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by Sawyer Loftus, Bangor Daily News

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

Public housing helped bring an end to Linda Gallagher-Garcia’s three years of intermittent homelessness in her hometown of Presque Isle, Maine, in 2020. With $200 in secondhand furniture, she made the apartment feel like home for her and her dog, Tex.

But when she fell behind on her rent and was evicted two years later, the fact that she was in public housing made her future more dire: Maine public housing authorities’ rules bar evicted tenants from returning to government-subsidized units and from receiving other benefits that could help them relocate.

Gallagher-Garcia had moved back to her hometown in northern Maine in 2017 after her husband died. She was working as a home health aide and struggled to earn enough to afford a place to live; then, when she got COVID-19 and had to take time off from her job, she fell behind on her rent. The Presque Isle Housing Authority evicted her in 2022. “I was sick,” she said. “It didn’t matter to them.” Citing confidentiality rules, the housing authority said it could not comment on her case.

Last spring, Maine lawmakers had a chance to help public housing tenants at risk of losing their homes when they created a fund to prevent evictions. But instead of doing what nearby Massachusetts and Connecticut did, and making public housing tenants eligible for the program, Maine did the opposite and specifically excluded them. That left public housing residents — who are more likely than others to become homeless after eviction — ineligible for the aid.

Those who crafted the law said they didn’t realize people in public housing might need such help. Gallagher-Garcia’s story shows why they do.

She owed just $955 in back rent and utilities when she got her eviction notice — an amount the new eviction prevention program could have covered if it had been in place and if she had been living in a privately owned apartment. Instead, at age 59, Gallagher-Garcia checked into the local emergency shelter where she stayed for two years. In total, state and federal dollars paid about $55,000 for her to stay there.

Gallagher-Garcia outside her old apartment at the Presque Isle Housing Authority’s elderly and disabled section. She lived there for two years before being evicted in 2022. (Linda Coan O’Kresik/Bangor Daily News)

Maine’s pilot eviction prevention program, called the Stable Home Fund, opened to applications in October. It provides eligible households with up to $800 a month for up to one year, with additional funds available to cover back rent.

The creators of the Stable Home Fund thought that public housing tenants already had enough aid. Public housing, which is funded with federal dollars, is supposed to be affordable for low-income families, the elderly and people with disabilities, with rent typically capped at 30% of household income. Public housing tenants, however, can still struggle to afford rent and be evicted just like tenants in private apartments.

In fact, in 2023, Maine’s public housing authorities filed a disproportionately high share of eviction cases, according to an analysis of court data obtained by the Bangor Daily News and ProPublica. The eviction filing rate for public housing authorities was more than twice as high as the rate for all rental housing: 10 eviction filings per 100 units for public housing compared with four filings per 100 units for all rental housing.

The cause of most public housing eviction filings in Maine was nonpayment of rent, based on a separate review of court data collected by Pine Tree Legal Assistance, Maine’s largest legal aid group.

Because of public housing rules forbidding tenants from returning after an eviction, and because public housing tenants are generally poorer than other renters, both publicly and privately owned properties become out of reach. (By contrast, people who have been evicted from privately owned housing are still eligible to live in public housing.)

As a result, the consequence of being evicted from public housing “is almost certainly homelessness and extreme housing instability for already vulnerable families,” said Marie Claire Tran-Leung, director of the National Housing Law Project’s evictions initiative.

That homelessness comes with a financial cost to state and local governments. A 2009 Maine study found that governments spent about one-and-a-half times more in services for a homeless person in the six months before they were placed in subsidized housing and given supportive services than in the six months after.

Aroostook County in Maine. Three-quarters of the state’s 2023 low-income eviction cases were in its rural 2nd Congressional District, which includes Presque Isle. (Linda Coan O’Kresik/Bangor Daily News) Public Housing Gets Excluded

Little is known about evictions in Maine, in part because the state’s paper-based court system makes it hard to obtain data. In 2023, Pine Tree Legal, a nonprofit that provides civil legal services to people with low incomes, spent a year traveling around the state to review eviction filings to understand why landlords try to remove tenants, how often renters don’t show up in court and how frequently they have representation. The Bangor Daily News and ProPublica analyzed the data, which covered about 40% of cases filed between 2019 and 2022. The newsrooms also obtained further data from the state court system on every eviction case filed by a public housing authority from January 2019 through August 2024.

Taken together, the data provides a window into a little-noticed aspect of Maine’s housing crisis. Since 2019, public housing authorities, which had a combined total of 3,299 units last year, went to court to evict low-income tenants about 1,300 times.

In 2023, their cases made up 5% of all eviction filings, despite the authorities having just 2% of the state’s rental units. Of the public housing cases, three-quarters were in the rural 2nd Congressional District, which covers most of the state outside the populous southern coastal region and includes Gallagher-Garcia’s hometown of Presque Isle.

The Presque Isle Housing Authority, where she lived, is in the geographically largest county east of the Mississippi River and has a population of just 67,000 residents. The housing authority filed nearly one eviction suit for every five of its public housing units in 2023, the highest rate of any housing authority in Maine, the Bangor Daily News and ProPublica found. The vast majority of cases in Presque Isle were for nonpayment of rent.

The housing authority said that a small minority of its cases resulted in actual eviction orders. (The state of Maine, however, does not track the number of people who leave after being threatened with eviction but before their cases are completed.)

The housing authority’s executive director, Jennifer Sweetser, explained that evictions are necessary because the agency’s budget relies on consistent rental payments. She also said that the housing authority doesn’t grant individual exceptions to eviction, which could be unfair or discriminatory. Instead, she said, the eviction process gives tenants a “neutral” way to resolve issues.

Farther south in the 2nd Congressional District, the Bangor housing authority filed more than twice as many eviction cases as the housing authority in Maine’s biggest city, Portland, located in the state’s other congressional district, even though Portland has many more public housing units.

This issue isn’t unique to Maine. Eviction Lab, a research organization based at Princeton University, has found that some public housing authorities around the country use evictions as a rent collection tactic, sometimes at higher rates than private landlords.

Victoria Morales runs the Quality Housing Coalition, based in Portland, and was the architect of the eviction prevention program that launched this year. She said she didn’t know how often Maine public housing tenants faced eviction until the Bangor Daily News and ProPublica shared their findings, as her organization doesn’t usually work with people in public housing. “I think it is hard to see that this exists if you’re not in it,” Morales said.

Morales excluded tenants in public housing from the fund because she said their rent is already supposed to be affordable. The goal was to help people facing eviction who were not already receiving some type of aid, she said. (In the end, however, the program allowed renters to apply who were receiving other types of housing assistance — just not those living in public housing or who had a federal Section 8 voucher.)

The program’s cost to the state was also a factor in limiting who was eligible, said state Rep. Rebecca Millett, D-Cape Elizabeth, who sponsored the legislation that spurred the fund. “We had to get it through the appropriation process when we were competing with all the other really important needs that our state is facing,” Millett said. Although Millett’s 2023 bill didn’t pass, a year later lawmakers decided to create and fund the rent relief program with $18 million through the supplemental budget process.

MaineHousing, a quasi-state agency that awarded a contract to Morales’ organization to run the program, estimated that 1,000 households could benefit over two years. In the first month, the program received 1,400 applications and had to start putting people on a waiting list.

Even with the high demand, two national housing experts said the Stable Home Fund could help more people if tenants of public housing could participate. That’s because monthly rent in public housing is much lower than on the private market.

Those experts said they don’t know of another eviction prevention program that excludes people in public housing. Kevin Connor, a spokesperson for the agency that runs Massachusetts’ program, said it is open to any household because the state wants to prevent homelessness, “whether they are in a house they own, an apartment they rent or a subsidized unit.”

Morales did not say whether she planned to advocate for public housing tenants to be included in the program in the future, but she said she would support the change if the state decided it was a priority.

Millett said she’d like to see the program expanded to help every Mainer who needs assistance, including people in public housing. But she will not be around when lawmakers convene in January; after 12 years in the Legislature, she didn’t run for reelection. Without Millett, and with no guarantee of future funding, the program’s longevity remains an open question.

After her eviction, Gallagher-Garcia was forced to move back into a shelter. (Linda Coan O’Kresik/Bangor Daily News) Evicted From Public Housing

Public housing delivered Gallagher-Garcia from homelessness. But being evicted from public housing pitched her right back into it.

One cool day in April 2022, her nieces and nephews helped her empty out her apartment, throwing her furniture into a dumpster. “Basically, I didn’t have anything,” she said, in the same matter-of-fact way that she described many of the other challenges she’s faced, including battling cancer. When she checked into the shelter, it ended her longest period of housing stability since 2017.

She couldn’t move in with her sister, Nancy Gallagher, who also lives in the housing authority, because the authority bars people who have been evicted from staying with other residents. She had to stay near Presque Isle because that’s where her job was. So Gallagher-Garcia went to the shelter. “I just didn’t have time to find anywhere else to go,” she said.

Gallagher-Garcia spends an afternoon at the apartment of her sister, Nancy Gallagher, in the Presque Isle Housing Authority. (Linda Coan O’Kresik/Bangor Daily News)

Her dog, Tex, went to the kennel in Caribou, the next town up the road. Under the shelter’s rules, Gallagher-Garcia had to leave her metal crochet needles behind at her sister’s apartment because they could be used as weapons. She also was required to leave the shelter every morning; when she didn’t have to go to work or see a doctor, she spent the day in her sister’s living room calling around for apartments.

In her second year at the shelter, in 2023, her health started to decline — first a hernia, then ovarian cancer. With that diagnosis came more tests, surgeries and chemotherapy. “January, February, March, three months behind each other, not even giving my body time to heal or anything, one surgery after another,” she said. She made frequent trips to see specialists as far away as Portland, four and a half hours away.

Living in a room at the shelter with three to four women, she had little privacy when nurses came to check on her surgical wounds. When other residents started asking what was going on, she decided to tell them. “I didn’t sugarcoat it,” she said about her discussion with a boy in the shelter. “I said, you know, I could go to sleep and not wake up.”

In July 2023, she returned to work part time despite continued chemotherapy treatments, so she could save up enough to leave the shelter. She didn’t like sitting around, she said: “I wanted to go back to work and have something to do for myself.”

Finally, in June, after two years in the shelter, she moved into a motel. She was glad to have a quiet place to stay, and she got her dog back after paying a fee. But it cost $1,000 a month, twice as much as her apartment at the public housing complex. After about nine months, she fell behind on her rent, and the motel kicked her out, too, she said.

As of early December, Gallagher-Garcia was still at the local homeless shelter, looking for a place of her own. Every week, she said, she called landlords, looking for someone to accept her despite her financial struggles and prior evictions.

Then, she found something: a hotel room for $1,200 a month. That’s more than the last place, which she couldn’t afford. But she just turned 62, and now she can draw Social Security. Between that and her job, she hopes she can make it work.

This story was supported in part by a grant from the Fund for Investigative Journalism.

Bangor Daily News reporter Sawyer Loftus may be reached at sloftus@bangordailynews.com.

by Paul Kiel

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

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.

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by Stephen Engelberg

ProPublica is a nonprofit newsroom that investigates abuses of power. This story was originally published in our Dispatches newsletter; sign up to receive notes from our journalists.

Elon,

I know your relationship with ProPublica got off to a rocky start when we contacted you about a story we were writing about your federal taxes. You replied with a lone punctuation mark — “?” — and subsequently called the story that mentioned you “a bunch of misleading stuff.”

We can agree to disagree on that story and a lot of other things. But we thought it might be useful to reach out again in light of your role, along with Vivek Ramaswamy, as co-head of the Department of Government Efficiency.

Simply put: If you’re trying to identify wasteful practices and spending by federal agencies, you’ll find a wealth of actionable issues that our reporting has surfaced over the past 16 years. You and Vivek noted in your recent Wall Street Journal op-ed on your plans for DOGE that “the federal government’s procurement process is also badly broken.”

Our reporting over the years provides some powerful illustrations of that point. ProPublica’s work on the Navy’s cost overruns and design flaws in its ships is second to none. We recently disclosed how Microsoft boxed its competitors out of providing cybersecurity software to the biggest government agencies, including the Pentagon. (Microsoft defended its conduct, saying in a statement that its “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.”)

Perhaps the most immediate relevance of our journalism to your work arises from your reported interest in creating a phone app that most Americans could use to file their taxes.

No national news organization has been more focused on this subject than ProPublica. We have thoroughly documented why the United States is one of the only industrialized countries in the world that does not provide free filing to its citizens: Companies like Intuit that make billions of dollars selling tax preparation software have persuaded Congress to block free filing and keep their businesses alive.

I’d encourage you to take a look at the story “Inside TurboTax’s 20-Year Fight to Stop Americans From Filing Their Taxes for Free.”

You’re a busy person, so I’ll provide a TL;DR version: The tax prep industry has blocked free filing by organizing a bipartisan coalition on Capitol Hill that is anchored by House Republicans but includes Democrats like Zoe Lofgren, who represents Silicon Valley.

The industry also attracted support from longtime Republican figures like Grover Norquist, who has branded proponents of free filing as “big spenders in Washington, D.C.” who are trying to “socialize all tax preparation in America.”

As you know (or will soon learn if you pursue this agenda), despite decades of resistance, the IRS recently launched a pilot program for free filing. It works pretty well, but it’ll likely remain small scale unless something changes in the current Washington status quo.

That’s where you and Vivek have a historic opportunity.

What has always struck me about Washington is its ability to resist fundamental change. People arrive with big plans for reforms and often end up becoming part of the problem.

I began my career as a Washington reporter in 1983, two years after President Ronald Reagan took office promising to upend how business was done in the capital. Reagan was serious about coming up with some concrete ideas for saving money and reducing waste. He created a presidential commission of business executives and urged its members to work like “tireless bloodhounds.”

“Don’t leave any stone unturned in your search to root out inefficiency,” the president said.

Two years later, the commission delivered 47 volumes of reforms that it said could save $424 billion in government spending over three years. Most of the proposals required congressional action, a daunting task when the Senate was controlled by Republicans and the House by Democrats. In the end, only 27% of the recommendations were enacted. By the time Reagan’s term was over, government spending was up and the deficit had grown.

I believe Republican control of the presidency and both houses of Congress gives you and Vivek a better shot at taking on issues like free tax filing that have long been dismissed as lost causes. There’s a broad coalition of Americans who voted for Donald Trump, many of whom feel the government cares little about their problems. Politicians of both parties understand that their futures may depend on taking real, measurable steps to address those concerns.

Eliminating the annual ritual of paying money to a third party in order to tell the government what it already knows about your personal finances could be both popular and more efficient.

There has been a lot of skepticism about whether it’s possible to achieve your goal of cutting trillions of dollars from the federal budget. It appears to me that you could only rack up that level of savings by slashing everything from Medicare to military spending. I think the president’s political advisers will take the ax out of your hands before you hit the first trillion.

That’s not to say there isn’t an array of government programs that could be better run. We see our job as holding power to account, and the waste of the people’s money is one focal point of our reporting. That’s why we’ve written repeatedly about waste and fraud in Medicare and Medicaid, the government’s two biggest health care programs. (We’ve also covered the way cuts to those programs harm people.)

I have little doubt that we will write stories in the coming years that will enrage people you know. Some of our work may even focus on you or your companies. With immense power comes immense scrutiny. (As we did several years ago, we will always reach out to you for your response before we publish anything about you.)

Still, I would be disappointed if we did not also publish a piece or two that prompted you to storm into Vivek’s office and say: “Damn, this is outrageous. We could fix this.”

Best,

Steve Engelberg

by Justin Elliott, Robert Faturechi and Alex Mierjeski

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

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.”

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

by Nadia Sussman, Duaa Eldeib, Liz Moughon and Lisa Riordan Seville

More than 20,000 pregnancies in the United States end in stillbirth each year. These losses are not inevitable. At least 1 in 4 U.S. stillbirths is likely preventable, according to a key study, and in pregnancies that last 37 weeks or more, nearly half of stillbirths may be preventable.

“Before a Breath,” a new feature documentary from ProPublica, weaves together the stories of three mothers who have lost children to stillbirth and are now striving to make pregnancy safer. Inspired by Duaa Eldeib’s groundbreaking reporting, which was a finalist for a Pulitzer Prize, this intimate, infuriating and ultimately hopeful film shines a light on the aftermath of stillbirth.

A Sneak Peek of “Before a Breath”

Other wealthy countries, including the Netherlands, Ireland and Australia, have made major strides in reducing their stillbirth rates. But a dearth of data, awareness, autopsies and research in the U.S. has hindered efforts at prevention.

“Before a Breath” breaks the silence around the U.S. stillbirth crisis and demonstrates that change is possible. We hope it will be a catalyst for critical conversations among expecting parents, medical providers, policymakers and bereaved families.

Starting in early 2025, we will roll out the film with screenings across the country. If you or someone you know wants to take part — by attending or hosting a screening, bringing the film to your college, medical school or hospital, or collaborating in other ways — we want to hear from you. We’re incredibly grateful to the many families, medical providers, researchers and advocates who have made our work possible. Now, we need your and your communities’ help to spread the word.

Please fill out the form and tell us how you would like to share the film. In the following weeks, we’ll respond with details on how to do so and a guide for planning your screening or event. In the meantime, you can head to ProPublica’s YouTube channel to check out sneak peeks of “Before a Breath” and meet Kanika Harris, Stephanie Lee and Debbie Haine Vijayvergiya.

We’ll be in touch.

(Sign Up to Screen Our New Documentary About Stillbirths)

by Topher Sanders

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

ProPublica spent months investigating how a single underregulated toxic chemical — formaldehyde — creates an inescapable cancer risk for everyone in America. It’s in the air outside, at levels that fail to meet the public health goals set by the Environmental Protection Agency. And it’s in our homes, coming from our couches, our clothes and our babies’ cribs — sometimes at levels that can trigger breathing problems, allergic reactions and asthma.

We modeled pollution data and deployed our own air monitors to measure formaldehyde levels around us. We interviewed more than 50 experts and read thousands of pages of scientific studies and EPA records. During it all, we kept in mind the single question we knew readers would most want answered: How can I reduce my exposure?

The following are some common sources of the chemical and suggestions for reducing your risk, as informed by our reporting.

Wood Furniture and Floors

Be careful when buying new furniture. One of the most significant sources of formaldehyde in the home has traditionally been furniture made with composite wood that uses glues to bind strands, particles, fibers or boards together. The adhesives used in this type of furniture can contain formaldehyde, which goes through a process called off-gassing, where the chemical is released into the air over time. Federal regulators have set limits on how much of the chemical some composite woods can release. But those limits, set more than a decade ago, are still well above the level that EPA scientists recently established to protect people from asthma, allergic reactions and other breathing problems.So, at the very least, you want to look at the item’s packaging for a label that shows it is compliant with the standards set under the Toxic Substances Control Act.

The law covers goods made of hardwood plywood, medium-density fiberboard and particleboard. All products covered by the law must feature some sort of label saying they comply with TSCA, though the labels can look different from product to product. Compliance does not mean the item is formaldehyde free. It means the company is certifying that any formaldehyde emissions are at a low enough concentration to meet TSCA’s requirements. Some types of composite woods aren’t covered by the law, and while those are used mainly for structural projects, they can also be used to make furniture and shelving. So if you are unsure what type of composite wood a piece of furniture is made from, make sure to ask a salesperson or company representative before you purchase.

Another label you can look for is the California Air Resources Board Phase 2. That, too, doesn’t mean the furniture or flooring is free of formaldehyde, but that it adheres to the state’s emission standards, which are similar to the TSCA rules. Some manufacturers include this on their labels for goods sold in and outside of California. Two other labels to look for are “no-added formaldehyde” (NAF) or “ultra-low-emitting formaldehyde” (ULEF). Those mean the manufacturer’s product has gone through additional testing.

If you do buy furniture you suspect contains formaldehyde, environmental experts suggest you allow the item to air out for as long as one full week in a highly ventilated area, such as a garage, however impractical that may be. If that isn’t possible, leave the windows open near the furniture to improve ventilation. It can take as long as two years for items to release most of their formaldehyde, so buying secondhand could be better for your health as well as your wallet. Purchasing solid wood furniture, while expensive, is the best alternative when trying to avoid high levels of formaldehyde.

