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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The White House did not respond to requests for comment.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Three hours later, her heart stopped.

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

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

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

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

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

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

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

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

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

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

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

“We Need to See the Doctor”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“All She Needed”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Three hours later, her heart stopped.

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

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

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

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

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

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

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

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

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

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

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

“We Need to See the Doctor”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“All She Needed”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In North Carolina alone, we identified 39 of these likely “segregation academies” that are still operating and that have received voucher money. Of these, 20 schools reported student bodies that were at least 85% white in a 2021-22 federal survey of private schools, the most recent data available.

Those 20 academies, all founded in the 1960s and 1970s, brought in more than $20 million from the state in the past three years alone. None reflected the demographics of their communities. Few even came close.

Northeast Academy, a small Christian school in rural Northampton County on the Virginia border, is among them. As of the 2021-22 survey, the school’s enrollment was 99% white in a county that runs about 40% white.

Every year since North Carolina launched its state-funded private school voucher program in 2014, the academy has received more and more money. Last school year, it received about $438,500 from the program, almost half of its total reported tuition. Northeast is on track to beat that total this school year.

Vouchers play a similar role at Lawrence Academy, an hour’s drive south. It has never reported Black enrollment higher than 3% in a county whose population hovers around 60% Black. A small school with less than 300 students, it received $518,240 in vouchers last school year to help pay for 86 of those students.

Farther south, Pungo Christian Academy has received voucher money every year since 2015 and, as of the last survey, had become slightly more white than when the voucher program began. It last reported a student body that was 98% white in a county that was 65% white.

Segregation academies that remain vastly white continue to play an integral role in perpetuating school segregation — and, as a result, racial separation in the surrounding communities. We found these academies benefiting from public money in Southern states beyond North Carolina. But because North Carolina collects and releases more complete data than many other states, it offers an especially telling window into what is happening across this once legally segregated region where legislatures are rapidly expanding and adopting controversial voucher-style programs.

Called Opportunity Scholarships, North Carolina’s voucher program launched in 2014. At first, it was only for low-income families and had barely more than 1,200 participants. Then last fall, state lawmakers expanded eligibility to students of all income levels and those already attending private school, a move that sparked furious debate over the future of public education.

“We are ensuring that every child has the chance to thrive,” Republican Rep. Tricia Cotham argued. But Democratic Rep. Julie von Haefen pointed to vouchers’ “legacy of white supremacy” and called the expansion “a gross injustice to the children of North Carolina.”

So many students flocked to the program that the state now has a waitlist of about 54,000 children. Paying for all of them to receive vouchers — at a cost of $248 million — would more than double the current number of participants in the program. Republicans in the General Assembly, along with three Democrats, passed a bill in September to do just that.

Gov. Roy Cooper, a Democrat, vetoed the measure. But the GOP supermajority is expected to override it before the year’s end, perhaps as early as Nov. 19.

Opportunity Scholarships don’t always live up to their name for Black children. Private schools don’t have to admit all comers. Nor do they have to provide busing or free meals. Due to income disparities, Black parents also are less likely to be able to afford the difference between a voucher that pays at most $7,468 a year and an annual tuition bill that can top $10,000 or even $20,000.

And unlike urban areas that have a range of private schools, including some with diverse student bodies, segregation academies are the only private schools available in some rural counties across the South.

Josh Cowen, a professor of education policy at Michigan State, studies these barriers and sees where vouchers fall short for some: “Eligibility does not mean access.”

Of the 20 vastly white segregation academies we identified that received voucher money in North Carolina, nine were at least 30 percentage points more white than the counties in which they operate, based on 2021-22 federal survey and census data.

Otis Smallwood, superintendent of the Bertie County Schools in rural northeastern North Carolina, witnesses this kind of gulf in the district he leads. So many white children in the area attend Lawrence Academy and other schools that his district’s enrollment runs roughly 22 percentage points more Black than the county overall.

He said he tries not to be political. But he feels the brunt of an intensifying Republican narrative against public schools, which still educate most of North Carolina’s children. “It’s been chipping, chipping, chipping, trying to paint this picture that public schools are not performing well,” Smallwood said. “It’s getting more and more and more extreme.”

When a ProPublica reporter told him that Lawrence Academy received $518,240 last school year in vouchers, he was dismayed: “That’s half a million dollars I think could be put to better benefit in public schools.”

If lawmakers override the governor’s veto to fund the waitlist, Smallwood’s district could suffer most. In a recent report, the Office of State Budget and Management projected Bertie County could lose more of its state funding than any other district — 1.6% next year.

Across the once legally segregated South, the volume of public money flowing through voucher-style programs is set to balloon in coming years. Georgia, Alabama, Arkansas, Louisiana, Florida and South Carolina all have passed new or expanded programs since 2023. (South Carolina’s state Supreme Court rejected its tuition grants in September, but GOP lawmakers are expected to try again with a revamped court.)

Voucher critics contend these programs will continue to worsen school segregation by helping wealthier white kids attend private schools; supporters argue they help more Black families afford tuition. But many of the states have made it hard to discern if either is happening by failing to require that the most basic demographic data be shared with the public — or even gathered.

This doesn’t surprise Cowen, who wrote the new book “The Privateers: How Billionaires Created a Culture War and Sold School Vouchers.” He said Southern legislatures in particular don’t want to know what the data would show because the results, framed by a legacy of racism, could generate negative headlines and lawsuit fodder.

States know how to collect vast troves of education data. North Carolina in particular is lauded among global researchers for “the robustness and the richness of the data system for public schools,” Cowen said.

North Carolina and Alabama are among the states that have gathered demographic information about voucher recipients but won’t tell the public the race of students who use them to attend a given school. In North Carolina, a spokesperson said doing so could reveal information about specific students, making that data not a public record under the Opportunity Scholarship statue.

For its $120 million tax credit program, Georgia does not collect racial demographic information or per-school spending. ProPublica was able to identify 20 segregation academies that signed up to take part, but it’s unclear how many are receiving that money or what the racial breakdown is of the students who use it.

“Why should we not be allowed to know where the money is going? It’s a deliberate choice by those who pass these laws,” said Jessica Levin, director of Public Funds Public Schools, a national anti-voucher campaign led by the nonprofit Education Law Center. “There is a lack of transparency and accountability.”

Advocacy groups that support widespread voucher use have resisted some rules that foster greater transparency out of concern that they might deter regulation-averse private schools from participating. Mike Long, president of the nonprofit Parents for Educational Freedom in North Carolina, is among those trying to rally as much private school buy-in for vouchers as possible.

“Their fear is that if they accept it, these are tax dollars, and therefore they would have to submit to government regulation,” Long said. “We’ve lobbied this legislature, and I think they understand it very well, that you can’t tie regulation to this.”

The share of Black students who have received vouchers in North Carolina has dropped significantly since the program's launch. In 2014, more than half the recipients were Black. This school year, the figure is 17%.

That share is unlikely to increase if lawmakers fund all 54,000 students on the waiting list. Because lower-income families were prioritized for vouchers, the applicants who remain on the list are mostly in higher income tiers — and those families are more likely to be white.

More Black parents don’t apply for vouchers because they don’t know about them, said Kwan Graham, who oversees parent liaisons for Parents for Educational Freedom in North Carolina.

Graham, who is Black, said parents haven’t voiced to her concerns that, “I’m Black, they don’t want me” at their local private schools. But she’s also not naive. Private schools can largely select — and reject — who they want.

The nonprofit Public Schools First NC has tallied admissions policies that private schools receiving vouchers use to reject applicants based on things like sexuality, religion and disability. Many also require in-person interviews or tours. Rather than overtly rejecting students based on race, which the voucher program prohibits, schools might say something like, “Come visit the school and see if you’re the ‘right fit,’” said Heather Koons, the nonprofit’s communications and research director.

Northeast Academy, Lawrence Academy and Pungo Christian all include nondiscrimination statements on their websites.

Back when segregation academies opened, some white leaders proudly declared their goal of preserving segregation. Others shrouded their racist motivations. Some white parents complained about federal government overreach and what they deemed social agendas and indoctrination in public schools. Even as violent backlash against integration erupted across the region, many white parents framed their decisions as quests for quality education, morality and Christian education, newspaper coverage and school advertisements from the time show.

Early on, Southern lawmakers found a way to use taxpayer money to give these academies a boost: They created school voucher programs that went chiefly to white students.

Courts ruled against or restricted the practice in the 1960s. But it didn’t really end.

“If you look at the history of the segregation movement, they wanted vouchers to prop up segregation academies,” said Bryan Mann, a University of Kansas professor who studies school segregation. “And now they’re getting vouchers in some of these areas to prop up these schools.”

More recently, Lawrence and Northeast academies both grew their enrollments while receiving voucher money even as the rural counties where they operate have lost population. Over three decades of responding to the federal private schools survey, both academies have reported enrolling almost no nonwhite children. And Pungo Christian has raised its average tuition by almost 50% over the past three school years. During that time, the small school has received almost $500,000 in vouchers.

None of the three academies’ headmasters responded to ProPublica’s request to discuss its findings or to lists of questions. And none have ever reported more than 3% Black enrollment despite operating in counties with substantial — even majority — Black populations.

One of the Democrats who helped Republicans expand North Carolina’s voucher program was Shelly Willingham, a Black representative whose district includes Bertie County, home of Lawrence Academy. He said he doesn’t love vouchers, but the bills have included funding for issues he does support.

He also said he encourages his constituents to take advantage of the vouchers. If there were any effort to make it more difficult for Black students to attend those schools, “then I would have a big problem,” Willingham said. “I don’t see that.”

Another Democrat who voted with Republicans was state Rep. Michael Wray, a white businessman and former House minority whip — who graduated from Northeast Academy.

Wray, whose voting record on vouchers over the years has been mixed, did not respond to multiple ProPublica requests to discuss his views. In 2013, he voted against the budget bill that established the Opportunity Scholarships. And in a recent Q&A with the local Daily Herald newspaper, when asked if he supports taxpayer money funding private schools, he responded: “I believe that when you siphon funds away from our public school budgets, it undermines the success of our schools overall.”

Rodney Pierce, a Black 46-year-old father and public school teacher, saw the voucher expansion in the state budget bill Wray voted for and felt history haunt him. Pierce had only one white student in his classes last year at Gaston STEM Leadership Academy. But about 30 miles across the rural county, white children filled Northeast Academy.

