the threshold for amending the state constitution through voter initiatives, which could make it harder to pass similar measures in the future.

The legislative moves follow the Nov. 5 election, in which the amendment to put abortion rights in the state constitution won by a 51.6%-48.4% margin. Starting Thursday, the right to abortion will be constitutionally guaranteed up to the point of fetal viability, while restrictions on post-viability abortions will remain in place.

In other states where voters approved abortion rights measures last month, there were no signs yet that lawmakers would also try to counter those measures.

Even before votes in Missouri had been counted, proponents of Amendment 3, as the measure was called, had anticipated that a victory would be met with efforts to somehow undercut abortion rights.

“These people will continue to rail against abortion,” said state Rep. Deb Lavender, a Democrat from the St. Louis suburbs.

Although Missouri already has a law recognizing life as beginning at conception, stating that unborn children have “protectable interests in life, health, and well-being,” the proposed constitutional amendment would go further. It would effectively elevate this principle to the state constitution and potentially complicate not only abortion rights but the legality of in vitro fertilization and the handling of embryos.

Several states have laws recognizing fetal personhood, but Missouri would be the second — after Alabama — to enshrine it in its constitution. That could create legal and ideological confusion or even conflicts, experts say.

“You could see voters saying, ‘I support a right to abortion,’ but also saying, ‘Life begins at conception,’ without understanding that you can’t have both of those things at the same time,” said Jamille Fields Allsbrook, a professor at St. Louis University School of Law and a former policy analyst for Planned Parenthood Federation of America.

The author of one of the personhood measures, Rep. Justin Sparks, a Republican from the St. Louis suburbs, said he was emboldened by the narrow margin of the abortion rights vote.

“A clear mandate has not been achieved,” he said. While the amendment had strong support in metro St. Louis and Kansas City and in the county that’s home to the University of Missouri, “the vast majority of the rest of the state voted in a different direction,” he added. “So I think it’s fair to again bring the question up.”

But state Sen. Tracy McCreery, a Democrat also from the St. Louis suburbs, noted that Sparks was going against the will of voters in the St. Louis area. “I find that even more disrespectful of the voters,” she said. “It wasn’t just voters that tend to vote Democratic that voted yes on Amendment 3. It was also Republican voters and independent voters, and I think that’s getting lost in this discussion.”

The measure to link abortion and transgender rights reflects the campaign before the election, when abortion opponents conflated these topics. Critics said this strategy seeks to distract from abortion rights, which had strong voter support, by capitalizing on voter discomfort with transgender issues.

While GOP lawmakers push these measures, the legal landscape around abortion in Missouri is already shifting. On Wednesday, a Jackson County Circuit Court heard arguments in a lawsuit brought by Planned Parenthood and the American Civil Liberties Union of Missouri that seeks to strike down Missouri’s near-total abortion ban and other laws that regulate abortion. The lawsuit followed the passage of Amendment 3. Planned Parenthood said if it wins in court it plans to resume abortion services in St. Louis, Kansas City and Columbia on Friday.

Missouri Attorney General Andrew Bailey has acknowledged that the amendment will legalize most abortions when it goes into effect, but he has said he intends to enforce remaining restrictions, such as a ban on abortions after fetal viability, a 72-hour waiting period and parental consent for minors.

Lawmakers are also pushing to raise the bar for passing constitutional amendments. Now, a simple majority is enough; that has allowed Missouri voters to bypass the legislature and pass progressive amendments that lawmakers oppose. A new bill would ask voters to pass a constitutional amendment requiring not just a statewide majority but also a majority of voters in five of the state’s eight congressional districts — a change critics argued would give disproportionate power to rural areas over urban voters. It would then be harder for voters to approve measures that don’t align with the priorities of the conservative politicians they tend to elect.

Earlier this year, a similar effort to make it harder to amend the constitution failed after Democrats in the Senate filibustered it.

Sparks criticized the Republican leadership in the General Assembly for allowing the failure, pointing to a Republican supermajority in both houses that could have passed the measure.

“We hold all the power,” Sparks said. “We hold all the procedural levers of power, and we can shut down debate in both houses any time, any day, for any bill we choose to.”

Florida shows how a higher threshold for voter initiatives might play out. In 2006, the state raised the bar for constitutional amendments to 60%. This year, a majority of voters — 57% — supported an abortion rights amendment, an even bigger margin than in Missouri, but not sufficient in Florida.

It’s not clear yet, though, whether any of the measures have enough support in Missouri’s General Assembly.

Lavender said that the campaign supporting abortion rights significantly outraised its opposition during the election. “It’s going to be difficult to overturn,” she said. “You’ll have the same money that supported it now going up against you.”

Some of the Nicaraguans had found housing in Rosa’s neighborhood, a trailer park at the edge of town. They sent their children to the same public schools. And they got jobs in the same factories and food-processing facilities that employed many of Rosa’s friends and relatives.

Then Rosa realized that many of the newcomers with ongoing asylum cases could apply for work permits and driver’s licenses — state and federal privileges that are unavailable to undocumented immigrants. Rosa’s feelings of indifference turned to frustration and resentment.

“It’s not fair,” said Rosa, who works as a janitor. “Those of us who have been here for years get nothing.”

Her anger is largely directed at President Joe Biden and the Democratic Party for failing to produce meaningful reforms to the immigration system that could benefit people like her. In our reporting on the new effects of immigration, ProPublica interviewed dozens of long-established Latino immigrants and their U.S.-born relatives in cities like Denver and Chicago and in small towns along the Texas border. Over and over, they spoke of feeling resentment as they watched the government ease the transition of large numbers of asylum-seekers into the U.S. by giving them access to work permits and IDs, and in some cities spending millions of dollars to provide them with food and shelter.

It’s one of the reasons so many Latino voters chose Donald Trump this election, giving him what appears to be Republicans’ biggest win in a presidential race since exit polls began tracking this data. Latinos’ increased support for Trump — who says he could use the military to execute his plans for mass deportations — defied conventional wisdom, disrupting long-held assumptions about loyalties to the Democratic Party. The shift could give Republicans reason to cater to Latinos to keep them in the party’s fold.

On the campaign trail, Trump singled out Whitewater after the police chief wrote a letter to Biden asking for help responding to the needs of the new Nicaraguan arrivals. While some residents were put off by Trump’s rhetoric about the city being destroyed by immigrants, it resonated with many of the longtime Mexican-immigrant residents we interviewed. They said they think the newcomers have unfairly received benefits that they never got when they arrived illegally decades ago — and that many still don’t have today.

Among those residents is one of Rosa’s friends and neighbors who asked to be identified by one of her surnames, Valadez, because she is undocumented and fears deportation. A single mother who cleans houses and buildings for a living, Valadez makes extra money on the side by driving immigrants who don’t have cars to and from work and to run errands. It’s a risky side hustle, though, because she’s frequently been pulled over and ticketed by police for driving without a license, costing her thousands of dollars in fines.

One day two summers ago, one of her sons found a small purse at a carnival in town. Inside they found a Wisconsin driver’s license, a work permit issued to a Nicaraguan woman and $300 in cash. Seeing the contents filled Valadez with bitterness. She asked her son to turn in the purse to the police but kept the $300. “I have been here for 21 years,” she said. “I have five children who are U.S. citizens. And I can’t get a work permit or a driver’s license.”

When she told that story to Rosa one afternoon this spring, her friend nodded emphatically in approval. Rosa, like Valadez, couldn’t vote. But two of Rosa’s U.S.-born children could, and they cast ballots for Trump. One of Rosa’s sons even drives a car with a bumper sticker that says “Let’s Go Brandon” — a popular anti-Biden slogan.

Rosa said she is glad her children voted for Trump. She’s not too worried about deportation, although she asked to be identified solely by her first name to reduce the risk. She believes Trump wants to deport criminals, not people like her who crossed the border undetected in the 1990s but haven’t gotten in trouble with the law. “They know who has been behaving well and who hasn’t been,” she said.

In the months leading up to the presidential election, numerous polls picked up on the kinds of frustrations felt by Rosa and her family. Those polls indicated that many voters considered immigration one of the most pressing challenges facing the country and that they were disappointed in the Biden administration’s record.

Biden had come into office in 2021 promising a more humane approach to immigration after four years of more restrictive policies during the first Trump administration. But record numbers of immigrants who were apprehended at the U.S.-Mexico border began to overwhelm the system. While the Biden administration avoided talking about the border situation like a crisis, the way Trump and the GOP had, outspoken critics like Republican Texas Gov. Greg Abbott amplified the message that things at the border were out of control while he arranged to bus thousands of immigrants to Democrat-controlled big cities around the country. In Whitewater, hundreds of Nicaraguans arrived on their own to fill jobs in local factories, and many of them drove to work without licenses, putting a strain on the small local police department with only one Spanish-speaking officer.

While the Biden administration kept a Trump expulsion policy in place for three years, it also created temporary parole programs and an app to allow asylum-seekers to make appointments to cross the border. The result was that hundreds of thousands more immigrants were allowed to come into the country and apply for work permits, but the efforts didn’t assuage the administration’s critics on the right or left. Meanwhile, moves to benefit undocumented workers who were already in the country were less publicized, said Kathleen Bush-Joseph, a policy analyst at the nonpartisan Migration Policy Institute.

The White House did not respond to requests for comment.

Conchita Cruz, a co-founder and co-executive director of the Asylum Seeker Advocacy Project, which serves a network of around 1 million asylum-seekers across the country, said that because of either court challenges or processing backlogs, Biden wasn’t able to deliver on many of his promises to make it easier for immigrants who’ve lived in this country for years to regularize their status.

“Policies meant to help immigrants have not always materialized,” she said.

Cruz said that while the administration extended the duration of work permits for some employment categories, backlogs have hampered the quick processing of those extensions. As of September, there were about 1.2 million pending work permit applications, according to U.S. Citizenship and Immigration Services data, with many pending for six months or more. USCIS said the agency has taken steps to reduce backlogs while processing a record number of applications.

Biden’s attempts to push for broad immigration reform in Congress, including a proposal his administration sent on his first day in office, went nowhere. Earlier this year, in an effort to prevent a political win for Biden before the election, Trump pressured Republicans to kill bipartisan legislation that would have increased border security.

Camila Chávez, the executive director of the Dolores Huerta Foundation in Bakersfield, California, said Democrats failed to combat misinformation and turn out Latino voters. She recalled meeting one young Latina Trump supporter while she knocked on voters’ doors with the foundation’s sister political action organization. The woman told her she was concerned that the new immigrant arrivals were bringing crime and cartel activity — and potentially were a threat to her own family’s safety.

“That’s our charge as organizations, to make sure that we are in the community and educating folks on how government works and to not vote against our own self-interests. Which is what’s happening now,” said Chávez, who is the daughter of famed farmworker advocate Dolores Huerta and a niece of Cesar Chávez.

Trump has made clear he intends to deliver on his deportation promises, though the details of how he’ll do it and who will be most affected remain unclear. The last time Trump was elected, he moved quickly to issue an executive order that said no “classes or categories” of people who were in the country illegally could be exempt from enforcement. Tom Homan, who Trump has picked to serve as his “border czar,” said during a recent interview with Fox & Friends that immigrants who were deemed to be a threat to public safety or national security would be a priority under a new administration. But he said immigrants with outstanding deportation orders will also be possible targets and that there will be raids at workplaces with large numbers of undocumented workers.

The Trump campaign did not respond to a request for comment.

Mike Madrid, a Republican strategist, said it’s wishful thinking to believe Trump will give any special treatment to undocumented immigrants who have been living and working in the U.S. for a long time. But he’s heard that sentiment among Latino voters in focus groups.

“They believe that they are playing by the rules and that they will be rewarded for it,” Madrid said. “Republicans have never been serious about legal migration, let alone illegal migration. They’re allowing themselves to believe that for no good reason.”

The Republican Party’s growing appeal to Latino voters was especially noticeable in places like Del Rio, a Texas border town. As ProPublica previously reported, Trump flipped the county where Del Rio sits from blue to red in 2020 and won it this year with 63% of the vote.

Sergio Garza Castillo, a Mexican immigrant who owns a gas station and convenience store in Del Rio, illustrates that political shift. Garza Castillo said he came to the U.S. legally as a teenager in the 1980s after his father, a U.S. citizen, petitioned and waited for more than a decade to bring his family across the border.

Ever since Garza Castillo became a U.S. citizen in 2000, he has tended to vote for Democrats, believing in their promise of immigration reform that could lead to more pathways to citizenship for long-established undocumented immigrants, including many of his friends and acquaintances.

But the Democrats “promised and they never delivered,” Garza Castillo said. “They didn’t normalize the status of the people who were already here, but instead they let in many migrants who didn’t come in the correct way.” He believes asylum-seekers should have to wait outside the country like he did.

He said he began to turn away from the Democrats in September 2021, when nearly 20,000 mostly Haitian immigrants seeking asylum waded across the Rio Grande from Mexico and camped out under the city’s international bridge near Garza Castillo’s gas station. Federal authorities had instructed the immigrants to wait there to be processed; some remained there for weeks, sleeping under tarps and blankets with little access to water and food. Garza Castillo said he and other business owners lost money when the federal government shut down the international bridge, an economic engine for Del Rio.

Some of the Haitian migrants were eventually deported; others were allowed into the U.S. to pursue asylum claims and given notices to appear in court in a backlogged immigration system that can take years to resolve a case. “That to me is offensive for those who have been living here for more than 10 years and haven’t been able to adjust their status,” Garza Castillo said.

He hopes Trump seizes on the opportunity to expand support from Latino voters by creating a path to citizenship for undocumented immigrants who’ve been here for years. “If he does that,” he said, “I think the Republican Party will be strong here for a long time.”

Wrapping his wife in a blanket as she mourned the loss of her pregnancy at 11 weeks, Hope Ngumezi wondered why no obstetrician was coming to see her.

Over the course of six hours on June 11, 2023, Porsha Ngumezi had bled so much in the emergency department at Houston Methodist Sugar Land that she’d needed two transfusions. She was anxious to get home to her young sons, but, according to a nurse’s notes, she was still “passing large clots the size of grapefruit.”

Hope dialed his mother, a former physician, who was unequivocal. “You need a D&C,” she told them, referring to dilation and curettage, a common procedure for first-trimester miscarriages and abortions. If a doctor could remove the remaining tissue from her uterus, the bleeding would end.

But when Dr. Andrew Ryan Davis, the obstetrician on duty, finally arrived, he said it was the hospital’s “routine” to give a drug called misoprostol to help the body pass the tissue, Hope recalled. Hope trusted the doctor. Porsha took the pills, according to records, and the bleeding continued.

Three hours later, her heart stopped.

The 35-year-old’s death was preventable, according to more than a dozen doctors who reviewed a detailed summary of her case for ProPublica. Some said it raises serious questions about how abortion bans are pressuring doctors to diverge from the standard of care and reach for less-effective options that could expose their patients to more risks. Doctors and patients described similar decisions they’ve witnessed across the state.

It was clear Porsha needed an emergency D&C, the medical experts said. She was hemorrhaging and the doctors knew she had a blood-clotting disorder, which put her at greater danger of excessive and prolonged bleeding. “Misoprostol at 11 weeks is not going to work fast enough,” said Dr. Amber Truehart, an OB-GYN at the University of New Mexico Center for Reproductive Health. “The patient will continue to bleed and have a higher risk of going into hemorrhagic shock.” The medical examiner found the cause of death to be hemorrhage.

D&Cs — a staple of maternal health care — can be lifesaving. Doctors insert a straw-like tube into the uterus and gently suction out any remaining pregnancy tissue. Once the uterus is emptied, it can close, usually stopping the bleeding.

But because D&Cs are also used to end pregnancies, the procedure has become tangled up in state legislation that restricts abortions. In Texas, any doctor who violates the strict law risks up to 99 years in prison. Porsha’s is the fifth case ProPublica has reported in which women died after they did not receive a D&C or its second-trimester equivalent, a dilation and evacuation; three of those deaths were in Texas.

Texas doctors told ProPublica the law has changed the way their colleagues see the procedure; some no longer consider it a first-line treatment, fearing legal repercussions or dissuaded by the extra legwork required to document the miscarriage and get hospital approval to carry out a D&C. This has occurred, ProPublica found, even in cases like Porsha’s where there isn’t a fetal heartbeat or the circumstances should fall under an exception in the law. Some doctors are transferring those patients to other hospitals, which delays their care, or they’re defaulting to treatments that aren’t the medical standard.

Misoprostol, the medicine given to Porsha, is an effective method to complete low-risk miscarriages but is not recommended when a patient is unstable. The drug is also part of a two-pill regimen for abortions, yet administering it may draw less scrutiny than a D&C because it requires a smaller medical team and because the drug is commonly used to induce labor and treat postpartum hemorrhage. Since 2022, some Texas women who were bleeding heavily while miscarrying have gone public about only receiving medication when they asked for D&Cs. One later passed out in a pool of her own blood.

“Stigma and fear are there for D&Cs in a way that they are not for misoprostol,” said Dr. Alison Goulding, an OB-GYN in Houston. “Doctors assume that a D&C is not standard in Texas anymore, even in cases where it should be recommended. People are afraid: They see D&C as abortion and abortion as illegal.”

Doctors and nurses involved in Porsha’s care did not respond to multiple requests for comment.

Several physicians who reviewed the summary of her case pointed out that Davis’ post-mortem notes did not reflect nurses’ documented concerns about Porsha’s “heavy bleeding.” After Porsha died, Davis wrote instead that the nurses and other providers described the bleeding as “minimal,” though no nurses wrote this in the records. ProPublica tried to ask Davis about this discrepancy. He did not respond to emails, texts or calls.

Houston Methodist officials declined to answer a detailed list of questions about Porsha’s treatment. They did not comment when asked whether Davis’ approach was the hospital’s “routine.” A spokesperson said that “each patient’s care is unique to that individual.”

“All Houston Methodist hospitals follow all state laws,” the spokesperson added, “including the abortion law in place in Texas.”

“We Need to See the Doctor”

Hope marveled at the energy Porsha had for their two sons, ages 5 and 3. Whenever she wasn’t working, she was chasing them through the house or dancing with them in the living room. As a finance manager at a charter school system, she was in charge of the household budget. As an engineer for an airline, Hope took them on flights around the world — to Chile, Bali, Guam, Singapore, Argentina.

The two had met at Lamar University in Beaumont, Texas. “When Porsha and I began dating,” Hope said, “I already knew I was going to love her.” She was magnetic and driven, going on to earn an MBA, but she was also gentle with him, always protecting his feelings. Both were raised in big families and they wanted to build one of their own.

When he learned Porsha was pregnant again in the spring of 2023, Hope wished for a girl. Porsha found a new OB-GYN who said she could see her after 11 weeks. Ten weeks in, though, Porsha noticed she was spotting. Over the phone, the obstetrician told her to go to the emergency room if it got worse.

To celebrate the end of the school year, Porsha and Hope took their boys to a water park in Austin, and as they headed back, on June 11, Porsha told Hope that the bleeding was heavier. They decided Hope would stay with the boys at home until a relative could take over; Porsha would drive to the emergency room at Houston Methodist Sugar Land, one of seven community hospitals that are part of the Houston Methodist system.

At 6:30 p.m, three hours after Porsha arrived at the hospital, she saw huge clots in the toilet. “Significant bleeding,” the emergency physician wrote. “I’m starting to feel a lot of pain,” Porsha texted Hope. Around 7:30 p.m., she wrote: “She said I might need surgery if I don’t stop bleeding,” referring to the nurse. At 7:50 p.m., after a nurse changed her second diaper in an hour: “Come now.”