Cosmetics and Personal Care

Inspect the ingredients in your personal care products. The European Union banned formaldehyde in cosmetics, but in the U.S., the Food and Drug Administration has yet to follow suit. Hair straighteners, particularly those marketed to Black women, have been found to contain formaldehyde. The chemical helps to form links with the amino acids in hair and, when heat is added, typically from a flat iron, the links are made stronger and the hair is straightened. But that heat can also turn formaldehyde into a gas and release it into the air.

When reading the ingredients labels, of course you should look for formaldehyde, but also watch out for formalin or methylene glycol, which are formaldehyde-related ingredients that release the chemical when heated. Those same three ingredients can also appear in nail care products. In nail hardeners, formaldehyde helps them bond to the keratin in nails. Also some nail polishes contain a toluenesulfonamide-formaldehyde resin that’s used to make the polish more resilient and adhere better to fingernails. That resin can release formaldehyde as it dries.

Candles, Indoor Fireplaces and Gas Stoves

Flames mean formaldehyde. The chemical is a byproduct of combustion, so anytime there is a fire, there is formaldehyde. This is as true for huge forest blazes as it is for lit candles or burning cigarettes. In the home, fireplaces and gas stoves can be a significant source of formaldehyde.

ProPublica reporters learned this firsthand earlier this year when they took formaldehyde readings at various places around New York and New Jersey. One of the highest concentrations was measured during a dinner party where candles were burned and a gas stove was operating. Multiple studies have also documented increased formaldehyde exposure when smoking cigarettes and vaping. Those who smoke can reduce indoor formaldehyde levels by doing it outdoors, but they will still be breathing in the chemical themselves.

As is true whenever formaldehyde is present, ventilation is crucial. If possible, open windows and doors when candles, fireplaces or stoves are used. Make a habit of turning on the stove vent when you cook. And while it’s expensive, if you’re able to, consider replacing your gas stove with an electric stove, which generally produces less formaldehyde. Naturally you might ask: Do air purifiers help? Researchers are still investigating how well air purifiers reduce formaldehyde. One study suggested that some air purifiers could even create formaldehyde as a by-product. Scented air fresheners can also introduce formaldehyde into the air.

Clothes

Sometimes formaldehyde is even in our clothes. Clothes that are designed to resist wrinkles or stains are more likely to contain the carcinogen. The chemical is used during the dyeing process and to help reduce shrinkage, mold growth and wrinkles. The use of formaldehyde in clothes can irritate skin conditions, such as eczema. But it’s often very difficult to tell whether clothing was made using the chemical. Labels generally won’t tell you. Clothes woven from natural fibers like linen, wool and cotton are less likely to have been made using formaldehyde than synthetic fabrics, like polyester. Washing all your new clothes before you wear them can help reduce your exposure. One recent study found formaldehyde in 20% of the cotton clothing researchers examined, but it was gone after the items had been washed.

Cars

Formaldehyde adhesives can be found in vehicle dashboards, seat coverings, flooring materials, carpeting, door trim, window sealant and armrests. And similar to furniture, the highest levels of formaldehyde are often found in new vehicles. To reduce your exposure to formaldehyde in cars, you should again rely on ventilation. On particularly hot days, you’ll want to allot time to roll down your car windows and allow the vehicle to air out. ProPublica found that not only do new cars contain levels of formaldehyde higher than the EPA calculated to protect people from breathing problems, allergic reactions or asthma symptoms, but cars as old as four years can continue to release potentially harmful levels of the chemical, particularly on hot days. Set your car’s air conditioner to allow outside air to circulate through the vehicle.

There is one throughline in all of the advice and research on reducing formaldehyde exposure indoors — ventilation. Opening windows and doors, turning on fans and ventilators, and leaving products in open spaces for long periods of time so they can release formaldehyde all allow the chemical to vent away from us. Formaldehyde’s ubiquity means there isn’t a way to absolutely wall ourselves off from it. But opening the window may be our cheapest and best course of action.

Sharon Lerner and Al Shaw contributed reporting.

by Topher Sanders, with additional reporting by Sharon Lerner and Al Shaw

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

The air was packed with savory and sweet aromas when I walked into my colleague’s Brooklyn apartment for dinner. The sizzle and pop of rice and green beans cooking on the gas stove blended with soft jazz coming from the TV. Candle flames danced and flickered.

But we weren’t gathering just to enjoy a late-summer meal. We were trying to expose an uninvited yet ever-present guest — formaldehyde.

The invisible chemical can be harmless in small amounts, but in larger concentrations, it can cause headaches, dizziness, respiratory illness and asthma. It is also responsible for more cancer than any other toxic air pollutant.

Because of its importance to many industries, formaldehyde has proven difficult to regulate. This year, President Joe Biden’s administration finally appeared to make some progress, though it was modest. If the past is any guide, however, even those limited efforts are likely to hit a dead end after Donald Trump is inaugurated. Knowing our risks is essential to protecting ourselves, experts say. Last week, ProPublica published a tool to show how much formaldehyde is in the outside air.

But our biggest exposure happens indoors, so my colleagues and I set out to do our own testing.

We read thousands of pages of scientific studies and Environmental Protection Agency documents on the dangers of formaldehyde, and we learned the toxic chemical is nearly impossible to escape. Formaldehyde is in furniture and flooring. It is in the adhesives used in wallpaper and carpets. It’s given off by candles, fireplaces and gas stoves. And it’s in hair products and cosmetics.

EPA scientists recently examined how low formaldehyde levels should be to ensure the chemical doesn’t trigger an allergic reaction, breathing problems or asthma symptoms, and the concentrations found inside the average home were far above that. Over a lifetime of exposure to the formaldehyde in an average home, a person’s risk of developing cancer is more than 250 times the risk level that the Clean Air Act sets as a goal. Even that number vastly underestimates the risk from cancer because the EPA did not factor in the chance of developing myeloid leukemia, the most common cancer caused by the chemical.

“It is everywhere, it is in everything,” University of California, Los Angeles researcher Nicholas Shapiro told me. Shapiro, who has spent years studying formaldehyde exposure, is working on a book, “Homesick,” that explores how formaldehyde, among other toxic chemicals in our homes, poses a danger to our health. “It is holding together our built environment and also chemically corroding us at the same time. It’s part of the fundamental paradox of the world that we’ve built, where this chemical is holding together our homes. We have built our society around it.”

My colleague Sharon Lerner and I traveled around New York City and New Jersey for weeks with equipment to measure the chemical’s presence.

The results proved concerning.

Out on the Town

Reporter Sharon Lerner fits a backpack with a pump that will allow for testing airborne formaldehyde levels before she heads outside. (Topher Sanders/ProPublica)

Sharon and I took a moment to wipe the July sweat from our brows as we got our testing equipment ready in a sprawling shopping center in Brooklyn. I placed a pump about the size of a large tape measure into Sharon’s backpack. The pump pulled in air through a two-foot rubber hose that extended out of the backpack’s main compartment.

I turned on the pump, which made a soft pneumatic sound. We were ready to ride the escalator up to an Ashley Furniture showroom in the Industry City mall.

“Can I help you guys find something?” a friendly salesperson asked.

“We’re just looking, thanks,” I replied.

We hoped the hose sticking out of Sharon’s backpack and the sound of the pump wouldn’t lead to more questions. For the next 20 minutes, we perused the showroom, opening cabinets, dressers and nightstands.

The store offers a wide range of budget furniture that can be made with foams, adhesives and wood composites that contain formaldehyde. These products go through a process called off-gassing, where chemicals they contain are released into the air over time. New furniture right out of the box has been shown to off-gas more than pieces that have been sitting out of their packaging for a while.

[Formaldehyde] is holding together our built environment and also chemically corroding us at the same time. It’s part of the fundamental paradox of the world that we’ve built, where this chemical is holding together our homes. We have built our society around it.”

—Nicholas Shapiro, a researcher at University of California, Los Angeles

Inside Ashley, it was hard to ignore the pungent fresh-furniture scent that wafted out of an opened cabinet or dresser. Sure, the furniture smelled, but we had no idea how much, if any, formaldehyde was present. The pump in Sharon’s backpack was collecting the air and any formaldehyde into a glass tube. As soon as we walked out, we placed the tube in a small cooler so we could send it to a lab for testing later.

We had other ideas about where to test. Sharon and another ProPublica colleague found a nail salon near New York City’s famed Canal Street. Some nail hardeners and polishes contain formaldehyde that may be listed on the product label as formalin or methylene glycol, according to the Food and Drug Administration. Also some nail polishes contain a toluenesulfonamide-formaldehyde resin that’s used to make the polish more resilient and adhere better to fingernails.

Standing on the busy sidewalk outside the salon with tourists buzzing by, I helped prepare the testing equipment. Once Sharon was inside, an employee soaked her hands and nails, then slathered them with goos, gels and paints. The air was acrid. The employee wore a disposable face mask, but other workers were unmasked as they clipped, sanded and shellacked customers’ nails.

A week or so later, I visited a Raymour & Flanigan furniture store in northern New Jersey. The sales folks didn’t pay much attention to me, so I didn’t have to worry about having an awkward conversation about the sound of the pump in my backpack. I walked around for more than 20 minutes, opening nightstand and dresser drawer.

Sharon and I stopped by a mall store that sells luxury soaps and lotions. We visited a cosmetics shop, a carpet store and a candle specialist. We packed up the air samples we collected and sent them to a certified industrial hygiene lab in Syracuse, New York, and waited.

The air pump in Sharon’s backpack collects a sample as she browses a New Jersey carpet store. (Topher Sanders/ProPublica)

The EPA has determined that continuous daily exposure to concentrations of formaldehyde above 7 micrograms per cubic meter of air may cause decreased lung function, trigger allergic reactions and worsen asthma symptoms. Children and older people with asthma can be especially sensitive. It can be hard for doctors to identify formaldehyde as the reason for these kinds of reactions because it doesn’t linger in our bodies and there isn’t a medical or laboratory test that can accurately measure the amount of formaldehyde you may have been exposed to.

The chemical’s impact on our bodies can intensify dramatically the longer we are exposed. For instance, the EPA found that exposure to any amount of formaldehyde above a tiny concentration (0.09 micrograms per cubic meter) elevates people’s lifetime cancer risk beyond the goal the agency set. If the agency included the risk of developing myeloid leukemia in that calculation, that tiny concentration would be even smaller (0.023 micrograms).

When the lab emailed me the results, it revealed that our air sample from Ashley contained the highest levels of formaldehyde in our testing — 13 times the amount the EPA says is low enough to prevent issues like asthma, decreased lung function and respiratory irritation. Other results were also concerning. The nail salon had a concentration more than 6 times the level the EPA says would prevent breathing problems. Raymour & Flanigan’s concentration was more than 7 times the safe level. Federal regulators have set limits on how much formaldehyde some composite woods can release. But those limits are still well above the level EPA scientists established to prevent allergic reactions and other health problems.

A person’s risk depends not just on the chemical’s concentration but on how long they’re exposed. At the places we went, Sharon and I had been exposed to those concentrations for a matter of minutes, but the stores’ employees spend hours every workday breathing in the chemical.

In response to questions from ProPublica, Ashley Furniture spokespeople said the company follows all laws and regulations for furniture manufacturing.

“Given the many factors that contribute to air quality and the presence of formaldehyde, it would be impossible to say whether the furniture located in the store you visited contributed to your findings,” one wrote to ProPublica. The company also claimed that a 2011 survey of New York City found concentrations of formaldehyde in the surrounding neighborhood that were even higher than we had found in the store. But the survey actually found formaldehyde levels of only 1.5 micrograms per cubic meter in the area, a tiny fraction of the 91 micrograms ProPublica found in the furniture store.

Formaldehyde doesn’t linger in our bodies and there isn’t a medical or laboratory test that can accurately measure the amount you may have been exposed to.

Raymour & Flanigan did not respond to questions.

One of the more disturbing results was from the dinner party at the Brooklyn apartment of my ProPublica colleague. The lab tests showed the concentration of formaldehyde was nearly 12 times the level the EPA set to protect against breathing problems and other health issues. Formaldehyde is a byproduct of combustion, and we suspected that the gas stove and candles were largely to blame for the high levels of the chemical that evening.

Like anyone, I couldn’t help but wonder how much formaldehyde might be present in my own home.

Inside the House

About two months before we started the testing, my wife and I purchased a kid-sized work desk for our 10-year-old daughter’s bedroom to give her a place to do homework, create art and make those annoyingly messy Rainbow Loom bracelets.

When I opened the box for the desk, I was hit with the familiar smell of budget furniture. I had no idea I was inhaling a chemical mixture that may have included formaldehyde.

It took me longer than it should have to assemble the desk, but when I finished I got a huge hug from my daughter. She loves it.

Now I was curious about how much, if any, formaldehyde was lingering in her room, which she shares with her 5-year-old sister.

According to the Department of Housing and Urban Development’s American Healthy Homes Survey, the average level of formaldehyde inside an American home is 23.2 micrograms for every cubic meter of air. The survey found that about 10% of homes have levels above 41 micrograms, which is almost 6 times the concentration the EPA set to protect against respiratory problems.

Americans spend most of their time inside, and for decades we’ve worked hard to engineer ways to insulate and seal off our homes from the outdoor heat and cold. But that insulation works to trap formaldehyde in our homes, and older insulation might itself contain the chemical.

I placed a formaldehyde testing badge in my daughters’ room. The badges don’t draw air into them like the pump Sharon and I used at Ashley Furniture. They are intended to be worn by a worker or to rest in an area so that they collect samples from the air that simply passes by them. I put another badge in our kitchen, where we have a gas stove.

The lab results showed that my daughters’ room contained formaldehyde at 19 micrograms per cubic meter, one of our lower results, but still nearly 3 times the threshold the EPA set to prevent respiratory problems. I couldn’t help but wonder what the measurements would have been had we tested the room right after I assembled her cute new desk, instead of months afterwards. Our home’s kitchen recorded a level of 25 micrograms per cubic meter, also well above the EPA’s threshold.

Our testing hardly meets the rigor of scientific research. But plenty of scholarly studies have confirmed formaldehyde’s presence in our everyday lives and mirror our findings. Researchers have found unhealthy concentrations of the chemical in child care centers, funeral homes and even bakeries. A 2016 study in Atlanta found portable and traditional classrooms had levels more than 3 times the EPA’s target. And research dating back decades has frequently found high concentrations in people’s homes, with sources including wooden toys, baby cribs, arts and crafts supplies, and air fresheners.

ProPublica reporter Topher Sanders wears a backpack fitted with a formaldehyde monitor through a retail store. Reporters also placed formaldehyde testing badges in cars and in Topher’s daughter’s bedroom. (First image: Topher Sanders/ProPublica; second image: Sharon Lerner/ProPublica; third image: Topher Sanders/ProPublica)

Two flashpoints over the last 20 years have generated intense scrutiny of the dangers of formaldehyde. In the first, researchers found in 2007 that Federal Emergency Management Agency trailers that served as emergency shelters for many displaced by hurricanes Katrina and Rita reeked of formaldehyde. Some of the trailers in Mississippi and Louisiana had as much as 635 micrograms per cubic meter — more than 5 times the amount of formaldehyde we found in the Ashley Furniture store. Residents complained of breathing problems, nosebleeds and headaches.

One of the more disturbing results was from the dinner party at the Brooklyn apartment of my ProPublica colleague. The lab tests showed the concentration of formaldehyde was nearly 12 times the level the EPA set to protect against breathing problems and other health issues.

The second flashpoint came in 2015 when a “60 Minutes” investigation revealed that laminated flooring products from the popular company Lumber Liquidators were off-gassing significant concentrations of formaldehyde. Those revelations led to years of lawsuits, new EPA rules and a $33 million criminal penalty assessed by the Department of Justice after the company lied to investors in official filings about there being formaldehyde in its products.

Other studies have confirmed that the poor are disproportionately exposed to high concentrations of the chemical. Shapiro, the UCLA researcher, spent two years talking to more than 200 people who were connected to or lived in FEMA trailers. He said the well-to-do can afford to live in homes with enough ventilation, space and technology to reduce their exposure to formaldehyde.

The chemical’s presence in our lives and the way it is regulated, he said, ensures it “is going to continue to disproportionately make lower-income people sick.”

So sure, formaldehyde is in our homes. But when you walk out the door and drive away, you get a reprieve, right? Unfortunately, I learned through this reporting that no, you might not. When you get in your car, formaldehyde may be along for the ride.

On a Drive

In cars, formaldehyde adhesives can be found in the dashboards, seat coverings, flooring materials, carpeting, door trim, window sealant and armrests. And just like furniture, the highest levels of formaldehyde are found when cars are fresh off the assembly line.

Last year, the European Union set limits on the amount of formaldehyde new cars and other consumer products are allowed to release. New vehicles must not emit more than 62 micrograms per cubic meter, a level that’s 8 times the concentration the EPA says is safe to avoid breathing problems and other harmful effects. In coming up with the standard, the European Commission said it tried to protect the public’s health while also “limiting the socio-economic burden and need for technological changes for a wide range of industries and sectors.” The U.S. has no limit for new cars.

Sharon and I took our testing equipment on the road. The employees at a Tesla dealership we visited in north New Jersey were kind and welcoming. They let us take the Model S for a 30-minute test drive. We played around with the car’s gadgets while running the air conditioning and letting our formaldehyde pump collect samples.

The vehicle was one of five we test drove. None would have violated the EU limit, but all of them registered formaldehyde readings above the EPA’s threshold for preventing respiratory problems.

The Tesla had the most formaldehyde, at 38 micrograms per cubic meter — 5 times the level EPA’s scientists set to avoid causing respiratory problems. A Honda Odyssey, one of the bestselling minivans in the country, had 34 micrograms. A Toyota Corolla, the popular compact sedan known for its reliability, contained 29 micrograms.

A spokesperson for Honda said the company is an industry leader in reducing volatile organic compounds like formaldehyde inside car cabins.

The Odyssey is “compliant with all applicable international regulatory values for vehicle interior VOC’s,” the spokesperson wrote, referring to volatile organic compounds.

Tesla and Toyota did not respond to ProPublica’s questions.

Even older cars can still emit formaldehyde. My family’s 4-year-old sedan registered 39 micrograms per cubic meter on a sunny July day that reached 93 degrees. That’s higher than any of the new cars we tested.

We were able to get results from 19 places where we tested the air. In all of them, formaldehyde concentrations were higher than the level the EPA set to protect people from experiencing asthma symptoms, allergic reactions and other breathing problems. Those venues included a high-end store selling personal care products, a well-known candle shop and a big-box building supplies retailer.

Karen Dannemiller, an environmental health scientist and associate professor at Ohio State University, studies the effects of chemicals on the indoor environment. She has also researched how smartphones could be used to help measure indoor formaldehyde levels. She said learning about the impact and prevalence of formaldehyde can be eye-opening.

“I think it can be overwhelming to hear all this information because obviously we all want to protect our families,” she said. The most important thing, Dannemiller said, is to consider how our purchases and choices impact our homes “and just do the best that we can to improve the health of our indoor spaces.”

by J. David McSwane

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Lisa Warwick found her husband gasping for air at the foot of the basement stairs and knew the miracle was over. It was Aug. 2, 2020, more than 11 years since Scot Warwick had been diagnosed with Stage 4 lung cancer. Most patients are dead in months, but her husband, who had just turned 51, had somehow destroyed the odds.

“Are we going in?” she asked.

“Yes,” he said. “We are going in.”

His body had endured six years of chemotherapy and an additional five of experimental therapies. According to his medical record, he had responded “singularly impressively.” Two months earlier he had been running 5 miles a day, but since the latest round of chemo he had rapidly declined.

Lisa Warwick guided her husband up the stairs, dragged him to the car and raced to St. Peter’s Hospital in downtown Helena, Montana.