Pierce taught history, with a deep interest in civil rights. He’d studied the voucher programs that white supremacists crafted to help white families flee to segregation academies.

“This stuff was in the works back in the 1960s,” Pierce said.

He was so outraged that he challenged Wray, a 10-term incumbent, for his state House seat. Pierce won the Democratic primary earlier this year by just 34 votes. He faced no opponent in November, so come next year he will cut the House’s support of vouchers by one vote.

“Particularly in the Black community, we care about our public schools,” he said.

Many Black families also have little to no relationship with their local private schools, especially those that opened specifically for white children and are still filled with them. The only times Pierce had set foot on Northeast Academy’s campus was when he covered a few sporting events there for the local newspaper.

People there were nice to him, he said, but he felt anxious: “You’re in an academy you know was started by people who didn’t want their children to go to school with Black children.”

His own three kids attend public schools. Even with vouchers, he said, he wouldn’t send them to a school founded as a segregation academy, much less one that still fosters segregation. He finds it insulting to force taxpayers, including the Black residents he will soon represent — about half of the people in his district — to pay to send other people’s children to these schools.

In the summer of 2021, President Joe Biden summoned the CEOs of the nation’s biggest tech companies to the White House.

A series of cyberattacks linked to Russia, China and Iran had left the government reeling, and the administration had asked the heads of Microsoft, Amazon, Apple, Google and others to offer concrete commitments to help the U.S. bolster its defenses.

“You have the power, the capacity and the responsibility, I believe, to raise the bar on cybersecurity,” Biden told the executives gathered in the East Room.

Microsoft had more to prove than most. Its own security lapses had contributed to some of the incursions that had prompted the summit in the first place, such as the so-called SolarWinds attack, in which Russian state-sponsored hackers stole sensitive data from federal agencies, including the National Nuclear Security Administration. Following the discovery of that breach, some members of Congress said the company should provide better cybersecurity for its customers. Others went further. Sen. Ron Wyden, a Democrat who chairs the Senate’s finance committee, called on the government to “reevaluate its dependence on Microsoft” before awarding it any more contracts.

In response to the president’s call for help, Microsoft CEO Satya Nadella pledged to give the government $150 million in technical services to help upgrade its digital security.

On the surface, it seemed a political win for the Biden administration and an instance of routine damage control from the world’s largest software company.

But Microsoft’s seemingly straightforward commitment belied a more complex, profit-driven agenda, a ProPublica investigation has found. The proposal was, in fact, a calculated business maneuver designed to bring in billions of dollars in new revenue, box competitors out of lucrative government contracts and tighten the company’s grip on federal business.

The White House Offer, as it was known inside Microsoft, would dispatch Microsoft consultants across the federal government to install the company’s cybersecurity products — which, as a part of the offer, were provided free of charge for a limited time.

But once the consultants installed the upgrades, federal customers would be effectively locked in, because shifting to a competitor after the free trial would be cumbersome and costly, according to former Microsoft employees involved in the effort, most of whom spoke on the condition of anonymity because they feared professional repercussions. At that point, the customer would have little choice but to pay for the higher subscription fees.

Two former sales leaders involved in the effort likened it to a drug dealer hooking a user with free samples. “If we give you the crack, and you take the crack, you’ll enjoy the crack,” one said. “And then when it comes time for us to take the crack away, your end users will say, ‘Don’t take it away from me.’ And you’ll be forced to pay me.”

The company, however, wanted more than those subscription fees, former salespeople said. The White House Offer would lead customers to buy other Microsoft products that ran on Azure, the company’s cloud platform, which carried additional charges based on how much storage space and computing power the customer used. The expectation was that the upgrades would ultimately “spin the meter” for Azure, helping Microsoft take market share from its main cloud rival, Amazon Web Services, the salespeople said.

In the years after Nadella made his commitment to Biden, Microsoft’s goals became reality. The Department of Defense, which had resisted the upgrades for years due to the steep cost, began paying for them once the free trial ended, laying the groundwork for future Azure consumption. So did many civilian agencies. The White House Offer got the government “hooked on Azure,” said Karan Sondhi, a former Microsoft salesperson with knowledge of the deals. “And it was successful beyond what any of us could have imagined.”

But while Microsoft’s gambit paid off handsomely for the company, legal experts told ProPublica the White House Offer deals never should have come to pass, as they sidestep or even possibly violate federal laws that regulate government procurement. Such laws generally bar gifts from contractors and require open competition for federal business.

Accepting free product upgrades and consulting services collectively worth hundreds of millions of dollars is “not like a free sample at Costco, where I can take a sample, say, ‘Thanks for the snack,’ and go on my merry way,” said Eve Lyon, an attorney who worked for four decades as a procurement specialist in the federal government. “Here, you have changed the IT culture, and it would cost a lot of money to go to another system.”

Microsoft defended its conduct. The company’s “sole goal during this period was to support an urgent request by the Administration to enhance the security posture of federal agencies who were continuously being targeted by sophisticated nation-state threat actors,” Steve Faehl, the security leader for Microsoft’s federal business, said in a statement. “There was no guarantee that agencies would purchase these licenses,” and they “were free to engage with other vendors to support their security needs,” Faehl said.

Pricing for Microsoft’s security suite was transparent, he said, and the company worked “closely with the Administration to ensure any service and support agreements were pursued ethically and in full compliance with federal laws and regulations.” Faehl said in the statement that Microsoft asked the White House to “review the deal for antitrust concerns and ensure everything was proper and they did so.”

The White House disputed that characterization, as did Tim Wu, a former presidential adviser who told ProPublica he discussed the offer with the company in a short, informal chat prior to the summit but provided no signoff. “If that’s what they’re saying, they’re misrepresenting what happened on that phone call,” he said.

A current White House official, in a statement to ProPublica, sought to distance the administration from Microsoft’s offer, which it had previously heralded as an “ambitious” cybersecurity initiative.

“This was a voluntary commitment made by Microsoft … and Microsoft alone was responsible for it,” the White House official said in the statement. Furthermore, they said the decisions to accept it were “handled solely by the respective agencies.”

“The White House is not involved in Agency decisions regarding cybersecurity and procurement,” the official said.

The official declined to comment on the legal and contracting concerns raised by experts but noted in the statement that the White House “is broadly concerned” about the risks of relying too much on any single technology vendor and “has been exploring potential policy steps to encourage Departments and Agencies to diversify where there is concentration.” Cybersecurity experts say that such concentration can leave users vulnerable to attack, outages or other disruption.

Yet the White House summit ushered in that very type of concentrated reliance, as well as the kind of anticompetitive behavior that the Biden administration has pledged to stamp out. Former Microsoft salespeople told ProPublica that during their White House Offer push, they advised federal departments to save money by dropping cybersecurity products they had purchased from competitors. Those products, they told them, were now “redundant.” Salespeople also fended off new competitors by explaining to federal customers that most of the cybersecurity tools they needed were included in the upgraded bundle.

Today, as a result of the deals, vast swaths of the federal government, including all of the military services in the Defense Department, are more reliant than ever on a single company to meet their IT needs. ProPublica’s investigation, supported by interviews with eight former Microsoft employees who were involved in the White House Offer, reveals for the first time how this sweeping transformation came to be — a change that critics say leaves Washington vulnerable, the very opposite of what Biden had set out to achieve with his summit.

“How did Microsoft become so pervasive of a player in the government?” said a former company sales leader. “Well, the government let themselves get coerced into Microsoft when Microsoft rolled the stuff out for free.”

“Everything That We Do Is Designed to Generate a Return”

The federal government is one of Microsoft’s largest customers and “the one that we’re most devoted to,” the company’s president, Brad Smith, has said. Each day, millions of federal employees use the Windows operating system and products like Word, Outlook, Excel and others to write reports, send emails, analyze data and log on to their devices. But in the months before Biden’s summit, the SolarWinds hack put that relationship to the test.

Discovered in late 2020, SolarWinds was one of the most damaging breaches in U.S. history and underscored the federal government’s vulnerability to a state-sponsored cyberattack.

Authorities established that Russian hackers exploited a flaw in a Microsoft product to steal sensitive government documents from the National Nuclear Security Administration and the National Institutes of Health, among other agencies. What they didn’t know, as ProPublica reported in June, was that one of the company’s own engineers had warned about the weakness for years, only to be dismissed by product leaders who were fearful that acknowledging it would undermine the company’s chances of winning a massive federal cloud computing contract.

But Microsoft’s known involvement was enough for Congress to summon Smith to testify in February 2021. Lawmakers focused on how Microsoft packaged its products into tiers of service — with advanced security tools attached to only the most expensive license, known to government customers as the G5.

At the time, many federal employees used a less expensive license known as the G3. As a result, they didn’t have access to the security features that might have alerted them to an intrusion and aided subsequent investigations.

Some lawmakers, like then-Rep. Jim Langevin of Rhode Island, accused the company of unfairly up-charging customers for what they considered to be basic security. “Is this a profit center for Microsoft?” he asked Smith during the hearing.

Smith replied: “We are a for-profit company. Everything that we do is designed to generate a return, other than our philanthropic work.”

Amid the criticism, Microsoft soon announced that it would provide federal customers with a “one-year free trial of Advanced Audit,” a tool that could help the government detect and investigate future attacks. Over the months that followed, Microsoft was “surprised there was not as aggressive of an uptake of Advanced Audit” as the company had wanted, Faehl, Microsoft’s federal security leader, told ProPublica. It would be a “lesson learned” going forward, he said.

That May, Biden signed an executive order requiring federal agencies to bolster their cyber defenses, declaring that “protecting our Nation from malicious cyber actors requires the Federal Government to partner with the private sector.” He added, “In the end, the trust we place in our digital infrastructure should be proportional to how trustworthy and transparent that infrastructure is, and to the consequences we will incur if that trust is misplaced.”

“Parting of the Red Sea”

Around that time, Anne Neuberger, a White House deputy national security adviser, called Smith and requested that Microsoft develop an initiative to announce at Biden’s White House cybersecurity summit that August. Like Langevin, the administration believed that the company’s advanced suite of cybersecurity tools, including ones intended to counter threats on user devices, should be included in the government’s existing licenses and that products should be delivered to customers with the most secure settings enabled by default. (Neither Neuberger nor Smith granted interview requests.)

Giving away a bundle of advanced security features permanently was a nonstarter inside Microsoft, an executive told ProPublica. But Smith spearheaded a team to develop an offer that appeared to be a compromise.