Still, the doctor didn’t mention a D&C at this point, records show. Medical experts told ProPublica that this wait-and-see approach has become more common under abortion bans. Unless there is “overt information indicating that the patient is at significant risk,” hospital administrators have told physicians to simply monitor them, said Dr. Robert Carpenter, a maternal-fetal medicine specialist who works in several hospital systems in Houston. Methodist declined to share its miscarriage protocols with ProPublica or explain how it is guiding doctors under the abortion ban.

As Porsha waited for Hope, a radiologist completed an ultrasound and noted that she had “a pregnancy of unknown location.” The scan detected a “sac-like structure” but no fetus or cardiac activity. This report, combined with her symptoms, indicated she was miscarrying.

But the ultrasound record alone was less definitive from a legal perspective, several doctors explained to ProPublica. Since Porsha had not had a prenatal visit, there was no documentation to prove she was 11 weeks along. On paper, this “pregnancy of unknown location” diagnosis could also suggest that she was only a few weeks into a normally developing pregnancy, when cardiac activity wouldn’t be detected. Texas outlaws abortion from the moment of fertilization; a record showing there is no cardiac activity isn’t enough to give physicians cover to intervene, experts said.

Dr. Gabrielle Taper, who recently worked as an OB-GYN resident in Austin, said that she regularly witnessed delays after ultrasound reports like these. “If it’s a pregnancy of unknown location, if we do something to manage it, is that considered an abortion or not?” she said, adding that this was one of the key problems she encountered. After the abortion ban went into effect, she said, “there was much more hesitation about: When can we intervene, do we have enough evidence to say this is a miscarriage, how long are we going to wait, what will we use to feel definitive?”

At Methodist, the emergency room doctor reached Davis, the on-call OB-GYN, to discuss the ultrasound, according to records. They agreed on a plan of “observation in the hospital to monitor bleeding.”

Around 8:30 p.m., just after Hope arrived, Porsha passed out. Terrified, he took her head in his hands and tried to bring her back to consciousness. “Babe, look at me,” he told her. “Focus.” Her blood pressure was dipping dangerously low. She had held off on accepting a blood transfusion until he got there. Now, as she came to, she agreed to receive one and then another.

By this point, it was clear that she needed a D&C, more than a dozen OB-GYNs who reviewed her case told ProPublica. She was hemorrhaging, and the standard of care is to vacuum out the residual tissue so the uterus can clamp down, physicians told ProPublica.

“Complete the miscarriage and the bleeding will stop,” said Dr. Lauren Thaxton, an OB-GYN who recently left Texas.

“At every point, it’s kind of shocking,” said Dr. Daniel Grossman, a professor of obstetrics and gynecology at the University of California, San Francisco who reviewed Porsha’s case. “She is having significant blood loss and the physician didn’t move toward aspiration.”

All Porsha talked about was her devastation of losing the pregnancy. She was cold, crying and in extreme pain. She wanted to be at home with her boys. Unsure what to say, Hope leaned his chest over the cot, passing his body heat to her.

At 9:45 p.m., Esmeralda Acosta, a nurse, wrote that Porsha was “continuing to pass large clots the size of grapefruit.” Fifteen minutes later, when the nurse learned Davis planned to send Porsha to a floor with fewer nurses, she “voiced concern” that he wanted to take her out of the emergency room, given her condition, according to medical records.

At 10:20 p.m., seven hours after Porsha arrived, Davis came to see her. Hope remembered what his mother had told him on the phone earlier that night: “She needs a D&C.” The doctor seemed confident about a different approach: misoprostol. If that didn’t work, Hope remembers him saying, they would move on to the procedure.

A pill sounded good to Porsha because the idea of surgery scared her. Davis did not explain that a D&C involved no incisions, just suction, according to Hope, or tell them that it would stop the bleeding faster. The Ngumezis followed his recommendation without question. “I’m thinking, ‘He’s the OB, he’s probably seen this a thousand times, he probably knows what’s right,’” Hope said.

But more than a dozen doctors who reviewed Porsha’s case were concerned by this recommendation. Many said it was dangerous to give misoprostol to a woman who’s bleeding heavily, especially one with a blood clotting disorder. “That’s not what you do,” said Dr. Elliott Main, the former medical director for the California Maternal Quality Care Collaborative and an expert in hemorrhage, after reviewing the case. “She needed to go to the operating room.” Main and others said doctors are obliged to counsel patients on the risks and benefits of all their options, including a D&C.

Performing a D&C, though, attracts more attention from colleagues, creating a higher barrier in a state where abortion is illegal, explained Goulding, the OB-GYN in Houston. Staff are familiar with misoprostol because it’s used for labor, and it only requires a doctor and a nurse to administer it. To do a procedure, on the other hand, a doctor would need to find an operating room, an anesthesiologist and a nursing team. “You have to convince everyone that it is legal and won’t put them at risk,” said Goulding. “Many people may be afraid and misinformed and refuse to participate — even if it’s for a miscarriage.”

Davis moved Porsha to a less-intensive unit, according to records. Hope wondered why they were leaving the emergency room if the nurse seemed so worried. But instead of pushing back, he rubbed Porsha’s arms, trying to comfort her. The hospital was reputable. “Since we were at Methodist, I felt I could trust the doctors.”

On their way to the other ward, Porsha complained of chest pain. She kept remarking on it when they got to the new room. From this point forward, there are no nurse’s notes recording how much she continued to bleed. “My wife says she doesn’t feel right, and last time she said that, she passed out,” Hope told a nurse. Furious, he tried to hold it together so as not to alarm Porsha. “We need to see the doctor,” he insisted.

Her vital signs looked fine. But many physicians told ProPublica that when healthy pregnant patients are hemorrhaging, their bodies can compensate for a long time, until they crash. Any sign of distress, such as chest pain, could be a red flag; the symptom warranted investigation with tests, like an electrocardiogram or X-ray, experts said. To them, Porsha’s case underscored how important it is that doctors be able to intervene before there are signs of a life-threatening emergency.

But Davis didn’t order any tests, according to records.

Around 1:30 a.m., Hope was sitting by Porsha’s bed, his hands on her chest, telling her, “We are going to figure this out.” They were talking about what she might like for breakfast when she began gasping for air.

“Help, I need help!” he shouted to the nurses through the intercom. “She can’t breathe.”

“All She Needed”

Hours later, Hope returned home in a daze. “Is mommy still at the hospital?” one of his sons asked. Hope nodded; he couldn’t find the words to tell the boys they’d lost their mother. He dressed them and drove them to school, like the previous day had been a bad dream. He reached for his phone to call Porsha, as he did every morning that he dropped the kids off. But then he remembered that he couldn’t.

Friends kept reaching out. Most of his family’s network worked in medicine, and after they said how sorry they were, one after another repeated the same message. All she needed was a D&C, said one. They shouldn’t have given her that medication, said another. It’s a simple procedure, the callers continued. We do this all the time in Nigeria.

Since Porsha died, several families in Texas have spoken publicly about similar circumstances. This May, when Ryan Hamilton’s wife was bleeding while miscarrying at 13 weeks, the first doctor they saw at Surepoint Emergency Center Stephenville noted no fetal cardiac activity and ordered misoprostol, according to medical records. When they returned because the bleeding got worse, an emergency doctor on call, Kyle Demler, said he couldn’t do anything considering “the current stance” in Texas, according to Hamilton, who recorded his recollection of the conversation shortly after speaking with Demler. (Neither Surepoint Emergency Center Stephenville nor Demler responded to several requests for comment.)

They drove an hour to another hospital asking for a D&C to stop the bleeding, but there, too, the physician would only prescribe misoprostol, medical records indicate. Back home, Hamilton’s wife continued bleeding until he found her passed out on the bathroom floor. “You don’t think it can really happen like that,” said Hamilton. “It feels like you’re living in some sort of movie, it’s so unbelievable.”

Across Texas, physicians say they blame the law for interfering with medical care. After ProPublica reported last month on two women who diedafter delays in miscarriage care, 111 OB-GYNs sent a letter to Texas policymakers, saying that “the law does not allow Texas women to get the lifesaving care they need.”

Dr. Austin Dennard, an OB-GYN in Dallas, told ProPublica that if one person on a medical team doubts the doctor’s choice to proceed with a D&C, the physician might back down. “You constantly feel like you have someone looking over your shoulder in a punitive, vigilante type of way.”

The criminal penalties are so chilling that even women with diagnoses included in the law’s exceptions are facing delays and denials. Last year, for example, legislators added an update to the ban for patients diagnosed with previable premature rupture of membranes, in which a patient’s water breaks before a fetus can survive. Doctors can still face prosecution for providing abortions in those cases, but they are offered the chance to justify themselves with what’s called an “affirmative defense,” not unlike a murder suspect arguing self defense. This modest change has not stopped some doctors from transferring those patients instead of treating them; Dr. Allison Gilbert, an OB-GYN in Dallas, said doctors send them to her from other hospitals. “They didn’t feel like other staff members would be comfortable proceeding with the abortion,” she said. “It’s frustrating that places still feel like they can’t act on some of these cases that are clearly emergencies.” Women denied treatment for ectopic pregnancies, another exception in the law, have filed federal complaints.

In response to ProPublica’s questions about Houston Methodist’s guidance on miscarriage management, a spokesperson, Gale Smith, said that the hospital has an ethics committee, which can usually respond within hours to help physicians and patients make “appropriate decisions” in compliance with state laws.

After Porsha died, Davis described in the medical record a patient who looked stable: He was tracking her vital signs, her bleeding was “mild” and she was “said not to be in distress.” He ordered bloodwork “to ensure patient wasn’t having concerning bleeding.” Medical experts who reviewed Porsha’s case couldn’t understand why Davis noted that a nurse and other providers reported “decreasing bleeding” in the emergency department when the record indicated otherwise. “He doesn’t document the heavy bleeding that the nurse clearly documented, including the significant bleeding that prompted the blood transfusion, which is surprising,” Grossman, the UCSF professor, said.

Patients who are miscarrying still don’t know what to expect from Houston Methodist.

This past May, Marlena Stell, a patient with symptoms nearly identical to Porsha’s, arrived at another hospital in the system, Houston Methodist The Woodlands. According to medical records, she, too, was 11 weeks along and bleeding heavily. An ultrasound confirmed there was no fetal heartbeat and indicated the miscarriage wasn’t complete. “I assumed they would do whatever to get the bleeding to stop,” Stell said.

Instead, she bled for hours at the hospital. She wanted a D&C to clear out the rest of the tissue, but the doctor gave her methergine, a medication that’s typically used after childbirth to stop bleeding but that isn’t standard care in the middle of a miscarriage, doctors told ProPublica. "She had heavy bleeding, and she had an ultrasound that's consistent with retained products of conception." said Dr. Jodi Abbott, an associate professor of obstetrics and gynecology at Boston University School of Medicine, who reviewed the records. "The standard of care would be a D&C."

Stell says that instead, she was sent home and told to “let the miscarriage take its course.” She completed her miscarriage later that night, but doctors who reviewed her case, so similar to Porsha’s, said it showed how much of a gamble physicians take when they don’t follow the standard of care. “She got lucky — she could have died,” Abbott said. (Houston Methodist did not respond to a request for comment on Stell’s care.)

It hadn’t occurred to Hope that the laws governing abortion could have any effect on his wife’s miscarriage. Now it’s the only explanation that makes sense to him. “We all know pregnancies can come out beautifully or horribly,” Hope told ProPublica. “Instead of putting laws in place to make pregnancies safer, we created laws that put them back in danger.”

For months, Hope’s youngest son didn’t understand that his mom was gone. Porsha’s long hair had been braided, and anytime the toddler saw a woman with braids from afar, he would take off after her, shouting, “That’s mommy!”

A couple weeks ago, Hope flew to Amsterdam to quiet his mind. It was his first trip without Porsha, but as he walked the city, he didn’t know how to experience it without her. He kept thinking about how she would love the Christmas lights and want to try all the pastries. How she would have teased him when he fell asleep on a boat tour of the canals. “I thought getting away would help,” he wrote in his journal. “But all I’ve done is imagine her beside me.”

Over the course of six hours on June 11, 2023, Porsha Ngumezi had bled so much in the emergency department at Houston Methodist Sugar Land that she’d needed two transfusions. She was anxious to get home to her young sons, but, according to a nurse’s notes, she was still “passing large clots the size of grapefruit.”

Hope dialed his mother, a former physician, who was unequivocal. “You need a D&C,” she told them, referring to dilation and curettage, a common procedure for first-trimester miscarriages and abortions. If a doctor could remove the remaining tissue from her uterus, the bleeding would end.

But when Dr. Andrew Ryan Davis, the obstetrician on duty, finally arrived, he said it was the hospital’s “routine” to give a drug called misoprostol to help the body pass the tissue, Hope recalled. Hope trusted the doctor. Porsha took the pills, according to records, and the bleeding continued.

Three hours later, her heart stopped.

The 35-year-old’s death was preventable, according to more than a dozen doctors who reviewed a detailed summary of her case for ProPublica. Some said it raises serious questions about how abortion bans are pressuring doctors to diverge from the standard of care and reach for less-effective options that could expose their patients to more risks. Doctors and patients described similar decisions they’ve witnessed across the state.

It was clear Porsha needed an emergency D&C, the medical experts said. She was hemorrhaging and the doctors knew she had a blood-clotting disorder, which put her at greater danger of excessive and prolonged bleeding. “Misoprostol at 11 weeks is not going to work fast enough,” said Dr. Amber Truehart, an OB-GYN at the University of New Mexico Center for Reproductive Health. “The patient will continue to bleed and have a higher risk of going into hemorrhagic shock.” The medical examiner found the cause of death to be hemorrhage.

D&Cs — a staple of maternal health care — can be lifesaving. Doctors insert a straw-like tube into the uterus and gently suction out any remaining pregnancy tissue. Once the uterus is emptied, it can close, usually stopping the bleeding.

But because D&Cs are also used to end pregnancies, the procedure has become tangled up in state legislation that restricts abortions. In Texas, any doctor who violates the strict law risks up to 99 years in prison. Porsha’s is the fifth case ProPublica has reported in which women died after they did not receive a D&C or its second-trimester equivalent, a dilation and evacuation; three of those deaths were in Texas.

Texas doctors told ProPublica the law has changed the way their colleagues see the procedure; some no longer consider it a first-line treatment, fearing legal repercussions or dissuaded by the extra legwork required to document the miscarriage and get hospital approval to carry out a D&C. This has occurred, ProPublica found, even in cases like Porsha’s where there isn’t a fetal heartbeat or the circumstances should fall under an exception in the law. Some doctors are transferring those patients to other hospitals, which delays their care, or they’re defaulting to treatments that aren’t the medical standard.

Misoprostol, the medicine given to Porsha, is an effective method to complete low-risk miscarriages but is not recommended when a patient is unstable. The drug is also part of a two-pill regimen for abortions, yet administering it may draw less scrutiny than a D&C because it requires a smaller medical team and because the drug is commonly used to induce labor and treat postpartum hemorrhage. Since 2022, some Texas women who were bleeding heavily while miscarrying have gone public about only receiving medication when they asked for D&Cs. One later passed out in a pool of her own blood.

“Stigma and fear are there for D&Cs in a way that they are not for misoprostol,” said Dr. Alison Goulding, an OB-GYN in Houston. “Doctors assume that a D&C is not standard in Texas anymore, even in cases where it should be recommended. People are afraid: They see D&C as abortion and abortion as illegal.”

Doctors and nurses involved in Porsha’s care did not respond to multiple requests for comment.

Several physicians who reviewed the summary of her case pointed out that Davis’ post-mortem notes did not reflect nurses’ documented concerns about Porsha’s “heavy bleeding.” After Porsha died, Davis wrote instead that the nurses and other providers described the bleeding as “minimal,” though no nurses wrote this in the records. ProPublica tried to ask Davis about this discrepancy. He did not respond to emails, texts or calls.

Houston Methodist officials declined to answer a detailed list of questions about Porsha’s treatment. They did not comment when asked whether Davis’ approach was the hospital’s “routine.” A spokesperson said that “each patient’s care is unique to that individual.”

“All Houston Methodist hospitals follow all state laws,” the spokesperson added, “including the abortion law in place in Texas.”

“We Need to See the Doctor”

Hope marveled at the energy Porsha had for their two sons, ages 5 and 3. Whenever she wasn’t working, she was chasing them through the house or dancing with them in the living room. As a finance manager at a charter school system, she was in charge of the household budget. As an engineer for an airline, Hope took them on flights around the world — to Chile, Bali, Guam, Singapore, Argentina.

The two had met at Lamar University in Beaumont, Texas. “When Porsha and I began dating,” Hope said, “I already knew I was going to love her.” She was magnetic and driven, going on to earn an MBA, but she was also gentle with him, always protecting his feelings. Both were raised in big families and they wanted to build one of their own.

When he learned Porsha was pregnant again in the spring of 2023, Hope wished for a girl. Porsha found a new OB-GYN who said she could see her after 11 weeks. Ten weeks in, though, Porsha noticed she was spotting. Over the phone, the obstetrician told her to go to the emergency room if it got worse.

To celebrate the end of the school year, Porsha and Hope took their boys to a water park in Austin, and as they headed back, on June 11, Porsha told Hope that the bleeding was heavier. They decided Hope would stay with the boys at home until a relative could take over; Porsha would drive to the emergency room at Houston Methodist Sugar Land, one of seven community hospitals that are part of the Houston Methodist system.

At 6:30 p.m, three hours after Porsha arrived at the hospital, she saw huge clots in the toilet. “Significant bleeding,” the emergency physician wrote. “I’m starting to feel a lot of pain,” Porsha texted Hope. Around 7:30 p.m., she wrote: “She said I might need surgery if I don’t stop bleeding,” referring to the nurse. At 7:50 p.m., after a nurse changed her second diaper in an hour: “Come now.”

Still, the doctor didn’t mention a D&C at this point, records show. Medical experts told ProPublica that this wait-and-see approach has become more common under abortion bans. Unless there is “overt information indicating that the patient is at significant risk,” hospital administrators have told physicians to simply monitor them, said Dr. Robert Carpenter, a maternal-fetal medicine specialist who works in several hospital systems in Houston. Methodist declined to share its miscarriage protocols with ProPublica or explain how it is guiding doctors under the abortion ban.

As Porsha waited for Hope, a radiologist completed an ultrasound and noted that she had “a pregnancy of unknown location.” The scan detected a “sac-like structure” but no fetus or cardiac activity. This report, combined with her symptoms, indicated she was miscarrying.

But the ultrasound record alone was less definitive from a legal perspective, several doctors explained to ProPublica. Since Porsha had not had a prenatal visit, there was no documentation to prove she was 11 weeks along. On paper, this “pregnancy of unknown location” diagnosis could also suggest that she was only a few weeks into a normally developing pregnancy, when cardiac activity wouldn’t be detected. Texas outlaws abortion from the moment of fertilization; a record showing there is no cardiac activity isn’t enough to give physicians cover to intervene, experts said.

Dr. Gabrielle Taper, who recently worked as an OB-GYN resident in Austin, said that she regularly witnessed delays after ultrasound reports like these. “If it’s a pregnancy of unknown location, if we do something to manage it, is that considered an abortion or not?” she said, adding that this was one of the key problems she encountered. After the abortion ban went into effect, she said, “there was much more hesitation about: When can we intervene, do we have enough evidence to say this is a miscarriage, how long are we going to wait, what will we use to feel definitive?”

At Methodist, the emergency room doctor reached Davis, the on-call OB-GYN, to discuss the ultrasound, according to records. They agreed on a plan of “observation in the hospital to monitor bleeding.”

Around 8:30 p.m., just after Hope arrived, Porsha passed out. Terrified, he took her head in his hands and tried to bring her back to consciousness. “Babe, look at me,” he told her. “Focus.” Her blood pressure was dipping dangerously low. She had held off on accepting a blood transfusion until he got there. Now, as she came to, she agreed to receive one and then another.