The emergency room doctor cited shortness of breath, fever and chills. He flagged that Warwick’s respiratory crisis could be the result of the chemotherapy. It had been restarted weeks before on the order of the oncologist who diagnosed him, the only doctor he’d consistently seen for more than a decade.

The next morning, a doctor named Randy Sasich arrived for his shift at St. Peter’s. An independent nonprofit with just under 100 beds, the hospital is the only acute-care facility for about 100 miles in any direction and has touched the lives of virtually every area resident going back generations. Helena, the state capital, remains a small vestige of the Old West, with just 34,000 residents, so luring doctors has always been a challenge. This was especially true in April 2020, at the onset of COVID-19, when Sasich signed a short-term contract.

Dr. Randy Sasich (Brooke Herbert for ProPublica)

A 47-year-old lung specialist, with degrees from Georgetown and Santa Clara University and experience at hospitals in major cities, Sasich was a rare get. The de facto director of the hospital’s intensive care unit, Sasich met with the morning shift’s coordinating doctor. Standing in the ICU, the two ran through patients, their needs, the usual, until Warwick.

We have a 51-year-old patient with metastatic lung cancer, diagnosed 11 years ago, Sasich remembered the doctor saying.

“There’s no way,” Sasich interrupted.

Well, he’s been treated for 11 years, the doctor explained.

“You don’t live 11 years after a Stage 4 lung cancer diagnosis,” Sasich said. “That doesn’t make any sense.”

Between patients, Sasich reviewed Warwick’s chart. Something must have been misread along a medical game of telephone, he reasoned, or he’d missed some great advancement in cancer treatment. He found the 2009 report that prompted the cancer diagnosis. A smoker at the time, Warwick had seen an ear, nose and throat doctor about a tiny lump on his neck. The ENT had sent a sample of cells from Warwick’s neck to the lab. A few days later he wrote in the file that they were “most likely consistent” with cancer.

That is not a cancer diagnosis, Sasich thought.

The records indicated that Warwick was referred to the hospital’s Cancer Treatment Center. Sasich’s curiosity graduated to shock: There was no biopsy. Yet Warwick was immediately placed on an aggressive chemotherapy regimen by the hospital’s sole oncologist, Dr. Thomas C. Weiner.

This is bad.

In his few months at St. Peter’s, Sasich had already questioned Weiner’s incomplete documentation and curious diagnoses and had taken his concerns to a veteran doctor for advice. To Sasich’s surprise, his colleague was fearful of challenging Weiner. According to Sasich, the doctor said: “I live here. My kids go to school here. I don’t want to move.”

Sasich scoured Warwick’s file, thinking someone must have ordered a lung tissue biopsy, which would capture more cells and target the suspected origin of the disease. Where was the lab report that confirmed cancer and ruled out everything else? From 2009 to 2019, he found none. Then, finally, there it was — in April 2020, just a few months earlier — a report on lung cells biopsied. Sasich read and reread the pathologist’s conclusion: no cancer.

“What the hell is going on here?” he whispered.

Despite the negative biopsy, Weiner had started Warwick on another round of chemotherapy, according to the medical records. Within two months, Warwick couldn’t walk upstairs, and now he was in the ICU while his wife and two children waited outside of the hospital because of COVID-19 protocols.

Sasich called the pathologist, who confirmed the finding. Sasich feared his own hypothesis. He worried what it would mean to Warwick and his family, but the “unbelievable conclusion” he had come to might save the patient’s life.

The next morning, Sasich entered the ICU where Warwick lay in the dark, oxygen pumping into his nose. Sasich pondered how to tell a man that everything he believed about himself for more than a decade was false.

Deposition of Dr. Randy Sasich

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Moments after Sasich left the room, Warwick called his wife. “He doesn’t know my history,” he told her. “He doesn’t know anything about me. He doesn’t know I’ve had this for 11 years. He doesn’t know anything. And this doctor’s telling me that I don’t have cancer? This guy’s an idiot.”

Sasich knew he had just challenged a powerful figure in Helena. He just had no idea how powerful.

While reporting on COVID-19’s toll in early 2022, I found myself in Helena, chatting over drinks with a handful of St. Peter’s medical staff. They wondered why I wasn’t asking about Tom Weiner. There was a deeper, haunting story, they told me, about the oncologist many inside the hospital suspected of hurting his patients. Despite those whispers, he was beloved by countless patients — “followers,” they called them. His nurses were wildly devoted to him — “a cult,” they said. The hospital administration feared him.

The rumors they shared, though vague, were disturbing and impossible to ignore. They portrayed a man whose ability to both inspire and intimidate had divided the town of Helena. It would take two years to unravel one doctor’s myth, a hospital’s complicity in creating it and the attempt to conceal a trail of suspicious deaths. One of them, I’d later learn, was of a 16-year-old girl.

Early in my reporting, I reached out to Weiner. Reluctant at first, he agreed to sit down with me. He was, he told me, the good guy in this story.

Dr. Thomas C. Weiner (Louise Johns, special to ProPublica)

Weiner, 61, is guarded about his own life. He was raised Lutheran. His mother was a nurse, his father an FBI agent who urged him to be a lawyer. Weiner told me he was never much of “a research guy.” Rather, he wanted to bring a personal touch to medicine, to help people in their most vulnerable moments. He attended medical school at Hahnemann University, now Drexel, in Philadelphia. There, he met his wife, a devout Catholic, and he converted. An avid mountain climber and skier, Weiner felt that American westward pull and, after training in hospitals in Pennsylvania and Vermont, took the job at St. Peter’s in 1996.

He arrived as something of a savior. In an ad in the Great Falls Tribune, the hospital announced that it had hired a permanent oncologist to direct its new cancer treatment center, replacing a rotation of doctors who made often precarious commutes from Great Falls, Bozeman or Missoula. For most of the next 24 years, he was the only option for thousands of cancer patients. It’s not an overstatement to say anyone who had cancer or knew someone who had cancer in that time knew of Weiner.

He was instantly popular. Among his first patients was fashion designer Liz Claiborne, whose husband described Weiner as “a solid rock of a man, cheerfully youthful, robust, square-shouldered, handsome in a quiet way.” The Weiners became prominent members of the Cathedral of St. Helena and donated money to the Vatican.

In our talks, he was as Claiborne’s husband described, if weathered by a quarter century in the dry high country. He is fit, almost always wearing hiking shoes, a North Face T-shirt on warm days, a fleece in the cold. With sharp blue eyes, he smiles when he explains his medical judgment, projecting an absolute conviction in what he believes and has done.

Weiner’s stature rose with the cancer center’s. In late 2000, a news article reported that it was now treating about 250 patients a year. Three months later, the facility announced it would be adding six chemotherapy chairs, a library and a meditation center. An article in the Independent Record, the local paper, noted, “In the five years that Weiner has been with the cancer treatment center, he has seen an increase from 12 or 13 patients per day to 35 or 40 patients per day.”

Weiner told me, and records confirm, that he billed for as many as 70 patient contacts a day. That pace made him an obvious outlier in data tracked by federal insurance regulators, but no one inside or outside the hospital slowed him down. He spoke proudly of his workload. He was always on call, he told me, and many of his patients had his cellphone number. As business boomed, so did Weiner’s wealth.

Deposition of Dr. Thomas C. Weiner

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Adding to a six-figure base salary, his pay was calculated by the number of relative value units, or RVUs, he billed on behalf of the hospital. The system compensates doctors using weighted values for certain types of visits or treatment. It works like this: A doctor might be paid $100 per RVU. A routine physical might be equal to 1 RVU, or $100; a more complicated and time-consuming procedure like radiation therapy might equal 8 RVUs, or $800. In other words, the more patient visits and treatments a doctor bills to insurance, the more that doctor and the hospital earn. Weiner described this system, which is common in American medicine, as “eat what you kill.”

In 2006, Weiner purchased a 3,400-square-foot home atop Mount Helena with a panoramic view of town. The next year, Weiner’s rising RVUs made him the hospital’s highest earner at $751,000, tax filings show. By 2010, Weiner was paid more than $1.3 million, more than three times the salary of hospital CEO John Solheim.

Around this time, according to court records, hospital administrators worried that Weiner’s pay could draw scrutiny from federal regulators for a violation of the Stark Law, which prohibits physicians who bill Medicare and Medicaid from referring patients in ways that enrich themselves. Those programs account for about 60% of St. Peter’s revenue. As questions about his pay intensified, Weiner responded by coordinating a staff rebellion, text messages show. A majority of St. Peter’s medical staff signed a letter of no confidence in Solheim, and Weiner was the lead signatory of a letter published in the Independent Record that charged the hospital with caring more about money than quality patient care. Not long after, Solheim resigned. He did not respond to my requests for comment. It’s unclear if the hospital at that time had its own concerns about the quality of Weiner’s care.

St. Peter’s had flourished since Weiner’s arrival, recording nearly 200,000 patient visits and bringing in more than $187 million in 2012. Weiner told me that most years his cancer care accounted for more than a quarter of the hospital’s revenue; St. Peter’s told me it was closer to 10%.

When negotiating his pay, emails show that Weiner leveraged his position as the region’s only oncologist, threatening to sue or quit, and he would prevail. With that power, he built a kingdom. In an unusual move, St. Peter’s allowed him to take over every facet of his patients’ care by naming himself their primary care physician. Because other options for cancer treatment were a long car ride or plane trip away, patients rarely sought a second opinion. Weiner protected his turf, resisting attempts to hire another oncologist or to transfer his patients to other doctors, court records show. As a result, few colleagues were looking over his shoulder. Inside the hospital, some referred to what he created as “his closed system.” As one doctor put it to me, if you were Weiner’s patient, “he grabbed on to you. He stayed with you for life. No one else would see you until you die.”

Concerns about Weiner’s billing and patient load persisted. Solheim’s successor, Nate Olson, also questioned his compensation. Weiner again helped organize a vote of no confidence, records show. Olson, who did not respond to requests for comment, stepped down in May 2016.

In 2019, St. Peter’s current CEO, Wade Johnson, hired an expert on the federal False Claims Act and fraudulent billing practices to study Weiner’s pay. The consultant described Weiner’s RVUs as “exceedingly high” and his compensation “a significant outlier.” Weiner logged nearly four times the visits and treatments of the median oncologist in the United States, despite working in a sparsely populated region. The consultant said the billings could be defended but warned they presented a potential legal and financial liability for both the hospital and Weiner.

From 2009 to 2020, the period Scot Warwick was under his care, the hospital paid Weiner more than $20.1 million. In all our conversations, he never shirked questions about his income. The bottom line, he told me, was that without him, St. Peter’s had no cancer center. “You want me to keep seeing everyone?” he said. “Then you’re going to pay me more, because I’m doing more work.”

Helena, Montana (Louise Johns, special to ProPublica)

Each morning Warwick lay in the ICU, Weiner visited, still dressed in his gym clothes. Over a decade Warwick had come to see his doctor as a friend. In their talks, Weiner dismissed Sasich’s hypothesis, though he agreed with the decision to stop administering the chemotherapy drug gemcitabine. As Sasich spent more time with Warwick, his confidence only grew. Throughout his treatment, Warwick had shown few symptoms of lung cancer and had continued to backpack, camp and kayak with his kids.

In Warwick’s records, a medically coded tit for tat ensued between the hometown celebrity and the outsider. Sasich ordered a new biopsy and tests to look for infection in Warwick’s lungs. “Dr. Sasich,” Weiner responded, “is still skeptical of the diagnosis.”

Lisa Warwick first heard from Sasich on Aug. 9, a week into her husband’s hospitalization. He wanted to explain the need for another lung biopsy. A habitual note taker, she scribbled words her mind could not accept: “This doesn’t present to me like cancer,” he told her.

“Well, how could that be?” she remembered thinking. “All our lives sucked for 11 years. I can’t imagine that we went through all that and it not be real.”

Sasich agonized about what to do. Doctors rarely challenge one another’s work. But after talking with the Warwicks, he filed an official complaint, accusing Weiner of an egregious mistake. He sent a letter to the hospital’s peer review committee, an internal group of doctors tasked with examining concerns about patient care. In it, he wrote that Warwick “would be the longest living case in the medical literature.”

One of the tests Sasich ordered indicated a possible fungal infection in Warwick’s lungs — not uncommon for patients whose immune systems have been wrecked. He was treated with steroids and an antibiotic cocktail. Warwick improved and, on Aug. 13, was sent home with an oxygen tank. Three days later, Lisa Warwick found him suffocating. He left home again for St. Peter’s, this time in an ambulance.

After a week of tests, Sasich called Lisa Warwick to tell her that her husband was experiencing a rare and excruciating reaction to the antibiotic Bactrim. Called Stevens-Johnson syndrome, it causes the skin to blister and peel. He was intubated and flown to a specialized burn unit at the University of Utah’s Huntsman hospital. The next day, Warwick’s left lung collapsed. A doctor told her to rush down to Salt Lake City.

For three weeks, Lisa Warwick lived at Huntsman, unable to leave and reenter because of COVID-19. Inside, doctors expressed to her confusion about Warwick’s diagnosis and sparse medical record.

When his right lung neared collapse, a doctor asked about his dying wishes — his code status. Do not resuscitate, Lisa Warwick said, a DNR. When they could do no more, the lead doctor pulled her aside. According to court records, he asked if she wanted an autopsy. As he asked, the doctor nodded his head up and down. She said yes.

Scot Warwick’s final communication with his wife was a faint squeeze of her hand. He died just after midnight on Wednesday, Sept. 16, 2020.

A memorial to Scot Warwick in the family home (Louise Johns, special to ProPublica)

About a month later, his widow heard from the medical examiner. This is how she recalled the conversation during court testimony:

“Mrs. Warwick, I’ve never had to make this call before,” he said. She began to take notes. “I’m sorry.”

“OK?”

“We did not find any cancer cells at all. We can’t find anywhere in his records that he had cancer and found no malignancy at all.” All signs indicated he died from lung failure caused by the drug gemcitabine. Chemotherapy killed him.

As the conversation closed, she asked: “What am I supposed to do with this? What do I do?”

“Get a lawyer,” he said.

Left to right: Peyton, Lisa and Brady Warwick (Louise Johns, special to ProPublica)

After Warwick’s death, Sasich bumped into Dr. Robert LaClair, the hospital’s kidney specialist and chair of the peer review committee. “How the fuck did this go on for so long?” Sasich asked. He considered LaClair an excellent specialist and consulted him frequently. From LaClair’s face, Sasich worried he had offended him.

A former Air Force doctor, LaClair has a certain respect for bureaucratic channels, which Sasich admits is not his domain. LaClair had worked with Weiner for 11 years and over that time had choked down his concerns. As he would later tell me: “I was caught up in the culture. We all were.”

LaClair revealed to Sasich that for months he had been quietly building a case against Weiner. According to court testimony, he advised Sasich to lay low as any attempt to remove Weiner had to be done “by the book.” Weiner had the money to sue the hospital and had threatened to do so many times. It could become a circus. Sasich was relieved that something was happening but was outraged that no one had acted before his patient suffered an agonizing death.

What LaClair didn’t tell Sasich was that the problem was worse than he knew. The review had begun a year earlier, after LaClair and a colleague questioned Weiner about his practice of providing minimal, often indiscernible, notes in his patient files. This poor documentation complicated follow-up care and, according to LaClair, intentionally made it difficult for others to question Weiner’s treatment. Court records show LaClair and his colleague also told Weiner to stop admitting scores of patients to the hospital for stays unrelated to cancer — stays that financially benefited him.

By early 2020, doctors and nurses had submitted enough confidential complaints for peer review to make LaClair act. He sent a half dozen patient files to medical experts at the University of Utah, but the conclusions had been delayed by COVID-19.

After Warwick died, St. Peter’s added his file for review. The doctor examining it quickly responded, thinking there must have been a clerical error: The packet didn’t include a biopsy to support the 2009 diagnosis. On Oct. 9, St. Peter’s received his analysis: “If he had cancer, this course of many years would be truly remarkable.” It went on, “The long-term treatment with toxic medications in the absence of a confirmed diagnosis of cancer is not reasonable.”

External reviews typically lack forceful language, perhaps by design. Medicine is nuanced, messy and rife with decision points and diverging paths, so doctors grading other doctors can sound deferential, even perfunctory. The eight Utah reviews were different.

Looking at a 2018 incident involving a 62-year-old man whom Weiner had diagnosed with throat cancer, a reviewer described several decisions as potential “malpractice” that led to an unnecessary two-month hospitalization. As with Warwick, there was no biopsy in the file.

Another review criticized what Weiner didn’t do. A 67-year-old woman with breast cancer had received chemotherapy and undergone a mastectomy and breast reconstruction. In a June 2019 check-up, Weiner noted “no evidence of any recurrence.” But records show that he didn’t conduct a breast examination. (Records show that this was a common failing in his breast cancer treatment.) Months later, the patient found a lump. A biopsy ordered at another hospital confirmed the cancer had been back for some time, which led to a second breast tissue removal, radiation and chemo.

Deposition of Dr. Robert LaClair

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“I’ve never seen so many cases of what we sent out that was not meeting standard of care. I’ve never seen that before, and I hope I never see it again,” LaClair would testify.

LaClair later told me, “When the Utah reports came back, it was like: ‘Holy fucking shit. This is going to suck.’”

On Oct. 15, 2020, St. Peter’s suspended Weiner and revoked his privileges. Banished from the kingdom he’d built over a quarter century, Weiner told me he felt only “blank.”

The hospital hired The Greeley Company, a health care consultancy, to scrutinize the records of dozens of additional patients, many of them dead. Weiner would be given an opportunity to defend himself and regain his job at an internal “fair hearing.”

Word of Weiner’s suspension devastated the nurses at his cancer center, the core group of women who called themselves “Tom’s wives” or his “girls.” They were the envy of nurses in other departments for the prestige of working for Weiner and for the perks. From 2005 to 2020, records show that he gave them at least $140,000 of his own money in bonuses and jewelry. Upon retirement, nurses could expect diamond solitaire earrings worth about $1,500. He invited them to his home for dinners and holiday parties. They messaged him regularly, wishing him well on his extended trips to Italy.

In the weeks following his suspension, they delivered food and sent supportive notes. They vowed to resist the administration. Weiner told them not to lose their jobs for him.

“I love you. I’m here. I’m so sorry. I’m praying,” nurse Emily Burton texted him.

“You can tell the girls I will be fighting,” Weiner responded. “But it will probably get bloody.”

To others, like nurse Meghan Giovenco, he expressed anger: “They are going for the jugular. Scum.”

When Weiner heard that Sasich questioned his work in front of his nurses, he texted a hospital administrator, “FYI put a muzzle on Sasich or else.”

News of Weiner’s suspension spread through social media and Helena’s shops and diners. Patients formed a Facebook group called “We stand with Dr. Tom Weiner.” He saved their lives, their spouses’ lives, they said. He remembered the names of their children and grandchildren. He was kind, brilliant. Dozens more joined, then hundreds and hundreds.

To those inside St. Peter’s, it resembled the campaigns that forced out the previous CEOs — only worse. Soon, the first of what would be more than a hundred small rallies was held outside the hospital. By ousting the region’s only oncologist, they contended, patients had been abandoned, consigned to long waits and a rotation of travel doctors. One sign proclaimed, “I WANT MY DR. WEINER, NOT THE SECOND STRING.” Their message spread to yard signs, bumper stickers and T-shirts. Supporters caravaned along Helena’s downtown, honking horns.

Signs of support for Weiner in Helena (Louise Johns, special to ProPublica)

The hospital fired Weiner on Nov. 17, 2020. Johnson, the CEO, convened a meeting with the cancer staff, telling them Warwick’s death was “the tip of the iceberg.” He barred attendees from recording the meeting, court documents show, and the hospital’s chief nurse paced the room, instructing employees to put their phones away. All of Weiner’s patients should seek second opinions, Johnson said.

Johnson also told the staff, “Don’t be surprised if black suits show up.” Weiner’s nurses understood this to mean that federal law enforcement or the Department of Health and Human Services would be investigating. “He explained it to be suits — there were going to be suits coming into the office and asking for things,” according to the testimony of nurse Andrea Thies, who, despite Johnson’s orders, took notes during the meeting.