Federal customers could have free, limited-time access to the upgraded G5 security capabilities and to consultants who would install them. “It was at the behest of the Administration that Microsoft provided enhanced security tools, at no cost, to agencies as soon as possible to level up their security baseline,” Faehl told ProPublica.

While the deal achieved the administration’s goal of better protection for the federal government, it also served Microsoft’s interests. Microsoft salespeople had been trying, unsuccessfully, for years to convince federal customers to upgrade to the G5. Department and agency officials balked at the higher price tag when they already had other vendors providing some of the same security capabilities. The G5’s retail price is nearly 60% more than the G3’s.

“We knew that this was a golden window that nobody could have foreseen opening up because we had been pushing” for the G5 upgrade “for years, and things were going very slow,” said a former Microsoft sales leader involved in the strategy. With the White House Offer, it was “like Moses leading us through the parting of the Red Sea, and we just rushed through it.”

Faehl told ProPublica that sales of the G5 had been slow prior to SolarWinds because federal customers wrongly believed “that they had sufficient security capabilities already in place.” He said the attack was “a wakeup call showing the status quo perspective to be insufficient.”

Microsoft was well aware of the possible legal implications of its offer. More than two decades ago, the U.S. Department of Justice sued the company in a landmark antitrust case that nearly resulted in its breakup. Federal prosecutors alleged that Microsoft maintained an illegal monopoly in the operating system market through anticompetitive behaviors that prevented rivals from getting a foothold. Ultimately, the Justice Department settled with Microsoft, and a federal judge approved a consent decree that imposed restrictions on how the company could develop and license software. Although the decree had long since expired, it nonetheless continued to loom large in the corporate culture.

When it came to the White House Offer, company insiders were “mindful of the concerns about Microsoft making products free that smaller companies sell,” an executive told ProPublica. A spokesperson explained, “That was the impetus for asking the administration to review it.”

The “review” consisted of a phone call between Microsoft’s Smith and Wu, who was Biden’s special assistant for technology and competition policy.

“Brad was like, ‘We think security is important, and we want to give the federal government better security,’” Wu recalled.

But, according to Wu, Smith said Microsoft’s lawyers were “overly paranoid” about antitrust concerns, and he was looking to “calm his own lawyers down.”

“I made it clear there was no ability in the White House to sign off on antitrust,” which is in the purview of the Justice Department or the Federal Trade Commission, Wu said. “I’m smart enough not to say, ‘Oh yeah, that’s fine with me.’ I’m not crazy.”

After the news organization asked Microsoft about Wu’s account, a spokesperson walked back the company’s original written statement, saying that Faehl was misinformed. “The White House arranged a call and we described details of our security offer and how it was structured to avoid antitrust concerns,” the spokesperson said. “It was an informal conversation and at no time did we ask for formal antitrust approval.”

Wu also told ProPublica that he felt pressure from the National Security Council’s Neuberger, who “wanted to get this deal done” in the wake of SolarWinds and other cyberattacks. “She pushed me to get on the phone with Brad,” he said. “I feel in some ways in retrospect I should not have even spoken with him. But I felt that I should help the NSC for what they presented as a formalistic exercise to help the national security.”

“The End Game”

After the White House summit, Microsoft’s sales teams quickly mobilized to sell the “WHO,” as it became known to insiders. The free consulting services were a crucial part of the strategy, former salespeople said. As Sondhi put it, “Just because you give the product away for free doesn’t mean they’re going to use it because it’s a pain in the ass to install new software and retrain staff.” The company wanted to avoid a repeat of the disappointing participation in the earlier Advanced Audit offer.

The consultants would work inside the agencies, where they would have government-provided desks, phones and internet, as well as access to federal computer networks, according to one proposal reviewed by ProPublica. From their perches in the bureaucracy, they would get the products up and running and train federal employees on how to use them. This would make the upgrades “sticky,” as they became ingrained in employees’ daily lives, former salespeople said.

Microsoft covered the free product upgrades for up to a year, the company told ProPublica. Faehl called the free upgrades “a short term option for protection while agencies put long term procurement plans in motion.” Or, as sales teams told customers, they “should not have to wait to be secure until they can procure.” The company also noted the offer came at a significant cost to Microsoft, “with no guarantee of renewal once the deal expired.”

But sales teams said they knew customers who accepted the White House Offer were unlikely to undo the intensive work of installing the upgrades when renewal time rolled around, locking them into the G5 for the long haul. Wes Anderson, a Microsoft vice president who oversaw teams working with the Defense Department, asked his staff to prepare forecasts showing which customers were expected to become paying G5 users at the end of the White House Offer, three people who worked in sales told ProPublica.

“It was explicit that this was the end game,” one former Microsoft sales leader who worked inside the Defense Department told ProPublica. “You will do whatever you need to do to get that software installed, operational and connected so the customer has their runway to renew.”

(On Oct. 30, two weeks after the news organization sent Microsoft questions for this story, the company announced in an email to employees that Anderson would be leaving Microsoft. Neither Anderson nor Microsoft commented on the departure. On the topic of Anderson’s request of his staff, the company said, “Forecasting is part of the rhythm of business for organizations in nearly every industry.”)

Salespeople pitched the White House Offer as “the easy button,” people familiar with the strategy told ProPublica. “Our argument was, ‘We have this whole suite of goodness,’” said a former Microsoft employee who worked with the Department of Defense. “‘You should upgrade because it will take care of everything rather than having a bunch of vendors that each do one of the 20 things that the G5 can do.’” Faehl told ProPublica the license bundles help federal customers “avoid the hassles of managing multiple contracts and licenses” and close security gaps by replacing a “patchwork of solutions” with “simplified, comprehensive protection.”

For the most part, as they predicted, the Microsoft sales teams found receptive audiences across the government. To help ingratiate themselves, they invoked their association with the White House in their pitches. In one example, from June 2022, a Microsoft representative wrote to Veterans Affairs officials to explain that, “working in conjunction with the White House,” it would provide “a no cost offer of professional services to provide hands-on assistance” to deploy the upgrades.

Money for Nothing?

As consultants fanned out across the federal government to turn on the new features, there was a sense of unease among some employees about the nature of the deals. Typically, the government obtains products and services through a competitive bidding process, selecting from a variety of proposals from different vendors. The White House Offer was different.

“No matter how you wanted to polish the turd, there was the appearance of no-bid contracts,” said a former Microsoft consultant involved in the WHO.

The federal government may receive so-called gratuitous — or free — services from donors as long as both parties have a written agreement stating that the donor will not be paid for the goods or services provided. Such agreements were in place for the consulting services in the White House Offer, the company said.

Those agreements may have helped Microsoft pass the “laugh test,” said Lyon, the former federal procurement attorney. “But just because something is technically legal does not make it right,” she said.

Other contracting experts said federal departments and agencies should have been more skeptical about accepting free products and consulting services from Microsoft, given the implications for competition and national security.

The cost and difficulty of switching from the Microsoft products presents a classic example of “vendor lock-in,” said Jessica Tillipman, associate dean for government procurement law studies at George Washington University Law School. “The free services are allowing the government to bypass a competitive procurement process and locking them in for future procurements,” she said.

Tillipman said that, in the future, the government should consider restrictions on gratuitous services in IT in order “to ensure you’re not locked in with a vendor who gets their foot in the door with a frighteningly expensive” giveaway.

“This is all designed to undermine future competitions,” she said.

James Nagle, a former Army contracting official and practicing attorney who specializes in the federal contracting process, went even further, saying that the White House Offer potentially violated existing law.

The Federal Acquisition Regulation, which governs government procurement, says that employees may not accept “gratuities,” or anything of value “from anyone who has or is seeking to obtain Government business.” And, as employees involved with the White House Offer told ProPublica, Microsoft was seeking future contract upgrades and new Azure revenue.

While “gratuities” are typically considered to be perks such as free meals, sports tickets or other gifts for personal use, Nagle argued that the rule could apply to the White House Offer, though he said he was not aware of any prior case using his interpretation. He compared it to a car manufacturer providing a government agency with a fleet of cars for a year for free because it wants the agency to procure that fleet for its staff. “Any contracting officer would say, ‘No, you can’t do that,’” Nagle said. Once employees get used to the cars, they’re reluctant to switch, he said, and the “impermissible gift” would create a built-in bias toward that manufacturer.

“That’s the problem here,” Nagle said. “This is not truly gratuitous. There’s another agenda in the works.”

Microsoft did not use the so-called gratuitous services agreements to give away the G5 upgrades, as it did for the consulting services. Instead, Faehl told ProPublica, the company considered them “a 100% discount” added to existing customer contracts. He said making this type of “strategic investment is … common practice among companies” and that contract teams on both sides reviewed the deals. Nagle viewed it differently, characterizing the free products as a “loss leader designed to lead to future sweetheart deals.”

Federal vendors may be banned from government contracting for violating the Federal Acquisition Regulation, though such an outcome would be highly unlikely for a vendor as large as Microsoft, Nagle said. Nonetheless, individual employees on both sides of improper deals in the past have been held accountable, he said.

Skirting fiscal law, however, may have set the stage for an even more serious legal concern, said Christopher Sagers, a professor of antitrust law at Cleveland State University in Ohio. Microsoft’s actions, Sagers said, might constitute what is known in antitrust law as “exclusionary conduct,” opening the door for illegal monopoly. “Microsoft, rather than competing on the merits, took steps to exclude competitors by making its product sticky in advance of opportunities for competition,” he said. The company used “an already dominant position to further cement their position.”

Microsoft disputed that point.

“We don’t believe our offer raised antitrust concerns, and we constructed it specifically to avoid any such issues,” a company spokesperson said. “We talked informally with a White House staffer about this.”

Wu, however, said the company did not make clear to him the financial and competitive implications of the offer.

“There is no way that was discussed,” Wu told ProPublica. “The only thing that Brad mentioned was upgrading federal agencies, offering them better stuff.” Upon hearing the news organization’s findings, he said: “That is a lot darker than it sounded. Once you’re in somewhere, it’s very hard to leave.

“Now I’m starting to feel guilty in some weird way about playing a role in a big deal that cost taxpayers money,” Wu said.

Taking Out the Competition

Former Microsoft salespeople said that all of the customers within the Defense Department who signed on to the White House Offer — including all the military branches — ultimately upgraded to the G5 and began paying for it when the time came to renew their agreements in 2022 and 2023.