By this point, it was clear that she needed a D&C, more than a dozen OB-GYNs who reviewed her case told ProPublica. She was hemorrhaging, and the standard of care is to vacuum out the residual tissue so the uterus can clamp down, physicians told ProPublica.

“Complete the miscarriage and the bleeding will stop,” said Dr. Lauren Thaxton, an OB-GYN who recently left Texas.

“At every point, it’s kind of shocking,” said Dr. Daniel Grossman, a professor of obstetrics and gynecology at the University of California, San Francisco who reviewed Porsha’s case. “She is having significant blood loss and the physician didn’t move toward aspiration.”

All Porsha talked about was her devastation of losing the pregnancy. She was cold, crying and in extreme pain. She wanted to be at home with her boys. Unsure what to say, Hope leaned his chest over the cot, passing his body heat to her.

At 9:45 p.m., Esmeralda Acosta, a nurse, wrote that Porsha was “continuing to pass large clots the size of grapefruit.” Fifteen minutes later, when the nurse learned Davis planned to send Porsha to a floor with fewer nurses, she “voiced concern” that he wanted to take her out of the emergency room, given her condition, according to medical records.

At 10:20 p.m., seven hours after Porsha arrived, Davis came to see her. Hope remembered what his mother had told him on the phone earlier that night: “She needs a D&C.” The doctor seemed confident about a different approach: misoprostol. If that didn’t work, Hope remembers him saying, they would move on to the procedure.

A pill sounded good to Porsha because the idea of surgery scared her. Davis did not explain that a D&C involved no incisions, just suction, according to Hope, or tell them that it would stop the bleeding faster. The Ngumezis followed his recommendation without question. “I’m thinking, ‘He’s the OB, he’s probably seen this a thousand times, he probably knows what’s right,’” Hope said.

But more than a dozen doctors who reviewed Porsha’s case were concerned by this recommendation. Many said it was dangerous to give misoprostol to a woman who’s bleeding heavily, especially one with a blood clotting disorder. “That’s not what you do,” said Dr. Elliott Main, the former medical director for the California Maternal Quality Care Collaborative and an expert in hemorrhage, after reviewing the case. “She needed to go to the operating room.” Main and others said doctors are obliged to counsel patients on the risks and benefits of all their options, including a D&C.

Performing a D&C, though, attracts more attention from colleagues, creating a higher barrier in a state where abortion is illegal, explained Goulding, the OB-GYN in Houston. Staff are familiar with misoprostol because it’s used for labor, and it only requires a doctor and a nurse to administer it. To do a procedure, on the other hand, a doctor would need to find an operating room, an anesthesiologist and a nursing team. “You have to convince everyone that it is legal and won’t put them at risk,” said Goulding. “Many people may be afraid and misinformed and refuse to participate — even if it’s for a miscarriage.”

Davis moved Porsha to a less-intensive unit, according to records. Hope wondered why they were leaving the emergency room if the nurse seemed so worried. But instead of pushing back, he rubbed Porsha’s arms, trying to comfort her. The hospital was reputable. “Since we were at Methodist, I felt I could trust the doctors.”

On their way to the other ward, Porsha complained of chest pain. She kept remarking on it when they got to the new room. From this point forward, there are no nurse’s notes recording how much she continued to bleed. “My wife says she doesn’t feel right, and last time she said that, she passed out,” Hope told a nurse. Furious, he tried to hold it together so as not to alarm Porsha. “We need to see the doctor,” he insisted.

Her vital signs looked fine. But many physicians told ProPublica that when healthy pregnant patients are hemorrhaging, their bodies can compensate for a long time, until they crash. Any sign of distress, such as chest pain, could be a red flag; the symptom warranted investigation with tests, like an electrocardiogram or X-ray, experts said. To them, Porsha’s case underscored how important it is that doctors be able to intervene before there are signs of a life-threatening emergency.

But Davis didn’t order any tests, according to records.

Around 1:30 a.m., Hope was sitting by Porsha’s bed, his hands on her chest, telling her, “We are going to figure this out.” They were talking about what she might like for breakfast when she began gasping for air.

“Help, I need help!” he shouted to the nurses through the intercom. “She can’t breathe.”

“All She Needed”

Hours later, Hope returned home in a daze. “Is mommy still at the hospital?” one of his sons asked. Hope nodded; he couldn’t find the words to tell the boys they’d lost their mother. He dressed them and drove them to school, like the previous day had been a bad dream. He reached for his phone to call Porsha, as he did every morning that he dropped the kids off. But then he remembered that he couldn’t.

Friends kept reaching out. Most of his family’s network worked in medicine, and after they said how sorry they were, one after another repeated the same message. All she needed was a D&C, said one. They shouldn’t have given her that medication, said another. It’s a simple procedure, the callers continued. We do this all the time in Nigeria.

Since Porsha died, several families in Texas have spoken publicly about similar circumstances. This May, when Ryan Hamilton’s wife was bleeding while miscarrying at 13 weeks, the first doctor they saw at Surepoint Emergency Center Stephenville noted no fetal cardiac activity and ordered misoprostol, according to medical records. When they returned because the bleeding got worse, an emergency doctor on call, Kyle Demler, said he couldn’t do anything considering “the current stance” in Texas, according to Hamilton, who recorded his recollection of the conversation shortly after speaking with Demler. (Neither Surepoint Emergency Center Stephenville nor Demler responded to several requests for comment.)

They drove an hour to another hospital asking for a D&C to stop the bleeding, but there, too, the physician would only prescribe misoprostol, medical records indicate. Back home, Hamilton’s wife continued bleeding until he found her passed out on the bathroom floor. “You don’t think it can really happen like that,” said Hamilton. “It feels like you’re living in some sort of movie, it’s so unbelievable.”

Across Texas, physicians say they blame the law for interfering with medical care. After ProPublica reported last month on two women who diedafter delays in miscarriage care, 111 OB-GYNs sent a letter to Texas policymakers, saying that “the law does not allow Texas women to get the lifesaving care they need.”

Dr. Austin Dennard, an OB-GYN in Dallas, told ProPublica that if one person on a medical team doubts the doctor’s choice to proceed with a D&C, the physician might back down. “You constantly feel like you have someone looking over your shoulder in a punitive, vigilante type of way.”

The criminal penalties are so chilling that even women with diagnoses included in the law’s exceptions are facing delays and denials. Last year, for example, legislators added an update to the ban for patients diagnosed with previable premature rupture of membranes, in which a patient’s water breaks before a fetus can survive. Doctors can still face prosecution for providing abortions in those cases, but they are offered the chance to justify themselves with what’s called an “affirmative defense,” not unlike a murder suspect arguing self defense. This modest change has not stopped some doctors from transferring those patients instead of treating them; Dr. Allison Gilbert, an OB-GYN in Dallas, said doctors send them to her from other hospitals. “They didn’t feel like other staff members would be comfortable proceeding with the abortion,” she said. “It’s frustrating that places still feel like they can’t act on some of these cases that are clearly emergencies.” Women denied treatment for ectopic pregnancies, another exception in the law, have filed federal complaints.

In response to ProPublica’s questions about Houston Methodist’s guidance on miscarriage management, a spokesperson, Gale Smith, said that the hospital has an ethics committee, which can usually respond within hours to help physicians and patients make “appropriate decisions” in compliance with state laws.

After Porsha died, Davis described in the medical record a patient who looked stable: He was tracking her vital signs, her bleeding was “mild” and she was “said not to be in distress.” He ordered bloodwork “to ensure patient wasn’t having concerning bleeding.” Medical experts who reviewed Porsha’s case couldn’t understand why Davis noted that a nurse and other providers reported “decreasing bleeding” in the emergency department when the record indicated otherwise. “He doesn’t document the heavy bleeding that the nurse clearly documented, including the significant bleeding that prompted the blood transfusion, which is surprising,” Grossman, the UCSF professor, said.

Patients who are miscarrying still don’t know what to expect from Houston Methodist.

This past May, Marlena Stell, a patient with symptoms nearly identical to Porsha’s, arrived at another hospital in the system, Houston Methodist The Woodlands. According to medical records, she, too, was 11 weeks along and bleeding heavily. An ultrasound confirmed there was no fetal heartbeat and indicated the miscarriage wasn’t complete. “I assumed they would do whatever to get the bleeding to stop,” Stell said.

Instead, she bled for hours at the hospital. She wanted a D&C to clear out the rest of the tissue, but the doctor gave her methergine, a medication that’s typically used after childbirth to stop bleeding but that isn’t standard care in the middle of a miscarriage, doctors told ProPublica. "She had heavy bleeding, and she had an ultrasound that's consistent with retained products of conception." said Dr. Jodi Abbott, an associate professor of obstetrics and gynecology at Boston University School of Medicine, who reviewed the records. "The standard of care would be a D&C."

Stell says that instead, she was sent home and told to “let the miscarriage take its course.” She completed her miscarriage later that night, but doctors who reviewed her case, so similar to Porsha’s, said it showed how much of a gamble physicians take when they don’t follow the standard of care. “She got lucky — she could have died,” Abbott said. (Houston Methodist did not respond to a request for comment on Stell’s care.)

It hadn’t occurred to Hope that the laws governing abortion could have any effect on his wife’s miscarriage. Now it’s the only explanation that makes sense to him. “We all know pregnancies can come out beautifully or horribly,” Hope told ProPublica. “Instead of putting laws in place to make pregnancies safer, we created laws that put them back in danger.”

For months, Hope’s youngest son didn’t understand that his mom was gone. Porsha’s long hair had been braided, and anytime the toddler saw a woman with braids from afar, he would take off after her, shouting, “That’s mommy!”

A couple weeks ago, Hope flew to Amsterdam to quiet his mind. It was his first trip without Porsha, but as he walked the city, he didn’t know how to experience it without her. He kept thinking about how she would love the Christmas lights and want to try all the pastries. How she would have teased him when he fell asleep on a boat tour of the canals. “I thought getting away would help,” he wrote in his journal. “But all I’ve done is imagine her beside me.”

In North Carolina alone, we identified 39 of these likely “segregation academies” that are still operating and that have received voucher money. Of these, 20 schools reported student bodies that were at least 85% white in a 2021-22 federal survey of private schools, the most recent data available.

Those 20 academies, all founded in the 1960s and 1970s, brought in more than $20 million from the state in the past three years alone. None reflected the demographics of their communities. Few even came close.

Northeast Academy, a small Christian school in rural Northampton County on the Virginia border, is among them. As of the 2021-22 survey, the school’s enrollment was 99% white in a county that runs about 40% white.

Every year since North Carolina launched its state-funded private school voucher program in 2014, the academy has received more and more money. Last school year, it received about $438,500 from the program, almost half of its total reported tuition. Northeast is on track to beat that total this school year.

Vouchers play a similar role at Lawrence Academy, an hour’s drive south. It has never reported Black enrollment higher than 3% in a county whose population hovers around 60% Black. A small school with less than 300 students, it received $518,240 in vouchers last school year to help pay for 86 of those students.

Farther south, Pungo Christian Academy has received voucher money every year since 2015 and, as of the last survey, had become slightly more white than when the voucher program began. It last reported a student body that was 98% white in a county that was 65% white.

Segregation academies that remain vastly white continue to play an integral role in perpetuating school segregation — and, as a result, racial separation in the surrounding communities. We found these academies benefiting from public money in Southern states beyond North Carolina. But because North Carolina collects and releases more complete data than many other states, it offers an especially telling window into what is happening across this once legally segregated region where legislatures are rapidly expanding and adopting controversial voucher-style programs.

Called Opportunity Scholarships, North Carolina’s voucher program launched in 2014. At first, it was only for low-income families and had barely more than 1,200 participants. Then last fall, state lawmakers expanded eligibility to students of all income levels and those already attending private school, a move that sparked furious debate over the future of public education.

“We are ensuring that every child has the chance to thrive,” Republican Rep. Tricia Cotham argued. But Democratic Rep. Julie von Haefen pointed to vouchers’ “legacy of white supremacy” and called the expansion “a gross injustice to the children of North Carolina.”

So many students flocked to the program that the state now has a waitlist of about 54,000 children. Paying for all of them to receive vouchers — at a cost of $248 million — would more than double the current number of participants in the program. Republicans in the General Assembly, along with three Democrats, passed a bill in September to do just that.

Gov. Roy Cooper, a Democrat, vetoed the measure. But the GOP supermajority is expected to override it before the year’s end, perhaps as early as Nov. 19.

Opportunity Scholarships don’t always live up to their name for Black children. Private schools don’t have to admit all comers. Nor do they have to provide busing or free meals. Due to income disparities, Black parents also are less likely to be able to afford the difference between a voucher that pays at most $7,468 a year and an annual tuition bill that can top $10,000 or even $20,000.

And unlike urban areas that have a range of private schools, including some with diverse student bodies, segregation academies are the only private schools available in some rural counties across the South.

Josh Cowen, a professor of education policy at Michigan State, studies these barriers and sees where vouchers fall short for some: “Eligibility does not mean access.”

Of the 20 vastly white segregation academies we identified that received voucher money in North Carolina, nine were at least 30 percentage points more white than the counties in which they operate, based on 2021-22 federal survey and census data.

Otis Smallwood, superintendent of the Bertie County Schools in rural northeastern North Carolina, witnesses this kind of gulf in the district he leads. So many white children in the area attend Lawrence Academy and other schools that his district’s enrollment runs roughly 22 percentage points more Black than the county overall.

He said he tries not to be political. But he feels the brunt of an intensifying Republican narrative against public schools, which still educate most of North Carolina’s children. “It’s been chipping, chipping, chipping, trying to paint this picture that public schools are not performing well,” Smallwood said. “It’s getting more and more and more extreme.”

When a ProPublica reporter told him that Lawrence Academy received $518,240 last school year in vouchers, he was dismayed: “That’s half a million dollars I think could be put to better benefit in public schools.”

If lawmakers override the governor’s veto to fund the waitlist, Smallwood’s district could suffer most. In a recent report, the Office of State Budget and Management projected Bertie County could lose more of its state funding than any other district — 1.6% next year.

Across the once legally segregated South, the volume of public money flowing through voucher-style programs is set to balloon in coming years. Georgia, Alabama, Arkansas, Louisiana, Florida and South Carolina all have passed new or expanded programs since 2023. (South Carolina’s state Supreme Court rejected its tuition grants in September, but GOP lawmakers are expected to try again with a revamped court.)

Voucher critics contend these programs will continue to worsen school segregation by helping wealthier white kids attend private schools; supporters argue they help more Black families afford tuition. But many of the states have made it hard to discern if either is happening by failing to require that the most basic demographic data be shared with the public — or even gathered.

This doesn’t surprise Cowen, who wrote the new book “The Privateers: How Billionaires Created a Culture War and Sold School Vouchers.” He said Southern legislatures in particular don’t want to know what the data would show because the results, framed by a legacy of racism, could generate negative headlines and lawsuit fodder.

States know how to collect vast troves of education data. North Carolina in particular is lauded among global researchers for “the robustness and the richness of the data system for public schools,” Cowen said.

North Carolina and Alabama are among the states that have gathered demographic information about voucher recipients but won’t tell the public the race of students who use them to attend a given school. In North Carolina, a spokesperson said doing so could reveal information about specific students, making that data not a public record under the Opportunity Scholarship statue.

For its $120 million tax credit program, Georgia does not collect racial demographic information or per-school spending. ProPublica was able to identify 20 segregation academies that signed up to take part, but it’s unclear how many are receiving that money or what the racial breakdown is of the students who use it.

“Why should we not be allowed to know where the money is going? It’s a deliberate choice by those who pass these laws,” said Jessica Levin, director of Public Funds Public Schools, a national anti-voucher campaign led by the nonprofit Education Law Center. “There is a lack of transparency and accountability.”

Advocacy groups that support widespread voucher use have resisted some rules that foster greater transparency out of concern that they might deter regulation-averse private schools from participating. Mike Long, president of the nonprofit Parents for Educational Freedom in North Carolina, is among those trying to rally as much private school buy-in for vouchers as possible.

“Their fear is that if they accept it, these are tax dollars, and therefore they would have to submit to government regulation,” Long said. “We’ve lobbied this legislature, and I think they understand it very well, that you can’t tie regulation to this.”

The share of Black students who have received vouchers in North Carolina has dropped significantly since the program's launch. In 2014, more than half the recipients were Black. This school year, the figure is 17%.

That share is unlikely to increase if lawmakers fund all 54,000 students on the waiting list. Because lower-income families were prioritized for vouchers, the applicants who remain on the list are mostly in higher income tiers — and those families are more likely to be white.

More Black parents don’t apply for vouchers because they don’t know about them, said Kwan Graham, who oversees parent liaisons for Parents for Educational Freedom in North Carolina.

Graham, who is Black, said parents haven’t voiced to her concerns that, “I’m Black, they don’t want me” at their local private schools. But she’s also not naive. Private schools can largely select — and reject — who they want.

The nonprofit Public Schools First NC has tallied admissions policies that private schools receiving vouchers use to reject applicants based on things like sexuality, religion and disability. Many also require in-person interviews or tours. Rather than overtly rejecting students based on race, which the voucher program prohibits, schools might say something like, “Come visit the school and see if you’re the ‘right fit,’” said Heather Koons, the nonprofit’s communications and research director.

Northeast Academy, Lawrence Academy and Pungo Christian all include nondiscrimination statements on their websites.

Back when segregation academies opened, some white leaders proudly declared their goal of preserving segregation. Others shrouded their racist motivations. Some white parents complained about federal government overreach and what they deemed social agendas and indoctrination in public schools. Even as violent backlash against integration erupted across the region, many white parents framed their decisions as quests for quality education, morality and Christian education, newspaper coverage and school advertisements from the time show.

Early on, Southern lawmakers found a way to use taxpayer money to give these academies a boost: They created school voucher programs that went chiefly to white students.

Courts ruled against or restricted the practice in the 1960s. But it didn’t really end.

“If you look at the history of the segregation movement, they wanted vouchers to prop up segregation academies,” said Bryan Mann, a University of Kansas professor who studies school segregation. “And now they’re getting vouchers in some of these areas to prop up these schools.”

More recently, Lawrence and Northeast academies both grew their enrollments while receiving voucher money even as the rural counties where they operate have lost population. Over three decades of responding to the federal private schools survey, both academies have reported enrolling almost no nonwhite children. And Pungo Christian has raised its average tuition by almost 50% over the past three school years. During that time, the small school has received almost $500,000 in vouchers.

None of the three academies’ headmasters responded to ProPublica’s request to discuss its findings or to lists of questions. And none have ever reported more than 3% Black enrollment despite operating in counties with substantial — even majority — Black populations.

One of the Democrats who helped Republicans expand North Carolina’s voucher program was Shelly Willingham, a Black representative whose district includes Bertie County, home of Lawrence Academy. He said he doesn’t love vouchers, but the bills have included funding for issues he does support.

He also said he encourages his constituents to take advantage of the vouchers. If there were any effort to make it more difficult for Black students to attend those schools, “then I would have a big problem,” Willingham said. “I don’t see that.”

Another Democrat who voted with Republicans was state Rep. Michael Wray, a white businessman and former House minority whip — who graduated from Northeast Academy.

Wray, whose voting record on vouchers over the years has been mixed, did not respond to multiple ProPublica requests to discuss his views. In 2013, he voted against the budget bill that established the Opportunity Scholarships. And in a recent Q&A with the local Daily Herald newspaper, when asked if he supports taxpayer money funding private schools, he responded: “I believe that when you siphon funds away from our public school budgets, it undermines the success of our schools overall.”

Rodney Pierce, a Black 46-year-old father and public school teacher, saw the voucher expansion in the state budget bill Wray voted for and felt history haunt him. Pierce had only one white student in his classes last year at Gaston STEM Leadership Academy. But about 30 miles across the rural county, white children filled Northeast Academy.