“You walked out of there feeling like, ‘Was I killing people?’” nurse Fallon Melby would later testify.

Deposition of nurse Fallon Melby

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Three weeks later, St. Peter’s posted an astonishing disclosure on its website: “The issues we have identified include the following: harm that was caused to patients by receiving treatments, including chemotherapy, that were not clinically indicated or necessary; failure to meet state and federal laws associated with the prescribing of narcotics; failure to refer patients to other specialists for appropriate treatments; and failure to meet requirements associated with clinical documentation.”

It’s unclear if the hospital referred any of these issues to the state’s medical board or to state and local law enforcement.

Days later, Weiner sued St. Peter’s and its executives for wrongful termination and defamation.

Early in 2021, Sasich was pulled aside by Shelly Harkins, the hospital’s chief medical officer. According to Sasich’s court testimony, she apologized for getting him caught up in this mess.

She next confided a story that rendered him “physically ill.” Hospital administrators had for years harbored suspicion about one case, a 16-year-old girl who died suddenly under Weiner’s care. Sasich remembered Harkins providing few details but saying Weiner was frustrated that another physician was treating his patient. Once he regained control of her treatment, the girl didn’t live long. “She told me that he gave her two doses of propofol,” Sasich testified, “and she died.”

Sasich hoped it was just a rumor, an exaggeration. But when he asked LaClair about it, the person who knew more than anyone about Weiner’s practice didn’t refute the story but for one correction. It wasn’t propofol.

“No,” LaClair told Sasich. “He uses phenobarbital.”

St. Peter’s Health CEO Wade Johnson (Louise Johns, special to ProPublica)

In the days after Weiner’s termination, dozens of his patients came into the hospital asking for refills of oxycodone, morphine and other opioids. The doctors taking over Weiner’s caseload couldn’t find the prescriptions in St. Peter’s electronic system, according to court records, and Weiner’s patient files were little help. So they turned to a state database that logs all pharmacy opioid sales and discovered he had been writing prescriptions by hand, which bypassed internal hospital controls. To their shock, they found that many of his patients had been on dangerous levels of narcotics for years. The state agency that oversees that drug registry did not respond to a request for comment.

Often the patients seeking painkillers didn’t have cancer and had no documented need for them. Weiner had ordered them as their primary care physician. Many were struggling with addiction. St. Peter’s created a document for doctors to track the crisis in real time. Their notes included: “nonsensical” and “one of the worst indications for opioids. I’m still piecing this together …” and “Many years on methadone. Not clear why.”

Weiner told me the hospital manufactured these allegations to justify firing him, and he denied writing prescriptions by hand.

St. Peter’s assembled a committee of pain management experts to review more than 2,000 patient files. Dr. Kyle Moore, an addiction specialist, led the effort to detoxify patients. He found that Weiner rarely accounted for what doctors call morphine equivalents; essentially, he didn’t do the math to ensure that when patients received drugs at different intervals and strengths they didn’t add up to a lethal dose. Weiner denied this. In the narcotics tracking memo, Moore is quoted as saying Weiner’s prescribing was “a greater danger to the community than coronavirus.”

The full scope of Weiner’s prescription practices may never be known. The hospital alerted the federal Drug Enforcement Administration, which began an investigation, a spokesperson told me. But court records show no attempt by St. Peter’s to quantify the problem beyond its initial scramble to detoxify patients. St. Peter’s would not tell me if it searched for patients in the community who overdosed or died, nor would it say whether it reported what it found to the state medical board.

While the front-line doctors taking over patients were horrified, court records show hospital administrators and the peer review committee had been warned more than a dozen times, since at least 2018, that Weiner was overprescribing. I learned that staff who raised concerns expected to be yelled at or intimidated by Weiner. In 2019, two nurses and a pharmacist questioned a Weiner order to apply a fentanyl patch on a 93-year-old woman who was already on opioids and bobbing in and out of consciousness. A nurse texted Weiner to ask whether he was sure. Weiner responded, “Tell them put it on or I will rip their lips off.” Weiner told me this was “an inside joke.”

Federal regulators also failed to address alarming trends. An analysis of Medicare drug data shows that, from 2013 to 2020, Weiner’s volume of opioid prescriptions ranked ninth among all cancer doctors who bill the program. When it came to morphine, Weiner consistently ranked among the top five. In 2017, he prescribed more morphine than any other cancer doctor. The Centers for Medicare and Medicaid Services did not respond to questions.

Before St. Peter’s fired Weiner, the hospital sent five pain management cases to The Greeley Company. All were deemed inappropriate. One case was Sharon Dibble, a 75-year-old with many health problems, including kidney failure and chronic obstructive pulmonary disease.

On March 6, 2018, for reasons that were unclear to the reviewers, Weiner doubled her extended-release morphine from 30 to 60 milligrams twice a day, on top of an oxycodone regimen. Four days later, Dibble’s daughter found her limp, blue in the face, not breathing. Paramedics rushed Dibble to St. Peter’s, where she was kept on life support for more than two weeks. She died on March 27.

St. Peter’s said the cause was acute respiratory failure — her body starved of oxygen and shut down. The family believed her mounting ailments overtook her. But that’s not what happened, according to the Greeley review. Weiner’s “excessively large increase” in morphine, it concluded, “led to respiratory arrest and the patient’s demise.”

When I raised the Greeley review with Weiner, he called it “ridiculous.” He told me that he swapped short-acting pain medicines for long-acting but that Dibble’s morphine equivalent was unchanged — a claim contradicted by medical records and the hospital’s review of her death. The Centers for Disease Control and Prevention cautions against exceeding the equivalent of 90 milligrams of morphine daily and warns anything above 120 risks overdose. Records show Dibble’s daily regimen equaled 195 milligrams of morphine.

St. Peter’s never told Dibble’s family what it knew.

Five years after Dibble’s death, I shared the report with her son and two daughters. During his mother’s last days, Tom Dibble made the decision to stop life-sustaining measures. It was, he thought, her time to go. Now, he feels duped.

“Not only did this individual cause her death,” he said, referring to Weiner, “but it’s pretty apparent that this whole thing was being covered up. We were never given any knowledge that this took place, and we have to live with this decision.”

Family photographs of Sharon Dibble (Louise Johns, special to ProPublica) From left to right: Dibble’s children, Cindy White, Tom Stevison and Melba VanSprang, and her husband, Dennis Dibble (Louise Johns, special to ProPublica)

Six months after Weiner’s firing, the hospital conducted its fair hearing. As in a trial, witnesses testify, attorneys cross-examine, but a fair hearing isn’t public, and the judges are doctors — in this case, a panel of three from St. Peter’s. Held in a hospital conference room, the hearing took six days. On the first night, LaClair spelled out the allegations — Warwick’s death, the numerous misdiagnoses, the narcotics and more.

But that wasn’t the worst of it. The hospital also accused Weiner of overriding his patient’s dying wishes. If a patient wants CPR or a machine to keep them breathing, they elect to be a “full code.” Weiner, the hospital said, had a pattern of altering, without consent, a patient’s status from full code to a DNR/DNI, do not resuscitate and do not intubate. The hospital would not tell me if it pursued a complete accounting of what the fair hearing panel determined to be “a serious violation of the standard of care and medical ethics.”

At the hearing, nurse Addie Weidow described two events in which she witnessed a patient’s code status being changed without permission, including one where a patient nearly died before an intervening doctor sent her to the ICU. In another instance, Weidow testified, the chart of a patient who was full code suddenly read DNR/DNI. Following hospital protocol, nurses tried to attach a purple wristband, signifying her wish to die without intervention. When the patient refused the band, Weidow said Weiner told them to “hang the band on the doorknob and leave it be.” In other words, if her heart stops, don’t enter the room. Weiner’s nurses called it “a slow code,” Weidow testified.

When Weiner left town, Dr. Ashley Coggins managed his patient load, giving her a rare view into his closed system. She testified that “many nurses have come to me in the last several years, telling me that that was a standard practice of his — to just change people’s code statuses once they were doing poorly.” She added: “He was basically using his own judgment as the judgment for people to live or die. It’s horrifying.”

During the hearing, a hospital attorney asked Dr. Kerry Hale about the 16-year-old girl, the rumor that now haunted Sasich. Hale couldn’t recall the girl’s name but remembered she had a Wilms tumor, a kidney cancer that affects mostly children, and was being treated on the pediatric floor. Then, out of nowhere, Weiner transferred her to his oncology floor “and then orders for DNR, and then three doses of phenobarbital were given, and the patient died, I believe, that evening.” Phenobarbital is a barbiturate commonly used to treat seizures during alcohol withdrawal. In large doses, it is lethal.

When Weiner’s turn came, his lawyer asked for his account. His answer was clinical and unflinching. “Mom wanted her comfortable,” he said. “So, I transferred her to the oncology floor, and I gave her pain meds, phenobarbital, and she died later.” Neither the hospital nor Weiner’s attorneys pressed him for more details.

“Comfort” was a word Weiner used often in our conversations. If a patient dies as a result of his treatment, he told me, it’s not unethical if his intent was to provide comfort. In medicine, this is called the principle of double effect. First developed by the Catholic saint and theologian Thomas Aquinas, it’s a set of criteria by which a person can morally justify ending someone’s life. It stipulates that a harmful consequence of a medical treatment, such as death, is permissible if it’s a secondary effect of beneficial treatment, such as alleviating pain with drugs. “It’s for their comfort,” Weiner told me. “It’s not that I euthanize them.”

At the fair hearing, Weiner denied the hospital’s accusations. “Part of my problem is I have a good memory,” he said, “so I just remember things, and I probably should put more in the chart.” It wasn’t odd that he prescribed high-dose opioids, he said. He’s an oncologist, and his patients were suffering. Why was he giving painkillers to people who didn’t have cancer? For most of his tenure, he said, St. Peter’s didn’t employ a pain specialist.

As for his end-of-life care, Weiner said he always discussed the options with patients — “tens of thousands,” he estimated — before altering their status.

The panel unanimously rejected Weiner’s appeal.

St. Peter’s (Louise Johns, special to ProPublica)

Despite being fired, Weiner maintained his medical license. The law only required St. Peter’s to report his suspension — not what it knew — to the state medical board and the National Practitioner Data Bank. The medical board would not comment on whether it conducted an investigation into Weiner.

Rather than go into private practice or retire, Weiner decided to sue St. Peter’s, spending, by his own account, millions of dollars. He told me that he expected the hospital to settle for as much as $20 million because “they can’t let out what they did.”

By suing, Weiner exposed himself and St. Peter’s to pretrial discovery. Over the next three years, thousands of documents — text messages, patient files, financial statements, the fair hearing transcripts — were entered in court as evidence. Hours of depositions by doctors, nurses, administrators and Weiner were recorded.

Although at odds in every other way, Weiner and St. Peter’s had one common interest: concealing the evidence. Both parties successfully petitioned the court to seal nearly all the discovery. I was able to obtain it.

If the residents of Helena had seen those files, they would know how Weiner built a high-volume business that billed as much as possible to public and private insurance, all the while sending numerous patients through a carousel of unnecessary and life-threatening treatments. They would have learned that the hospital had financial incentives to look away.

Evidence of that high-volume business was hiding in plain sight, in data published by CMS. An analysis of Medicare Part B billing data shows that, from 2013 to 2020, Weiner billed for 40,000 15-minute visits, more than any other doctor — of any specialty — in the nation. The publicly available data offers just a glimpse of what St. Peter’s knew was a much bigger problem. “He’d see 15 patients in 30 minutes,” LaClair told me. This made Weiner rich and apparently missed the gaze of insurance regulators.

If Weiner was such an outlier, why did he never come to the attention of CMS? I reached out to John Hargraves, a data expert at the Health Care Cost Institute in Washington. CMS investigators, he told me, are looking for obvious fraud, such as doctors billing for more expensive work than they delivered. Instead, Weiner crammed in an extraordinarily high number of less expensive patient visits into each day.

When I asked St. Peter’s about what I had found, the hospital refuted none of it. It would not answer questions about Scot Warwick or Sharon Dibble or any other patients despite being given health privacy waivers signed by the families. CEO Johnson turned down requests for an interview. Andrea Groom, the hospital spokesperson, emailed a statement that broadly declined to comment, citing ongoing litigation. “We believe this situation is isolated to a single, former physician, and we remain confident in the exceptional care provided by St. Peter’s medical staff,” it said.

In a follow-up email, Groom wrote: “Dr. Weiner was a highly productive physician, but this was not necessarily alarming, given that he was the only medical oncologist treating cancer patients for a large service area during much of his time with St. Peter’s Health.” Patient satisfaction ratings were high, she said, and complaints were rare. Groom added that “there was no reason at the time for St. Peter’s to believe that Dr. Weiner was providing substandard care.”

In a court filing, the hospital told a judge it expects to be sued by more Weiner patients.

What the hospital’s response ignores is that St. Peter’s enabled and protected Weiner. As LaClair said in his deposition, Weiner’s colleagues didn’t stop him earlier “because we were afraid of him.” In court filings, St. Peter’s admitted that for years it knew of “serious concerns of physician colleagues and staff members with several patient deaths.” When I asked Weiner why the hospital would publicly accuse him of various types of malpractice but withhold its concerns about his end-of-life care, he said it’s because administrators knew what he was doing and even encouraged it.

Fifteen months before he was fired, Weiner and his nurses took over the hospital’s end-of-life care. I found an August 2019 text message exchange between the hospital’s chief nurse, Kari Koehler, and Weiner that made it official: “Are you still okay if all end of life patients go to onc[ology] even if they aren’t yours? I just feel like those nurses do it best!”

Weiner responded: “I agree!!”

By the summer of 2021, the pro-Weiner Facebook group had about 4,000 members. The hospital CEO was “evil,” “a true devil” and “puke.” The group campaigned successfully to have Weiner named “Helena’s Best Physician” in the Independent Record and raised the money to rent billboards that read “WE STAND WITH DR. WEINER.” When I asked Weiner why the town was cleaved in two over him, he smiled and offered a correction. “I wouldn’t call it 50/50,” he said. “More like 80/20.”

For Lisa Warwick and her two children, each Weiner sign was a reminder to keep silent. “I was worried about violence against us,” she told me. That summer, the family sued St. Peter’s for Warwick’s wrongful death. In her deposition, the widow said: “My children lost their father. I lost my husband. It wasn’t quick. It was long. And it was torturous. And it was terrible. And I would never, ever wish that on anyone — ever.”

In his depositions, and later to me, Weiner maintained that Scot Warwick had Stage 4 lung cancer for 11 years. The April 2020 biopsy that didn’t show cancer? The pathologist missed the spot where the cancer was, he said. In our conversations, Weiner said that the cancer had passed back-and-forth between Warwick’s two lungs.

“He was pretty advanced, though?” I asked. “Don’t you think it would be hard to miss?”

“Well, you would think,” he said. “I agree with you. I was kind of pissed off.”

What about the doctor in Utah who performed the autopsy? He also missed the cancer, Weiner said.

The Warwicks and St. Peter’s eventually settled the case for an undisclosed amount. Weiner was not held liable because he was a hospital employee. Neither the family nor their attorney have solved the mystery of why three private health insurers paid for 11 years of Stage 4 lung cancer treatment. None of the companies responded when I asked.

When I shared Weiner’s claim that 80% of Helena residents stood behind him, Sasich didn’t disagree. He drove past the protesters on his way to work. In the hospital, Weiner’s nurses barely looked at him. The billboard gave him chills. He couldn’t understand why people weren’t demanding answers.

Weiner’s supporters outside St. Peter’s (Louise Johns, special to ProPublica)

The mystery of the 16-year-old girl tore at him. He replayed the scenes in his head — Harkins, the chief medical officer, telling him that she may have been killed, LaClair confirming it. He asked a hospital attorney if they were investigating; “we’re aware of the case,” he was told. He took what he knew to Helena’s police chief. He had a brief meeting with a fraud investigator at the U.S. Department of Health and Human Services. No one seemed interested in pursuing it, Sasich told me.

Sasich’s inquiries came back to Weiner, who added him as a defendant in the lawsuit, accusing him of defamation. Sasich has denied the allegation.

Buried in the thousands of pages of medical records, correspondence and memos that build the hospital’s case against Weiner is a single sheet that summarizes the dying moments of seven people. In broken cursive, someone wrote in pen, “Phenobarbital cases.” Ranging in age from 53 to 77, they represent a small sample of those who died under Weiner’s care.

The memo tracks the final hours of a 62-year-old woman, admitted for stomach pain on Oct. 3, 2018. Four days later, at 6:01 p.m., she received 260 milligrams of phenobarbital for “terminal agitation.” Two hours passed. She received another 260 milligrams, then another at 10:58 p.m. — a total of 780 milligrams. She died just after midnight.

Unlike the narcotics and misdiagnosis cases, the hospital didn’t send these for outside review but rather enlisted its chief pharmacist, Starla Blank. During the fair hearing, Blank said the events were alarming because it wasn’t clear whether the patients were near death. “In most of the cases the patients were talking and visited with Dr. Weiner prior to their — prior to them getting the phenobarbital,” she said.

Still, St. Peter’s, which declined to comment on the phenobarbital cases, chose to ignore Blank’s assessment. In its final written account, the hospital concluded that the seven patients “were at end of life and that there were no remaining viable treatment options for them.”

One case is conspicuously missing from the phenobarbital memo.

There is no mention of the 16-year-old girl. In Harkins’ deposition, she recalled the case but not her name. LaClair’s testimony offered few details of an unnamed girl. Under oath, the hospital’s chief nursing officer referred to “a child” who had received so much phenobarbital as to arouse concern with nurses.

An online search of “Thomas Weiner” produces dozens of obituaries that express gratitude to the oncologist and his nurses for treating loved ones. One shows a photo of a thin girl with a big smile and blonde hair held back with barrettes. It speaks of hot air balloon rides in Arizona and beach trips in Oregon. She and her little brother built a play cabin in the woods and made pocket change selling lemonade. She loved camping and kayaking. At age 6, she was diagnosed with a Wilms tumor, but she didn’t let it rule her life. Her mother, who wrote the obituary, quotes her as saying, “Having cancer is no fun, but that doesn’t mean that you can’t have fun just because you have cancer.”

Her name was Nadine Long.

Deposition of Dr. Shelly Harkins

Watch video ➜

While I was reasonably sure this was the girl whose memory haunted the halls of St. Peter’s, I decided to knock on the door of the man who finally acted to stop Weiner but, by his own admission, had waited far too long.

To my surprise, Dr. Robert LaClair welcomed me into his home. Earlier that week in September 2023, a Montana judge had sided with St. Peter’s and thrown out Weiner’s lawsuit. The hospital had a right to enforce quality care under federal law, the judge ruled. In an addendum, the judge explained the hospital had not defamed the oncologist. Weiner vowed to file an appeal with the state Supreme Court. The judge did say, however, that Weiner’s defamation suit against Sasich could go forward. In LaClair’s study, we discussed Scot Warwick, the narcotics, the code status changes — cases he’d no longer have to recount in a trial. A weight seemed to be lifting from him, until I mentioned the name few knew. Taken aback at “Nadine,” his eyes welled. LaClair had read her file but had not sent it for outside review. He exhaled and after a long moment said: “Trust me, it’s so bad. You have no idea. She wasn’t terminal.”

By June 2024, Weiner and I had talked for many months. Sometimes, he’d offer an anecdote about an anonymous patient, unaware that I could identify their names and compare the stories with medical and court records. Invariably, he portrayed himself as a gifted and dedicated doctor. One was about a moribund young girl who needed him to intervene when a less capable doctor wasn’t keeping her comfortable. It was time to ask what happened to Nadine Long.

We sat at a long table in a hotel conference room in downtown Helena. Dressed in jeans and a short-sleeved polo shirt, he agreed to be recorded, attached a microphone to his lapel and talked first about a recent trip to Rome. Well into the interview, I presented him with a privacy waiver signed by Nadine’s family, and he told me his version of her final days.