A Defense Department spokesperson said in a written statement that the department followed federal acquisition law and “conducted internal tests and evaluations of multiple vendor capabilities.” The upgrade, the spokesperson said, was “crucial” to meeting the department’s cybersecurity objectives. The department declined to answer follow-up questions, including to specify which vendors it evaluated before deciding on the G5.

John Sherman, the department’s chief information officer at the time of the White House Offer dealmaking, defended both the government’s decision and Microsoft’s strategy. “I am sure Microsoft, like any company, would be trying to increase their business with any customer,” he told ProPublica.

He added, “We didn’t have any particular preference for Microsoft in terms of favoritism or anything like that, but we knew it worked, which is why we wanted to proceed with that.”

Many civilian agencies also upgraded to the G5 during this timeframe, said Sondhi, who now works at Microsoft competitor Trellix as chief technology officer for the company’s public-sector business.

For Microsoft, winning more government business was only half the picture. It also saw the White House Offer as an opportunity to knock out its competitors.

During and after their sales push, Microsoft salespeople advised government departments and agencies to remove competing products from their IT lineups to cut costs, saying the Microsoft bundle would render those other products redundant. Internally, employees called it the “take-out” strategy. “The play is: ‘You’re paying for it in the G5. It’s a waste of government money to have both,’” a former sales leader who worked with the Defense Department told ProPublica.

Sondhi said that in a typical scenario, an upgrade to the 5-level can displace the existing work of a half dozen vendors or more. Executives from cybersecurity companies Trellix and Proofpoint, for example, told ProPublica they lost federal business in the wake of the White House Offer deals.

The White House Offer also enhanced Microsoft’s competitive position by reducing the likelihood that the government would open bidding for cybersecurity products in the future, given the cornucopia of offerings in the G5. Within the company, this was known as “taking opportunities off the street,” former sales leaders said.

The fallout impacted companies that were in the midst of completing the authorization process the government requires of vendors providing cloud-based services. Several told ProPublica that cybersecurity contract opportunities are now scarce.

“We are chipping away, but it’s largely, by far, a Microsoft-owned landscape,” an executive at one competing vendor told ProPublica.

Faehl dismissed those complaints, saying that customers kept the upgrades because they performed well and that competitors “should look inward to see why their products do not meet or exceed Microsoft results.”

Reckoning With the “Monoculture”

Microsoft has something few other companies possess: a panoply of products that span the IT ecosystem. Rivals say the company leveraged its existing dominance in certain products — like the Windows operating system and classic workplace applications — to gain dominance in others, namely cybersecurity and cloud computing.

“No one has the kind of capital that Microsoft does,” Sondhi said. “They can just absorb the cost of the giveaway until the customer’s first bill.”

A coalition backed by some of Microsoft’s major competitors, including Google and Amazon, has raised similar issues with the Federal Trade Commission, which in 2023 gathered public comments on the business practices of cloud computing providers. Among the FTC’s areas of ongoing interest: “Are there signs that cloud markets are functioning less than fully competitively, and that certain business practices are inhibiting competition?”

Competition is not the only issue at stake. As Washington has deepened its relationship with Microsoft, congressional leaders have raised concerns about what they call a cybersecurity “monoculture” in the federal government. Some, like Wyden and Sen. Eric Schmitt, a Republican from Missouri, have blasted the Defense Department in particular for “doubling down on a failed strategy of increasing its dependence on Microsoft.”

“Although we welcome the Department’s decision to invest in greater cybersecurity, we are deeply concerned that DoD is choosing not to pursue a multi-vendor approach that would result in greater competition, lower long-term costs, and better outcomes related to cybersecurity,” the two lawmakers wrote in a letter to Sherman, then the department’s chief information officer, in May.

Microsoft’s Faehl pushed back. “The suggestion that our customers are any more at risk because they use Windows, or Azure, or Office is wrong,” he said. “We partner closely with our security competitors because we see them as partners against threat actors we face in common.”

Still, just last year, Chinese hackers exploited Microsoft security lapses to breach the email accounts of senior U.S. officials. Investigating the attack, the federal Cyber Safety Review Board faulted the company for a “cascade of … avoidable errors” and pressed it to overhaul its security culture. Microsoft has since pledged to place security “above all else.” In June, Smith told Congress that Microsoft would strive to establish a “culture that encourages every employee to look for problems, find problems, report problems, help fix problems and then learn from the problems.”

It’s learning from the successes, too. The same week that Smith testified before Congress, and nearly three years after Nadella made his commitment at Biden’s summit, Microsoft made a new offer, this time to “support hospitals serving more than 60 million people living in rural America.”

The playbook was familiar. In its announcement, the company said that eligible hospitals could have the private-sector equivalent of the G5 “at no cost for one year.” As before, Faehl said Microsoft made the commitment “at the behest of the White House.”

For Lincare, paying multimillion-dollar legal settlements is an integral part of doing business.

The company, the largest distributor of home oxygen equipment in the United States, admitted billing Medicare for ventilators it knew customers weren’t using (2024) and overcharging Medicare and thousands of elderly patients (2023). It settled allegations of violating a law against kickbacks (2018) and charging Medicare for patients who had died (2017). The company resolved lawsuits alleging a “nationwide scheme to pay physicians kickbacks to refer their patients to Lincare” (2006) and that it falsified claims that its customers needed oxygen (2001). (Lincare admitted wrongdoing in only the two most recent settlements.)

Such a litany of Medicare-related misconduct might be expected to provoke drastic action from the Department of Health and Human Services, which oversees the federal health insurance program that covers 1 in 6 Americans. Given that most of Lincare’s estimated $2.4 billion in annual revenues are paid by Medicare, HHS wields tremendous power over the company.

Sure enough, as part of the 2023 settlement, HHS placed Lincare on the agency’s equivalent of probation, a so-called corporate integrity agreement. The foreboding-sounding document includes a “death penalty” provision: Any “material breach” of the probation agreement, which runs for five years, “constitutes an independent basis for Lincare’s exclusion from participation in the Federal health care programs.” Such a ban could effectively kill Lincare’s business.

That sounds dire. Except that before that corporate integrity agreement was signed in 2023, Lincare was under the same form of probation, with the same death penalty provision, from 2018 to 2023, and violated its terms. From 2006 to 2011, Lincare was similarly on probation and also violated the terms, according to the government. And before that — well, you get the picture. Lincare has been on probation four times since 2001. And despite a pattern not only of fraud, but of breaking its probation agreements, Lincare has never been required to do more than pay settlements that amount to pennies relative to its profits.

This is not an aberration. While HHS routinely imposes the death penalty on small operations, it has never barred a national Medicare supplier like Lincare from continuing to do business with the government. Some companies, it seems, are too big to ban.

Lincare’s lengthy record of misbehavior isn’t a surprise to people in the medical equipment business. What is surprising is the federal government’s willingness to pull its punches with a company that has fleeced taxpayers and elderly customers again and again.

Federal officials have never pursued the company executives who oversee this behavior even though two of them, Chief Operating Officer Greg McCarthy and Chief Compliance Officer Jenna Pedersen, have worked at Lincare through all four of the company’s probationary periods. No one has faced criminal charges for activity the government’s own investigators deemed fraud.

Medicare has continued to pay Lincare billions even as many of the company’s customers revile it. Evaluations on customer-review websites are lacerating, and complaints to state attorneys general abound. On the Better Business Bureau’s website, 888 reviewers gave Lincare an average score of 1.3 out of 5. They cite dirty and broken equipment, charges that continue even after equipment has been returned, harassing sales and collection calls, and nightmarish customer service. As one person wrote in April, Lincare is “running a scam where they have guaranteed income” and “the customer can’t do a thing.”

HHS has always been reluctant to cut off big suppliers. Medicare’s first objective is to make sure nothing interrupts the flow of medications, devices and services to beneficiaries. And were HHS to seek to ban Lincare, the company would surely launch a long, costly legal war. But even if the cost of such combat reached many millions of dollars, it would still be a tiny fraction of the amount lost to fraud, which is yet another contributor to the soaring medical costs that bedevil the country. “This is taxpayer money,” said Jerry Martin, a former U.S. attorney who represented an ex-Lincare executive in a whistleblower suit against the company. “We need to pay people that don’t have four corporate-integrity agreements.”

Weak enforcement is not the only problem. Lincare is paid to rent oxygen equipment to patients, with HHS covering most of the monthly bills. But those rental fees often add up to many times what it would cost simply to buy the equipment. “If this were a rational country,” Bruce Vladeck, who ran Medicare from 1993 to 1997, told ProPublica, “the government would buy a million [oxygen] concentrators and pay Amazon or somebody to deliver them.”

In a seven-month investigation, ProPublica examined how Medicare’s largest provider of home medical equipment has managed to take advantage of its customers for a quarter of a century while fending off meaningful enforcement. ProPublica interviewed more than 60 current and former employees and executives, Medicare and Justice Department officials, patient advocates, and health care experts. ProPublica also reviewed dozens of court cases involving Lincare and thousands of pages of internal company documents, sales presentations and emails.

The investigation reveals a dismal picture of a company with a sales culture that depends on squeezing infirm and elderly patients and the government for every penny. Lincare employees are pressured to sell — whether a customer needs a product or not — on pain of losing their jobs.

And the company’s record of misbehavior and conflict extends far beyond its sales and billing practices. Lincare has paid $9.5 million in settlements for data breaches and mishandling patient and employee records. It has faced claims of violating wage rules, harassing customers with sales and collection calls, and tolerating racist comments to an African American employee. (Lincare lost the latter suit at trial and is appealing.) The company has repeatedly sparred in court with former executives, including a 2017 suit in which longtime executive Sharon Ford claimed that the company had cheated her out of a $1 million bonus. (A judge ruled in favor of Ford at trial before the case was overturned on appeal.) Ford testified that Lincare had earned an industry reputation as “The Evil Empire.” And when Lincare’s CEO, Crispin Teufel, resigned last year to become CEO of a rival company, Lincare sued him for breach of contract and misappropriating trade secrets. Teufel ultimately admitted to downloading confidential company records and was blocked from taking the new job. (Teufel did not respond to requests for comment. His replacement, Jeff Barnhard, took over as Lincare’s CEO in July 2023.)