Pierce taught history, with a deep interest in civil rights. He’d studied the voucher programs that white supremacists crafted to help white families flee to segregation academies.

“This stuff was in the works back in the 1960s,” Pierce said.

He was so outraged that he challenged Wray, a 10-term incumbent, for his state House seat. Pierce won the Democratic primary earlier this year by just 34 votes. He faced no opponent in November, so come next year he will cut the House’s support of vouchers by one vote.

“Particularly in the Black community, we care about our public schools,” he said.

Many Black families also have little to no relationship with their local private schools, especially those that opened specifically for white children and are still filled with them. The only times Pierce had set foot on Northeast Academy’s campus was when he covered a few sporting events there for the local newspaper.

People there were nice to him, he said, but he felt anxious: “You’re in an academy you know was started by people who didn’t want their children to go to school with Black children.”

His own three kids attend public schools. Even with vouchers, he said, he wouldn’t send them to a school founded as a segregation academy, much less one that still fosters segregation. He finds it insulting to force taxpayers, including the Black residents he will soon represent — about half of the people in his district — to pay to send other people’s children to these schools.

In the summer of 2021, President Joe Biden summoned the CEOs of the nation’s biggest tech companies to the White House.

A series of cyberattacks linked to Russia, China and Iran had left the government reeling, and the administration had asked the heads of Microsoft, Amazon, Apple, Google and others to offer concrete commitments to help the U.S. bolster its defenses.

“You have the power, the capacity and the responsibility, I believe, to raise the bar on cybersecurity,” Biden told the executives gathered in the East Room.

Microsoft had more to prove than most. Its own security lapses had contributed to some of the incursions that had prompted the summit in the first place, such as the so-called SolarWinds attack, in which Russian state-sponsored hackers stole sensitive data from federal agencies, including the National Nuclear Security Administration. Following the discovery of that breach, some members of Congress said the company should provide better cybersecurity for its customers. Others went further. Sen. Ron Wyden, a Democrat who chairs the Senate’s finance committee, called on the government to “reevaluate its dependence on Microsoft” before awarding it any more contracts.

In response to the president’s call for help, Microsoft CEO Satya Nadella pledged to give the government $150 million in technical services to help upgrade its digital security.

On the surface, it seemed a political win for the Biden administration and an instance of routine damage control from the world’s largest software company.

But Microsoft’s seemingly straightforward commitment belied a more complex, profit-driven agenda, a ProPublica investigation has found. The proposal was, in fact, a calculated business maneuver designed to bring in billions of dollars in new revenue, box competitors out of lucrative government contracts and tighten the company’s grip on federal business.

The White House Offer, as it was known inside Microsoft, would dispatch Microsoft consultants across the federal government to install the company’s cybersecurity products — which, as a part of the offer, were provided free of charge for a limited time.

But once the consultants installed the upgrades, federal customers would be effectively locked in, because shifting to a competitor after the free trial would be cumbersome and costly, according to former Microsoft employees involved in the effort, most of whom spoke on the condition of anonymity because they feared professional repercussions. At that point, the customer would have little choice but to pay for the higher subscription fees.

Two former sales leaders involved in the effort likened it to a drug dealer hooking a user with free samples. “If we give you the crack, and you take the crack, you’ll enjoy the crack,” one said. “And then when it comes time for us to take the crack away, your end users will say, ‘Don’t take it away from me.’ And you’ll be forced to pay me.”

The company, however, wanted more than those subscription fees, former salespeople said. The White House Offer would lead customers to buy other Microsoft products that ran on Azure, the company’s cloud platform, which carried additional charges based on how much storage space and computing power the customer used. The expectation was that the upgrades would ultimately “spin the meter” for Azure, helping Microsoft take market share from its main cloud rival, Amazon Web Services, the salespeople said.

In the years after Nadella made his commitment to Biden, Microsoft’s goals became reality. The Department of Defense, which had resisted the upgrades for years due to the steep cost, began paying for them once the free trial ended, laying the groundwork for future Azure consumption. So did many civilian agencies. The White House Offer got the government “hooked on Azure,” said Karan Sondhi, a former Microsoft salesperson with knowledge of the deals. “And it was successful beyond what any of us could have imagined.”

But while Microsoft’s gambit paid off handsomely for the company, legal experts told ProPublica the White House Offer deals never should have come to pass, as they sidestep or even possibly violate federal laws that regulate government procurement. Such laws generally bar gifts from contractors and require open competition for federal business.

Accepting free product upgrades and consulting services collectively worth hundreds of millions of dollars is “not like a free sample at Costco, where I can take a sample, say, ‘Thanks for the snack,’ and go on my merry way,” said Eve Lyon, an attorney who worked for four decades as a procurement specialist in the federal government. “Here, you have changed the IT culture, and it would cost a lot of money to go to another system.”

Microsoft defended its conduct. The company’s “sole goal during this period was to support an urgent request by the Administration to enhance the security posture of federal agencies who were continuously being targeted by sophisticated nation-state threat actors,” Steve Faehl, the security leader for Microsoft’s federal business, said in a statement. “There was no guarantee that agencies would purchase these licenses,” and they “were free to engage with other vendors to support their security needs,” Faehl said.

Pricing for Microsoft’s security suite was transparent, he said, and the company worked “closely with the Administration to ensure any service and support agreements were pursued ethically and in full compliance with federal laws and regulations.” Faehl said in the statement that Microsoft asked the White House to “review the deal for antitrust concerns and ensure everything was proper and they did so.”

The White House disputed that characterization, as did Tim Wu, a former presidential adviser who told ProPublica he discussed the offer with the company in a short, informal chat prior to the summit but provided no signoff. “If that’s what they’re saying, they’re misrepresenting what happened on that phone call,” he said.

A current White House official, in a statement to ProPublica, sought to distance the administration from Microsoft’s offer, which it had previously heralded as an “ambitious” cybersecurity initiative.

“This was a voluntary commitment made by Microsoft … and Microsoft alone was responsible for it,” the White House official said in the statement. Furthermore, they said the decisions to accept it were “handled solely by the respective agencies.”

“The White House is not involved in Agency decisions regarding cybersecurity and procurement,” the official said.

The official declined to comment on the legal and contracting concerns raised by experts but noted in the statement that the White House “is broadly concerned” about the risks of relying too much on any single technology vendor and “has been exploring potential policy steps to encourage Departments and Agencies to diversify where there is concentration.” Cybersecurity experts say that such concentration can leave users vulnerable to attack, outages or other disruption.

Yet the White House summit ushered in that very type of concentrated reliance, as well as the kind of anticompetitive behavior that the Biden administration has pledged to stamp out. Former Microsoft salespeople told ProPublica that during their White House Offer push, they advised federal departments to save money by dropping cybersecurity products they had purchased from competitors. Those products, they told them, were now “redundant.” Salespeople also fended off new competitors by explaining to federal customers that most of the cybersecurity tools they needed were included in the upgraded bundle.

Today, as a result of the deals, vast swaths of the federal government, including all of the military services in the Defense Department, are more reliant than ever on a single company to meet their IT needs. ProPublica’s investigation, supported by interviews with eight former Microsoft employees who were involved in the White House Offer, reveals for the first time how this sweeping transformation came to be — a change that critics say leaves Washington vulnerable, the very opposite of what Biden had set out to achieve with his summit.

“How did Microsoft become so pervasive of a player in the government?” said a former company sales leader. “Well, the government let themselves get coerced into Microsoft when Microsoft rolled the stuff out for free.”

“Everything That We Do Is Designed to Generate a Return”

The federal government is one of Microsoft’s largest customers and “the one that we’re most devoted to,” the company’s president, Brad Smith, has said. Each day, millions of federal employees use the Windows operating system and products like Word, Outlook, Excel and others to write reports, send emails, analyze data and log on to their devices. But in the months before Biden’s summit, the SolarWinds hack put that relationship to the test.

Discovered in late 2020, SolarWinds was one of the most damaging breaches in U.S. history and underscored the federal government’s vulnerability to a state-sponsored cyberattack.

Authorities established that Russian hackers exploited a flaw in a Microsoft product to steal sensitive government documents from the National Nuclear Security Administration and the National Institutes of Health, among other agencies. What they didn’t know, as ProPublica reported in June, was that one of the company’s own engineers had warned about the weakness for years, only to be dismissed by product leaders who were fearful that acknowledging it would undermine the company’s chances of winning a massive federal cloud computing contract.

But Microsoft’s known involvement was enough for Congress to summon Smith to testify in February 2021. Lawmakers focused on how Microsoft packaged its products into tiers of service — with advanced security tools attached to only the most expensive license, known to government customers as the G5.

At the time, many federal employees used a less expensive license known as the G3. As a result, they didn’t have access to the security features that might have alerted them to an intrusion and aided subsequent investigations.

Some lawmakers, like then-Rep. Jim Langevin of Rhode Island, accused the company of unfairly up-charging customers for what they considered to be basic security. “Is this a profit center for Microsoft?” he asked Smith during the hearing.

Smith replied: “We are a for-profit company. Everything that we do is designed to generate a return, other than our philanthropic work.”

Amid the criticism, Microsoft soon announced that it would provide federal customers with a “one-year free trial of Advanced Audit,” a tool that could help the government detect and investigate future attacks. Over the months that followed, Microsoft was “surprised there was not as aggressive of an uptake of Advanced Audit” as the company had wanted, Faehl, Microsoft’s federal security leader, told ProPublica. It would be a “lesson learned” going forward, he said.

That May, Biden signed an executive order requiring federal agencies to bolster their cyber defenses, declaring that “protecting our Nation from malicious cyber actors requires the Federal Government to partner with the private sector.” He added, “In the end, the trust we place in our digital infrastructure should be proportional to how trustworthy and transparent that infrastructure is, and to the consequences we will incur if that trust is misplaced.”

“Parting of the Red Sea”

Around that time, Anne Neuberger, a White House deputy national security adviser, called Smith and requested that Microsoft develop an initiative to announce at Biden’s White House cybersecurity summit that August. Like Langevin, the administration believed that the company’s advanced suite of cybersecurity tools, including ones intended to counter threats on user devices, should be included in the government’s existing licenses and that products should be delivered to customers with the most secure settings enabled by default. (Neither Neuberger nor Smith granted interview requests.)

Giving away a bundle of advanced security features permanently was a nonstarter inside Microsoft, an executive told ProPublica. But Smith spearheaded a team to develop an offer that appeared to be a compromise.

Federal customers could have free, limited-time access to the upgraded G5 security capabilities and to consultants who would install them. “It was at the behest of the Administration that Microsoft provided enhanced security tools, at no cost, to agencies as soon as possible to level up their security baseline,” Faehl told ProPublica.

While the deal achieved the administration’s goal of better protection for the federal government, it also served Microsoft’s interests. Microsoft salespeople had been trying, unsuccessfully, for years to convince federal customers to upgrade to the G5. Department and agency officials balked at the higher price tag when they already had other vendors providing some of the same security capabilities. The G5’s retail price is nearly 60% more than the G3’s.

“We knew that this was a golden window that nobody could have foreseen opening up because we had been pushing” for the G5 upgrade “for years, and things were going very slow,” said a former Microsoft sales leader involved in the strategy. With the White House Offer, it was “like Moses leading us through the parting of the Red Sea, and we just rushed through it.”

Faehl told ProPublica that sales of the G5 had been slow prior to SolarWinds because federal customers wrongly believed “that they had sufficient security capabilities already in place.” He said the attack was “a wakeup call showing the status quo perspective to be insufficient.”

Microsoft was well aware of the possible legal implications of its offer. More than two decades ago, the U.S. Department of Justice sued the company in a landmark antitrust case that nearly resulted in its breakup. Federal prosecutors alleged that Microsoft maintained an illegal monopoly in the operating system market through anticompetitive behaviors that prevented rivals from getting a foothold. Ultimately, the Justice Department settled with Microsoft, and a federal judge approved a consent decree that imposed restrictions on how the company could develop and license software. Although the decree had long since expired, it nonetheless continued to loom large in the corporate culture.

When it came to the White House Offer, company insiders were “mindful of the concerns about Microsoft making products free that smaller companies sell,” an executive told ProPublica. A spokesperson explained, “That was the impetus for asking the administration to review it.”

The “review” consisted of a phone call between Microsoft’s Smith and Wu, who was Biden’s special assistant for technology and competition policy.

“Brad was like, ‘We think security is important, and we want to give the federal government better security,’” Wu recalled.

But, according to Wu, Smith said Microsoft’s lawyers were “overly paranoid” about antitrust concerns, and he was looking to “calm his own lawyers down.”

“I made it clear there was no ability in the White House to sign off on antitrust,” which is in the purview of the Justice Department or the Federal Trade Commission, Wu said. “I’m smart enough not to say, ‘Oh yeah, that’s fine with me.’ I’m not crazy.”

After the news organization asked Microsoft about Wu’s account, a spokesperson walked back the company’s original written statement, saying that Faehl was misinformed. “The White House arranged a call and we described details of our security offer and how it was structured to avoid antitrust concerns,” the spokesperson said. “It was an informal conversation and at no time did we ask for formal antitrust approval.”

Wu also told ProPublica that he felt pressure from the National Security Council’s Neuberger, who “wanted to get this deal done” in the wake of SolarWinds and other cyberattacks. “She pushed me to get on the phone with Brad,” he said. “I feel in some ways in retrospect I should not have even spoken with him. But I felt that I should help the NSC for what they presented as a formalistic exercise to help the national security.”

“The End Game”

After the White House summit, Microsoft’s sales teams quickly mobilized to sell the “WHO,” as it became known to insiders. The free consulting services were a crucial part of the strategy, former salespeople said. As Sondhi put it, “Just because you give the product away for free doesn’t mean they’re going to use it because it’s a pain in the ass to install new software and retrain staff.” The company wanted to avoid a repeat of the disappointing participation in the earlier Advanced Audit offer.

The consultants would work inside the agencies, where they would have government-provided desks, phones and internet, as well as access to federal computer networks, according to one proposal reviewed by ProPublica. From their perches in the bureaucracy, they would get the products up and running and train federal employees on how to use them. This would make the upgrades “sticky,” as they became ingrained in employees’ daily lives, former salespeople said.

Microsoft covered the free product upgrades for up to a year, the company told ProPublica. Faehl called the free upgrades “a short term option for protection while agencies put long term procurement plans in motion.” Or, as sales teams told customers, they “should not have to wait to be secure until they can procure.” The company also noted the offer came at a significant cost to Microsoft, “with no guarantee of renewal once the deal expired.”

But sales teams said they knew customers who accepted the White House Offer were unlikely to undo the intensive work of installing the upgrades when renewal time rolled around, locking them into the G5 for the long haul. Wes Anderson, a Microsoft vice president who oversaw teams working with the Defense Department, asked his staff to prepare forecasts showing which customers were expected to become paying G5 users at the end of the White House Offer, three people who worked in sales told ProPublica.

“It was explicit that this was the end game,” one former Microsoft sales leader who worked inside the Defense Department told ProPublica. “You will do whatever you need to do to get that software installed, operational and connected so the customer has their runway to renew.”

(On Oct. 30, two weeks after the news organization sent Microsoft questions for this story, the company announced in an email to employees that Anderson would be leaving Microsoft. Neither Anderson nor Microsoft commented on the departure. On the topic of Anderson’s request of his staff, the company said, “Forecasting is part of the rhythm of business for organizations in nearly every industry.”)

Salespeople pitched the White House Offer as “the easy button,” people familiar with the strategy told ProPublica. “Our argument was, ‘We have this whole suite of goodness,’” said a former Microsoft employee who worked with the Department of Defense. “‘You should upgrade because it will take care of everything rather than having a bunch of vendors that each do one of the 20 things that the G5 can do.’” Faehl told ProPublica the license bundles help federal customers “avoid the hassles of managing multiple contracts and licenses” and close security gaps by replacing a “patchwork of solutions” with “simplified, comprehensive protection.”

For the most part, as they predicted, the Microsoft sales teams found receptive audiences across the government. To help ingratiate themselves, they invoked their association with the White House in their pitches. In one example, from June 2022, a Microsoft representative wrote to Veterans Affairs officials to explain that, “working in conjunction with the White House,” it would provide “a no cost offer of professional services to provide hands-on assistance” to deploy the upgrades.

Money for Nothing?

As consultants fanned out across the federal government to turn on the new features, there was a sense of unease among some employees about the nature of the deals. Typically, the government obtains products and services through a competitive bidding process, selecting from a variety of proposals from different vendors. The White House Offer was different.

“No matter how you wanted to polish the turd, there was the appearance of no-bid contracts,” said a former Microsoft consultant involved in the WHO.

The federal government may receive so-called gratuitous — or free — services from donors as long as both parties have a written agreement stating that the donor will not be paid for the goods or services provided. Such agreements were in place for the consulting services in the White House Offer, the company said.

Those agreements may have helped Microsoft pass the “laugh test,” said Lyon, the former federal procurement attorney. “But just because something is technically legal does not make it right,” she said.

Other contracting experts said federal departments and agencies should have been more skeptical about accepting free products and consulting services from Microsoft, given the implications for competition and national security.

The cost and difficulty of switching from the Microsoft products presents a classic example of “vendor lock-in,” said Jessica Tillipman, associate dean for government procurement law studies at George Washington University Law School. “The free services are allowing the government to bypass a competitive procurement process and locking them in for future procurements,” she said.

Tillipman said that, in the future, the government should consider restrictions on gratuitous services in IT in order “to ensure you’re not locked in with a vendor who gets their foot in the door with a frighteningly expensive” giveaway.

“This is all designed to undermine future competitions,” she said.

James Nagle, a former Army contracting official and practicing attorney who specializes in the federal contracting process, went even further, saying that the White House Offer potentially violated existing law.

The Federal Acquisition Regulation, which governs government procurement, says that employees may not accept “gratuities,” or anything of value “from anyone who has or is seeking to obtain Government business.” And, as employees involved with the White House Offer told ProPublica, Microsoft was seeking future contract upgrades and new Azure revenue.

While “gratuities” are typically considered to be perks such as free meals, sports tickets or other gifts for personal use, Nagle argued that the rule could apply to the White House Offer, though he said he was not aware of any prior case using his interpretation. He compared it to a car manufacturer providing a government agency with a fleet of cars for a year for free because it wants the agency to procure that fleet for its staff. “Any contracting officer would say, ‘No, you can’t do that,’” Nagle said. Once employees get used to the cars, they’re reluctant to switch, he said, and the “impermissible gift” would create a built-in bias toward that manufacturer.

“That’s the problem here,” Nagle said. “This is not truly gratuitous. There’s another agenda in the works.”

Microsoft did not use the so-called gratuitous services agreements to give away the G5 upgrades, as it did for the consulting services. Instead, Faehl told ProPublica, the company considered them “a 100% discount” added to existing customer contracts. He said making this type of “strategic investment is … common practice among companies” and that contract teams on both sides reviewed the deals. Nagle viewed it differently, characterizing the free products as a “loss leader designed to lead to future sweetheart deals.”

Federal vendors may be banned from government contracting for violating the Federal Acquisition Regulation, though such an outcome would be highly unlikely for a vendor as large as Microsoft, Nagle said. Nonetheless, individual employees on both sides of improper deals in the past have been held accountable, he said.

Skirting fiscal law, however, may have set the stage for an even more serious legal concern, said Christopher Sagers, a professor of antitrust law at Cleveland State University in Ohio. Microsoft’s actions, Sagers said, might constitute what is known in antitrust law as “exclusionary conduct,” opening the door for illegal monopoly. “Microsoft, rather than competing on the merits, took steps to exclude competitors by making its product sticky in advance of opportunities for competition,” he said. The company used “an already dominant position to further cement their position.”