It was March 2015. He was in New York, on Broadway, waiting with his wife for a matinee showing of “Les Misérables,” when Nadine’s mother called. She said her daughter was “in horrible pain. They won’t take care of her pain. Please come home.” After the show, he flew to Helena, arriving near midnight, and drove straight to St. Peter’s. Nadine was screaming and crying.

Weiner had treated Nadine since she was a child, when she was first diagnosed with cancer and when it recurred the following year. The cancer had now come a third time. Nadine had a pleural effusion — fluid built up between the lung and the chest cavity — that restricted her breathing. Her mother had talked with the oncologist filling in for Weiner, who was trying to transfer Nadine for further testing at St. Jude Children’s Hospital in Memphis, Tennessee. Weiner reviewed Nadine’s scans. “She was going down like a stone,” he told me. “She had hours to a day or two to live. There were no more cards to play.”

Hearing this, Nadine’s mother no longer wanted her transferred. “She just wanted her comfortable,” Weiner said. He gave Nadine a choice: a torrent of undignified treatments and pain with no promise of survival or “leave it up to God, and we’re just going to keep her comfortable.”

At that point, he moved Nadine to his oncology floor, to his nurses, “and she got some pain meds — I don’t remember how much phenobarbital — and she died later.”

His response mirrored what I had read in the fair hearing transcript. I had by then reviewed Nadine’s medical record, some of which I presented to him.

Weiner had examined Nadine less than a week earlier. In her file, he wrote, “she looks good … everything looks stable right now.” I asked how he could have missed what he claimed was an advanced and terminal disease.

“That’s how fast — the nature of that tumor when it comes back, it comes back with a vengeance,” Weiner said. “That fast.”

With her family’s consent, I had shared Nadine’s records with Dr. Sarah Friebert of Akron Children’s Hospital in Ohio. She specializes in pediatric oncology and founded and directs the hospital’s pediatric palliative care center. She wanted to be clear that she was not speaking for her employer.

I read aloud to Weiner some of her review.

“Here’s a girl who was skiing and then she’s dead a week later, and that’s — that’s concerning,” Friebert told me. “She ate 75% of her dinner on the night she died. Her vitals were not out of whack.” Nadine should have been sent to another hospital for testing, Friebert said, because nothing definitively showed she couldn’t have been treated. It’s not clear she was going to die, Friebert said.

Weiner determined she was dying based on a test of the fluid in her lungs, which was insufficient, she said. Neither Friebert nor I could find any evidence in Nadine’s file that Weiner ordered a biopsy that confirmed terminal cancer.

Friebert uses phenobarbital to calm children as they die of disease, but she told me Weiner “was escalating the phenobarbital in a way that is way out of proportion with what I would ever have done.” The intent, she said, could not have been comfort. “These doses were obscene,” she said. “He killed her with it.”

That a respected oncologist questioned his care didn’t seem to faze Weiner. She wasn’t there, he told me, and therefore can’t make such judgments. “I completely disagree,” he said. “This is a girl that’s got — her body is riddled with cancer, and she’s in horrible pain. Now did the phenobarbital hasten her death? Yeah, it did.”

In all our conversations, Weiner insisted his intent is always to provide comfort, never to hasten death, but here he equivocated.

“Could it have shortened her life?” Weiner asked. “Yes. Again, in most of these cases, could I not give phenobarbital, and would that patient live longer? The answer is yes.” Weiner paused. “But longer in, like, hours? I mean, is that worth being in misery for those hours?”

“My goal was not to kill Nadine,” he added. “My goal was to make her comfortable.”

I had shown him the “phenobarbital cases” memo, and we’d discussed the code status changes, Scot Warwick, the narcotics and now Nadine. Finally, I had to ask, “Are you killing your patients?”

“Well, uh, no. I’m not,” he responded.

“Why did you hesitate?” I asked.

“Well,” he said. “It depends on what you mean by killing them.”

Photos of Nadine Long and her mother, Cheri Long, and father, Dan Beadle (Louise Johns, special to ProPublica)

Nadine’s parents live outside of Helena, at the end of a cattle road that curls around the peak where their daughter once played and her ashes now rest. Dan Beadle, her father, is an evidence technician for the county sheriff’s office. Her mother, Cheri Long, recently retired as an administrator at Carroll College in downtown Helena. They led me through the mudroom to the kitchen’s farmhouse table, where I asked them to recount the worst days of their lives.

While on a family vacation in New Hampshire in April 2005, Nadine was diagnosed with a Wilms tumor. She had her left kidney removed and received radiation. When the family returned to Montana, they met with Weiner, who directed her chemotherapy. During those treatments, Nadine bonded with his nurses, “the true loves of her life,” Long said. She appeared to be in remission. But a year later, the cancer reappeared in the spot where her kidney had been removed, Weiner told the family. Nadine received chemo and other treatments until about 2010, when Weiner said she was cancer free. She continued to see Weiner and his nurses for annual check-ups and more.

“Dr. Weiner always had a policy that once you’re his patient, he’s your primary physician,” Long said. “I don’t know if that’s normal.”

Nadine attended the same Catholic school as Weiner’s children. Her uniforms were hand-me-downs from his older daughter. The two families were friendly but not close. Nadine’s parents respected Weiner, although, as Long put it, he could be domineering.

Nadine also had bipolar disorder. When she was 14, a psychiatrist wrote that she struggled with information processing. He said her “insecurities, anxiety, and tendencies toward frustration when challenged dramatically interfered with her critical thinking skills.” But she was also “kind, compassionate, very empathic.”

In February 2015, Nadine’s parents noticed her hunching forward, struggling to breathe. She came to see Weiner on March 2. As with most of her visits, it lasted just a few minutes. “He listened to her lungs and said, ‘Everything’s good,’” her father recalled. “Then he tried to palpate a little bit, and she was extremely ticklish, so she started squirming around, and then at some point he goes, ‘I think we’re good to go.’”

Six days later, Nadine buckled and fell while skiing and was rushed to the St. Peter’s emergency room. Her parents were out of town when Nadine called to say: “Mommy, I’m in the hospital. My lung collapsed.” They raced to St. Peter’s, where they learned nurses had inserted a chest tube and drained her lungs of fluid, but no one would tell them more. Weiner was in New York City. For the next five days in the pediatric ward, Nadine vacillated between moments of calm and kicking and screaming, but her vitals were steady.

They felt they weren’t getting straight answers from Weiner’s backup oncologist. Long asked that Nadine be transferred to St. Jude. But as those arrangements were being made, Weiner appeared. “Finally,” Long remembered thinking, “We were like, ‘Someone who’s going to tell us the truth instead of tiptoeing around us.’”

She learned later that a St. Peter’s employee had phoned Weiner. His claim that he returned because Long called asking him to provide comfort to her daughter?

“That’s a flat-out lie,” she told me. “We did not ask for him to come home from his vacation.”

Weiner told her a large malignant mass was compressing Nadine’s lungs and would soon suffocate her. “How he described it was, ‘It’s doubling every day, and today it’s the size of a soccer ball,’” Long said.

Soon after, Weiner spoke with Nadine. “He spoke to our daughter, not to us,” Long said, “He told her, ‘You can choose the medical path or the God path.’” The conversation was “between the two of them. We were there, and he would check — he would look at us,” Long said. “Taking the God way was saying, ‘I fought my fight, and I’m ready to meet Jesus.’”

The teenager who struggled with processing information and critical thinking chose the God path. Her parents, terrified that she might needlessly suffer, didn’t object. On March 13, Nadine was changed from a full code to DNR/DNI, despite the day’s progress report that said, “She is alert and oriented, in no acute distress.” Weiner transferred her to the oncology floor.

Nadine had been heavily drugged since she’d arrived: Dilaudid, morphine, oxycodone, fentanyl. The next day, Nadine’s heart and respiratory rates elevated. She was panicking. “Saturday afternoon, she’s thrashing, she’s fighting, she can’t breathe,” Long said. Her father and a nurse couldn’t hold her down. They believed she was suffocating. The parents agreed to Weiner’s comfort measures.

Nadine’s medical file shows that he ordered a nurse to inject phenobarbital, which a computer tracked.

3:45 p.m. — 260 milligrams.

Nadine was still thrashing around. The nurse later said he was nervous about increasing the phenobarbital and called Weiner into the room. “He came in and stood there and oversaw,” Long said. “He just kept saying, ‘more, more.’”

5:26 p.m. — 390 milligrams.

It’s unclear when Nadine fell into sedation. After the initial doses, Weiner left the room.

7:47 p.m. — 390 milligrams.

Two of Weiner’s nurses who had doted on Nadine for years stayed late.

9:54 p.m. — 390 milligrams.

Relieved she was no longer in pain, her parents held on to her and each other.

1:45 a.m. — DISCHARGE.

Her heart stopped.

Nadine received 1,430 milligrams of a drug whose standard dosage for an adult is 260 milligrams. She weighed 100 pounds.

Nadine’s parents asked St. Peter’s to investigate the care she received. They wanted to know how Weiner could have missed a massive tumor a week before she died. Two months later, they met with the hospital’s director of risk management, who told them, Long said, “that he was reviewed and provided great care.”

For nine years, that answer had satisfied them. Believing Weiner had spared Nadine of pain in death, they put up a “We Stand With Doctor Weiner” sign in their yard. But now, having looked at Nadine’s medical file, they wanted to know if they had been manipulated, if she was actually terminal. Citing confidentiality laws, St. Peter’s has refused to provide the family the review, nor would it confirm to me that a review exists.

Beadle and Long with their son, Levi, on the hillside behind their home in Marysville, Montana (Louise Johns, special to ProPublica)

In August, Jesse Laslovich, the U.S. attorney for the District of Montana, and St. Peter’s announced a $10.8 million settlement for numerous violations of the False Claims Act: billing for unnecessary treatments, prescribing unneeded narcotics and more. The settlement, Laslovich said, “is not an indictment on the quality of care being provided by St. Peter’s Health as well as their doctors and their providers.”

The same day it announced the settlement, the U.S. attorney’s office sued Weiner. It accused him of getting rich by prescribing needless treatments, double billing, seeing patients more frequently than necessary and “upcoding” — billing for more expensive treatments than were delivered. The prosecutor pointed to Weiner’s enormous caseload as evidence that he had little regard for patient outcomes. Weiner’s attorney denied the allegations and has filed a motion to dismiss the case.

After the hospital reported Weiner’s narcotics practice to the DEA, the agency investigated, according to Steffan Tubbs with its Rocky Mountain field division. He told me investigators brought a potential criminal case to the U.S. attorney’s office but that prosecutors instead decided to pursue civil penalties against Weiner. A spokesperson for the U.S. attorney declined to comment.

In a press release, St. Peter’s commended itself for “acting with integrity” for alerting the DEA and laid blame on a rogue doctor. In settling, the hospital acknowledged that Weiner falsely billed multiple federal health care programs. But it did not acknowledge that his billing practices had been a constant problem and an obvious outlier for at least a decade. The prosecutor was silent on Weiner’s billing practices with private insurance.

The Montana State Supreme Court has yet to issue a ruling on Weiner’s appeal. His defamation suit against Sasich continues.

Weiner’s Montana medical license was renewed in 2023 and is set to expire in March. For now, he is free to practice medicine and prescribe drugs.

Neither the settlement nor the lawsuit against Weiner focus on the harm he exacted on countless patients. It’s unclear if any state or federal law enforcement agencies are looking into Weiner’s trail of suspicious deaths. Counting Scot Warwick, Sharon Dibble, Nadine Long and the seven documented phenobarbital cases, there are at least 10.

How We Reported This Story

J. David McSwane obtained and reviewed thousands of pages of court documents and medical records. He also obtained text messages and work emails. He visited Helena, Montana, numerous times and interviewed dozens of former patients; current and former St. Peter’s Hospital staff members; Dr. Thomas Weiner and his supporters. He tracked Weiner’s years as director of the hospital’s Cancer Treatment Center and his practice by cross-referencing those records with witness accounts. He identified more than 100 cases in which St. Peter’s staff had expressed some level of concern. He met with the families of patients who died under Weiner’s care and, in several instances, obtained HIPAA waivers so that Weiner and the hospital could speak about those cases. To get some sense of the scope of Weiner’s practice, he and data reporter Haru Coryne analyzed data published by the Centers for Medicare and Medicaid Services; they looked at billing data in the Medicare Part B program and prescribing data in the Medicare Part D program from 2013 to 2020. They shared their analysis with a data expert and CMS, which did not respond to questions. Research reporter Mollie Simon helped McSwane identify Nadine Long and provided archival material.

Do You Have a Tip for ProPublica? Help Us Do Journalism.

Mollie Simon and Haru Coryne contributed research and data analysis. Additional design and development by Allen Tan and Zisiga Mukulu.

by Megan O’Matz and Joel Jacobs

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A new settlement that will end a payday-like loan operation in Minnesota puts additional pressure on a Native American tribe that has been on the defensive for its high borrowing rates across the country.

The Lac du Flambeau Band of Lake Superior Chippewa Indians has been telling customers that its practices are allowable, but that stance has become harder to maintain. Shortly before Thanksgiving, the Wisconsin tribe agreed to settle a civil suit filed by Minnesota Attorney General Keith Ellison alleging that LDF broke state law, which requires reasonable lending rates, by charging Minnesotans between 200% and 800% annual interest. The state also claimed LDF had violated statutes on consumer fraud, deceptive trade and false advertising.

In the consent decree, LDF’s top official denied the allegations but formally agreed to stop lending to people in Minnesota unless the tribe adheres to the state’s strict usury laws and other regulations, including licensing requirements.

Tribal Council President John Johnson Sr., the lone defendant in the case, also promised that the tribe’s lending arm would forgive all outstanding loans to Minnesotans, estimated to be worth more than $1 million. A judge must still approve the consent agreement.

“I will not allow Minnesotans to be exploited by predatory lenders,” Ellison said in a press release announcing the settlement.

Johnson did not return calls or emails seeking comment. He is board president of the LDF Business Development Corp., which runs a variety of tribal companies, including its lending operation.

Previously, Johnson has said LDF’s lending practices are transparent and its collection methods are fair and ethical. “In offering unsecured loans, we consciously embrace the risk involved, reflecting our commitment to aid those facing urgent financial needs,” Johnson said in an April email to ProPublica.

The move by Minnesota to cut off lending companies controlled by LDF comes shortly after ProPublica reported extensively in August and September on LDF’s loan operations, finding that over the past decade, the tribe has grown to become one of the leading players in the tribal lending industry. Its loans contribute to the debt people shoulder throughout the country. A ProPublica analysis found companies owned by the LDF tribe showed up as a creditor in roughly 1 out of every 100 bankruptcy cases sampled nationwide.

The Minnesota attorney general’s office reported in its federal court filing that the state had received many consumer complaints about LDF Holdings, the tribe’s lending arm, that described extreme hardship caused by “continuing demands for payment of excessive interest.”

It gave the example of a Burnsville resident who took out a $1,398 loan from the LDF company Lendumo in December 2023 at an annual percentage rate of 795%. The loan snowballed to $8,593.

After Minnesota authorities reached out to LDF on behalf of the borrower, LDF argued that the loan was legal and not subject to state law, but Lendumo resolved the complaint “as a courtesy” — though not before demanding an additional $389, court records state.

“These are the highest, most nefarious APRs that we see,” said Anne Leland Clark, executive director of Exodus Lending, a nonprofit in Minnesota that refinances payday loans for borrowers using tax dollars and private donations. About a quarter of the loans they have refinanced since 2015 are tribal loans, she said.

This summer, in a class-action lawsuit out of Virginia, tribal council leaders agreed to a landmark settlement that cancels $1.4 billion in outstanding loans nationwide and provides $37.4 million in restitution and attorney fees. LDF officials will pay $2 million of that, while the remainder is to be paid by nontribal partners involved in five of the tribe’s lending firms. A final approval hearing is scheduled for Dec. 13.

Despite the national settlement and the action in Minnesota, Johnson has not signaled that the tribe will exit the lucrative lending business or alter its practices. ProPublica previously determined that LDF entered the loan business in 2012 and set up at least two dozen lending companies and websites, some of which remain active today.

LDF works with outside firms to operate businesses offering short-term installment loans. Unlike traditional payday loans, these are not due by the next pay period; typically, they are repaid over months in installments via automatic bank deductions.

One defunct website associated with LDF, Lendgreen, was the subject of a 2023 U.S. Supreme Court ruling that held that tribes must abide by the U.S. Bankruptcy Code, including provisions protecting debtors from continued collection efforts and harassment during the restructuring process.

Only a few dozen of the country’s 574 federally recognized tribes engage in online lending. Those that do often see it as an economic boon for their community, bringing in much-needed revenue for tribal government operations, which have limited options for expansion in their often-remote areas of the country.

LDF grew its footprint, ProPublica found, by partnering with multiple outside managers and financiers. Revenue data is not public, but historically, in the tribal lending model of payday lending, these outsiders have taken the lion’s share of the profits, according to lawsuits.

Lac du Flambeau Tribal President John Johnson Sr., the lone defendant in Minnesota’s suit over the tribe’s lending practices (Angela Major/WPR)

In a prior email to ProPublica, Johnson described LDF’s lending operation as an engine for community improvement. “The importance of our business extends far beyond simple economics; it is interwoven with the very fabric of our community, supporting a myriad of vital services,” Johnson wrote.

LDF and other tribal lenders contend that they are able to offer loans at exorbitant rates because of Native American tribes’ sovereign rights and immunities.

LDF’s loan documents have included provisions waiving Minnesota law, according to the state’s lawsuit, and improperly limited consumers’ rights to challenge repayment demands, falsely claiming Minnesota law doesn’t apply because of sovereign immunity.

The attorney general’s office also cited a letter from LDF Holdings to a borrower that stated: “the loan is not subject to state law and the [LDF lender] is not required to be licensed with any state. Your loan is legal.”

The tribe has stressed that it follows tribal law and federal law, which has no interest rate cap except for active-duty military members and their families.

States are not powerless, however, to address the issue.

Courts have ruled that while states cannot pursue tribes for monetary damages, they can sue the executives in charge and obtain injunctions stopping future harm.

“The truth is that out-of-state businesses and businesses incorporated under the laws of other sovereigns must comply with Minnesota law when transacting business in Minnesota,” Ellison wrote.

The LDF settlement is the second enforcement action by Ellison directed at tribal lenders operating in Minnesota.

In February, his office obtained a settlement agreement with top lending executives of the Fort Belknap Indian Community in Montana. It, too, bars the tribe — which denied any wrongdoing — from making future loans in Minnesota. Calling itself an industry leader, the Fort Belknap operation revealed in an annual report that it had processed more than 300,000 loans nationwide in 2021. The tribe’s economic development arm, which legal filings show gets most of its revenue from lending, reported more than $180 million in revenue that year.

In an interview with ProPublica in March, Ellison said other states with strong usury laws could follow Minnesota’s lead. “I hope other states do look at what we did and take note.” He declined to be interviewed for this story.

Minnesota strengthened its usury laws with legislation that took effect in January 2024 governing small-dollar loans. It eliminated a sliding scale of set fees and imposed a stricter APR cap: 36% in many instances, but 50% for licensed lenders that conduct an analysis on whether a borrower can repay.

Johnson told the attorney general’s office that the tribe had stopped originating new loans to Minnesotans as of Dec. 31, 2023, a day before the law took effect, according to the consent decree.

by Jeremy Kohler

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

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.”

by Lomi Kriel and Jessica Priest

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This article is co-published with The Texas Tribune, a nonprofit, nonpartisan local newsroom that informs and engages with Texans. Sign up for The Brief Weekly to get up to speed on their essential coverage of Texas issues.

Texas leaders have shown a decadeslong antipathy toward Medicaid, the federal-state health insurance program that covers millions of low-income and vulnerable residents.

They declined additional federal money that, under the Affordable Care Act, would have allowed Medicaid to offer health care coverage to more low-income families. The state was among the last to insure women for an entire year after they gave birth. And when the federal government last year ended a policy that required states to keep people on their Medicaid rolls during the coronavirus pandemic, Texas officials rushed to kick off those they deemed ineligible, ignoring persistent warnings that the speedy process could lead to some people being wrongfully removed.