Lincare declined multiple requests to make executives available for interviews. After ProPublica provided a lengthy document listing every assertion in this article, along with separate such letters to executives McCarthy and Pedersen, the company responded with a three-paragraph statement. It asserted that Lincare is “committed to delivering high-quality and clinically appropriate equipment, supplies, and services” but acknowledged “missteps in the past.” The company said its “new leadership” had “commenced a comprehensive review of our policies and procedures to help ensure we are complying fully with all state and federal regulations” and that “investments and enhancements we have made over the last several months will help prevent these issues from repeating in the future.” Lincare did not respond to follow-up questions requesting examples of the steps the company says it’s taking, including whether it has terminated any executives as part of this push.

When ProPublica asked a top Medicare enforcer why Lincare had eluded banishment, her answer suggested she views probation as a continuing ed class rather than a harsh punishment. “It’s like taking a college course,” said Tamara Forys, who is in charge of administrative and civil remedies for HHS’ Office of Inspector General. “At the end of the day, it’s really up to you to change your corporate culture and to study, to learn to pass the class … to embrace that and take those lessons learned and move them forward.” A spokesperson for the Centers for Medicare and Medicaid Services, which runs Medicare, declined to comment on Lincare but said the agency “is committed to preventing fraud and protecting people with Medicare from falling victim to fraud.”

There’s little incentive to refrain from misbehaving in an environment that tolerates bad behavior, said Lewis Morris, who was chief counsel to HHS’ Office of Inspector General from 2002 to 2012. “As long as that [settlement] check is less than the amount you stole, it’s a good business proposition."

Indeed, Lincare has counted on the government’s tepid response, two former company executives told ProPublica. Top management, they said, responds to fraud warnings by conducting a cost-benefit analysis. “I’ve sat in meetings where they said, ‘We might have $5 to $10 million risk — if caught,’” said Owen Kirk Staggs, who ran one of Lincare’s businesses in 2017 and fell out with the company. “‘But we’ve made $50 million. So let’s go for it. The risk is worth the reward.’”

Libby, Montana, provides a glimpse of the way Lincare operates. Oxygen is an urgent need in this mountain town of 2,857. Libby suffers from the lingering effects of “the worst case of industrial poisoning of a whole community in American history,” in the words of the Environmental Protection Agency. An open-pit vermiculite mine, which operated from 1963 to 1990, coated the area — and residents’ lungs — with needle-like asbestos fibers. More than 2,000 Libby citizens have been diagnosed with respiratory diseases since then; some 700 have died.

Hundreds of ailing residents relied on Lincare for home concentrators, which provide nearly pure oxygen extracted from room air. Medicare and Medicare Advantage plans (which the government also funds) covered 80% of the monthly rental of about $135; patients paid the remaining 20%.

In 2020, Brandon Haugen noticed something suspicious in Lincare’s bills. Haugen was a customer service representative at the company’s local distribution site, one of 700 such locations around the country. (Lincare serves 1.8 million respiratory patients in 48 states.)

Lincare was allowed to charge patients and their insurers for a maximum of 36 months under federal rules. After that point, patients could use the equipment without further charge. Lincare, however, kept billing local patients and their Medicare Advantage plans far beyond 36 months — in some cases, for years. To Haugen, this looked like fraud.

Haugen conferred with center manager Ben Montgomery. The two, who had grown up in the area, had been buddies since seventh grade, after getting to know each other at summer Bible camp. Then 38, earnest and just beginning to gray out of their boyishness, the two men were concerned. The patients the men dealt with were their neighbors.

A regional Lincare manager assured them that charging beyond 36 months for Medicare Advantage patients “is the correct way to bill.” Skeptical, Montgomery raised the issue with Lincare’s headquarters in Clearwater, Florida. Lincare’s compliance director told him, according to Montgomery, that “it’s the patients’ problem to fix it if they want it to stop”; that was “just how it worked.” Further questions, sent to Lincare’s chief compliance officer, Pedersen, went nowhere. “It seemed pretty obvious they were well aware of this,” Montgomery told ProPublica. “For me, these were my customers that you were screwing over.”

Among them was Neil Bauer, now 80, who lives in a ramshackle house “out in the boondocks,” as he put it, 38 miles southeast of Libby. Bauer spent his career as a barber, head of investigations for the county sheriff’s department and a member of the local school board. He’s been on oxygen for more than a decade and quickly gets short of breath. “I can’t do stuff so much now,” he said. His wife is on oxygen, too. “We just have a sick family,” Bauer said.

Lincare had kept billing Bauer for his concentrator for seven years after it was supposed to stop. The monthly copays weren’t huge, but they added up to $2,325 that he shouldn’t have been charged over that period, a daunting sum for Bauer, who lives on a fixed income — and a hefty mark-up over the cost of the equipment, which can be purchased online for $799. For its part, Medicare Advantage paid Lincare $9,299 for Bauer’s concentrator during this period, along with another $5,760 for the months Lincare was legally permitted to bill. All told, the rental payments to Lincare, during authorized and unauthorized periods, were $16,547 for that one $799 piece of equipment. “We paid forever,” said Bauer. “Never was I told that we could have one without having to pay anything.”

Haugen and Montgomery studied billing records. Among the customers in their tiny office, Lincare was improperly charging at least 33 people and their Medicare plans. The two began to wonder how far this problem extended. An employee in Idaho confirmed the same practice was occurring there. “In my mind,” Montgomery said, “I went, ‘This is Libby, Montana. Multiply that by every center in the country. This is obviously a lot bigger deal.’”

Montgomery and Haugen had seen enough. On Jan. 18, 2021, they emailed a joint resignation letter to Lincare’s top management, recounting their concerns about billing that “likely affects thousands of patients company wide.” Citing the lack of response from corporate officials, they wrote, “we can only conclude that this is a known issue that is being covered up by Lincare.”

Haugen had 10 children. Montgomery had four. Neither man had another job lined up. “Had this not happened,” said Montgomery, who had been at the company for 13 years, “I would have seen myself retiring from Lincare.”

Instead, they became whistleblowers. They retained a law firm and sued Lincare in Spokane, Washington, the site of Lincare’s regional headquarters. After federal prosecutors decided to back the case, Lincare settled in August 2023. The company admitted to overbilling Medicare plans and patients across the country for years and paid $29 million to settle the matter, with $5.7 million of that going to Montgomery, Haugen and their lawyers. Dan Fruchter, the assistant U.S. attorney leading the government’s case, told ProPublica that the overbillings likely involved “tens of thousands” of patients.

Lincare agreed to its fourth stint of probation with HHS; the new corporate-integrity agreement took effect on the day after the previous one expired. The conduct Montgomery and Haugen flagged had gone on for years while the company was already on probation. But Lincare got the government lawyers to agree that nobody would try to impose the Medicare death penalty. Lincare asserted in the settlement that it had installed software (which it did only after learning of the government investigation) that will prevent billing beyond 36 months. Lincare promised to ensure “full and timely” compliance with the agreement and prevent future wrongdoing.

Medicare fraud, including in the “durable medical equipment” category that Lincare operates in, has long been an intractable problem. It cost the U.S. Treasury an estimated $60 billion in 2023 alone.

The government deploys large sums to try to stop it. HHS’ inspector general’s office has a $432 million budget and a staff of 1,600. Those resources are effectively extended by whistleblowers — most of the cases against Lincare have been such suits — who can receive a percentage of a civil settlement if they reveal wrongdoing, and by federal prosecutors, who can also bring cases or join those filed by whistleblowers. Last year HHS recovered $3.2 billion from fraudulent schemes.

But the agency’s enforcers have wielded their biggest deterrent almost entirely against small perpetrators. In 2023, they banned 2,112 small firms and individuals from Medicare reimbursement.

HHS hasn’t done the same with companies that operate on a national scale. Forys, the agency enforcer, said she worries that expelling a big provider from Medicare could leave customers in the lurch. In April, Inspector General Christi Grimm defended her office’s work in congressional testimony but also asserted that its resources are inadequate. A lack of staff keeps it from even investigating “between 300 and 400 viable criminal and civil health care cases” annually, she testified, as well as more than half the fraud referrals from Medicare’s outside audit contractors.

A different reason for going easy on big companies was suggested by Vladeck, the former Medicare chief. Seeking to bar a large supplier for repeatedly violating probation would require exhaustive documentation and years of litigation against squadrons of well-paid corporate lawyers. As a result, Vladeck said, “there’s a real incentive, from a bureaucratic point of view, to just slap their wrist, give them a kick and make them apologize. … It’s a cost of doing business.”

There are steps enforcers could take, but almost never do, that would make companies take notice, according to Jacob Elberg, a former federal prosecutor who is now a professor at Seton Hall Law School. (Among his publications is a 2021 law review article titled “Health Care Fraud Means Never Having to Say You’re Sorry.”) Elberg’s research shows that HHS and prosecutors tend to negotiate far smaller civil settlements than the law allows, and they rarely prosecute company executives. They also almost never take cases to trial. In short, enforcers have long signaled to companies that they’re looking for a smooth path to a cash payment rather than a stern punishment for a company and its leaders. “It is generally a safe assumption,” Elberg said, “that the result will be a civil settlement at an amount that is tolerable.”

For its part, Congress may soon be weighing a new law that would reshape how the oxygen industry is paid by Medicare. But rather than clamp down on corporations, the legislation seems poised to do the opposite. A new bill called the SOAR (Supplemental Oxygen Access Reform) Act would hand companies like Lincare hundreds of millions more, by raising reimbursement rates and eliminating competitive bidding among equipment providers. Advocates say the legislation will help patients by making some forms of oxygen more available and improving service. But along the way it will reward Lincare and its rivals.

Congress has a history of treating oxygen companies generously. For years, lawmakers set Medicare reimbursements for oxygen equipment at levels that even HHS, in 1997, characterized as “grossly excessive.” Over the succeeding decade and a half, Lincare took advantage, snatching up hundreds of small suppliers and becoming the industry’s largest player.

In 2006, under pressure to reduce costs, Congress approved steps to curb oxygen payments, including the introduction of competitive bidding and the 36-month cap on payments for equipment rentals. But even those strictures were watered down after the industry poured money into political contributions and lobbyists, who warned that cuts would harm elderly patients.

Lincare compensated by amping up strategies that generated profits, with little apparent regard for Medicare’s rules, which say it will reimburse costs for equipment only when there is evidence of “medical necessity.” The company aggressively courted doctors and incentivized sales, through bonuses the company paid for each new device “setup.” According to a 2016 commission schedule, reps could earn $40 for winning an order for a new sleep apnea machine, $100 for a new oxygen patient and $200 for a noninvasive ventilator. The entire staff of each Lincare center could receive a small bonus for signing up a high percentage of new patients for automatic monthly billing. Patients who refused auto-billing, a company document advised, should be warned they might face “collection activity” and service cutoffs. “Sales is our top priority!” declared a 2020 PowerPoint to train new hires.