Microsoft disputed that point.

“We don’t believe our offer raised antitrust concerns, and we constructed it specifically to avoid any such issues,” a company spokesperson said. “We talked informally with a White House staffer about this.”

Wu, however, said the company did not make clear to him the financial and competitive implications of the offer.

“There is no way that was discussed,” Wu told ProPublica. “The only thing that Brad mentioned was upgrading federal agencies, offering them better stuff.” Upon hearing the news organization’s findings, he said: “That is a lot darker than it sounded. Once you’re in somewhere, it’s very hard to leave.

“Now I’m starting to feel guilty in some weird way about playing a role in a big deal that cost taxpayers money,” Wu said.

Taking Out the Competition

Former Microsoft salespeople said that all of the customers within the Defense Department who signed on to the White House Offer — including all the military branches — ultimately upgraded to the G5 and began paying for it when the time came to renew their agreements in 2022 and 2023.

A Defense Department spokesperson said in a written statement that the department followed federal acquisition law and “conducted internal tests and evaluations of multiple vendor capabilities.” The upgrade, the spokesperson said, was “crucial” to meeting the department’s cybersecurity objectives. The department declined to answer follow-up questions, including to specify which vendors it evaluated before deciding on the G5.

John Sherman, the department’s chief information officer at the time of the White House Offer dealmaking, defended both the government’s decision and Microsoft’s strategy. “I am sure Microsoft, like any company, would be trying to increase their business with any customer,” he told ProPublica.

He added, “We didn’t have any particular preference for Microsoft in terms of favoritism or anything like that, but we knew it worked, which is why we wanted to proceed with that.”

Many civilian agencies also upgraded to the G5 during this timeframe, said Sondhi, who now works at Microsoft competitor Trellix as chief technology officer for the company’s public-sector business.

For Microsoft, winning more government business was only half the picture. It also saw the White House Offer as an opportunity to knock out its competitors.

During and after their sales push, Microsoft salespeople advised government departments and agencies to remove competing products from their IT lineups to cut costs, saying the Microsoft bundle would render those other products redundant. Internally, employees called it the “take-out” strategy. “The play is: ‘You’re paying for it in the G5. It’s a waste of government money to have both,’” a former sales leader who worked with the Defense Department told ProPublica.

Sondhi said that in a typical scenario, an upgrade to the 5-level can displace the existing work of a half dozen vendors or more. Executives from cybersecurity companies Trellix and Proofpoint, for example, told ProPublica they lost federal business in the wake of the White House Offer deals.

The White House Offer also enhanced Microsoft’s competitive position by reducing the likelihood that the government would open bidding for cybersecurity products in the future, given the cornucopia of offerings in the G5. Within the company, this was known as “taking opportunities off the street,” former sales leaders said.

The fallout impacted companies that were in the midst of completing the authorization process the government requires of vendors providing cloud-based services. Several told ProPublica that cybersecurity contract opportunities are now scarce.

“We are chipping away, but it’s largely, by far, a Microsoft-owned landscape,” an executive at one competing vendor told ProPublica.

Faehl dismissed those complaints, saying that customers kept the upgrades because they performed well and that competitors “should look inward to see why their products do not meet or exceed Microsoft results.”

Reckoning With the “Monoculture”

Microsoft has something few other companies possess: a panoply of products that span the IT ecosystem. Rivals say the company leveraged its existing dominance in certain products — like the Windows operating system and classic workplace applications — to gain dominance in others, namely cybersecurity and cloud computing.

“No one has the kind of capital that Microsoft does,” Sondhi said. “They can just absorb the cost of the giveaway until the customer’s first bill.”

A coalition backed by some of Microsoft’s major competitors, including Google and Amazon, has raised similar issues with the Federal Trade Commission, which in 2023 gathered public comments on the business practices of cloud computing providers. Among the FTC’s areas of ongoing interest: “Are there signs that cloud markets are functioning less than fully competitively, and that certain business practices are inhibiting competition?”

Competition is not the only issue at stake. As Washington has deepened its relationship with Microsoft, congressional leaders have raised concerns about what they call a cybersecurity “monoculture” in the federal government. Some, like Wyden and Sen. Eric Schmitt, a Republican from Missouri, have blasted the Defense Department in particular for “doubling down on a failed strategy of increasing its dependence on Microsoft.”

“Although we welcome the Department’s decision to invest in greater cybersecurity, we are deeply concerned that DoD is choosing not to pursue a multi-vendor approach that would result in greater competition, lower long-term costs, and better outcomes related to cybersecurity,” the two lawmakers wrote in a letter to Sherman, then the department’s chief information officer, in May.

Microsoft’s Faehl pushed back. “The suggestion that our customers are any more at risk because they use Windows, or Azure, or Office is wrong,” he said. “We partner closely with our security competitors because we see them as partners against threat actors we face in common.”

Still, just last year, Chinese hackers exploited Microsoft security lapses to breach the email accounts of senior U.S. officials. Investigating the attack, the federal Cyber Safety Review Board faulted the company for a “cascade of … avoidable errors” and pressed it to overhaul its security culture. Microsoft has since pledged to place security “above all else.” In June, Smith told Congress that Microsoft would strive to establish a “culture that encourages every employee to look for problems, find problems, report problems, help fix problems and then learn from the problems.”

It’s learning from the successes, too. The same week that Smith testified before Congress, and nearly three years after Nadella made his commitment at Biden’s summit, Microsoft made a new offer, this time to “support hospitals serving more than 60 million people living in rural America.”

The playbook was familiar. In its announcement, the company said that eligible hospitals could have the private-sector equivalent of the G5 “at no cost for one year.” As before, Faehl said Microsoft made the commitment “at the behest of the White House.”

For Lincare, paying multimillion-dollar legal settlements is an integral part of doing business.

The company, the largest distributor of home oxygen equipment in the United States, admitted billing Medicare for ventilators it knew customers weren’t using (2024) and overcharging Medicare and thousands of elderly patients (2023). It settled allegations of violating a law against kickbacks (2018) and charging Medicare for patients who had died (2017). The company resolved lawsuits alleging a “nationwide scheme to pay physicians kickbacks to refer their patients to Lincare” (2006) and that it falsified claims that its customers needed oxygen (2001). (Lincare admitted wrongdoing in only the two most recent settlements.)

Such a litany of Medicare-related misconduct might be expected to provoke drastic action from the Department of Health and Human Services, which oversees the federal health insurance program that covers 1 in 6 Americans. Given that most of Lincare’s estimated $2.4 billion in annual revenues are paid by Medicare, HHS wields tremendous power over the company.

Sure enough, as part of the 2023 settlement, HHS placed Lincare on the agency’s equivalent of probation, a so-called corporate integrity agreement. The foreboding-sounding document includes a “death penalty” provision: Any “material breach” of the probation agreement, which runs for five years, “constitutes an independent basis for Lincare’s exclusion from participation in the Federal health care programs.” Such a ban could effectively kill Lincare’s business.

That sounds dire. Except that before that corporate integrity agreement was signed in 2023, Lincare was under the same form of probation, with the same death penalty provision, from 2018 to 2023, and violated its terms. From 2006 to 2011, Lincare was similarly on probation and also violated the terms, according to the government. And before that — well, you get the picture. Lincare has been on probation four times since 2001. And despite a pattern not only of fraud, but of breaking its probation agreements, Lincare has never been required to do more than pay settlements that amount to pennies relative to its profits.

This is not an aberration. While HHS routinely imposes the death penalty on small operations, it has never barred a national Medicare supplier like Lincare from continuing to do business with the government. Some companies, it seems, are too big to ban.

Lincare’s lengthy record of misbehavior isn’t a surprise to people in the medical equipment business. What is surprising is the federal government’s willingness to pull its punches with a company that has fleeced taxpayers and elderly customers again and again.

Federal officials have never pursued the company executives who oversee this behavior even though two of them, Chief Operating Officer Greg McCarthy and Chief Compliance Officer Jenna Pedersen, have worked at Lincare through all four of the company’s probationary periods. No one has faced criminal charges for activity the government’s own investigators deemed fraud.

Medicare has continued to pay Lincare billions even as many of the company’s customers revile it. Evaluations on customer-review websites are lacerating, and complaints to state attorneys general abound. On the Better Business Bureau’s website, 888 reviewers gave Lincare an average score of 1.3 out of 5. They cite dirty and broken equipment, charges that continue even after equipment has been returned, harassing sales and collection calls, and nightmarish customer service. As one person wrote in April, Lincare is “running a scam where they have guaranteed income” and “the customer can’t do a thing.”

HHS has always been reluctant to cut off big suppliers. Medicare’s first objective is to make sure nothing interrupts the flow of medications, devices and services to beneficiaries. And were HHS to seek to ban Lincare, the company would surely launch a long, costly legal war. But even if the cost of such combat reached many millions of dollars, it would still be a tiny fraction of the amount lost to fraud, which is yet another contributor to the soaring medical costs that bedevil the country. “This is taxpayer money,” said Jerry Martin, a former U.S. attorney who represented an ex-Lincare executive in a whistleblower suit against the company. “We need to pay people that don’t have four corporate-integrity agreements.”

Weak enforcement is not the only problem. Lincare is paid to rent oxygen equipment to patients, with HHS covering most of the monthly bills. But those rental fees often add up to many times what it would cost simply to buy the equipment. “If this were a rational country,” Bruce Vladeck, who ran Medicare from 1993 to 1997, told ProPublica, “the government would buy a million [oxygen] concentrators and pay Amazon or somebody to deliver them.”

In a seven-month investigation, ProPublica examined how Medicare’s largest provider of home medical equipment has managed to take advantage of its customers for a quarter of a century while fending off meaningful enforcement. ProPublica interviewed more than 60 current and former employees and executives, Medicare and Justice Department officials, patient advocates, and health care experts. ProPublica also reviewed dozens of court cases involving Lincare and thousands of pages of internal company documents, sales presentations and emails.

The investigation reveals a dismal picture of a company with a sales culture that depends on squeezing infirm and elderly patients and the government for every penny. Lincare employees are pressured to sell — whether a customer needs a product or not — on pain of losing their jobs.

And the company’s record of misbehavior and conflict extends far beyond its sales and billing practices. Lincare has paid $9.5 million in settlements for data breaches and mishandling patient and employee records. It has faced claims of violating wage rules, harassing customers with sales and collection calls, and tolerating racist comments to an African American employee. (Lincare lost the latter suit at trial and is appealing.) The company has repeatedly sparred in court with former executives, including a 2017 suit in which longtime executive Sharon Ford claimed that the company had cheated her out of a $1 million bonus. (A judge ruled in favor of Ford at trial before the case was overturned on appeal.) Ford testified that Lincare had earned an industry reputation as “The Evil Empire.” And when Lincare’s CEO, Crispin Teufel, resigned last year to become CEO of a rival company, Lincare sued him for breach of contract and misappropriating trade secrets. Teufel ultimately admitted to downloading confidential company records and was blocked from taking the new job. (Teufel did not respond to requests for comment. His replacement, Jeff Barnhard, took over as Lincare’s CEO in July 2023.)

Lincare declined multiple requests to make executives available for interviews. After ProPublica provided a lengthy document listing every assertion in this article, along with separate such letters to executives McCarthy and Pedersen, the company responded with a three-paragraph statement. It asserted that Lincare is “committed to delivering high-quality and clinically appropriate equipment, supplies, and services” but acknowledged “missteps in the past.” The company said its “new leadership” had “commenced a comprehensive review of our policies and procedures to help ensure we are complying fully with all state and federal regulations” and that “investments and enhancements we have made over the last several months will help prevent these issues from repeating in the future.” Lincare did not respond to follow-up questions requesting examples of the steps the company says it’s taking, including whether it has terminated any executives as part of this push.

When ProPublica asked a top Medicare enforcer why Lincare had eluded banishment, her answer suggested she views probation as a continuing ed class rather than a harsh punishment. “It’s like taking a college course,” said Tamara Forys, who is in charge of administrative and civil remedies for HHS’ Office of Inspector General. “At the end of the day, it’s really up to you to change your corporate culture and to study, to learn to pass the class … to embrace that and take those lessons learned and move them forward.” A spokesperson for the Centers for Medicare and Medicaid Services, which runs Medicare, declined to comment on Lincare but said the agency “is committed to preventing fraud and protecting people with Medicare from falling victim to fraud.”

There’s little incentive to refrain from misbehaving in an environment that tolerates bad behavior, said Lewis Morris, who was chief counsel to HHS’ Office of Inspector General from 2002 to 2012. “As long as that [settlement] check is less than the amount you stole, it’s a good business proposition."

Indeed, Lincare has counted on the government’s tepid response, two former company executives told ProPublica. Top management, they said, responds to fraud warnings by conducting a cost-benefit analysis. “I’ve sat in meetings where they said, ‘We might have $5 to $10 million risk — if caught,’” said Owen Kirk Staggs, who ran one of Lincare’s businesses in 2017 and fell out with the company. “‘But we’ve made $50 million. So let’s go for it. The risk is worth the reward.’”

Libby, Montana, provides a glimpse of the way Lincare operates. Oxygen is an urgent need in this mountain town of 2,857. Libby suffers from the lingering effects of “the worst case of industrial poisoning of a whole community in American history,” in the words of the Environmental Protection Agency. An open-pit vermiculite mine, which operated from 1963 to 1990, coated the area — and residents’ lungs — with needle-like asbestos fibers. More than 2,000 Libby citizens have been diagnosed with respiratory diseases since then; some 700 have died.

Hundreds of ailing residents relied on Lincare for home concentrators, which provide nearly pure oxygen extracted from room air. Medicare and Medicare Advantage plans (which the government also funds) covered 80% of the monthly rental of about $135; patients paid the remaining 20%.

In 2020, Brandon Haugen noticed something suspicious in Lincare’s bills. Haugen was a customer service representative at the company’s local distribution site, one of 700 such locations around the country. (Lincare serves 1.8 million respiratory patients in 48 states.)

Lincare was allowed to charge patients and their insurers for a maximum of 36 months under federal rules. After that point, patients could use the equipment without further charge. Lincare, however, kept billing local patients and their Medicare Advantage plans far beyond 36 months — in some cases, for years. To Haugen, this looked like fraud.

Haugen conferred with center manager Ben Montgomery. The two, who had grown up in the area, had been buddies since seventh grade, after getting to know each other at summer Bible camp. Then 38, earnest and just beginning to gray out of their boyishness, the two men were concerned. The patients the men dealt with were their neighbors.

A regional Lincare manager assured them that charging beyond 36 months for Medicare Advantage patients “is the correct way to bill.” Skeptical, Montgomery raised the issue with Lincare’s headquarters in Clearwater, Florida. Lincare’s compliance director told him, according to Montgomery, that “it’s the patients’ problem to fix it if they want it to stop”; that was “just how it worked.” Further questions, sent to Lincare’s chief compliance officer, Pedersen, went nowhere. “It seemed pretty obvious they were well aware of this,” Montgomery told ProPublica. “For me, these were my customers that you were screwing over.”

Among them was Neil Bauer, now 80, who lives in a ramshackle house “out in the boondocks,” as he put it, 38 miles southeast of Libby. Bauer spent his career as a barber, head of investigations for the county sheriff’s department and a member of the local school board. He’s been on oxygen for more than a decade and quickly gets short of breath. “I can’t do stuff so much now,” he said. His wife is on oxygen, too. “We just have a sick family,” Bauer said.

Lincare had kept billing Bauer for his concentrator for seven years after it was supposed to stop. The monthly copays weren’t huge, but they added up to $2,325 that he shouldn’t have been charged over that period, a daunting sum for Bauer, who lives on a fixed income — and a hefty mark-up over the cost of the equipment, which can be purchased online for $799. For its part, Medicare Advantage paid Lincare $9,299 for Bauer’s concentrator during this period, along with another $5,760 for the months Lincare was legally permitted to bill. All told, the rental payments to Lincare, during authorized and unauthorized periods, were $16,547 for that one $799 piece of equipment. “We paid forever,” said Bauer. “Never was I told that we could have one without having to pay anything.”

Haugen and Montgomery studied billing records. Among the customers in their tiny office, Lincare was improperly charging at least 33 people and their Medicare plans. The two began to wonder how far this problem extended. An employee in Idaho confirmed the same practice was occurring there. “In my mind,” Montgomery said, “I went, ‘This is Libby, Montana. Multiply that by every center in the country. This is obviously a lot bigger deal.’”

Montgomery and Haugen had seen enough. On Jan. 18, 2021, they emailed a joint resignation letter to Lincare’s top management, recounting their concerns about billing that “likely affects thousands of patients company wide.” Citing the lack of response from corporate officials, they wrote, “we can only conclude that this is a known issue that is being covered up by Lincare.”

Haugen had 10 children. Montgomery had four. Neither man had another job lined up. “Had this not happened,” said Montgomery, who had been at the company for 13 years, “I would have seen myself retiring from Lincare.”

Instead, they became whistleblowers. They retained a law firm and sued Lincare in Spokane, Washington, the site of Lincare’s regional headquarters. After federal prosecutors decided to back the case, Lincare settled in August 2023. The company admitted to overbilling Medicare plans and patients across the country for years and paid $29 million to settle the matter, with $5.7 million of that going to Montgomery, Haugen and their lawyers. Dan Fruchter, the assistant U.S. attorney leading the government’s case, told ProPublica that the overbillings likely involved “tens of thousands” of patients.

Lincare agreed to its fourth stint of probation with HHS; the new corporate-integrity agreement took effect on the day after the previous one expired. The conduct Montgomery and Haugen flagged had gone on for years while the company was already on probation. But Lincare got the government lawyers to agree that nobody would try to impose the Medicare death penalty. Lincare asserted in the settlement that it had installed software (which it did only after learning of the government investigation) that will prevent billing beyond 36 months. Lincare promised to ensure “full and timely” compliance with the agreement and prevent future wrongdoing.

Medicare fraud, including in the “durable medical equipment” category that Lincare operates in, has long been an intractable problem. It cost the U.S. Treasury an estimated $60 billion in 2023 alone.

The government deploys large sums to try to stop it. HHS’ inspector general’s office has a $432 million budget and a staff of 1,600. Those resources are effectively extended by whistleblowers — most of the cases against Lincare have been such suits — who can receive a percentage of a civil settlement if they reveal wrongdoing, and by federal prosecutors, who can also bring cases or join those filed by whistleblowers. Last year HHS recovered $3.2 billion from fraudulent schemes.

But the agency’s enforcers have wielded their biggest deterrent almost entirely against small perpetrators. In 2023, they banned 2,112 small firms and individuals from Medicare reimbursement.

HHS hasn’t done the same with companies that operate on a national scale. Forys, the agency enforcer, said she worries that expelling a big provider from Medicare could leave customers in the lurch. In April, Inspector General Christi Grimm defended her office’s work in congressional testimony but also asserted that its resources are inadequate. A lack of staff keeps it from even investigating “between 300 and 400 viable criminal and civil health care cases” annually, she testified, as well as more than half the fraud referrals from Medicare’s outside audit contractors.

A different reason for going easy on big companies was suggested by Vladeck, the former Medicare chief. Seeking to bar a large supplier for repeatedly violating probation would require exhaustive documentation and years of litigation against squadrons of well-paid corporate lawyers. As a result, Vladeck said, “there’s a real incentive, from a bureaucratic point of view, to just slap their wrist, give them a kick and make them apologize. … It’s a cost of doing business.”

There are steps enforcers could take, but almost never do, that would make companies take notice, according to Jacob Elberg, a former federal prosecutor who is now a professor at Seton Hall Law School. (Among his publications is a 2021 law review article titled “Health Care Fraud Means Never Having to Say You’re Sorry.”) Elberg’s research shows that HHS and prosecutors tend to negotiate far smaller civil settlements than the law allows, and they rarely prosecute company executives. They also almost never take cases to trial. In short, enforcers have long signaled to companies that they’re looking for a smooth path to a cash payment rather than a stern punishment for a company and its leaders. “It is generally a safe assumption,” Elberg said, “that the result will be a civil settlement at an amount that is tolerable.”