Come January, when Donald Trump assumes the presidency for the second time, Texas leaders could get another opportunity to whittle down the program — this time with fewer constraints.

Trump has not shared any plans to cut Medicaid, which covers about 80 million Americans, and his campaign did not respond to requests for comment. Health care advocates and experts, however, say that his past efforts to scale back the program, as well as positions taken by conservative groups and Republican lawmakers who back him, indicate that it would likely be a target for severe reductions.

“We expect the Republicans to move very quickly to cut Medicaid dramatically and indeed end its guarantee of coverage as it exists today,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families in Washington, D.C.

Currently, the federal government picks up, on average, nearly 70% of Medicaid spending, with states assuming the remaining costs. (A state’s share varies based mostly on what percentage of its residents are impoverished.) Any decisions to cut federal spending would likely lead states to shrink the number of people they deem eligible and the care that enrollees are entitled to receive, Alker and other experts said.

That would be particularly devastating in Texas, which already has one of the country’s lowest percentages of residents covered through Medicaid and where officials lack the political will to make up the difference in funding with state money, experts say. Parents with two children, for example, must earn less than $285 monthly to qualify for Medicaid for themselves.

“Our elected officials would have to decide whether they want to cut health care for pregnant women, kids, people with disabilities, or seniors because that is essentially who Medicaid covers in Texas,” Adriana Kohler, a policy director for Texans Care for Children, a statewide nonprofit that advocates for families, said in a statement.

Spokespeople for Gov. Greg Abbott, a Republican, and the state’s Health and Human Services Commission did not respond to repeated requests for comment. During Abbott’s prior role as the state’s attorney general, he helped to lead a successful lawsuit against the federal government, ensuring that states did not risk losing Medicaid funding entirely if they didn’t want to cover more residents as part of the Affordable Care Act.

Even when Texas does offer Medicaid coverage to its most vulnerable residents, state officials enabled a system that creates often insurmountable barriers to receiving care. A 2018 Dallas Morning News investigation found that some of the insurance companies Texas hired to administer Medicaid benefits systematically denied expensive and, at times, life-saving treatments to bolster profits. Critics say problems with the system persist despite legislative reforms spurred by that series of stories.

Texas insures more than 4 million residents through Medicaid, which amounts to a smaller percentage of its total population than almost any other state. But given its sheer size, the state still covers the third most people in the nation, behind only California and New York. The program provides health care for 3 in 8 children, 3 in 5 nursing home residents and 2 in 7 people with disabilities in Texas, according to KFF, a national health policy research organization. It is the top funder for nursing homes and long-term care services for the disabled and elderly, and it pays for nearly half of all births in the state.

Michael Morgan, a 75-year-old retired nurse who lives in Fort Worth, is among those who worry that if Trump caps or cuts the amount of money the federal government spends on Medicaid, the state could make it even harder to get coverage for his daughter Hannah. She has Down syndrome and schizencephaly, a brain malformation, and she is deaf and partially blind, she doesn’t speak, and she needs assistance to walk and eat.

Morgan is depleting his limited savings to pay for Hannah’s health care expenses after she lost Medicaid coverage earlier this year when she turned 19. He submitted a new application for her in May — she should qualify for Medicaid because of her disabilities. State officials denied her coverage in November, arguing that Morgan did not meet the deadline to return a form providing his consent for the agency to access his daughter’s medical and financial records. Morgan, who plans to appeal the denial, said in an interview that he received the form a day before the deadline.

“I don’t know how much more they can cut it,” he said of Medicaid in Texas.

During his first term, Trump tried unsuccessfully to repeal the Affordable Care Act, which provides health coverage to 45 million Americans. His administration also repeatedly supported spending caps for Medicaid, including block grants that would give states a fixed amount of federal funding, no matter how many people needed the insurance or how much their health care cost. Currently, Medicaid covers all people who qualify, no matter the expense.

While those efforts did not significantly advance during Trump’s first term, Republicans will hold majorities in both the House and the Senate come January, and they have signaled an openness to impose caps on spending and establish requirements that most adults in the program hold jobs. They argue that Medicaid spending is unsustainable and that the program is susceptible to waste, fraud and abuse.

Republicans who have supported such measures include U.S. Sen. John Cornyn and U.S. Rep. Jodey Arrington, a Lubbock Republican who leads the House Budget Committee.

GOP policy primers — including Project 2025, published by the conservative think tank The Heritage Foundation, and one from the Republican Study Committee, a conservative congressional caucus — have also called for cutting Medicaid.

Arrington, whose spokespeople did not respond to repeated requests for an interview, told reporters last month that he supported a “responsible and reasonable work requirement.” Harvard University health professors who studied a previous work mandate in Arkansas that Trump allowed during his first term found that most adults using Medicaid were already employed or qualified for an exemption, but thousands of residents still lost health care, at least in part because of the onerous process of continuously proving their eligibility.

This is not the first time Arrington has pushed work requirements and sought to lower the share of health care costs that the federal government pays to states. He previously proposed cutting federal Medicaid spending by more than a quarter, or $1.9 trillion.

Cornyn, whose spokespeople also repeatedly declined to comment, said last month that he would not support cuts to Medicare, the federal health insurance program for seniors and the disabled, or to Social Security. Still, he suggested that Medicaid cuts were on the table.

“We can’t just keep doing things the way we’ve been doing them,” Cornyn told Politico Pro, adding that “block grants make a lot of sense.”

William T. Smith, a 65-year-old retired construction worker who lives along the U.S.-Mexico border in Brownsville, said that he voted for Trump partly because he agrees that “there’s too much fat” and supports cutting some federal programs.

Smith has chronic obstructive pulmonary disease, which affects his lungs and makes it difficult to breathe. He said he also has bipolar disorder, sleep apnea and chronic pain after decades of performing manual labor.

Smith said Medicaid, which he has been trying to get since the summer, should not be where the federal government looks to reduce expenses. Instead, he said, the federal government should take savings from cutting other programs and put the money toward more people’s care.

“I don’t think they’re going to yank health care away from people,” he said. “If they do, I’d be really angry.”

Caught in Texas’ Medicaid and Food Stamp Application Backlog? Know Someone Who Is? Help Us Report.

Dan Keemahill contributed reporting.

by Al Shaw and Sharon Lerner

Formaldehyde causes more cancer than any other toxic chemical in the air. It’s emitted from cars, trucks, planes, industrial facilities and many other sources. It’s also formed in the atmosphere when other chemicals combine in the presence of sunlight. Even if you don’t live in a high-traffic area or an industrial zone, the geography and climate of your area could increase your cancer risk from formaldehyde because of this so-called “secondary formation.”

ProPublica is releasing a lookup tool that allows anyone in the country to understand their outdoor risk from formaldehyde. Search for your address to see risks from the chemical on your block and where it comes from.

by Sharon Lerner and Al Shaw

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

In a world flush with hazardous air pollutants, there is one that causes far more cancer than any other, one that is so widespread that nobody in the United States is safe from it.

It is a chemical so pervasive that a new analysis by ProPublica found it exposes everyone to elevated risks of developing cancer no matter where they live. And perhaps most worrisome, it often poses the greatest risk in the one place people feel safest: inside their homes.

As the backbone of American commerce, formaldehyde is a workhorse in major sectors of the economy, preserving bodies in funeral homes, binding particleboards in furniture and serving as a building block in plastic. The risk isn’t just to the workers using it; formaldehyde threatens everyone as it pollutes the air we all breathe and leaks from products long after they enter our homes. It is virtually everywhere.

Federal regulators have known for more than four decades that formaldehyde is toxic, but their attempts to limit the chemical have been repeatedly thwarted by the many companies that rely on it.

This year, the Biden administration finally appeared to make some progress. The Environmental Protection Agency is expected to take a step later this month toward creating new rules that could restrict formaldehyde.

But the agency responsible for protecting the public from the harms of chemicals has significantly underestimated the dangers posed by formaldehyde, a ProPublica investigation has found.

Formaldehyde threatens everyone as it pollutes the air we all breathe and leaks from products long after they enter our homes. It is virtually everywhere.

The EPA is moving ahead after setting aside some of its own scientists’ conclusions about how likely the chemical is to cause myeloid leukemia, a potentially fatal blood cancer that strikes an estimated 29,000 people in the U.S. each year. The result is that even the EPA’s alarming estimates of cancer risk vastly underestimate — by as much as fourfold — the chances of formaldehyde causing cancer.

The agency said it made the decision because its estimate for myeloid leukemia was “too uncertain” to include. The EPA noted that the National Academies of Sciences, Engineering and Medicine, which the agency paid to review its report, agreed with its decision not to include myeloid leukemia in its cancer risk. But four former government scientists with experience doing statistical analyses of health harms told ProPublica that the myeloid leukemia risk calculation was sound. One said the risk was even greater than the agency’s estimate.

Jennifer Jinot, one of the EPA scientists who spent years calculating the leukemia risk, said there is always uncertainty around estimates of the health effects of chemicals. The real problem, she said, was cowardice.

“In the end, they chickened out,” said Jinot, who retired in 2017 after 26 years working at the EPA. “It was kind of heartbreaking.”

The EPA has also retreated from some of its own findings on the other health effects of formaldehyde, which include asthma in both children and adults; other respiratory ailments, including reduced lung function; and reproductive harms, such as miscarriages and fertility problems. In a draft report expected to be finalized this month, the agency identified many instances in which formaldehyde posed a health threat to the public but questioned whether most of those rose to a level the agency needed to address. In response to questions from ProPublica, the EPA wrote in an email that the report was not final and that the agency was in the process of updating it.

Even the EPA’s alarming estimates of cancer risk vastly underestimate — by as much as fourfold — the chances of formaldehyde causing cancer.

Still, if the past is any guide, even the limited efforts of President Joe Biden’s administration are all but guaranteed to hit a dead end after Donald Trump is inaugurated. And one of the longest-running attempts to restrict a dangerous chemical in American history would be set back yet again.

ProPublica reporters have spent months investigating formaldehyde, its sweeping dangers and the government’s long, frustrating battle to curb how much of it we breathe.

They have analyzed federal air pollution data from each of the nation’s 5.8 million populated census blocks and done their own testing in homes, cars and neighborhood businesses. They have interviewed more than 50 experts and pored through thousands of pages of scientific studies and EPA records. They’ve also reviewed the actions of the previous Trump administration and what’s been disclosed about the next.

The conclusion: The public health risks from formaldehyde are greater and more prevalent than widely understood — and any hope of fully addressing them may well be doomed, at least for the foreseeable future.

Since its inception, the EPA has been outgunned by the profitable chemical industry, whose experts create relatively rosy narratives about their products. That battle intensified over the last four years as the EPA tried to evaluate the scope of the public health threat posed by formaldehyde.

Regulatory rules put the onus on the government to prove a chemical is harmful rather than on industry to prove its products are safe. Regardless of who is in the White House, the EPA has staff members with deep ties to chemical companies. During some administrations, it is run by industry insiders, who often cycle between jobs in the private sector and the government.

If the past is any guide, even the limited efforts of President Joe Biden’s administration are all but guaranteed to hit a dead end after Donald Trump is inaugurated.

Trump has already vowed to roll back regulations he views as anti-business — an approach that promises to upend the work of government far beyond formaldehyde protections. Still, this one chemical makes clear the potential human toll of crafting rules to serve commerce rather than public health. And Trump’s last term as president shows how quickly and completely the efforts now underway might be stopped.

At the EPA, he appointed a key figure from the chemical industry who had previously defended formaldehyde. The agency then quietly shelved a report on the chemical’s toxicity. It refused to enforce limits on formaldehyde released from wood products until a judge forced its hand. And it was under Trump that the agency first decided not to include its estimate of the risk of developing myeloid leukemia in formaldehyde’s overall cancer risk calculation, weakening the agency’s ability to protect people from the disease.

The latest efforts to address formaldehyde pollution are likely to meet a similar fate, according to William Boyd, a professor at UCLA School of Law who specializes in environmental governance. Boyd has described formaldehyde as a sort of poster child for the EPA’s inability to regulate chemicals. Because formaldehyde is key to so many lucrative industrial processes, companies that make and use it have spent lavishly on questioning and delaying government efforts to rein it in.

“The Biden administration was finally bringing some closure to that process,” said Boyd. “But we have every reason to suspect that those efforts will now be revised. And it will likely take years for the EPA to do anything on this.”

Invisible Threat

Perhaps best known for preserving dead frogs in high school biology labs, formaldehyde is as ubiquitous in industry as salt is in cooking. Between 1 billion and 5 billion pounds are manufactured in the U.S. each year, according to EPA data from 2019.

Outdoor air is often suffused with formaldehyde gas from cars, smoke, factories, and oil and gas extraction, sometimes at worrying levels that are predicted to worsen with climate change. Much of the formaldehyde outdoors is also spontaneously formed from other pollutants.

The public health risks from formaldehyde are greater and more prevalent than widely understood — and any hope of fully addressing them may well be doomed, at least for the foreseeable future.

Invisible to the eye, the gas increases the chances of getting cancer — severely in some parts of the country.

This year, the EPA released its most sophisticated estimate of the chance of developing cancer as a result of exposure to chemicals in outdoor air in every populated census block across the United States. The agency’s sprawling assessment shows that, among scores of individual air pollutants, formaldehyde poses the greatest cancer risk — by far.

But ProPublica’s analysis of that same data showed something far more concerning: It isn’t just that formaldehyde poses the greatest risk. It’s that its risk far exceeds the agency’s own goals, sometimes by significant amounts.

ProPublica found that, in every census block, the risk of getting cancer from exposure to formaldehyde in outdoor air over a lifetime is higher than the limit of one incidence of cancer in a million people, the agency’s goal for air pollutants. That risk level means that if a million people in an area are continuously exposed to formaldehyde over 70 years, the chemical would cause at most one case of cancer, on top of those from other risks people already face.

According to ProPublica’s analysis of the EPA’s 2020 AirToxScreen data, some 320 million people live in areas of the U.S. where the lifetime cancer risk from outdoor exposure to formaldehyde is 10 times higher than the agency’s ideal.

(ProPublica is releasing a lookup tool that allows anyone in the country to understand their outdoor risk from formaldehyde.)

Trump has already vowed to roll back regulations he views as anti-business — an approach that promises to upend the work of government far beyond formaldehyde protections.

In the Los Angeles/San Bernardino, California, area alone, some 7.2 million people are exposed to formaldehyde at a cancer risk level more than 20 times higher than the EPA’s goal. In an industrial area east of downtown Los Angeles that is home to several warehouses, the lifetime cancer risk from air pollution is 80 times higher, most of it stemming from formaldehyde.

Even those alarming figures underestimate the true danger. As the EPA admits, its cancer risk calculation fails to reflect the chances of developing myeloid leukemia. If it had used its own scientists’ calculation — “the best estimate currently available,” according to the agency’s August report — the threat of the chemical would be shown to be far more severe. Instead of causing 20 cancer cases for every million people in the U.S., formaldehyde would be shown to cause approximately 77.

Using the higher figure to set regulations of the chemical could eventually help prevent thousands of cases of myeloid leukemia, according to ProPublica’s analysis.

As Mary Faltas knows, the diagnosis can upend a life.

Faltas, 60, is still sorting through the aftermath of having myeloid leukemia, which she developed in 2019. “It’s like having a storm come through,” she said recently. “It’s gone, but now you’re left with everything else to deal with.”

It wasn’t always clear she’d survive. There are two types of myeloid leukemia. Faltas had the more deadly acute form and spent a year and a half undergoing chemotherapy, fighting life-threatening infections and receiving a bone marrow transplant. Too sick to work, she lost her job as a dental assistant. She and her husband were forced to sell their house in Apopka, Florida, and downsize to a small condo — a move that took place when she was too weak to pack a box.

It’s almost always impossible to pinpoint a single cause for someone’s cancer. But Faltas has spent her entire life in places where the EPA’s data shows there is a cancer risk 30 times the level the agency says it strives to meet. And in that way, she’s typical. Nationwide, that’s the average lifetime cancer risk from air pollution; formaldehyde accounts for most of it. Factor in the EPA’s myeloid leukemia calculation, and Faltas has lived in places where cancer risk from formaldehyde alone is 50 to 70 times the agency’s goal.

According to ProPublica’s analysis of the EPA’s 2020 AirToxScreen data, some 320 million people live in areas of the U.S. where the lifetime cancer risk from outdoor exposure to formaldehyde is 10 times higher than the agency’s ideal.

Layered on top of the outdoor risk we all face is the much more considerable threat indoors — posed by formaldehyde in furniture, flooring, printer ink and dozens of other products. The typical home has a formaldehyde level more than three times higher than the one the EPA says would protect people against respiratory symptoms. The agency said it came up with its recommended level to protect sensitive subgroups and that the potential for health effects just above it are “unknown.”

The EPA’s own calculations show that formaldehyde exposure in those homes would cause as many as 255 cancer cases in every million people exposed over their lifetimes — and that doesn’t reflect the risk of myeloid leukemia. The agency also said “there may not be a feasible way currently to reduce the average indoor level of formaldehyde to a point where there is no or almost no potential risk.”

ProPublica will delve more into indoor risks, and how to guard against them, in the coming days.

The Long Road to Nowhere

The fruitless attempts to limit public exposure to formaldehyde stretch back to the early ’80s, soon after the chemical was shown to cause cancer in rats.

The typical home has a formaldehyde level more than three times higher than the one the EPA says would protect people against respiratory symptoms.

The EPA planned to take swift action to reduce the risks from formaldehyde, but an appointee of President Ronald Reagan named John Todhunter stopped the effort. He argued that formaldehyde didn’t pose a significant risk to people. A House investigation later revealed he had met with chemical industry representatives, including a lobbyist from the Formaldehyde Institute, just before making his decision. Todhunter denied being influenced but resigned under pressure.

In 1991, under President George H.W. Bush, the EPA finally deemed formaldehyde a probable human carcinogen and calculated the likelihood of it causing an extremely rare cancer that affects a part of the throat called the nasopharynx. But it quickly became clear that more protection was needed.

A 2003 study showed that factory workers exposed to high levels of formaldehyde were 3 1/2 times more likely to develop myeloid leukemia than workers exposed to low levels of the chemical. “Having human data showing an effect like that … it’s a rare thing,” said Jinot, the former EPA statistician and toxicologist. “You want to seize that opportunity.”

She and colleagues at the agency crunched numbers, immersed themselves in the medical literature and consulted with other scientists to conclude that formaldehyde was a known carcinogen and caused myeloid leukemia, among other cancers.

But in 2004, their work hit a roadblock. Sen. James Inhofe, R-Okla., persuaded the EPA to delay the update of its formaldehyde report until the National Cancer Institute released the results of a study that was underway.

The harms, meanwhile, continued to mount. In 2006, people who lost their homes in Hurricane Katrina and were housed in government trailers began to report feeling sick. The symptoms, which included breathing difficulties, eye irritation and nosebleeds, were traced to high levels of formaldehyde.

In 2006, people who lost their homes in Hurricane Katrina and were housed in government trailers began to report feeling sick. The symptoms, which included breathing difficulties, eye irritation and nosebleeds, were traced to high levels of formaldehyde.

In 2009, under the Obama administration, the EPA was once again poised to release its report on the toxicity of formaldehyde. By then, the National Cancer Institute’s study had been published, making the link between formaldehyde and myeloid leukemia even clearer.

This time, another U.S. senator intervened. David Vitter, R-La., who had received donations from chemical companies and a formaldehyde lobbyist, held up the confirmation of an EPA nominee. He agreed to approve the nomination in exchange for an additional review of the formaldehyde report by a panel of the National Academies of Sciences, Engineering and Medicine.

The outside review found “problems with clarity and transparency of the methods” used in the EPA report and recommended that, in its next version, the EPA employ “vigorous editing” and explain its arguments more clearly.