Once it had a customer, Lincare would pitch them more costly products and services. One way Lincare did this was through a program called CareChecks. Promoted as a “patient monitoring” benefit, CareChecks were aimed, according to a company presentation, at generating “internal growth.” If a patient exhibited a persistent phlegmy cough, Lincare could persuade their doctor to prescribe a special vibrating vest to loosen chest mucus. Nebulizer patients might be candidates for home oxygen. Patients using apnea devices were potential candidates for ventilators. “We’d make patients think we were coming in clinically to assess them,” a former Lincare manager said, “when really it was to make money off of them.”

Selling replacement parts could also be lucrative. At Lincare call centers that sold items like hoses, masks and filters for CPAP machines (used to treat apnea), hundreds of commissioned agents in Nashville, Tennessee, and Tampa, Florida, were equipped with programs displaying what items each patient was eligible for under Medicare. By law, patients had to request replacement parts. But frequently, that wasn’t what happened, according to Staggs, who oversaw the CPAP business in 2017. He discovered that top salespeople, whose bonuses could total $8,000 a month, averaged just a few minutes on the phone per order. That wasn’t nearly enough time to identify what items, if any, customers actually needed. Staggs listened to recorded calls and found that, after reaching customers, agents often placed them on hold until they hung up, then ordered them every product that Medicare would cover.

At Lincare, results were closely tracked and widely shared in weekly emails displaying the best and worst performers in each region. Notes taken by one manager show supervisors’ performance demands during weekly conference calls: “Unacceptable to miss goal … stop the excuses … If this is not being done, wrong [center manager] in place … If you’re not getting O2 and not getting Care Checks — you shit the bed. Stop accepting mediocre, lazy responses ….”

“If we didn’t meet our quota, they were going to chop our heads,” said former Illinois sales rep Sandra Gauch, who worked for Lincare for 17 years before joining a whistleblower suit and quitting in 2022.

One salesperson was so fearful of missing her quota, according to Gauch, that she signed her mother up for a ventilator that she didn’t need. A company audit in 2018 found that only 10 of 56 ventilator patients at one center were using them consistently. Some patients hadn’t used their devices for years. Yet Lincare kept billing Medicare.

Only one thing mattered as much as maximizing new equipment rentals, according to former employees and company documents: minimizing customers’ attempts to end rentals. A call to retrieve breathing equipment meant that it was no longer wanted or being used, and Lincare was supposed to retrieve it and promptly stop billing Medicare and the patient. The person’s health might have improved. They might have gone into the hospital — or died. The reason didn’t matter; at Lincare, “pickups” were a black mark, deducted from employees’ performance scores, jeopardizing their bonuses and jobs.

As a result, employees said, such requests were dreaded, delayed and deterred. Clinical staff were sent to “reeducate” customers to keep using their devices. Patients were told they’d need to sign a form stating they were acting “against medical advice.”

Lincare managers made it clear that pickups should be discouraged. In a 2010 email, an Ohio center manager instructed subordinates: “As we have already discussed, absolutely no pick-ups/inactivation’s are to be do[ne] until I give you the green light. Even if they are deceased.” In 2018, an Illinois supervisor emailed her deputies that pickups were barred without her explicit approval: “Not even Death that I don’t approve first.”

In February 2022, Justin Linafelter, an area manager in Denver, responded to the latest corporate email celebrating monthly “Achievement Rankings” for oxygen sales by pointing out that almost all of the centers atop the rankings had at least 150 “pending pickups,” customers who weren’t using their equipment but whom the company appeared to still be billing. “Some of these centers are just ignoring pickups to make this list.”

That was only one of Linafelter’s concerns. In July of that year, he emailed headquarters, saying he no longer had “the resources to be successful at my job.” The customer service staff in Denver had been cut in half, Linafelter explained, and he’d been barred from hiring replacements. Denver’s remaining staff was “at a point of exhaustion,” threatening patient care.

The morning after Linafelter expressed concerns to Lincare in 2022, he was summoned to a conference call with the head of HR and fired, for what he was told was a “corporate restructuring.” Linafelter, who had worked at Lincare for nine years, said, “I got thrown away like a piece of trash.”

Other former employees offer similar accounts. In 2020, Jillian Watkins, a center manager in Huntington, West Virginia, repeatedly alerted supervisors that Lincare was improperly billing for equipment that patients weren’t using. Lincare blocked her from firing a subordinate who’d falsified documents supporting the charges, then fired Watkins, citing “inadequate direction and leadership.”

Then came a series of turns. Pedersen, the chief compliance officer, effectively confirmed Watkins’ assertions, belatedly alerting the government about $486,000 in improper billings by Lincare. But Pedersen blamed the billings on Watkins, writing to Medicare that the company had “terminated” her to “prevent [the problem] from recurring.” After Watkins sued, Pedersen admitted in a deposition that Watkins’ firing “had nothing to do with the overpayment.” In April 2024, a federal judge ruled that Watkins had presented “a prima facie case of retaliation.” The suit was privately settled in mediation.

Staggs, too, was ousted, he said, after he warned top Lincare executives about improper practices at the CPAP call centers. Staggs emailed a Lincare HR officer: “Patients are being shipped supplies that they never have ordered. … This is fraud and I have gotten zero support or attention to this matter when I raise the issue to my leadership.” Only months after starting, he was fired in November 2017. He later filed a whistleblower suit; Lincare denied wrongdoing. After the U.S. attorney’s office in Nashville declined to join the case in 2022, Staggs withdrew the action.

Staggs’ account of improper billings matches an industry pattern that appears to continue to this day. In a 2018 report, HHS’ inspector general estimated that Medicare had paid more than $631 million in improper claims for CPAP and other supplies over a two-year period. Another HHS analysis identified an additional $566 million in potential overpayments for apnea devices.

The agency’s oversight “was not sufficient to ensure that suppliers complied with Medicare requirements,” the 2018 report concluded. Six years later, HHS has not taken public action against Lincare relating to CPAPs.

Today, fraudulent billing among Medicare equipment providers remains a “major concern,” according to the inspector general. The agency says it continues to review the issue.

With pink manicured nails that matched her trim pink blazer, she tapped out a message on her phone to a top election lawyer for the Trump campaign and the Republican National Committee. “Got it passed,” she wrote to Gineen Bresso, photographs reviewed by ProPublica show.

What had passed that September afternoon in Atlanta was a state rule, championed by Adams, that would allow poll watchers like those she’d trained to gain greater access to sensitive areas in counting centers where votes were being tallied. The rule was a priority for supporters of former President Donald Trump who are looking to pave the way to challenge election results if their candidate loses this week’s vote.

The win was one in a string of them for Adams, who quickly ascended from a little-known, financially troubled conservative activist to a surprise appointee to the Fulton County board of elections. Her note to Bresso signaled not just this particular victory but the extent to which the 61-year-old has used her new perch to carry out the efforts of national players seeking to tilt the election in Trump’s favor.

Fulton itself is significant in state and national politics for a host of reasons: its sheer concentration of Democratic voters (380,000 in 2020, more than any other Georgia county), the scrutiny it received from national election skeptics after Trump lost the state by fewer than 12,000 votes — and, now, its newest election board member’s outsize role in trying to influence Georgia’s election processes.

Her actions in her nine months on the Fulton County board have been prodigious. She secretly helped push another, arguably higher-stakes rule through the state election board that vastly expanded the authority of county board members to refuse to certify votes they deem suspicious. She herself refused to certify the results of the presidential primary in March (though the board’s Democratic majority overruled her), and then she sued her board and election director, asserting local officials should be allowed to refuse to certify vote totals if there are discrepancies, which experts say are almost always innocuous. Some of her lawyers in that case work for the America First Policy Institute, an advocacy group staffed with former Trump officials.

So far, Adams’ efforts have mostly failed. Two judges have invalidated rules that Adams backed, with one calling them “illegal, unconstitutional and void.” But other efforts are still underway. The month after joining the Fulton County election board, Adams became regional coordinator for the Election Integrity Network, the group founded by lawyer Cleta Mitchell, who joined Trump on a call when he asked Georgia’s secretary of state to “find” him enough votes to overturn the 2020 election results there.

In that role, Adams runs weekly calls for Republican activists who have described Georgia’s voting as rigged, and she has pulled conservative members of local election boards into a loose coalition, many of whom have challenged results in their counties, too. And prominent conservative election lawyers, writers and national groups have used Adams’ push against certification in Georgia as the basis for a national argument.

Adams did not respond to numerous requests for comment or a detailed list of questions. Nor did representatives for the Election Integrity Network.

The Georgia-based group that hired Adams in 2022, Tea Party Patriots Action, has received millions of dollars from organizations closely tied to conservative legal activist and fundraiser Leonard Leo and billionaire Richard Uihlein, tax records show. Uihlein-backed groups launched unsubstantiated attacks on the legitimacy of voter rolls in at least a dozen states after the 2020 election.

A representative for Uihlein did not respond to questions. A representative for Leo would not elaborate on his contributions to organizations that supported Tea Party Patriots.

The true test of Adams’ effectiveness will come on Election Day — and, if the results in Georgia are anywhere near as close and consequential as they were in 2020, in the days and weeks beyond.

“She’s trying to help Trump win or trying to create chaos in the administration of the election in order to cast aspersions on it if he doesn’t win,” said Patrise Perkins-Hooker, who served as chair of the county election board when Adams joined. Perkins-Hooker described Adams’ work as centered on carrying out the agenda of right-wing activists and not making “the elections run smoothly or transparently.”

In response to ProPublica’s questions, the Republican National Committee provided a statement that said: “The Georgia state election board passed commonsense safeguards to secure Georgia's elections. The Trump-Vance Campaign and RNC supported these rules to bring transparency and accountability to the election process.” It also said, “The RNC defended these rules in court against attacks from Kamala and the DNC and will continue to fight against Democrat election interference.”

Back in 2020, Mitchell and others challenging the results across the country had to rely on disorganized groups of Trump supporters who came together at the last minute and were mostly unfamiliar with election systems. Experts now warn about the more pronounced impact that election deniers like Adams will have, given that they have come to occupy positions of power in local election administration. As Trump said at an October rally in North Carolina: “The vote counter is far more important than the candidate.”