For its part, Congress may soon be weighing a new law that would reshape how the oxygen industry is paid by Medicare. But rather than clamp down on corporations, the legislation seems poised to do the opposite. A new bill called the SOAR (Supplemental Oxygen Access Reform) Act would hand companies like Lincare hundreds of millions more, by raising reimbursement rates and eliminating competitive bidding among equipment providers. Advocates say the legislation will help patients by making some forms of oxygen more available and improving service. But along the way it will reward Lincare and its rivals.

Congress has a history of treating oxygen companies generously. For years, lawmakers set Medicare reimbursements for oxygen equipment at levels that even HHS, in 1997, characterized as “grossly excessive.” Over the succeeding decade and a half, Lincare took advantage, snatching up hundreds of small suppliers and becoming the industry’s largest player.

In 2006, under pressure to reduce costs, Congress approved steps to curb oxygen payments, including the introduction of competitive bidding and the 36-month cap on payments for equipment rentals. But even those strictures were watered down after the industry poured money into political contributions and lobbyists, who warned that cuts would harm elderly patients.

Lincare compensated by amping up strategies that generated profits, with little apparent regard for Medicare’s rules, which say it will reimburse costs for equipment only when there is evidence of “medical necessity.” The company aggressively courted doctors and incentivized sales, through bonuses the company paid for each new device “setup.” According to a 2016 commission schedule, reps could earn $40 for winning an order for a new sleep apnea machine, $100 for a new oxygen patient and $200 for a noninvasive ventilator. The entire staff of each Lincare center could receive a small bonus for signing up a high percentage of new patients for automatic monthly billing. Patients who refused auto-billing, a company document advised, should be warned they might face “collection activity” and service cutoffs. “Sales is our top priority!” declared a 2020 PowerPoint to train new hires.

Once it had a customer, Lincare would pitch them more costly products and services. One way Lincare did this was through a program called CareChecks. Promoted as a “patient monitoring” benefit, CareChecks were aimed, according to a company presentation, at generating “internal growth.” If a patient exhibited a persistent phlegmy cough, Lincare could persuade their doctor to prescribe a special vibrating vest to loosen chest mucus. Nebulizer patients might be candidates for home oxygen. Patients using apnea devices were potential candidates for ventilators. “We’d make patients think we were coming in clinically to assess them,” a former Lincare manager said, “when really it was to make money off of them.”

Selling replacement parts could also be lucrative. At Lincare call centers that sold items like hoses, masks and filters for CPAP machines (used to treat apnea), hundreds of commissioned agents in Nashville, Tennessee, and Tampa, Florida, were equipped with programs displaying what items each patient was eligible for under Medicare. By law, patients had to request replacement parts. But frequently, that wasn’t what happened, according to Staggs, who oversaw the CPAP business in 2017. He discovered that top salespeople, whose bonuses could total $8,000 a month, averaged just a few minutes on the phone per order. That wasn’t nearly enough time to identify what items, if any, customers actually needed. Staggs listened to recorded calls and found that, after reaching customers, agents often placed them on hold until they hung up, then ordered them every product that Medicare would cover.

At Lincare, results were closely tracked and widely shared in weekly emails displaying the best and worst performers in each region. Notes taken by one manager show supervisors’ performance demands during weekly conference calls: “Unacceptable to miss goal … stop the excuses … If this is not being done, wrong [center manager] in place … If you’re not getting O2 and not getting Care Checks — you shit the bed. Stop accepting mediocre, lazy responses ….”

“If we didn’t meet our quota, they were going to chop our heads,” said former Illinois sales rep Sandra Gauch, who worked for Lincare for 17 years before joining a whistleblower suit and quitting in 2022.

One salesperson was so fearful of missing her quota, according to Gauch, that she signed her mother up for a ventilator that she didn’t need. A company audit in 2018 found that only 10 of 56 ventilator patients at one center were using them consistently. Some patients hadn’t used their devices for years. Yet Lincare kept billing Medicare.

Only one thing mattered as much as maximizing new equipment rentals, according to former employees and company documents: minimizing customers’ attempts to end rentals. A call to retrieve breathing equipment meant that it was no longer wanted or being used, and Lincare was supposed to retrieve it and promptly stop billing Medicare and the patient. The person’s health might have improved. They might have gone into the hospital — or died. The reason didn’t matter; at Lincare, “pickups” were a black mark, deducted from employees’ performance scores, jeopardizing their bonuses and jobs.

As a result, employees said, such requests were dreaded, delayed and deterred. Clinical staff were sent to “reeducate” customers to keep using their devices. Patients were told they’d need to sign a form stating they were acting “against medical advice.”

Lincare managers made it clear that pickups should be discouraged. In a 2010 email, an Ohio center manager instructed subordinates: “As we have already discussed, absolutely no pick-ups/inactivation’s are to be do[ne] until I give you the green light. Even if they are deceased.” In 2018, an Illinois supervisor emailed her deputies that pickups were barred without her explicit approval: “Not even Death that I don’t approve first.”

In February 2022, Justin Linafelter, an area manager in Denver, responded to the latest corporate email celebrating monthly “Achievement Rankings” for oxygen sales by pointing out that almost all of the centers atop the rankings had at least 150 “pending pickups,” customers who weren’t using their equipment but whom the company appeared to still be billing. “Some of these centers are just ignoring pickups to make this list.”

That was only one of Linafelter’s concerns. In July of that year, he emailed headquarters, saying he no longer had “the resources to be successful at my job.” The customer service staff in Denver had been cut in half, Linafelter explained, and he’d been barred from hiring replacements. Denver’s remaining staff was “at a point of exhaustion,” threatening patient care.

The morning after Linafelter expressed concerns to Lincare in 2022, he was summoned to a conference call with the head of HR and fired, for what he was told was a “corporate restructuring.” Linafelter, who had worked at Lincare for nine years, said, “I got thrown away like a piece of trash.”

Other former employees offer similar accounts. In 2020, Jillian Watkins, a center manager in Huntington, West Virginia, repeatedly alerted supervisors that Lincare was improperly billing for equipment that patients weren’t using. Lincare blocked her from firing a subordinate who’d falsified documents supporting the charges, then fired Watkins, citing “inadequate direction and leadership.”

Then came a series of turns. Pedersen, the chief compliance officer, effectively confirmed Watkins’ assertions, belatedly alerting the government about $486,000 in improper billings by Lincare. But Pedersen blamed the billings on Watkins, writing to Medicare that the company had “terminated” her to “prevent [the problem] from recurring.” After Watkins sued, Pedersen admitted in a deposition that Watkins’ firing “had nothing to do with the overpayment.” In April 2024, a federal judge ruled that Watkins had presented “a prima facie case of retaliation.” The suit was privately settled in mediation.

Staggs, too, was ousted, he said, after he warned top Lincare executives about improper practices at the CPAP call centers. Staggs emailed a Lincare HR officer: “Patients are being shipped supplies that they never have ordered. … This is fraud and I have gotten zero support or attention to this matter when I raise the issue to my leadership.” Only months after starting, he was fired in November 2017. He later filed a whistleblower suit; Lincare denied wrongdoing. After the U.S. attorney’s office in Nashville declined to join the case in 2022, Staggs withdrew the action.

Staggs’ account of improper billings matches an industry pattern that appears to continue to this day. In a 2018 report, HHS’ inspector general estimated that Medicare had paid more than $631 million in improper claims for CPAP and other supplies over a two-year period. Another HHS analysis identified an additional $566 million in potential overpayments for apnea devices.

The agency’s oversight “was not sufficient to ensure that suppliers complied with Medicare requirements,” the 2018 report concluded. Six years later, HHS has not taken public action against Lincare relating to CPAPs.

Today, fraudulent billing among Medicare equipment providers remains a “major concern,” according to the inspector general. The agency says it continues to review the issue.

With pink manicured nails that matched her trim pink blazer, she tapped out a message on her phone to a top election lawyer for the Trump campaign and the Republican National Committee. “Got it passed,” she wrote to Gineen Bresso, photographs reviewed by ProPublica show.

What had passed that September afternoon in Atlanta was a state rule, championed by Adams, that would allow poll watchers like those she’d trained to gain greater access to sensitive areas in counting centers where votes were being tallied. The rule was a priority for supporters of former President Donald Trump who are looking to pave the way to challenge election results if their candidate loses this week’s vote.

The win was one in a string of them for Adams, who quickly ascended from a little-known, financially troubled conservative activist to a surprise appointee to the Fulton County board of elections. Her note to Bresso signaled not just this particular victory but the extent to which the 61-year-old has used her new perch to carry out the efforts of national players seeking to tilt the election in Trump’s favor.

Fulton itself is significant in state and national politics for a host of reasons: its sheer concentration of Democratic voters (380,000 in 2020, more than any other Georgia county), the scrutiny it received from national election skeptics after Trump lost the state by fewer than 12,000 votes — and, now, its newest election board member’s outsize role in trying to influence Georgia’s election processes.

Her actions in her nine months on the Fulton County board have been prodigious. She secretly helped push another, arguably higher-stakes rule through the state election board that vastly expanded the authority of county board members to refuse to certify votes they deem suspicious. She herself refused to certify the results of the presidential primary in March (though the board’s Democratic majority overruled her), and then she sued her board and election director, asserting local officials should be allowed to refuse to certify vote totals if there are discrepancies, which experts say are almost always innocuous. Some of her lawyers in that case work for the America First Policy Institute, an advocacy group staffed with former Trump officials.

So far, Adams’ efforts have mostly failed. Two judges have invalidated rules that Adams backed, with one calling them “illegal, unconstitutional and void.” But other efforts are still underway. The month after joining the Fulton County election board, Adams became regional coordinator for the Election Integrity Network, the group founded by lawyer Cleta Mitchell, who joined Trump on a call when he asked Georgia’s secretary of state to “find” him enough votes to overturn the 2020 election results there.

In that role, Adams runs weekly calls for Republican activists who have described Georgia’s voting as rigged, and she has pulled conservative members of local election boards into a loose coalition, many of whom have challenged results in their counties, too. And prominent conservative election lawyers, writers and national groups have used Adams’ push against certification in Georgia as the basis for a national argument.

Adams did not respond to numerous requests for comment or a detailed list of questions. Nor did representatives for the Election Integrity Network.

The Georgia-based group that hired Adams in 2022, Tea Party Patriots Action, has received millions of dollars from organizations closely tied to conservative legal activist and fundraiser Leonard Leo and billionaire Richard Uihlein, tax records show. Uihlein-backed groups launched unsubstantiated attacks on the legitimacy of voter rolls in at least a dozen states after the 2020 election.

A representative for Uihlein did not respond to questions. A representative for Leo would not elaborate on his contributions to organizations that supported Tea Party Patriots.

The true test of Adams’ effectiveness will come on Election Day — and, if the results in Georgia are anywhere near as close and consequential as they were in 2020, in the days and weeks beyond.

“She’s trying to help Trump win or trying to create chaos in the administration of the election in order to cast aspersions on it if he doesn’t win,” said Patrise Perkins-Hooker, who served as chair of the county election board when Adams joined. Perkins-Hooker described Adams’ work as centered on carrying out the agenda of right-wing activists and not making “the elections run smoothly or transparently.”

In response to ProPublica’s questions, the Republican National Committee provided a statement that said: “The Georgia state election board passed commonsense safeguards to secure Georgia's elections. The Trump-Vance Campaign and RNC supported these rules to bring transparency and accountability to the election process.” It also said, “The RNC defended these rules in court against attacks from Kamala and the DNC and will continue to fight against Democrat election interference.”

Back in 2020, Mitchell and others challenging the results across the country had to rely on disorganized groups of Trump supporters who came together at the last minute and were mostly unfamiliar with election systems. Experts now warn about the more pronounced impact that election deniers like Adams will have, given that they have come to occupy positions of power in local election administration. As Trump said at an October rally in North Carolina: “The vote counter is far more important than the candidate.”

When Adams placed her hand on a Bible in February and took an oath to fairly administer Fulton County’s elections, voting rights advocates and Democrats thought they had scored a victory. Eight months earlier, they had twice swatted back efforts by the county GOP to install an activist who’d made his name challenging residents’ voter registrations. The Republicans had sued to force the election board to accept him, then relented and put Adams forward instead.

“It was universal support for Julie,” said Earl Ferguson, a vice chair of the Fulton County Republicans, who has also filed challenges to voters’ eligibility and repeated debunked conspiracy theories about the reliability of voting machines at election board meetings. (Ferguson does not agree that the points he made about the machines were not valid.) “She is honest and very capable, and very pleasant.”

After Trump lost the 2020 election, Adams and a small group of conservative activists became regular attendees at election board meetings. On a few occasions, she addressed the board during the public comment period, questioning the integrity of the county’s elections and its certification process. But she was much less outspoken than other activists in the group.

“When Adams was appointed, little was known about her connections to election deniers to justify opposition,” said Max Flugrath, spokesperson for Fair Fight, the Georgia-based voting advocacy organization. “Voting rights groups instead focused on opposing candidates with documented anti-voter records.”

Adams had worked in human resources and executive recruiting. Records show she also had experienced major financial setbacks. She’d filed for bankruptcy in 2005, and her mortgage company had auctioned her Cobb County home on the courthouse steps in 2010. A landlord later sued her, and she agreed to pay more than $13,000 in back rent, according to a 2021 consent agreement.

That same year, she trained 32 poll watchers to monitor the 2021 municipal elections. And she told county commissioners that she believed some tally sheets from an audit of the 2020 election had been “falsified.”

In 2022, Tea Party Patriots Action, the politically active arm of one of the largest national Tea Party groups, hired Adams as a field director, paying her about $124,000 a year according to tax filings.

Her hire came at a time when the group was pulling in cash and intensifying its focus on election issues. Groups funded by Leo, who is seen as the architect behind the Supreme Court’s conservative supermajority, provided the Tea Party group and a related foundation at least $1.1 million between 2020 and 2022, records show, including a 2021 grant related to election integrity. The group also hired Leo’s firm as consultants.

In 2022, Tea Party Patriots Action more than doubled its annual revenue, thanks in part to a $2.5 million grant from Restoration of America — which is backed by Uihlein, the billionaire owner of the packing supplies company Uline. That year, former Trump campaign official Gina Swoboda was a Restoration for America executive director. Restoration has spent the years since Trump lost in 2020 pushing the unfounded idea that discrepancies in voter roll data between the number of votes and the number of ballots cast are evidence of fraud, despite insistence by elected officials from both parties that the claims are baseless.

That year, the Tea Party group added a program to bring in poll watchers and workers in Georgia, records show. And it had Adams in place.

Representatives for the Tea Party group and Restoration of America did not respond to requests for comment. Swoboda did not respond to questions.

Adams has run scores of poll watcher and worker online trainings, with some drawing dozens of people, records reviewed by ProPublica show. In a May training, Adams listed over 10 things that she wants trainees to report, from the serial numbers on voting machines to the names of poll managers. “There’s no such thing as too much documentation,” she said in a recording of a May training. “If something doesn’t feel right to you, you need to write it out.”

At an October training, she told the roughly three dozen attendees, including those joining from out of state, to first report discrepancies to their state GOP and RNC hotlines and then to VoterGA, an organization whose leader has cast doubt on the outcome of the 2020 election. The Republican Party and right-wing organizations plan to use the poll watchers’ reports in post-election litigation, ProPublica has reported.

“VoterGA has an 18-year proven track record of nonpartisan activity,” said co-founder Garland Favorito. “Republicans and Democrats are told to call their own party hotlines for election issues. We have no plans or resources to file any type of speculative litigation in any matter.”

While working for the Tea Party, Adams also led weekly meetings frequented by prominent state activists, RNC officials, GOP county heads, conservative election board members and voter registration challengers, according to records including emails obtained by the watchdog group Citizens for Responsibility and Ethics in Washington and shared with ProPublica.

Agendas included subjects such as “Voter Integrity concerns for 2024 Elections” and warnings like “New York Times Reporter traveling to several counties in Georgia.”

In 2022, Adams had appeared at the Election Integrity Network’s Georgia chapter launch and was described the following year as its state liaison in social media posts by other activists.

But much of her work was done behind the scenes. So when the county GOP nominated her to join the election board in the heavily Democratic Fulton County, commissioners approved the choice 6-0.

After Adams joined the board in February, it did not take long for fellow members to begin worrying about her intentions. The board is made up of four political appointees, two by each party, led by a chair chosen by the Democratic-majority county commission. Traditionally, the board’s primary goal has been to make Fulton elections run smoothly, past and present board members said.

However, Perkins-Hooker, the chair when Adams joined, said that during meetings, she could see Adams receiving text messages from a Republican activist “telling her what to say, and what to do.” After Perkins-Hooker stepped down in April, the new chair banned board members from using phones during meetings.

“She came with a mission to try and paint our elections as being fraught with fraud and incompetency,” said Perkins-Hooker, an opinion echoed by other board members.

Adams had been on the board for just a few weeks when, in March, she was elevated to regional coordinator for the Election Integrity Network, the organization that Mitchell, Trump’s lawyer, had launched. The new position put her near the top of the leadership’s organizational chart.

Adams quickly began pushing conservative priorities at election board meetings. She wanted poll watchers to have more access to vote tallies from election machines. And she was very concerned about the mechanics of certifying elections. Though a century of case law says that certification is a mandatory duty for officials like her — whom experts compare to scorekeepers, not referees — Adams began questioning if she had to do it. She demanded reams of information she said that she needed to be certain of the results before certifying.

At Adams’ third meeting, in March, she and the other Republican board member shocked Democratic board members by voting against the certification of the presidential primary election — though the Democratic majority overruled them.

Adams’ push to have power over certification of election results couldn’t succeed under the state’s current rules, so she set out to change them.

To do so, she lobbied to remake the body that determined them, the State Election Board, which at the time was composed of two moderate Republican members, two MAGA-aligned members and a Democrat. She activated the coalition she had been building with the support of national Republicans, inviting them to a March meeting where the goal was to ensure that the moderate Republican on the State Election Board was replaced. “The Georgia House of Representatives needs to take action immediately!!!!” the meeting invitation read, providing the phone number of the speaker of the house.

Not long afterward, the speaker replaced that board member with a conservative media personality whom Trump would soon praise by name at a rally.

The new Trump-backed majority quickly began passing rules that the prior board had criticized as illegal, including one, originally pushed by Adams, expanding the power of county board members to refuse to certify votes they found suspicious. It was passed by the new board along with another rule potentially allowing county board members to delay certification.

A national outcry ensued, with The New York Times calling it “The Republican Plan to Challenge a Harris Victory.”

Three of the nation’s leading conservative election lawyers backed the new rules. A conservative group ran ads targeting swing state election officials that echoed the lawyers’ arguments. And the certification rule Adams pushed became a talking point for conservative media outlets. One article in The Federalist argued that it “could stop leftists from bullying election officials into certifying results without completing their duties.” Lawyers for the Republican National Committee and a Trump-aligned conservative think tank also defended the certification rules in Georgia superior court, testing arguments that certifying election results was optional.

Adams’ arguments that certification is not mandatory inspired David Hancock, a GOP member of Gwinnett County’s election board, to vote against certifying the same presidential primary as Adams. (He described several minor inconsistencies as sufficient reason for him not to certify.) “It was, like, a big deal,” Hancock said of Adams’ decision to vote against certifying.

Because two judges in October invalidated the new rules passed by the State Election Board, the mechanics of the election this week will be the same as before Adams’ pushes to empower poll watchers and county election board members.