But the EPA would not issue that next version for more than a decade. After the outside review, the chemical industry seized on its findings as evidence of fundamental problems at the agency. For years afterward, the EPA’s release of chemical assessments — and its work on the formaldehyde assessment — slowed. “They became completely cowardly,” Jinot said. “They were shell-shocked and retreated.”

As the EPA went about revising its report, it fell behind others around the world in recognizing that formaldehyde causes cancer. The World Health Organization’s arm that researches cancer had already concluded in 2006 that the chemical is a carcinogen. Five years later, scientists with the Department of Health and Human Services found that formaldehyde causes cancer, citing studies linking it to myeloid leukemia.

Between 2011 and 2017, the Foundation for Chemistry Research and Initiatives, which had been created by an industry trade group, funded 20 studies of the chemical. The research presented formaldehyde as relatively innocuous. The industry trade group still disputes the mainstream science, insisting that “the weight of scientific evidence” shows that formaldehyde does not cause myeloid leukemia.

The trade group’s panel on formaldehyde also complained that regulation would be devastating for business. The argument was undercut by one of the few limits the EPA did manage to put in place.

In 2016, the EPA issued a rule limiting the release of formaldehyde from certain wood products sold in the U.S. Under Trump, the agency did not implement the rule until a court ordered it to in 2018.

The World Health Organization’s arm that researches cancer had already concluded in 2006 that the chemical is a carcinogen.

But once the regulation was in effect, many companies complied with it. Necessity bred invention, and furniture and wood products makers found glues and binders with no added formaldehyde.

Still, under Trump, the EPA refused to move forward with other efforts that had been underway to tighten regulations of formaldehyde. When he assumed office, the agency was yet again preparing to publish the toxicity report that Jinot had been working on.

One of the new Trump appointments to the EPA was David Dunlap, a chemical engineer who, as the director of environmental regulatory affairs for Koch Industries, had tried to persuade the EPA that formaldehyde doesn’t cause leukemia. Koch’s subsidiary, Georgia-Pacific, made formaldehyde and many products that emit it. (Georgia-Pacific has since sold its chemicals business to Bakelite Synthetics.) At the EPA, Dunlap had authority over the division where Jinot and other scientists were working on the toxicity report.

Ethics rules require federal employees not to participate in matters affecting former clients for two years. Dunlap complied with the law, recusing himself in 2018 from work on formaldehyde, but only after taking part in internal agency discussions about its health effects. He signed his recusal paperwork the same day the EPA killed the toxicity report. Dunlap did not respond to requests for comment.

Imperfect Progress, Inevitable Disruption

This August, the Biden EPA finally managed to carry that report across the finish line, getting it reviewed by other agencies and the White House. For the first time, it also set a threshold to protect people from breathing difficulties caused by formaldehyde, such as increased asthma symptoms and reduced lung function.

In a draft of another key report on formaldehyde released this year, the EPA found that levels of the chemical were high enough to potentially trigger health problems in dozens of scenarios, including workers using lawn and garden products and consumers who might inhale the chemical as it wafts from cleaners, foam seating and flooring. But the agency is required to address risks only if they are deemed “unreasonable.” For many of those risks, the EPA said it wasn’t certain they were unreasonable.

The EPA made the decision after employing a variety of unusual scientific strategies. One involved outdoor air. The EPA first estimated the amount of formaldehyde in the air near some of the country’s biggest polluters. To determine whether those amounts posed an unreasonable risk of harm, the agency compared them to a specific benchmark — the highest concentration of formaldehyde measured by government monitors in outdoor air between 2015 and 2020. EPA records show that peak level was recorded in 2018 in Fontana, California, about 50 miles east of Los Angeles. The EPA concluded the levels near polluting factories would not be unreasonable if they were below this record high, even though local scientists had noted that the Fontana reading didn’t meet their quality control standards, according to documents obtained by ProPublica. Local air quality officials said they didn’t know what caused the temporary spike in the level of formaldehyde near the Fontana monitor.

The fact that an air monitor in Fontana once registered a fluke reading that dwarfs the level of formaldehyde in the air near her home is of little comfort to Rocky Rissler.

A retired teacher, Rissler shares her home in Weld County, Colorado, with her husband, Rick, two horses, one dog and 12 highland cows; she calls it the “Ain’t Right Ranch” — a name that feels increasingly fitting as the number of oil and gas facilities near her home has ballooned in recent years.

The rural area is one of hundreds around the country — many of them in Colorado, New Mexico, North Dakota and West Virginia — where the formaldehyde risk is elevated because of oil and gas production. Gusts of nausea-inducing pollution have become so frequent that Rissler now carries a peppermint spray with her at all times to ease the discomfort. She has frequent headaches, and her asthma has worsened to the point where she’s been hospitalized three times in recent years.

During the past four years, no fewer than 75 trade groups have pushed back against the EPA’s findings.

Rissler, who is 60 but says she feels “closer to 99,” has also been diagnosed with chronic bronchitis and chronic obstructive pulmonary disease, or COPD — conditions that have been linked to formaldehyde exposure. Just walking up the slight hill from her horse barn to her front door can leave her winded.

“It feels like a gorilla is sitting on my chest,” she said. And while she used to jog in her youth, “these days, I’m only running if there’s a bear chasing me.”

Under Biden, EPA scientists have been sharply divided over how to gauge all the dangers of formaldehyde. Some employees throughout the agency have been working to strengthen the final health assessment expected later this month. But they are fighting against immense outside pressure.

During the past four years, no fewer than 75 trade groups have pushed back against the EPA’s findings. Among them are the Fertilizer Institute, the Golf Course Superintendents Association of America, the Toy Association, the National Chicken Council, the Asphalt Roofing Manufacturers Association, the Independent Lubricant Manufacturers Association, the RV Industry Association, the Halogenated Solvents Industry Alliance and the American Chemistry Council, which represents more than 190 companies and led the charge. Meanwhile, scientists with ties to the industry are pushing the EPA to abandon its own toxicity calculations and use theirs instead — a move that could seriously weaken future limits on the chemical.

Despite campaign assurances that he wants “really clean water, really clean air,” Trump is expected to eviscerate dozens of environmental protections, including many that limit pollution in water and air.

“I’ve seen the industry engage on lots of different risk assessments,” said Tracey Woodruff, a professor and director of the Program on Reproductive Health and the Environment at the University of California, San Francisco. “This one feels next level.”

An EPA spokesperson wrote in an email that the agency’s draft risk evaluation of formaldehyde was “based purely on the best available science.”

The industry’s fortunes have now shifted with Trump’s election.

Despite campaign assurances that he wants “really clean water, really clean air,” Trump is expected to eviscerate dozens of environmental protections, including many that limit pollution in water and air. He will have support from a Republican Congress, where some have long wanted to rewrite environmental laws, including the one regulating chemicals.

Trump has already laid out a plan to require federal agencies to cut 10 rules for every one they introduce, a far more aggressive approach than he took during his last time in the White House, when he rolled back more than 100 environmental rules. And his transition team has floated the idea of relocating the EPA headquarters, a move that would surely cause massive reductions in staff.

According to regulatory experts consulted by ProPublica, the incoming administration could directly interfere with the ongoing review of formaldehyde in several ways. The EPA could simply change its reports on the chemical’s health effects.

“They can just say they’re reopening the risk assessment and take another look at it. There may be some legal hurdles to overcome, but they can certainly try,” said Robert Sussman, an attorney who represents environmental groups and served in the EPA under Presidents Bill Clinton and Barack Obama.

Project 2025, the conservative playbook organized by the Heritage Foundation, calls for the EPA’s structure and mission to be “greatly circumscribed.” Its chapter on the agency specifically recommends the elimination of the division that evaluated the toxicity of formaldehyde and hundreds of other chemicals over the past three decades. Project 2025 also aims to take away funding for research on the health effects of toxic chemicals and open the EPA to industry-funded science.

Trump distanced himself from Project 2025, saying, “I don’t know what the hell it is.” But after the election, some of his surrogates have openly embraced the document, and Trump picked an architect of the conservative plan to fill a key cabinet post.

Last month, Trump announced he had chosen former U.S. Rep. Lee Zeldin of New York to head the EPA. Zeldin could not be reached for comment, and the Trump transition team did not respond to questions about formaldehyde. In his announcement, Trump said Zeldin would deliver deregulatory decisions “to unleash the power of American businesses.”

“The election of Trump is a dream for people who want to deregulate all chemicals,” said Woodruff, the University of California, San Francisco, professor. “We are going to continue to see people get sick and die from this chemical.”

Do You Work for the Federal Government? ProPublica Wants to Hear From You.

Kirsten Berg contributed research.

by Audrey Dutton

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

A string of suspicious deaths. Two cases of infanticide that were nearly labeled as sudden infant death syndrome. A curiously low rate of opioid overdose deaths. These are among the red flags Idahoans have pointed to over the decades as they tried to get those in power to change Idaho’s system for death investigation, which relies on elected county coroners with virtually no state support or oversight.

Lawmakers have come close a few times to instituting reforms. But every attempt has failed. Often, the reason is simple, current and former coroners and national experts told ProPublica in recent months: Nobody wants to spend money on death.

But that leaves Idaho with a system where one coroner can choose not to follow national standards while a neighboring county’s coroner does.

Calls for reform to Idaho’s system have popped up nearly every decade since at least the 1950s. Some of the earliest pleas for change came from local physicians and state health officials, alarmed by Idaho’s refusal to modernize its approach to death investigations.

November 1951

The Idaho Statesman highlighted a national magazine article that called Idaho “the best place in the nation for a criminal to ‘get away with murder’ in the literal sense” because the state exemplified “how an antiquated county coroner’s system can contribute to frequent miscarriages of justice.”

(Idaho Statesman. Highlighted by ProPublica.) March 1959

A doctor who’d served as coroner of Idaho’s largest county resigned, citing “antiquated and totally inadequate” state law. He said legislators that year declined to introduce a bill that was “a middle of the road endeavor between the abysmal inadequacy of existing law and a central state medical examiners system.”

September 1965

Dr. T. O. Carver, state health administrator at the time, told The Associated Press, “I think ... if someone wanted to commit a homicide without having it discovered, Idaho would be a good place to do it.” Carver praised Oregon’s medical examiner system and said changing Idaho to a similar setup would cost more, but it would yield evidence and truth.

(Sandpoint News-Bulletin via Bonner County Daily Bee. Highlighted by ProPublica.) October 1965

The director of Idaho’s vital records bureau raised alarm about the qualifications of coroners, the state’s autopsy rate and “questionable” death investigations. The director said coroners handled 600 to 700 deaths in Idaho each year, and 10% or less had autopsies.

Fall of 1976

A hospital pathologist in rural Idaho called for replacing the state’s “archaic” coroner system with a medical examiner’s office. “Idaho is one state where it would be very easy to commit murder and go undetected,” he said, according to news archives. “With a little intelligence and care, no one would ever know it happened under the present coroner system in our counties.”

(Times-News. Highlighted by ProPublica.) March 1997

Following a string of suspicious deaths, the Idaho Statesman again urged reform in an editorial: “Idaho must recognize that the elected coroner system can take it only so far,” the writers said. “Idaho residents need protection. They need coroners, pathologists and medical examiners who can work with law enforcement” to catch criminals.

(Idaho Statesman. Highlighted by ProPublica.) December 1998

The Post Register in eastern Idaho produced a series on child deaths that found a dearth of autopsies, including two cases of infanticide that were almost attributed to SIDS. In the five years that followed, legislators mulled coroner reform bills but didn’t pass any. A county prosecutor told the paper, “It’s not working in the late twentieth century, it’s not going to work in the twenty-first century.”

January 2006

Ten years after her son’s death was ruled a suicide without an autopsy, a Boise woman who became an advocate wrote in the Idaho Statesman, “Legislators must take a fresh look at laws governing the coroner system in Idaho.”

February 2019

A former state senator, family physician and county coroner wrote in his blog that Idaho was “quite likely” underreporting opioid overdose deaths, partly because coroners weren’t detecting and reporting them. “Ever since I was the Latah County Coroner for 15 years I have wondered about the wisdom of the county coroner system for the state of Idaho,” Dan Schmidt wrote. “To all the County Coroners, ask yourselves, are you happy with the system you have for investigating deaths? Are you doing a good job? Are there ways this could be done better?”

by Audrey Dutton

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

Idaho has known for at least 73 years that its frontier-era coroner system does not work. For just as long, the state has failed to make meaningful changes to it.

In a review of legislative records and news archives going back to 1951, ProPublica found a pattern — repeating almost every decade — of reform-minded legislators, trade groups, members of the public, doctors, lawyers and even some coroners pushing to change how Idaho handles death investigations.

ProPublica reported last month how a coroner in eastern Idaho didn’t follow national standards to figure out why 2-month-old Onyxx Cooley died in his sleep last winter. As the coroner would later tell ProPublica, Idaho law says nothing about following any standards. The law provides no oversight, no state medical examiner and no other resources to ensure each county has adequate access to autopsies.

Almost unchanged since the late 1800s, the law does little more than say Idaho’s coroners are responsible for explaining the state’s most inexplicable deaths.

But for decades, it’s been well known that Idaho’s patchwork of 44 coroner’s offices leaves grief-stricken parents without answers in their children’s deaths; creates disparities in coroners’ investigations based on where a person dies; and may even allow murderers to escape prosecution.

“The system needs a complete reform, as a whole,” Dotti Owens, former Ada County coroner, told ProPublica this year.

In the death of Onyxx, the coroner decided not to order an autopsy for the infant, go to the scene or talk with the family. Instead, he deferred to an emergency room doctor’s diagnosis of sudden infant death syndrome, or SIDS. Frustrated detectives called a neighboring county’s coroner to see if he could intervene.

In an interview with ProPublica last month, the coroner, Rick Taylor, defended how he handled the death, saying he talked with doctors and police on the scene and looked at Onyxx’s medical records. “We did basically what I call a ‘paperwork autopsy,’” he said.

Onyxx died weeks before a state agency issued a report to state legislators that warned them of structural failures in Idaho’s coroner system. Legislators said they were stunned by the findings.

Diamond and Alexis Cooley hold a photo of their son, Onyxx, who died in his sleep in February in eastern Idaho. (Natalie Behring for ProPublica)

Idaho continues to entrust death investigations to elected coroners, who have no oversight and few rules to follow, and whose budgets can rise and fall on the whims of other county politicians — unlike in places such as Washington, where state funding helps provide some stability.

There’s no centralized authority to whom Idaho families or prosecutors can appeal when a coroner doesn’t follow standards. And nearly all of Idaho’s counties lack the facilities and pathologists to do their own autopsies, so a coroner must drive a body to a morgue hours away every time they order an autopsy.

Idaho Child Death Reviewers Point to Coroner System

There is one statewide group whose sole purpose is to find patterns and safety gaps in deaths that may help save children’s lives in the future.

The Child Fatality Review Team is among those who have flagged problems with Idaho’s coroner system for decades.

“Something needs to happen,” the team’s current chair, Tahna Barton, said.

In its annual reports on child deaths, the team pointed year after year to the inconsistent work by coroners who lack sufficient budgets, staffing, experience and training.

“We strongly urge the introduction of new legislation to establish a state medical examiner system,” the team’s 1997 report said.

There have been no significant reforms since then.

In 2012, the team said it received “problematic” documents from coroners detailing how one infant wasn’t autopsied until after its body was embalmed and how another’s death certificate didn’t match what the autopsy found.

Nine years ago, the team said Idaho’s population boom put a strain on coroner’s offices, which “historically operated with small staff sizes and lean budgets and have not received additional funding to support ever-increasing caseloads.” Since then, the state has consistently ranked among the fastest growing in the U.S., while few coroners’ budgets have kept pace.

The Child Fatality Review Team’s most recent report, on 2021 deaths, said the problem lingers: too many cases, not enough time or money.

Reforms Fail as Officials Refuse Oversight and Spending

At every turn in the past 50 years, people with a vested interest in keeping Idaho’s coroner system as unregulated as possible have halted efforts to change it.

It often comes down to money.

Idaho leaves it up to each coroner to decide whether to follow national standards and up to each county to decide whether the coroner has the funds to do the job right. As long as that hands-off approach by the state holds, as it has for decades, nothing will change, said Owens, the former Ada County coroner.

“We need to have state statutes that outline the fact that, you know, infants should be autopsied unless there’s a medical diagnosis. The problem with that is, if we go ahead and we mandate that, who’s going to do it all? We don’t have the resources to do it all, which is half of the problem,” Owens said.

That tension has thwarted reform efforts since last century.

As reformers worked in January 1975 to draft legislation that would have changed Idaho from an elected coroner system to one headed by a state medical examiner, funeral home directors organized a preemptive strike. A local funeral director warned commissioners of a rural county in northernmost Idaho that lawmakers might approve reforms that would create “prohibitive” costs to local governments. The commissioners “voted to write their legislators opposing this while it is still in legislative committee,” the local newspaper reported.

It worked. A few weeks later, the legislator behind the proposal backed down, a state senator told the county’s local newspaper.

A group of law enforcement officials, attorneys and a physician who doubled as county coroner met again in November 1975 to gear up for another try.

We need to have state statutes that outline the fact that, you know, infants should be autopsied unless there’s a medical diagnosis. The problem with that is, if we go ahead and we mandate that, who’s going to do it all?

—Dotti Owens, former Ada County coroner

The group wrote a proposal to scrap the elected coroner system and instead hire a full-time forensic pathologist to serve as Idaho’s state medical examiner. Part-time physicians would be appointed to head district offices, with some medically trained assistants to help them. Gov. Cecil Andrus “endorsed the concept,” according to wire reports at the time. The proposal never gained traction; news reports said it would have required both an act of the Legislature and a constitutional amendment.

Lawmakers again tried to improve Idaho’s system around the turn of the 21st century.

Two bills, in 1999 and 2000, would have created a state medical examiner’s office to oversee autopsies, support and train coroners, and provide something Idaho never had before: a “uniform protocol” for death investigations.

Two other bills, in 2003 and 2004, tried to take a narrower scope: setting an autopsy requirement for sudden unexplained infant deaths.

None passed.

One bill sponsor, a Democrat from North Idaho, told a House committee in 2003 of her own baby’s death being ruled SIDS without an autopsy, the committee records show. “She stated that parents deserve to know if the infant died of SIDS and autopsies could relieve some guilt for the parents.”

A woman whose Idaho grandson’s sudden death was attributed to SIDS also supported reform, saying SIDS “is a horrible explanation to give a parent or grandparent. It is like having your child kidnapped and never knowing what happened to them,” she wrote to lawmakers. “One beginning to find the cause is through autopsies. We need standards set so that a cause can be found to help prevent this death from occurring. No one should experience the pain of losing a child, and especially not knowing why.”

The reforms had support from local and national groups, including the American Academy of Pediatrics, the National Association of Medical Examiners and the state pediatric and firefighters’ associations.

The bills collapsed under pressure from local governments and individual coroners. The state coroner’s association and state association of counties made a contradictory argument: that the mandate to autopsy SIDS deaths was unnecessary because Idaho coroners already were doing autopsies in those deaths; but a mandate to do so would “require an increase in every coroner’s budget.”

Idaho is at the bottom nationally for autopsies in deaths attributed to SIDS, according to a ProPublica analysis of nationwide death certificate data. Idaho also has the lowest rate of any state for autopsies performed in child deaths from unknown or unnatural causes.

And in February of this year, Onyxx Cooley became part of that statistic.

Data reporter Ellis Simani contributed data analysis.

Rose Lundy, The Maine Monitor

This article was produced by The Maine Monitor, which was a member of ProPublica’s Local Reporting Network in 2022-23. Sign up for Dispatches to get stories like this one as soon as they are published.

In the first major update to assisted living and residential care regulations in more than 15 years, the Maine Department of Health and Human Services has proposed significantly increasing staffing requirements, among other changes.

The proposed updates follow an investigation by The Maine Monitor and ProPublica into the state’s largest residential care facilities. It found dozens of violations of resident rights, including incidents of abuse and neglect, as well as more than 100 cases in which residents wandered away from their facilities and hundreds of medication and treatment violations.