When Adams placed her hand on a Bible in February and took an oath to fairly administer Fulton County’s elections, voting rights advocates and Democrats thought they had scored a victory. Eight months earlier, they had twice swatted back efforts by the county GOP to install an activist who’d made his name challenging residents’ voter registrations. The Republicans had sued to force the election board to accept him, then relented and put Adams forward instead.

“It was universal support for Julie,” said Earl Ferguson, a vice chair of the Fulton County Republicans, who has also filed challenges to voters’ eligibility and repeated debunked conspiracy theories about the reliability of voting machines at election board meetings. (Ferguson does not agree that the points he made about the machines were not valid.) “She is honest and very capable, and very pleasant.”

After Trump lost the 2020 election, Adams and a small group of conservative activists became regular attendees at election board meetings. On a few occasions, she addressed the board during the public comment period, questioning the integrity of the county’s elections and its certification process. But she was much less outspoken than other activists in the group.

“When Adams was appointed, little was known about her connections to election deniers to justify opposition,” said Max Flugrath, spokesperson for Fair Fight, the Georgia-based voting advocacy organization. “Voting rights groups instead focused on opposing candidates with documented anti-voter records.”

Adams had worked in human resources and executive recruiting. Records show she also had experienced major financial setbacks. She’d filed for bankruptcy in 2005, and her mortgage company had auctioned her Cobb County home on the courthouse steps in 2010. A landlord later sued her, and she agreed to pay more than $13,000 in back rent, according to a 2021 consent agreement.

That same year, she trained 32 poll watchers to monitor the 2021 municipal elections. And she told county commissioners that she believed some tally sheets from an audit of the 2020 election had been “falsified.”

In 2022, Tea Party Patriots Action, the politically active arm of one of the largest national Tea Party groups, hired Adams as a field director, paying her about $124,000 a year according to tax filings.

Her hire came at a time when the group was pulling in cash and intensifying its focus on election issues. Groups funded by Leo, who is seen as the architect behind the Supreme Court’s conservative supermajority, provided the Tea Party group and a related foundation at least $1.1 million between 2020 and 2022, records show, including a 2021 grant related to election integrity. The group also hired Leo’s firm as consultants.

In 2022, Tea Party Patriots Action more than doubled its annual revenue, thanks in part to a $2.5 million grant from Restoration of America — which is backed by Uihlein, the billionaire owner of the packing supplies company Uline. That year, former Trump campaign official Gina Swoboda was a Restoration for America executive director. Restoration has spent the years since Trump lost in 2020 pushing the unfounded idea that discrepancies in voter roll data between the number of votes and the number of ballots cast are evidence of fraud, despite insistence by elected officials from both parties that the claims are baseless.

That year, the Tea Party group added a program to bring in poll watchers and workers in Georgia, records show. And it had Adams in place.

Representatives for the Tea Party group and Restoration of America did not respond to requests for comment. Swoboda did not respond to questions.

Adams has run scores of poll watcher and worker online trainings, with some drawing dozens of people, records reviewed by ProPublica show. In a May training, Adams listed over 10 things that she wants trainees to report, from the serial numbers on voting machines to the names of poll managers. “There’s no such thing as too much documentation,” she said in a recording of a May training. “If something doesn’t feel right to you, you need to write it out.”

At an October training, she told the roughly three dozen attendees, including those joining from out of state, to first report discrepancies to their state GOP and RNC hotlines and then to VoterGA, an organization whose leader has cast doubt on the outcome of the 2020 election. The Republican Party and right-wing organizations plan to use the poll watchers’ reports in post-election litigation, ProPublica has reported.

“VoterGA has an 18-year proven track record of nonpartisan activity,” said co-founder Garland Favorito. “Republicans and Democrats are told to call their own party hotlines for election issues. We have no plans or resources to file any type of speculative litigation in any matter.”

While working for the Tea Party, Adams also led weekly meetings frequented by prominent state activists, RNC officials, GOP county heads, conservative election board members and voter registration challengers, according to records including emails obtained by the watchdog group Citizens for Responsibility and Ethics in Washington and shared with ProPublica.

Agendas included subjects such as “Voter Integrity concerns for 2024 Elections” and warnings like “New York Times Reporter traveling to several counties in Georgia.”

In 2022, Adams had appeared at the Election Integrity Network’s Georgia chapter launch and was described the following year as its state liaison in social media posts by other activists.

But much of her work was done behind the scenes. So when the county GOP nominated her to join the election board in the heavily Democratic Fulton County, commissioners approved the choice 6-0.

After Adams joined the board in February, it did not take long for fellow members to begin worrying about her intentions. The board is made up of four political appointees, two by each party, led by a chair chosen by the Democratic-majority county commission. Traditionally, the board’s primary goal has been to make Fulton elections run smoothly, past and present board members said.

However, Perkins-Hooker, the chair when Adams joined, said that during meetings, she could see Adams receiving text messages from a Republican activist “telling her what to say, and what to do.” After Perkins-Hooker stepped down in April, the new chair banned board members from using phones during meetings.

“She came with a mission to try and paint our elections as being fraught with fraud and incompetency,” said Perkins-Hooker, an opinion echoed by other board members.

Adams had been on the board for just a few weeks when, in March, she was elevated to regional coordinator for the Election Integrity Network, the organization that Mitchell, Trump’s lawyer, had launched. The new position put her near the top of the leadership’s organizational chart.

Adams quickly began pushing conservative priorities at election board meetings. She wanted poll watchers to have more access to vote tallies from election machines. And she was very concerned about the mechanics of certifying elections. Though a century of case law says that certification is a mandatory duty for officials like her — whom experts compare to scorekeepers, not referees — Adams began questioning if she had to do it. She demanded reams of information she said that she needed to be certain of the results before certifying.

At Adams’ third meeting, in March, she and the other Republican board member shocked Democratic board members by voting against the certification of the presidential primary election — though the Democratic majority overruled them.

Adams’ push to have power over certification of election results couldn’t succeed under the state’s current rules, so she set out to change them.

To do so, she lobbied to remake the body that determined them, the State Election Board, which at the time was composed of two moderate Republican members, two MAGA-aligned members and a Democrat. She activated the coalition she had been building with the support of national Republicans, inviting them to a March meeting where the goal was to ensure that the moderate Republican on the State Election Board was replaced. “The Georgia House of Representatives needs to take action immediately!!!!” the meeting invitation read, providing the phone number of the speaker of the house.

Not long afterward, the speaker replaced that board member with a conservative media personality whom Trump would soon praise by name at a rally.

The new Trump-backed majority quickly began passing rules that the prior board had criticized as illegal, including one, originally pushed by Adams, expanding the power of county board members to refuse to certify votes they found suspicious. It was passed by the new board along with another rule potentially allowing county board members to delay certification.

A national outcry ensued, with The New York Times calling it “The Republican Plan to Challenge a Harris Victory.”

Three of the nation’s leading conservative election lawyers backed the new rules. A conservative group ran ads targeting swing state election officials that echoed the lawyers’ arguments. And the certification rule Adams pushed became a talking point for conservative media outlets. One article in The Federalist argued that it “could stop leftists from bullying election officials into certifying results without completing their duties.” Lawyers for the Republican National Committee and a Trump-aligned conservative think tank also defended the certification rules in Georgia superior court, testing arguments that certifying election results was optional.

Adams’ arguments that certification is not mandatory inspired David Hancock, a GOP member of Gwinnett County’s election board, to vote against certifying the same presidential primary as Adams. (He described several minor inconsistencies as sufficient reason for him not to certify.) “It was, like, a big deal,” Hancock said of Adams’ decision to vote against certifying.

Because two judges in October invalidated the new rules passed by the State Election Board, the mechanics of the election this week will be the same as before Adams’ pushes to empower poll watchers and county election board members.

But at a combative Fulton County board meeting the week before the election, Adams made clear that she wasn’t going to let the judge’s rulings stop her from continuing her campaign. Despite the county’s lawyer telling her that the certification rule she had pushed had been stayed, she argued that it had actually not been, citing her lawyers. “I’ve learned how the system works — or at least how it was supposed to work,” Adams said. “I’ve learned how sometimes it doesn’t work as the law requires, right here in Fulton County.”

The firm’s use of workers in Mexico was confirmed by a spokesperson for Trump Media, which operates the Truth Social platform. The workers were hired through another entity to code and perform other technical duties, according to a person with knowledge of Trump Media. The reliance on foreign labor was met with outrage among the company's own staff, who accused its leadership of betraying their “America First” ideals, the person said.

The outsourcing to Mexico helped prompt a recent whistleblower letter from staff to Trump Media’s board that has been roiling the company.

That complaint, reported by ProPublica last month, calls for the board to fire CEO Devin Nunes, a former Republican congressman. The letter alleges he has “severely” mismanaged the company. It also asserts the company is hiring “America Last” — with Nunes imposing a directive to hire only foreign contractors at the expense of “American workers who are deeply committed to our mission.”

“This approach not only contradicts the America First principles we stand for but also raises concerns about the quality, dedication, and alignment of our workforce with our core values,” the complaint reads.

A Trump Media spokesperson said the company uses “two individual workers” in Mexico. “Presenting the fact that [Trump Media] works with precisely two specialist contractors in Mexico as some sort of sensational scandal is just the latest in a long line of defamatory conspiracy theories invented by the serial fabricators at ProPublica,” the spokesperson said.

The spokesperson declined to answer other questions about the company’s Mexican contractors, including how much they’ve been paid, how many have been used over time and how their hiring squares with Trump’s promises to punish firms that send jobs outside of the U.S. The Trump campaign did not respond to questions.

For a company of its prominence, Trump Media has a tiny permanent staff, employing just a few dozen people as of the end of last year, only a portion of whom work on the Truth Social technology.

Trump Media’s hiring of Mexican coders also prompted frustration within the staff, the person with knowledge of the company said, because they were perceived by staff to not have the technical expertise to do the work.

On its homepage, Truth Social bills itself as “Proudly made in the United States of America. 🇺🇸”

Both as president and in his campaign for a second term, Trump has criticized companies that send jobs abroad, particularly to Mexico. If elected, he has pledged to “stop outsourcing” and “punish” companies that send jobs abroad.

For example, Trump recently threatened agricultural machinery giant John Deere with tariffs if it went through with plans to move some of its manufacturing to Mexico.

“I’m just notifying John Deere right now, if you do that, we’re putting a 200 percent tariff on everything you want to sell into the United States,” Trump said.