But at a combative Fulton County board meeting the week before the election, Adams made clear that she wasn’t going to let the judge’s rulings stop her from continuing her campaign. Despite the county’s lawyer telling her that the certification rule she had pushed had been stayed, she argued that it had actually not been, citing her lawyers. “I’ve learned how the system works — or at least how it was supposed to work,” Adams said. “I’ve learned how sometimes it doesn’t work as the law requires, right here in Fulton County.”

The firm’s use of workers in Mexico was confirmed by a spokesperson for Trump Media, which operates the Truth Social platform. The workers were hired through another entity to code and perform other technical duties, according to a person with knowledge of Trump Media. The reliance on foreign labor was met with outrage among the company's own staff, who accused its leadership of betraying their “America First” ideals, the person said.

The outsourcing to Mexico helped prompt a recent whistleblower letter from staff to Trump Media’s board that has been roiling the company.

That complaint, reported by ProPublica last month, calls for the board to fire CEO Devin Nunes, a former Republican congressman. The letter alleges he has “severely” mismanaged the company. It also asserts the company is hiring “America Last” — with Nunes imposing a directive to hire only foreign contractors at the expense of “American workers who are deeply committed to our mission.”

“This approach not only contradicts the America First principles we stand for but also raises concerns about the quality, dedication, and alignment of our workforce with our core values,” the complaint reads.

A Trump Media spokesperson said the company uses “two individual workers” in Mexico. “Presenting the fact that [Trump Media] works with precisely two specialist contractors in Mexico as some sort of sensational scandal is just the latest in a long line of defamatory conspiracy theories invented by the serial fabricators at ProPublica,” the spokesperson said.

The spokesperson declined to answer other questions about the company’s Mexican contractors, including how much they’ve been paid, how many have been used over time and how their hiring squares with Trump’s promises to punish firms that send jobs outside of the U.S. The Trump campaign did not respond to questions.

For a company of its prominence, Trump Media has a tiny permanent staff, employing just a few dozen people as of the end of last year, only a portion of whom work on the Truth Social technology.

Trump Media’s hiring of Mexican coders also prompted frustration within the staff, the person with knowledge of the company said, because they were perceived by staff to not have the technical expertise to do the work.

On its homepage, Truth Social bills itself as “Proudly made in the United States of America. 🇺🇸”

Both as president and in his campaign for a second term, Trump has criticized companies that send jobs abroad, particularly to Mexico. If elected, he has pledged to “stop outsourcing” and “punish” companies that send jobs abroad.

For example, Trump recently threatened agricultural machinery giant John Deere with tariffs if it went through with plans to move some of its manufacturing to Mexico.

“I’m just notifying John Deere right now, if you do that, we’re putting a 200 percent tariff on everything you want to sell into the United States,” Trump said.

He has made a similar threat against automakers building cars in Mexico, demanding they hire American workers and manufacture domestically.

“I'm not going to let them build a factory right across the border,” Trump promised, “and sell millions of cars into the United States and destroy Detroit further."

Trump owns nearly 60% of the social media company, a stake worth around $3.5 billion at the stock’s Friday closing price — more than half of the former president’s net worth.

The results of the election are widely seen as a major factor in the future value of the company. As the Nov. 5 election draws closer, Trump Media’s stock price has fluctuated wildly even as little or nothing has changed in the company’s actual business, which generates scant revenue. The stock closed Friday down 40% from its recent peak on Tuesday. Despite that drop, it has still nearly doubled since the beginning of October.

One Trump Media board member, Eric Swider, offered a defense of relying on foreign labor in a statement to ProPublica from his lawyer.

“President Trump maintains an America First policy, which includes prioritizing American workers. Trump Media, however, is a global multi-media company. For a global multi-media company to utilize subcontractors, which in turn may utilize coders located in a foreign country, is a practice common to the industry,” the statement said. “Such global multi-media companies like Trump Media would have no right to control the employment decisions of its subcontractors, which may employ workers in a multitude of different countries in addition to the United States.”

Swider, a businessman based in Puerto Rico, serves on the board alongside better known figures such as Donald Trump Jr. and Linda McMahon, the former Trump cabinet member who is now co-chair of his transition team.

The outsourcing to Mexico is not the only instance of Trump Media relying on foreign workers. ProPublica previously reported that the company used a foreign firm to source labor in the Balkans.

Nunes, for his part, is quoted in a new book about Truth Social, “Disappearing the President,” boasting about his ability to keep costs down at Trump Media, though he didn’t mention outsourcing.

“Nobody grew as fast as we did. I don't think there's any other example even close to us out there, especially with as little money as we spent,” Nunes said. “Don't forget that. We built this for a fraction of what these other companies were built for.”

Josseli Barnica grieved the news as she lay in a Houston hospital bed on Sept. 3, 2021: The sibling she’d dreamt of giving her daughter would not survive this pregnancy.

The fetus was on the verge of coming out, its head pressed against her dilated cervix; she was 17 weeks pregnant and a miscarriage was “in progress,” doctors noted in hospital records. At that point, they should have offered to speed up the delivery or empty her uterus to stave off a deadly infection, more than a dozen medical experts told ProPublica.

But when Barnica’s husband rushed to her side from his job on a construction site, she relayed what she said the medical team had told her: “They had to wait until there was no heartbeat,” he told ProPublica in Spanish. “It would be a crime to give her an abortion.”

For 40 hours, the anguished 28-year-old mother prayed for doctors to help her get home to her daughter; all the while, her uterus remained exposed to bacteria.

Three days after she delivered, Barnica died of an infection.

Barnica is one of at least two Texas women who ProPublica found lost their lives after doctors delayed treating miscarriages, which fall into a gray area under the state’s strict abortion laws that prohibit doctors from ending the heartbeat of a fetus.

Neither had wanted an abortion, but that didn’t matter. Though proponents insist that the laws protect both the life of the fetus and the person carrying it, in practice, doctors have hesitated to provide care under threat of prosecution, prison time and professional ruin.

ProPublica is telling these women’s stories this week, starting with Barnica’s. Her death was “preventable,” according to more than a dozen medical experts who reviewed a summary of her hospital and autopsy records at ProPublica’s request; they called her case “horrific,” “astounding” and “egregious.”

The doctors involved in Barnica’s care at HCA Houston Healthcare Northwest did not respond to multiple requests for comment on her case. In a statement, HCA Healthcare said “our responsibility is to be in compliance with applicable state and federal laws and regulations” and said that physicians exercise their independent judgment. The company did not respond to a detailed list of questions about Barnica’s care.

Like all states, Texas has a committee of maternal health experts who review such deaths to recommend ways to prevent them, but the committee’s reports on individual cases are not public and members said they have not finished examining cases from 2021, the year Barnica died.

ProPublica is working to fill gaps in knowledge about the consequences of abortion bans. Reporters scoured death data, flagging Barnica’s case for its concerning cause of death: “sepsis” involving “products of conception.” We tracked down her family, obtained autopsy and hospital records and enlisted a range of experts to review a summary of her care that ProPublica created in consultation with two doctors.

Among those experts were more than a dozen OB-GYNs and maternal-fetal medicine specialists from across the country, including researchers at prestigious institutions, doctors who regularly handle miscarriages and experts who have served on state maternal mortality review committees or held posts at national professional medical organizations.

After reviewing the four-page summary, which included the timeline of care noted in hospital records, all agreed that requiring Barnica to wait to deliver until after there was no detectable fetal heartbeat violated professional medical standards because it could allow time for an aggressive infection to take hold. They said there was a good chance she would have survived if she was offered an intervention earlier.

“If this was Massachusetts or Ohio, she would have had that delivery within a couple hours,” said Dr. Susan Mann, a national patient safety expert in obstetric care who teaches at Harvard University.

Many noted a striking similarity to the case of Savita Halappavanar, a 31-year-old woman who died of septic shock in 2012 after providers in Ireland refused to empty her uterus while she was miscarrying at 17 weeks. When she begged for care, a midwife told her, “This is a Catholic country.” The resulting investigation and public outcry galvanized the country to change its strict ban on abortion.

But in the wake of deaths related to abortion access in the United States, leaders who support restricting the right have not called for any reforms.

Last month, ProPublica told the stories of two Georgia women, Amber Thurman and Candi Miller, whose deaths were deemed “preventable” by the state’s maternal mortality review committee after they were unable to access legal abortions and timely medical care amid an abortion ban.

Georgia Gov. Brian Kemp called the reporting “fear mongering.” Former President Donald Trump has not weighed in — except to joke that his Fox News town hall on women’s issues would get “better ratings” than a press call where Thurman’s family spoke about their pain.

Leaders in Texas, which has the nation’s oldest abortion ban, have witnessed the consequences of such restrictions longer than those in any other state.

In lawsuits, court petitions and news stories, dozens of women have said they faced dangers when they were denied abortions starting in 2021. One suffered sepsis like Barnica, but survived after three days in intensive care. She lost part of her fallopian tube. Lawmakers have made small concessions to clarify two exceptions for medical emergencies, but even in those cases, doctors risk up to 99 years in prison and fines of $100,000; they can argue in court that their actions were not a crime, much like defendants can claim self-defense after being charged with murder.

Amid the deluge of evidence of the harm, including research suggesting Texas’ legislation has increased infant and maternal deaths, some of the ban’s most prominent supporters have muted their public enthusiasm for it. U.S. Sen. Ted Cruz, who once championed the fall of Roe v. Wade and said, “Pregnancy is not a life-threatening illness,” is now avoiding the topic amid a battle to keep his seat. And Gov. Greg Abbott, who said early last year that “we promised we would protect the life of every child with a heartbeat, and we did,” has not made similar statements since.

Both declined to comment to ProPublica, as did state Attorney General Ken Paxton, whose commitment to the ban remains steadfast as he fights for access to the out-of-state medical records of women who travel for abortions. Earlier this month, as the nation grappled with the first reported, preventable deaths related to abortion access, Paxton celebrated a decision by the U.S. Supreme Court that allowed Texas to ignore federal guidance requiring doctors to provide abortions that are needed to stabilize emergency patients.

“This is a major victory,” Paxton said.

“They Had to Wait Until There Was No Heartbeat”

To Barnica, an immigrant from Honduras, the American dream seemed within reach in her corner of Houston, a neighborhood filled with restaurants selling El Salvadoran pupusas and bakeries specializing in Mexican conchas. She found work installing drywall, saved money to support her mother back home and met her husband in 2019 at a community soccer game.

A year later, they welcomed a big-eyed baby girl whose every milestone they celebrated. “God bless my family,” Barnica wrote on social media, alongside a photo of the trio in matching red-and-black plaid. “Our first Christmas with our Princess. I love them.”

Barnica longed for a large family and was thrilled when she conceived again in 2021.

Trouble struck in the second trimester.

On Sept. 2, 2021, at 17 weeks and four days pregnant, she went to the hospital with cramps, according to her records. The next day, when the bleeding worsened, she returned. Within two hours of her arrival on Sept. 3, an ultrasound confirmed “bulging membranes in the vagina with the fetal head in the open cervix,” dilated at 8.9 cm, and that she had low amniotic fluid. The miscarriage was “in progress,” the radiologist wrote.

When Barnica’s husband arrived, she told him doctors couldn’t intervene until there was no heartbeat.

The next day, Dr. Shirley Lima, an OB on duty, diagnosed an “inevitable” miscarriage.

In Barnica’s chart, she noted that the fetal heartbeat was detected and wrote that she was providing Barnica with pain medication and “emotional support.”

In a state that hadn’t banned abortion, Barnica could have immediately been offered the options that major medical organizations, including international ones, say is the standard of evidence-based care: speeding up labor with medication or a dilation and evacuation procedure to empty the uterus.

“We know that the sooner you intervene in these situations, the better outcomes are,” said Dr. Steven Porter, an OB-GYN in Cleveland.

But Texas’ new abortion ban had just gone into effect. It required physicians to confirm the absence of a fetal heartbeat before intervening unless there was a “medical emergency,” which the law did not define. It required doctors to make written notes on the patient’s condition and the reason abortion was necessary.

The law did not account for the possibility of a future emergency, one that could develop in hours or days without intervention, doctors told ProPublica.

Barnica was technically still stable. But lying in the hospital with her cervix open wider than a baseball left her uterus exposed to bacteria and placed her at high risk of developing sepsis, experts told ProPublica. Infections can move fast and be hard to control once they take hold.

The scenario felt all too familiar for Dr. Leilah Zahedi-Spung, a maternal-fetal medicine specialist who used to work in Tennessee and reviewed a summary of Barnica’s records at ProPublica’s request.

Abortion bans put doctors in an impossible position, she said, forcing them to decide whether to risk malpractice or a felony charge. After her state enacted one of the strictest bans in the country, she also waited to offer interventions in cases like Barnica’s until the fetal heartbeat stopped or patients showed signs of infection, praying every time that nothing would go wrong. It’s why she ultimately moved to Colorado.

The doctors treating Barnica “absolutely didn’t do the right thing,” she said. But she understood why they would have felt “totally stuck,” especially if they worked at a hospital that hadn’t promised to defend them.

Even three years after Barnica’s death, HCA Healthcare, the hospital chain that treated Barnica, will not disclose whether it has a policy on how to treat miscarriages.

Some HCA shareholders have asked the company to prepare a report on the risks to the company related to the bans in states that restrict abortion, so patients would understand what services they could expect and doctors would know under what circumstances they would be protected. But the board of directors opposed the proposal, partly because it would create an “unnecessary expense and burdens with limited benefits to our stockholders.” The proposal was supported by 8% of shareholders who voted.

The company’s decision to abstain has repercussions far beyond Texas; the nation’s largest for-profit hospital chain has said it delivers more babies than any other health care provider in America, and 70% of its hospitals are in states where abortion is restricted.

As the hours passed in the Houston hospital, Barnica couldn’t find relief. On the phone with her aunt Rosa Elda Calix Barnica, she complained that doctors kept performing ultrasounds to check the fetal heartbeat but were not helping her end the miscarriage.

Around 4 a.m. on Sept. 5, 40 hours after Barnica had arrived, doctors could no longer detect any heart activity. Soon after, Lima delivered Barnica’s fetus, giving her medication to help speed up the labor.

Dr. Joel Ross, the OB-GYN who oversaw her care, discharged her after about eight more hours.

The bleeding continued, but when Barnica called the hospital, she was told that was expected. Her aunt grew alarmed two days later when the bleeding grew heavier.

Go back, she told her niece.

On the evening of Sept. 7, Barnica’s husband rushed her to the hospital as soon as he got off from work. But COVID-19 protocols meant only one visitor could be in the room with her, and they didn’t have a babysitter for their 1-year-old daughter.

So he left and tried to get some sleep.

“I fully expected her to come home,” he said.

But she never did. Her family planned two funerals, one in Houston and another in Honduras.

Nine days after her death, Barnica’s husband was processing his shock, learning how to be a single dad and struggling to raise funds to bury his wife and the son he had hoped to raise.

Meanwhile, Lima was pulling up Barnica’s medical chart to make an addition to her records.

The notes she added made one point abundantly clear: “When I was called for delivery,” she wrote, “the fetus no longer had detectable heart tones.”

“They Should Vote With Their Feet”

Texas has been on the forefront of fighting abortion access.

At the time of Barnica’s miscarriage in 2021, the Supreme Court had not yet overturned the constitutional right to terminate a pregnancy. But Texas lawmakers, intent on being the first to enact a ban with teeth, had already passed a harsh civil law using a novel legal strategy that circumvented Roe v. Wade: It prohibited doctors from performing an abortion after six weeks by giving members of the public incentives to sue doctors for $10,000 judgments. The bounty also applied to anyone who “aided and abetted” an abortion.

A year later, after the Dobbs v. Jackson ruling was handed down, an even stricter criminal law went into effect, threatening doctors with up to 99 years in prison and $100,000 in fines.

Soon after the ruling, the Biden administration issued federal guidance reminding doctors in hospital emergency rooms they have a duty to treat pregnant patients who need to be stabilized, including by providing abortions for miscarriages.

Texas Attorney General Ken Paxton fought against that, arguing that following the guidance would force doctors to “commit crimes” under state law and make every hospital a “walk-in abortion clinic.” When a Dallas woman asked a court for approval to end her pregnancy because her fetus was not viable and she faced health risks if she carried it to term, Paxton fought to keep her pregnant. He argued her doctor hadn’t proved it was an emergency and threatened to prosecute anyone who helped her. “Nothing can restore the unborn child’s life that will be lost as a result,” he wrote to the court.

No doctor in Texas, or the 20 other states that criminalize abortion, has been prosecuted for violating a state ban. But the possibility looms over their every decision, dozens of doctors in those states told ProPublica, forcing them to consider their own legal risks as they navigate their patient’s health emergencies. The lack of clarity has resulted in many patients being denied care.

In 2023, Texas lawmakers made a small concession to the outcry over the uncertainty the ban was creating in hospitals. They created a new exception for ectopic pregnancies, a potentially fatal condition where the embryo attaches outside the uterine cavity, and for cases where a patient’s membranes rupture prematurely before viability, which introduces a high risk of infection. Doctors can still face prosecution, but are allowed to make the case to a judge or jury that their actions were protected, not unlike self-defense arguments after homicides. Barnica’s condition would not have clearly fit this exception.

This year, after being directed to do so by the state Supreme Court, the Texas Medical Board released new guidance telling doctors that an emergency didn’t need to be “imminent” in order to intervene and advising them to provide extra documentation regarding risks.

But in a recent interview, the board’s president, Dr. Sherif Zaafran, acknowledged that these efforts only go so far and the group has no power over criminal law: “There’s nothing we can do to stop a prosecutor from filing charges against the physicians.”

Asked what he would tell Texas patients who are miscarrying and unable to get treatment, he said they should get a second opinion: “They should vote with their feet and go and seek guidance from somebody else.”

An immigrant from El Salvador who works 12-hour shifts, Barnica’s husband doesn’t follow American politics or the news. He had no inkling of the contentious national debate over how abortion bans are affecting maternal health care when ProPublica contacted him.

Now he is raising a 4-year-old daughter with the help of Barnica’s younger brother; every weekend, they take her to see her grandmother, who knows how to braid her hair in pigtails.

All around their home, he keeps photos of Barnica so that the little girl grows up knowing how much her mother loved her. He sees flashes of his wife when his daughter dances. She radiates the same delight.

When asked about Barnica, he can’t get out many words; his leg is restless, his eyes fixed on the floor. Barnica’s family calls him a model father.

He says he’s just doing his best.

Twelve years ago, Sen. Sherrod Brown, the Ohio Democrat, took the stage at his election night party in Columbus to celebrate winning a second term. Barack Obama had just carried Ohio for the second time, after emphasizing his administration’s rescue of the auto industry. Brown wanted to proclaim that success onstage, but he was losing his voice, so his wife, the writer Connie Schultz, took over for him.

As she got to Jeep expanding its Toledo operations and General Motors building the Chevy Cruze at its rejuvenated plant near Youngstown, Brown started interjecting croaks to make sure she got the details right. “The aluminum is made in Cleveland … the transmission is made in Toledo … the engine is made in Defiance … the airbag is made in Brunswick.”

I thought about that moment often while on the campaign trail in Ohio this month. Brown is running for re-election again. But the political landscape is much changed. Ohio is no longer a presidential battleground. GM no longer makes the Cruze — the Lordstown plant where it was assembled closed in 2019. And Brown, who won his last two races by 5 and 7 points, is in a tight race against a car dealership magnate named Bernie Moreno.

Brown and a dwindling band of Democrats in Ohio are still making the case for a certain kind of Democratic Party — one that cares about the working class, that invests in their towns and factories and values the manufacturing jobs that power the nation. That case should have become easier to make of late. Over the past four years, the Biden administration has championed huge investments in renewable energy and computer chip production; two new Intel plants are under construction near Columbus. Yet the political landscape is tougher than ever for Brown and the last remaining Ohio Democrats.