As part of the news organizations’ investigation, one facility owner called the current staffing requirement “scary,” “unsafe” and “completely inadequate.” Experts, advocates and providers said requiring higher staffing levels, better training and more nursing care would help address these problems.

During a public hearing this month, the department proposed doubling the number of direct care workers at residential care facilities overnight and setting stricter rules in memory care units that go beyond the state and federal staffing requirements at nursing homes. DHHS must present its proposed regulations to lawmakers by Jan. 10 in order for them to be considered in the upcoming legislative session.

Assisted living programs serve older Mainers, adults with intellectual and developmental disabilities, and people with mental illness. These facilities offer less medical care than nursing homes, but they have expanded in recent years after the state capped the number of nursing home beds in the 1990s. In the last decade, at least 26 nursing homes have closed in Maine.

That shift has meant that the needs of residents in these facilities have “increased significantly,” said Brenda Gallant, Maine’s long-term care ombudsman, the state’s advocate for residents and their families. “Current regulations for assisted housing have not kept pace with the increasing needs of residents,” Gallant said, citing assessments from the state in recent years that as many as one-third of residents in these facilities could qualify for nursing home care.

Currently, residential care facilities with more than 10 beds require one direct care worker for 12 residents during the day, one for 18 residents during the evening, and one for 30 overnight. Under the proposed regulations, these ratios would be increased to one direct care worker for eight residents during the day and evening shifts and one for 15 residents overnight.

Currently, facilities with 10 or fewer beds must at all times have at least one responsible adult present. That would be increased to two on duty at all times.

For memory care units, the proposed staffing requirements are even stricter — and higher than those currently required in nursing homes: one direct care worker for five residents during the day and evening, and one worker for 10 residents on overnight shifts.

Experts and advocates have told The Monitor that residents with Alzheimer’s disease and other dementias are among the most vulnerable because they have a tendency to wander. The proposed regulations also require assessing residents for risk of elopement, defined as “leaving a secure facility without authorization or supervision.” The Monitor and ProPublica found that there were at least 115 reported elopements at Maine residential care facilities from 2020 to 2022, according to state inspection records and a database of incidents reported to the health department.

“Significant New Costs”

The proposed changes came as “quite a shock,” said Angela Cole Westhoff, president and CEO of the Maine Health Care Association, which represents nursing homes and assisted living facilities across the state.

Westhoff and facility administrators repeatedly asked the state during this month’s hearing to pause the process in order to get more industry input. A DHHS spokesperson did not respond to questions about what would happen if it missed the Jan. 10 deadline for submitting proposals to the Legislature in favor of more discussion.

The staffing requirements will mean adding about 2,000 more direct care workers, according to estimates from MHCA.

“This industry is not financially positioned to incur significant new costs without a corresponding increase in MaineCare spending and private pay pricing,” Westhoff said, referring to Maine’s version of Medicaid. Providers strongly disputed DHHS’ assertion that the rule was expected to have “minimal fiscal impact on licensed providers.”

DLTC Healthcare & Bella Point, a company that owns and operates 17 residential care facilities, estimated the change would cost an additional $108,000 annually for each 30-bed facility.

The director of finance and human resources for Schooner Estates, Schooner Memory Care and Fallbrook Woods estimated the three facilities would need to add 68 full-time-equivalent employees, totaling $4.5 million a year.

Woodlands Senior Living, which operates 16 facilities in Maine, said it would need to hire more than 300 staff members across its facilities, totaling nearly $13 million a year.

Many providers said they would likely have to pass these costs on to residents unless the regulations came with an increase in MaineCare reimbursement from the state.

Facility owners and administrators also warned that increased staffing requirements would be difficult to meet due to workforce shortages. During the hearing, one resident services director in Saco said they have been trying to hire a nurse for more than two years. Another administrator said her facility’s last opening took two months to fill, and when they finally hired, the candidate had “no qualifications” and required months of training.

DHHS spokesperson Lindsay Hammes said the department could not comment about the proposals during the rulemaking process and noted that the proposals could change based on public comments, which were accepted until Nov. 25.

“The Stakes Here Are High”

While facility representatives offered vocal opposition at the recent hearing, others testified in support.

Citing a recent survey of direct care workers, Nicole Marchesi, who works in the ombudsman’s office, said increasing staff ratios could help prevent burnout and turnover.

“Staff continue to express the frustration around caring for residents who are nursing home level of care in assisted living,” Marchesi said. “When staffing is insufficient, resident safety is jeopardized.”

Gallant, the long-term care ombudsman, and Legal Services for Maine Elders also recommended having license renewal and survey inspections completed annually, rather than every two years, and creating a standard practice to follow up on plans of correction when facilities are cited for deficiencies. In their investigation into elopements, The Monitor and ProPublica found that in the vast majority of cases, DHHS never inspects facilities and rarely imposes sanctions.

“The stakes here are high,” wrote John Brautigam on behalf of Legal Services for Maine Elders. “These rules have the potential to prevent neglect, improve health outcomes, and foster environments where residents feel valued and safe. We owe it to them to ensure these protections are as strong as possible.”

by Nick Grube, Honolulu Civil Beat

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

When the federal government stepped in to rent housing for survivors of the devastating 2023 fires on Maui, officials said they didn’t want to drive up rental rates or give landlords an incentive to evict tenants in order to secure lucrative government contracts.

On paper, the plan sounded good: It would rely on finding empty vacation rentals and second homes, which was consistent with Federal Emergency Management Agency policy.

But new reporting shows that FEMA didn’t take basic steps to ensure that happened: When the agency inked contracts with private companies to identify homes they could rent for survivors, it didn’t prohibit them from signing up properties that had been occupied by long-term residents.

Without such safeguards, and with FEMA offering rates well above what residents typically paid each month in rent, some landlords kicked out tenants and housed wildfire survivors for more money. Local economists warned that rents could rise across the small island and that Maui’s housing crisis could intensify — and both have come to pass, Civil Beat and ProPublica found.

A study of the impact of emergency housing programs on Maui’s economy, commissioned by FEMA itself, found that median rent rose 44% from early 2023 to June 2024. Though researchers concluded that was primarily due to the loss of so much housing in the fires, they said anecdotal evidence and hundreds of complaints to state agencies indicated that “the behavior of some landlords may have changed” in response to FEMA’s high prices, leading to increased rents and displacement.

Reporting by Civil Beat and ProPublica corroborates the researchers’ conclusion. Tenants, housing advocates, government officials and property owners have said that landlords have jacked up rents and that residents have been displaced by wildfire survivors or others who will pay more.

“It seemed pretty clear they were setting up a bounty system for removing long-term residents,” said Justin Tyndall, an associate professor at the University of Hawaii who co-wrote a report cautioning that FEMA’s housing program could cause residents to be displaced. “If you could just find a way to get your tenant to leave, then you would be eligible for these enormous rents from FEMA. So it’s unsurprising that people would find creative ways to try to tap into that money.”

When it launched the program, the agency did instruct potential contractors to lease units “not available to the general public.” David Greenberg, the head of Parliament LLC, one of the companies FEMA hired, said in an email that the agency made it clear that leasing properties from landlords who had forced out tenants, even if the company didn’t know about it, would cause Parliament to lose its contract. He said his employees sought out properties advertised as vacation rentals and were instructed to “explicitly ask owners and property managers if there were any existing tenants.”

FEMA officials told Civil Beat and ProPublica that the 1,362 properties in the agency’s housing program were primarily vacation rentals and second homes, though they didn’t know exactly how many. They also said FEMA’s policy allows for flexibility; because housing on the island was limited and their program couldn’t meet survivors’ needs with vacation rentals alone, the agency allowed any property owner to sign up as long as the home was safe and ready for move-in.

One nonprofit that also leased properties was more proactive in trying to prevent profiteering by landlords. The Council for Native Hawaiian Advancement, a prominent local nonprofit, ran the only nongovernmental leasing program after the fires. On the online application for its program, property owners had to attest that they were not evicting anyone in order to house survivors. They had to say what type of rental property they had and whether it was furnished. And if a landlord said a property was a short-term rental, staff tried to verify that through property tax records or Airbnb listings.

The online application for the Council for Native Hawaiian Advancement’s housing program told property owners they couldn’t evict anyone in order to house a wildfire survivor and required them to check a box promising they weren’t doing so. (Obtained by Honolulu Civil Beat and ProPublica. Highlighted by ProPublica.)

Additionally, if a landlord said a property was a long-term rental — the type of property FEMA hoped to avoid — CNHA requested prior leases and the names of previous tenants so staff could make sure no one had been pushed out, according to Skye Kolealani Razon-Olds, who oversees the nonprofit’s emergency housing and recovery efforts. When the nonprofit did lease long-term rentals, it offered lower rates than for vacation rentals. By contrast, FEMA said it generally set its rates to be competitive with what tourists typically paid.

“We knew the areas that were typically used for short-term rentals, we had deeper conversations with folks, and we were willing to say no,” Razon-Olds said. “Most of the stuff that we went for was short-term rental, so we knew that we weren’t going to be moving somebody.”

Bob Fenton, the FEMA regional administrator in charge of disaster relief after the fires, acknowledged that the agency didn’t require contractors to avoid long-term rentals. “It’s not like we put in the contract: must be in the vacation rental market,” he said. He said he wasn’t aware of FEMA’s contractors taking the steps that CNHA did but added that the agency is open to suggestions on how to improve the program. “Those are all ideas, recommendations, lessons learned that we’ll take into account as we continue to operate here,” he said.

In practice, it largely fell to FEMA’s contractors to ensure that their efforts to secure housing didn’t lead landlords to force people out. Greenberg, the head of Parliament, said his company refused to work with several landlords who were trying to evict current tenants. “If we caught even a whiff of impropriety, we would move on to the next unit.”

However, the online application that the company created for property owners didn’t ask anything about tenants or what type of rental it was — just the address, the number of bedrooms and bathrooms, when it would be available and additional information such as whether pets were allowed or if it was accessible for people with disabilities.

In response to allegations that companies like his were more focused on speed than vetting properties, Greenberg said, “I am proud of the balance we upheld in ensuring that all of our properties were compliant, owners were treated with respect, and the survivors living in our units were received with dignity.” He didn’t answer a question about whether his employees inquired about prior tenants.

Fenton acknowledged that the agency wouldn’t normally know if someone had been forced out before its contractor leased a unit. In “fewer than 10” cases, Fenton said, it learned that a landlord had improperly terminated a tenant’s lease in order to participate in FEMA’s program. It kicked those properties out.

Parliament was one of three companies hired by FEMA to manage properties; representatives of the other two, Lima Charlie Inc. and Aesthetic Home Investments, did not respond to questions from Civil Beat and ProPublica.

Two landlords who had rented to long-term tenants before the fires told Civil Beat and ProPublica that FEMA’s contractors spent little time vetting their properties. Hank Rapoza, a Maui-based real estate agent, said he contacted Parliament in December or January about leasing his two-bedroom condo in Wailea. He said a representative asked if the unit was vacant and didn’t inquire further when he said it was. The company offered him $7,500 a month, far more than the $3,500 he had charged before.

“The $7,500 was more than fair, so I said I’ll take it,” Rapoza said. “After I said that, I had a lease sent to me in three hours that I signed. That’s how fast they were.”

Steven Clark, the other landlord, said signing up for the program was remarkably easy. After the fires he listed a newly renovated three-bedroom home in Makawao, asking $4,000 a month. In November, he said, he was eating tacos from a food truck in Kahului when a representative of Lima Charlie called and offered him $8,000 a month. Clark said no one asked about previous tenants; the representative just wanted to know if the place was empty. Clark said it was. “They took me at my word,” Clark said. They struck a deal before he finished his lunch.

Struggling to Keep or Find Housing After Maui’s Wildfires? Tell Us Your Story.

by Molly Redden

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Donald Trump is entering his second term with vows to cut a vast array of government services and a radical plan to do so. Rather than relying on his party’s control of Congress to trim the budget, Trump and his advisers intend to test an obscure legal theory holding that presidents have sweeping power to withhold funding from programs they dislike.

“We can simply choke off the money,” Trump said in a 2023 campaign video. “For 200 years under our system of government, it was undisputed that the president had the constitutional power to stop unnecessary spending.”

His plan, known as “impoundment,” threatens to provoke a major clash over the limits of the president’s control over the budget. The Constitution gives Congress the sole authority to appropriate the federal budget, while the role of the executive branch is to dole out the money effectively. But Trump and his advisers are asserting that a president can unilaterally ignore Congress’ spending decisions and “impound” funds if he opposes them or deems them wasteful.

Trump’s designs on the budget are part of his administration’s larger plan to consolidate as much power in the executive branch as possible. This month, he pressured the Senate to go into recess so he could appoint his cabinet without any oversight. (So far, Republicans who control the chamber have not agreed to do so.) His key advisers have spelled out plans to bring independent agencies, such as the Department of Justice, under political control.

If Trump were to assert a power to kill congressionally approved programs, it would almost certainly tee up a fight in the federal courts and Congress and, experts say, could fundamentally alter Congress’ bedrock power.

“It’s an effort to wrest the entire power of the purse away from Congress, and that is just not the constitutional design,” said Eloise Pasachoff, a Georgetown Law professor who has written about the federal budget and appropriations process. “The president doesn’t have the authority to go into the budget bit by bit and pull out the stuff he doesn’t like.”

Trump’s claim to have impoundment power contravenes a Nixon-era law that forbids presidents from blocking spending over policy disagreements as well as a string of federal court rulings that prevent presidents from refusing to spend money unless Congress grants them the flexibility.

In an op-ed published Wednesday, tech billionaire Elon Musk and former Republican presidential candidate Vivek Ramaswamy, who are overseeing the newly created, nongovernmental Department of Government Efficiency, wrote that they planned to slash federal spending and fire civil servants. Some of their efforts could offer Trump his first Supreme Court test of the post-Watergate Congressional Budget and Impoundment Control Act of 1974, which requires the president to spend the money Congress approves. The law allows exceptions, such as when the executive branch can achieve Congress’ goals by spending less, but not as a means for the president to kill programs he opposes.

Trump and his aides have been telegraphing his plans for a hostile takeover of the budgeting process for months. Trump has decried the 1974 law as “not a very good act” in his campaign video and said, “Bringing back impoundment will give us a crucial tool with which to obliterate the Deep State.”

Musk and Ramaswamy have seized that mantle, writing, “We believe the current Supreme Court would likely side with him on this question.”

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The once-obscure debate over impoundment has come into vogue in MAGA circles thanks to veterans of Trump’s first administration who remain his close allies. Russell Vought, Trump’s former budget director, and Mark Paoletta, who served under Vought as the Office of Management and Budget general counsel, have worked to popularize the idea from the Trump-aligned think tank Vought founded, the Center for Renewing America.

On Friday, Trump announced he had picked Vought to lead OMB again. “Russ knows exactly how to dismantle the Deep State and end Weaponized Government, and he will help us return Self Governance to the People,” Trump said in a statement.

Vought was also a top architect of the controversial Project 2025. In private remarks to a gathering of MAGA luminaries uncovered by ProPublica, Vought boasted that he was assembling a “shadow” Office of Legal Counsel so that Trump is armed on day one with the legal rationalizations to realize his agenda.

“I don’t want President Trump having to lose a moment of time having fights in the Oval Office about whether something is legal or doable or moral,” Vought said.

Trump spokespeople and Vought did not respond to requests for comment.

The prospect of Trump seizing vast control over federal spending is not merely about reducing the size of the federal government, a long-standing conservative goal. It is also fueling new fears about his promises of vengeance.

A similar power grab led to his first impeachment. During his first term, Trump held up nearly $400 million in military aid to Ukraine while he pressured President Volodymyr Zelenskyy to open a corruption investigation into Joe Biden and his family. The U.S. Government Accountability Office later ruled his actions violated the Impoundment Control Act.

Pasachoff predicted that, when advantageous, the incoming Trump administration will attempt to achieve the goals of impoundment without picking such a high-profile fight.

Trump tested piecemeal ways beyond the Ukrainian arms imbroglio to withhold federal funding as a means to punish his perceived enemies, said Bobby Kogan, a former OMB adviser under Biden and the senior director of federal budget policy at the left-leaning think tank American Progress. After devastating wildfires in California and Washington, Trump delayed or refused to sign disaster declarations that would have unlocked federal relief aid because neither state had voted for him. He targeted so-called sanctuary cities by conditioning federal grants on local law enforcement’s willingness to cooperate with mass deportation efforts. The Biden administration eventually withdrew the policy.

Trump and his aides claim there is a long presidential history of impoundment dating back to Thomas Jefferson.

Most historical examples involve the military and cases where Congress had explicitly given presidents permission to use discretion, said Zachary Price, a professor at the University of California College of the Law, San Francisco. Jefferson, for example, decided not to spend money Congress had appropriated for gun boats — a decision the law, which appropriated money for “a number not exceeding fifteen gun boats” using “a sum not exceeding fifty thousand dollars,” authorized him to make.

President Richard Nixon took impoundment to a new extreme, wielding the concept to gut billions of dollars from programs he simply opposed, such as highway improvements, water treatment, drug rehabilitation and disaster relief for farmers. He faced overwhelming pushback both from Congress and in the courts. More than a half dozen federal judges and the Supreme Court ultimately ruled that the appropriations bills at issue did not give Nixon the flexibility to cut individual programs.

Vought and his allies argue the limits Congress placed in 1974 are unconstitutional, saying a clause in the Constitution obligating the president to “faithfully execute” the law also implies his power to forbid its enforcement. (Trump is fond of describing Article II, where this clause lives, as giving him “the right to do whatever I want as president.”)

The Supreme Court has never directly weighed in on whether impoundment is constitutional. But it threw water on that reasoning in an 1838 case, Kendall v. U.S., about a federal debt payment.

“To contend that the obligation imposed on the President to see the laws faithfully executed, implies a power to forbid their execution, is a novel construction of the constitution, and entirely inadmissible,” the justices wrote.

During his cutting spree, Nixon’s own Justice Department argued roughly the same.

“With respect to the suggestion that the President has a constitutional power to decline to spend appropriated funds,” William Rehnquist, the head of the Office of Legal Counsel whom Nixon later appointed to the Supreme Court, warned in a 1969 legal memo, “we must conclude that existence of such a broad power is supported by neither reason nor precedent.”

by Melissa Sanchez and Mica Rosenberg

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At first, she didn’t think much about the Nicaraguan asylum-seekers who began moving into town a few years ago. Rosa was an immigrant too, one of the many undocumented Mexican immigrants who’d settled nearly 30 years ago in Whitewater, a small university town in southeast Wisconsin.

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.

Immigrants seeking asylum arrive in Philadelphia in December 2022. They had been bused in from Texas, which has sent thousands of immigrants to cities around the country this way during the Biden administration. (Photo by Ryan Collerd/AFP via Getty Images)

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.”

Sergio Garza Castillo, who owns a gas station and convenience store in Del Rio, Texas, had long voted for Democrats. But his frustration with border policy led him to vote for Trump this year. (Gerardo del Valle/ProPublica)

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.”

Anjeanette Damon, Nicole Foy, Perla Trevizo and Gerardo del Valle contributed reporting.

by Lizzie Presser and Kavitha Surana

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

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.

ProPublica condensed 200 pages of medical records into a summary of the case in consultation with two maternal-fetal medicine specialists and then reviewed it with more than a dozen experts around the country, including researchers at prestigious universities, OB-GYNs who regularly handle miscarriages, and experts in maternal health.

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.”

Hope visits his wife’s gravesite in Pearland, Texas. (Danielle Villasana for ProPublica)

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 and his two sons outside their home in Houston (Danielle Villasana for ProPublica)

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.”

A sonogram of Porsha’s firstborn on the fridge in the family home. She was excited to have a third child. (Danielle Villasana for ProPublica)

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”

Hope with his son (Danielle Villasana for ProPublica)

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 died after 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.”

First image: Hope now wears his and Porsha’s wedding rings around his neck. Second image: Porsha’s son plays with cards capturing memories of his mother. (Danielle Villasana for ProPublica)

Mariam Elba and Lexi Churchill contributed research.