There are several possible explanations. Sixty percent of Ohio residents have only a high school diploma, an associate degree or a few years of college — a relatively high percentage. Union membership has dwindled from its peak in 1989. And the Biden investments have taken a while to ramp up.

At a Brown rally outside an International Brotherhood of Electrical Workers hall in Dayton, the head of the local building trades council, David Cox, told me that his members were getting more work than they’d seen in 35 years. Then why, I asked, wasn’t this restoring support for Democrats among workers? “It takes a little while for these guys to wake up,” Cox said.

But Democrats often overlook another dynamic at play here, and that’s the role of place: Even if your own finances are secure, if you look out your window and see your city or town struggling, you believe you are, too. Some academics have referred to this as a sense of “shared fate,” and it could be a powerful force in this election, especially in small cities in the industrial Midwest — such as Reading and Erie in Pennsylvania, Saginaw and Battle Creek in Michigan, Oshkosh and Racine in Wisconsin — where Brown and other Democrats are fighting to hang on to their seats and where Kamala Harris needs to do well (or at least hold her own).

In 2007, the academic Lorlene Hoyt and the city planning consultant André Leroux assembled a nationwide list of “forgotten cities” that were old and small, with a population of 15,000 to 150,000 and a median household income of less than $35,000. Recently, the urban researcher Michael Bloomberg updated it. Of the 179 cities now on the list, 37 are in Pennsylvania, Michigan and Wisconsin. And leading the way, with 23 cities, is Ohio.

Pundits often overlook these sorts of places (they tend to focus on big blue cities, deep-red rural areas and the suburbs in between), but given how clustered these smaller cities are in Michigan, Pennsylvania and Wisconsin, they will matter greatly in the battle for both the White House and for control of Congress. Lately, two of Ohio’s have gained special prominence: Middletown (population 50,000) as the hometown of JD Vance, and Springfield (roughly 60,000) as home to a large community of Haitian immigrants that both Vance and Donald Trump have made a target of their rhetoric.

I have visited dozens of these cities. They often have handsome downtowns with stately central squares and ornate, century-old bank buildings that rise 10 or 12 stories, but it can be difficult to find a cup of coffee after 2 p.m. or a place to watch a ballgame on TV at night. The local news is full of the sort of items I found a few weeks ago in a newspaper in Lima, Ohio (population 35,000): a report that the area was getting its 12th Dollar General store and a letter to the editor lamenting the closure of a Dana Incorporated auto-parts plant with 280 jobs. Just as troubling, young people are becoming harder to find; they’re more drawn to thriving larger cities, such as Columbus, which has been vacuuming up strivers from across the state.

For decades, these smaller cities leaned Democratic, but in the past decade, they have turned redder. In 2012, Obama won Green Bay, Wisconsin, by nearly twice as large a margin as Joe Biden did in 2020; Obama won Saginaw by an extra 15 percentage points. Even in Biden’s hometown, Scranton, Pennsylvania, Obama’s margin was more than 4,000 votes larger.

What’s so perplexing to liberals about this shift is that many of the people who left the Democratic Party are doing well for themselves; these cities are full of small-business owners, factory workers and retirees with pensions getting by under a Democratic president. But seeing your small city become a shadow of its former self can open you to a hard-edge populist message even if you yourself are managing. That’s what scholars mean by “shared fate,” and it’s what’s missed when we analyze voting behavior only by income or education level or race.

Rep. Marcy Kaptur — an Ohio Democrat who is a city planner by training and, after more than 40 years in office, the longest-serving woman in the history of Congress — understands this visceral reality. Her mother was a union organizer at a spark plug factory, and she has watched these wrenching changes play out from Toledo to the smaller cities she has represented, such as Sandusky and Lorain.

It’s rare to hear her talk up the social issues that often dominate debate on the left. Instead, she is most insistent about whether the nation’s industrial base can support its military, whether small cities have economic development expertise, whether workers at Toledo’s closed power plant can find new jobs. “I believe economics isn’t destiny, but it’s 85% of it,” she told me this month during a visit to a new Cleveland-Cliffs steel plant in Toledo.

For years, she has been struggling to get Democratic leaders to care about left-behind districts such as hers. In 2018, Hillary Clinton boasted that the areas she had carried in her 2016 loss produced two-thirds of the nation’s gross domestic product, as if votes from the economically thriving areas counted more. Two years earlier, Chuck Schumer, now Senate majority leader, declared, “For every blue-collar Democrat we lose in western Pennsylvania, we will pick up two moderate Republicans in the suburbs of Philadelphia. And you can repeat that in Ohio and Illinois and Wisconsin.”

This logic confounds Kaptur, who is now in a closely fought race with a state legislator, Derek Merrin. “A country can’t survive when vast segments of your population cannot get ahead,” she told me. Last year, to impress on party leaders how much ground Democrats are losing in districts like hers, her office produced a chart ranking the 435 House districts by median income. The moral: Democrats now represented most higher-income districts — in places like the Bay Area, the Northeast and metro Washington — while Republicans dominated in many lower-income ones. Her own district was 341st on the ranking, surrounded by red ones. “Washington has trouble seeing us,” she said. “They need binoculars.”

For Brown, the plight of these small cities is personal, because he’s from an archetypal one: Mansfield (population 48,000), which has lost a string of manufacturers. This month, the first person whom I met upon arriving at its central square was a woman asking for money. Brown’s father was a doctor, but as Brown often reminds voters, he went to school with the children of factory workers, a perspective that set him, like Kaptur, against trade deals such as NAFTA that many other Democrats supported.

“Politicians of both parties have done the bidding of wealthy corporations and sold the country out over and over and over again,” he said at a United Auto Workers hall in Toledo this month.

After the event, I asked him about the difficulties facing small cities. “Those cities were even more damaged than metropolitan areas because young people often tended to leave because there wasn’t the economic opportunity,” he said. “So I pay special attention to them.”

On the campaign trail, this means making more visits to the smaller cities than most other Democrats might. These cities also figure prominently in Brown’s stump rhetoric. “I grew up in Mansfield, Ohio, a town that looks a lot like Springfield, looks a lot like Zanesville, looks a lot like Hamilton or Middletown” is how Brown opened his remarks outside the union hall in Dayton, a city also on the updated “forgotten” list. After that event, he fell into an extended conversation with a new sort of small-city leader: one of the pioneers of the Haitian community in Springfield, who now owns five houses there and had come to Dayton to see Brown speak.

Without a doubt, Brown’s and Kaptur’s understanding of such places has helped them survive as long as they have as the state turned redder. It’s not as if their opponents have been offering these small cities many concrete solutions of their own. Far from it: Moreno’s ads center on his backing by Trump, and virtually all of the tens of millions of dollars in attack ads being run against Brown by outside groups focus on transgender youth.

There’s a painful irony in this for Democrats such as Brown and Kaptur. For years, they have been urging their party to pay more heed to these scattered outposts of their base: to Mansfield and Middletown, Springfield and Sandusky, all across their state and region. They were largely vindicated in their warnings about trade policy and political fallout, and a national Democratic response finally arrived in the past few years.

But in many places, demoralization had already spread so far, and local institutions had withered so much, that it became much easier for an opposition message based on nationwide culture-war appeals to register. Brown is as vulnerable now as he has ever been — running only 4 points ahead of Harris in the latest poll — and Kaptur’s race is just as competitive. This is doubly painful for them because they have largely skirted the culture-war front over the years, concentrating instead on economic issues.

Brown and Kaptur may well survive their latest challenges. But it’s hard to see how Democrats will revive their standing in Ohio — or enhance their prospects in the nearby swing states that remain more within their reach, such as Michigan and Pennsylvania — without helping these small cities revive, too. As Kaptur told me simply, sitting in her Toledo office overlooking the Maumee River: “They need to be seen.”

A key ally to former President Donald Trump detailed plans to deploy the military in response to domestic unrest, defund the Environmental Protection Agency and put career civil servants “in trauma” in a series of previously unreported speeches that provide a sweeping vision for a second Trump term.

In private speeches delivered in 2023 and 2024, Russell Vought, who served as Trump’s director of the Office of Management and Budget, described his work crafting legal justifications so that military leaders or government lawyers would not stop Trump’s executive actions.

He said the plans are a response to a “Marxist takeover” of the country; likened the moment to 1776 and 1860, when the country was at war or on the brink of it; and said the timing of Trump’s candidacy was a “gift of God.”

ProPublica and Documented obtained videos of the two speeches Vought delivered during events for the Center for Renewing America, a pro-Trump think tank led by Vought. The think tank’s employees or fellows include Jeffrey Clark, the former senior Justice Department lawyer who aided Trump’s attempts to overturn the 2020 election result; Ken Cuccinelli, a former acting deputy secretary in the Department of Homeland Security under Trump; and Mark Paoletta, a former senior budget official in the Trump administration. Other Trump allies such as former White House adviser Steve Bannon and U.S. Reps. Chip Roy and Scott Perry either spoke at the conferences or appeared on promotional materials for the events.

Vought does not hide his agenda or shy away from using extreme rhetoric in public. But the apocalyptic tone and hard-line policy prescriptions in the two private speeches go further than his earlier pronouncements. As OMB director, Vought sought to use Trump’s 2020 “Schedule F” executive order to strip away job protections for nonpartisan government workers. But he has never spoken in such pointed terms about demoralizing federal workers to the point that they don’t want to do their jobs. He has spoken in broad terms about undercutting independent agencies but never spelled out sweeping plans to defund the EPA and other federal agencies.

Vought’s plans track closely with Trump’s campaign rhetoric about using the military against domestic protesters or what Trump has called the “enemy within.” Trump’s desire to use the military on U.S. soil recently prompted his longest-serving chief of staff, retired Marine Gen. John Kelly, to speak out, saying Trump “certainly prefers the dictator approach to government.”

Other policies mentioned by Vought dovetail with Trump’s plans, such as embracing a wartime footing on the southern border and rolling back transgender rights. Agenda 47, the campaign’s policy blueprint, calls for revoking President Joe Biden’s order expanding gender-affirming care for transgender people; Vought uses even more extreme language, decrying the “transgender sewage that’s being pumped into our schools and institutions” and referring to gender-affirming care as “chemical castration.”

Since leaving government, Vought has reportedly remained a close ally of the former president. Speaking in July to undercover journalists posing as relatives of a potential donor, Vought said Trump had “blessed” the Center for Renewing America and was “very supportive of what we do,” CNN reported.

Vought did not respond to requests for comment.

"Since the Fall of 2023, President Trump’s campaign made it clear that only President Trump and the campaign, and NOT any other organization or former staff, represent policies for the second term,” Danielle Alvarez, a senior adviser to the Trump campaign, said in a statement. She did not directly address Vought’s statements.

Karoline Leavitt, his campaign’s national press secretary, added there have been no discussions on who would serve in a second Trump administration.

In addition to running his think tank, Vought was the policy director of the Republican National Committee’s official platform committee ahead of the nominating convention. He’s also an architect of Project 2025, the controversial coalition effort mapping out how a second Trump administration can quickly eliminate obstacles to rolling out a hard-right policy agenda.

As ProPublica and Documented reported, Project 2025 has launched a massive program to recruit, vet and train thousands of people to “be ready on day one” to serve in a future conservative administration. (Trump has repeatedly criticized Project 2025, and his top aides have said the effort has no connection to the official campaign despite the dozens of former Trump aides and advisers who contributed to Project 2025.)

Vought is widely expected to take a high-level government role if Trump wins a second term. His name has even been mentioned as a potential White House chief of staff. The videos obtained by ProPublica and Documented offer an unfiltered look at Vought’s worldview, his plans for a Trump administration and his fusing of MAGA ideology and Christian nationalism.

A Shadow Government in Waiting

In his 2024 speech, Vought said he was spending the majority of his time helping lead Project 2025 and drafting an agenda for a future Trump presidency. “We have detailed agency plans,” he said. “We are writing the actual executive orders. We are writing the actual regulations now, and we are sorting out the legal authorities for all of what President Trump is running on.”

Vought laid out how his think tank is crafting the legal rationale for invoking the Insurrection Act, a law that gives the president broad power to use the military for domestic law enforcement. The Washington Post previously reported the issue was at the top of the Center for Renewing America’s priorities.

“We want to be able to shut down the riots and not have the legal community or the defense community come in and say, ‘That’s an inappropriate use of what you’re trying to do,’” he said. Vought held up the summer 2020 unrest following George Floyd’s murder as an example of when Trump ought to have had the ability to deploy the armed forces but was stymied.

Vought’s preparations for a future Trump administration involve building a “shadow” Office of Legal Counsel, he told the gathered supporters in May 2023. That office, part of the Justice Department, advises the president on the scope of their powers. Vought made clear he wants the office to help Trump steamroll the kind of internal opposition he faced in his first term.

Historically, the OLC has operated with a degree of independence. “If, all of a sudden, the office is full of a bunch of loyalists whose only job is to rubber-stamp the White House’s latest policy directive, whose only goal is to justify the ends by whatever means, that would be quite dangerous,” said an attorney who worked in the office under a previous Republican administration and requested anonymity to speak freely.

Another priority, according to Vought, was to “defund” certain independent federal agencies and demonize career civil servants, which include scientists and subject matter experts. Project 2025’s plan to revive Schedule F, an attempt to make it easier to fire a large swath of government workers who currently have civil service protections, aligns with Vought’s vision.

“We want the bureaucrats to be traumatically affected,” he said. “When they wake up in the morning, we want them to not want to go to work because they are increasingly viewed as the villains. We want their funding to be shut down so that the EPA can't do all of the rules against our energy industry because they have no bandwidth financially to do so.

“We want to put them in trauma.”

Vought also revealed the extent of the Center for Renewing America’s role in whipping up right-wing panic ahead of the 2022 midterms over an increase in asylum-seekers crossing at the U.S.-Mexico border.

In February 2022, Arizona Attorney General Mark Brnovich released a legal opinion claiming the state was under “invasion” by violent cartels and could invoke war powers to deploy National Guard troops to its southern border. The legally dubious “invasion” theory became a potent Republican talking point.

Vought said in the 2023 speech that he and Cuccinelli, the former top Homeland Security official for Trump, personally lobbied Brnovich on the effort. “We said, ‘Look, you can write your own opinion, but here’s a draft opinion of what this should look like,’” Vought said.

The nonpartisan watchdog group American Oversight later obtained an email in which Vought pitched the “invasion” framework to Brnovich.

Brnovich wrote in an email to ProPublica that he recalled multiple discussions with Cuccinelli about border security. But he added that “the invasion opinion was the result of a formal request from a member of the Arizona legislature. And I can assure you it was drafted and written by hard working attorneys (including myself) in our office.”

In the event Trump loses, Vought called for Republican leaders of states such as Florida and Texas to “create red-state sanctuaries” by “kicking out all the feds as much as they possibly can.”

“Nothing Short of a Quiet Revolution”

The two speeches delivered by Vought, taken together, offer an unvarnished look at the animating ideology and political worldview of a key figure in the MAGA movement.

Over the last century, Vought said, the U.S. has “experienced nothing short of a quiet revolution” and abandoned what he saw as the true meaning and force of the Constitution. The country today, he argued, was a “post-constitutional regime,” one that no longer adhered to the separation of powers among the three branches of government as laid out by the framers.

He lamented that the conservative right and the nation writ large had become “too secular” and “too globalist.” He urged his allies to join his mission to “renew a consensus of America as a nation under God.”

And in one of his most dramatic flourishes, he likened the 2024 election to moments in America’s history when the country was facing all-out war.

“We are here in the year of 2024, a year that very well [could] — and I believe it will — rival 1776 and 1860 for the complexity and the uncertainty of the forces arrayed against us,” Vought told his audience, referring to years when the colonies declared independence from Britain and the first state seceded over President Abraham Lincoln’s election. “God put us here for such a time as this.”

Vought said that independent agencies and unelected bureaucrats and experts wield far too much power while the traditional legislative process is a sham. He extended that critique to agencies like the Department of Justice and the Federal Reserve, whose independence from the White House had long been protected by both political parties.

“The left in the U.S. doesn’t want an energetic president with the power to motivate the executive branch to the will of the American people consistent with the laws of the country,” he said in the 2024 speech. “They don’t want a vibrant Congress where great questions are debated and decided in front of the American people. They don’t want empowered members. They want discouraged and bored backbenchers.”

He added, “The all-empowered career expert like Tony Fauci is their model, wielding power behind the curtains.” Fauci was one of the top public health experts under Trump at the start of the COVID-19 pandemic and a key figure in coordinating the national response.

What sets Vought apart from most of his fellow conservative activists is that he accuses powerful organizations on the right of being complicit in the current system of government, singling out the Federalist Society for Law and Public Policy Studies, the conservative and libertarian legal network co-chaired by activist Leonard Leo. The society is widely seen as an instrumental force in cultivating young conservative lawyers and building a bench of future judges whose embrace of legal theories like originalism and textualism have led to decisions overturning abortion rights, environmental protections and social welfare policies.

Yet in his 2024 speech, Vought accused the Federalist Society and “originalist judges” of being a part of the problem, perpetuating the “post-constitutional structure” that Vought lamented by not ruling more aggressively to weaken or dismantle independent regulatory agencies that Vought and his allies view as illegitimate or unconstitutional.

It was “like being in a contract quietly revoked two decades ago, in which one party didn’t tell the other,” he said. “At some point, reality needs to set in. Instead, we have the vaunted so-called Federalist Society and originalist judges acting as a Praetorian Guard for this post-constitutional structure.”

Echoing Trump’s rhetoric, Vought implicitly endorsed the false claim of a stolen 2020 election and likened the media’s debunkings of that claim to Chinese Communist propaganda.

“In the aftermath of the election, we had all these people going around saying, ‘Well, I don’t see any evidence of voter fraud. The media’s not giving enough [of] a compelling case,’” he said. “Well, that compelling case has emerged. But does a Christian in China ask and come away saying, ‘You know, there’s no persecution, because I haven’t read about it in the state regime press?’ No, they don’t.”

Vought referred to the people detained for alleged crimes committed on Jan. 6, 2021, as “political prisoners” and defended the lawyers Jeffrey Clark and John Eastman, who have both faced criminal charges for their role in Trump’s attempts to overturn the 2020 election. Federal law enforcement agencies, he added, “are keeping political opponents in jail, and I think we need to be honest about that.”

The left, Vought continued, has the ultimate goal of ending representative democracy altogether. “The stark reality in America is that we are in the late stages of a complete Marxist takeover of the country,” he said, “in which our adversaries already hold the weapons of the government apparatus, and they have aimed it at us. And they are going to continue to aim it until they no longer have to win elections.”

When Democrats called Trump an “existential threat to democracy,” they were not merely calling for his defeat at the ballot box, he said, but were using “coded language the national security state uses overseas when they are overthrowing other governments” to discourage the military from putting down anti-Trump protests should he win.

“They’re making Trump out to be a would-be dictator or an authoritarian,” he said. “So they’re actively working now to ensure, on a number of levels, that the military will perceive this as dictatorial and therefore not respond to any orders to quell any violence.”

Trump, Vought insisted, has the credibility and the track record to defeat the “Marxist” left and bring about the changes that Vought and his MAGA allies seek. In his view, the Democratic Party’s agenda and its “quiet revolution” could be stopped only by a “radical constitutionalist,” someone in the mold of Thomas Jefferson or James Madison. For Vought, no one was in a better position to fill that role than Trump.

“We have in Donald Trump a man who is so uniquely positioned to serve this role, a man whose own interests perfectly align with the interests of the country,” Vought said. “He has seen what it has done to him, and he has seen what they are trying to do to the country.

“That,” he added, “is nothing more than a gift of God.”