He has made a similar threat against automakers building cars in Mexico, demanding they hire American workers and manufacture domestically.

“I'm not going to let them build a factory right across the border,” Trump promised, “and sell millions of cars into the United States and destroy Detroit further."

Trump owns nearly 60% of the social media company, a stake worth around $3.5 billion at the stock’s Friday closing price — more than half of the former president’s net worth.

The results of the election are widely seen as a major factor in the future value of the company. As the Nov. 5 election draws closer, Trump Media’s stock price has fluctuated wildly even as little or nothing has changed in the company’s actual business, which generates scant revenue. The stock closed Friday down 40% from its recent peak on Tuesday. Despite that drop, it has still nearly doubled since the beginning of October.

One Trump Media board member, Eric Swider, offered a defense of relying on foreign labor in a statement to ProPublica from his lawyer.

“President Trump maintains an America First policy, which includes prioritizing American workers. Trump Media, however, is a global multi-media company. For a global multi-media company to utilize subcontractors, which in turn may utilize coders located in a foreign country, is a practice common to the industry,” the statement said. “Such global multi-media companies like Trump Media would have no right to control the employment decisions of its subcontractors, which may employ workers in a multitude of different countries in addition to the United States.”

Swider, a businessman based in Puerto Rico, serves on the board alongside better known figures such as Donald Trump Jr. and Linda McMahon, the former Trump cabinet member who is now co-chair of his transition team.

The outsourcing to Mexico is not the only instance of Trump Media relying on foreign workers. ProPublica previously reported that the company used a foreign firm to source labor in the Balkans.

Nunes, for his part, is quoted in a new book about Truth Social, “Disappearing the President,” boasting about his ability to keep costs down at Trump Media, though he didn’t mention outsourcing.

“Nobody grew as fast as we did. I don't think there's any other example even close to us out there, especially with as little money as we spent,” Nunes said. “Don't forget that. We built this for a fraction of what these other companies were built for.”

Josseli Barnica grieved the news as she lay in a Houston hospital bed on Sept. 3, 2021: The sibling she’d dreamt of giving her daughter would not survive this pregnancy.

The fetus was on the verge of coming out, its head pressed against her dilated cervix; she was 17 weeks pregnant and a miscarriage was “in progress,” doctors noted in hospital records. At that point, they should have offered to speed up the delivery or empty her uterus to stave off a deadly infection, more than a dozen medical experts told ProPublica.

But when Barnica’s husband rushed to her side from his job on a construction site, she relayed what she said the medical team had told her: “They had to wait until there was no heartbeat,” he told ProPublica in Spanish. “It would be a crime to give her an abortion.”

For 40 hours, the anguished 28-year-old mother prayed for doctors to help her get home to her daughter; all the while, her uterus remained exposed to bacteria.

Three days after she delivered, Barnica died of an infection.

Barnica is one of at least two Texas women who ProPublica found lost their lives after doctors delayed treating miscarriages, which fall into a gray area under the state’s strict abortion laws that prohibit doctors from ending the heartbeat of a fetus.

Neither had wanted an abortion, but that didn’t matter. Though proponents insist that the laws protect both the life of the fetus and the person carrying it, in practice, doctors have hesitated to provide care under threat of prosecution, prison time and professional ruin.

ProPublica is telling these women’s stories this week, starting with Barnica’s. Her death was “preventable,” according to more than a dozen medical experts who reviewed a summary of her hospital and autopsy records at ProPublica’s request; they called her case “horrific,” “astounding” and “egregious.”

The doctors involved in Barnica’s care at HCA Houston Healthcare Northwest did not respond to multiple requests for comment on her case. In a statement, HCA Healthcare said “our responsibility is to be in compliance with applicable state and federal laws and regulations” and said that physicians exercise their independent judgment. The company did not respond to a detailed list of questions about Barnica’s care.

Like all states, Texas has a committee of maternal health experts who review such deaths to recommend ways to prevent them, but the committee’s reports on individual cases are not public and members said they have not finished examining cases from 2021, the year Barnica died.

ProPublica is working to fill gaps in knowledge about the consequences of abortion bans. Reporters scoured death data, flagging Barnica’s case for its concerning cause of death: “sepsis” involving “products of conception.” We tracked down her family, obtained autopsy and hospital records and enlisted a range of experts to review a summary of her care that ProPublica created in consultation with two doctors.

Among those experts were more than a dozen OB-GYNs and maternal-fetal medicine specialists from across the country, including researchers at prestigious institutions, doctors who regularly handle miscarriages and experts who have served on state maternal mortality review committees or held posts at national professional medical organizations.

After reviewing the four-page summary, which included the timeline of care noted in hospital records, all agreed that requiring Barnica to wait to deliver until after there was no detectable fetal heartbeat violated professional medical standards because it could allow time for an aggressive infection to take hold. They said there was a good chance she would have survived if she was offered an intervention earlier.

“If this was Massachusetts or Ohio, she would have had that delivery within a couple hours,” said Dr. Susan Mann, a national patient safety expert in obstetric care who teaches at Harvard University.

Many noted a striking similarity to the case of Savita Halappavanar, a 31-year-old woman who died of septic shock in 2012 after providers in Ireland refused to empty her uterus while she was miscarrying at 17 weeks. When she begged for care, a midwife told her, “This is a Catholic country.” The resulting investigation and public outcry galvanized the country to change its strict ban on abortion.

But in the wake of deaths related to abortion access in the United States, leaders who support restricting the right have not called for any reforms.

Last month, ProPublica told the stories of two Georgia women, Amber Thurman and Candi Miller, whose deaths were deemed “preventable” by the state’s maternal mortality review committee after they were unable to access legal abortions and timely medical care amid an abortion ban.

Georgia Gov. Brian Kemp called the reporting “fear mongering.” Former President Donald Trump has not weighed in — except to joke that his Fox News town hall on women’s issues would get “better ratings” than a press call where Thurman’s family spoke about their pain.

Leaders in Texas, which has the nation’s oldest abortion ban, have witnessed the consequences of such restrictions longer than those in any other state.

In lawsuits, court petitions and news stories, dozens of women have said they faced dangers when they were denied abortions starting in 2021. One suffered sepsis like Barnica, but survived after three days in intensive care. She lost part of her fallopian tube. Lawmakers have made small concessions to clarify two exceptions for medical emergencies, but even in those cases, doctors risk up to 99 years in prison and fines of $100,000; they can argue in court that their actions were not a crime, much like defendants can claim self-defense after being charged with murder.

Amid the deluge of evidence of the harm, including research suggesting Texas’ legislation has increased infant and maternal deaths, some of the ban’s most prominent supporters have muted their public enthusiasm for it. U.S. Sen. Ted Cruz, who once championed the fall of Roe v. Wade and said, “Pregnancy is not a life-threatening illness,” is now avoiding the topic amid a battle to keep his seat. And Gov. Greg Abbott, who said early last year that “we promised we would protect the life of every child with a heartbeat, and we did,” has not made similar statements since.

Both declined to comment to ProPublica, as did state Attorney General Ken Paxton, whose commitment to the ban remains steadfast as he fights for access to the out-of-state medical records of women who travel for abortions. Earlier this month, as the nation grappled with the first reported, preventable deaths related to abortion access, Paxton celebrated a decision by the U.S. Supreme Court that allowed Texas to ignore federal guidance requiring doctors to provide abortions that are needed to stabilize emergency patients.

“This is a major victory,” Paxton said.

“They Had to Wait Until There Was No Heartbeat”

To Barnica, an immigrant from Honduras, the American dream seemed within reach in her corner of Houston, a neighborhood filled with restaurants selling El Salvadoran pupusas and bakeries specializing in Mexican conchas. She found work installing drywall, saved money to support her mother back home and met her husband in 2019 at a community soccer game.

A year later, they welcomed a big-eyed baby girl whose every milestone they celebrated. “God bless my family,” Barnica wrote on social media, alongside a photo of the trio in matching red-and-black plaid. “Our first Christmas with our Princess. I love them.”

Barnica longed for a large family and was thrilled when she conceived again in 2021.

Trouble struck in the second trimester.

On Sept. 2, 2021, at 17 weeks and four days pregnant, she went to the hospital with cramps, according to her records. The next day, when the bleeding worsened, she returned. Within two hours of her arrival on Sept. 3, an ultrasound confirmed “bulging membranes in the vagina with the fetal head in the open cervix,” dilated at 8.9 cm, and that she had low amniotic fluid. The miscarriage was “in progress,” the radiologist wrote.

When Barnica’s husband arrived, she told him doctors couldn’t intervene until there was no heartbeat.

The next day, Dr. Shirley Lima, an OB on duty, diagnosed an “inevitable” miscarriage.

In Barnica’s chart, she noted that the fetal heartbeat was detected and wrote that she was providing Barnica with pain medication and “emotional support.”

In a state that hadn’t banned abortion, Barnica could have immediately been offered the options that major medical organizations, including international ones, say is the standard of evidence-based care: speeding up labor with medication or a dilation and evacuation procedure to empty the uterus.

“We know that the sooner you intervene in these situations, the better outcomes are,” said Dr. Steven Porter, an OB-GYN in Cleveland.

But Texas’ new abortion ban had just gone into effect. It required physicians to confirm the absence of a fetal heartbeat before intervening unless there was a “medical emergency,” which the law did not define. It required doctors to make written notes on the patient’s condition and the reason abortion was necessary.

The law did not account for the possibility of a future emergency, one that could develop in hours or days without intervention, doctors told ProPublica.

Barnica was technically still stable. But lying in the hospital with her cervix open wider than a baseball left her uterus exposed to bacteria and placed her at high risk of developing sepsis, experts told ProPublica. Infections can move fast and be hard to control once they take hold.

The scenario felt all too familiar for Dr. Leilah Zahedi-Spung, a maternal-fetal medicine specialist who used to work in Tennessee and reviewed a summary of Barnica’s records at ProPublica’s request.

Abortion bans put doctors in an impossible position, she said, forcing them to decide whether to risk malpractice or a felony charge. After her state enacted one of the strictest bans in the country, she also waited to offer interventions in cases like Barnica’s until the fetal heartbeat stopped or patients showed signs of infection, praying every time that nothing would go wrong. It’s why she ultimately moved to Colorado.

The doctors treating Barnica “absolutely didn’t do the right thing,” she said. But she understood why they would have felt “totally stuck,” especially if they worked at a hospital that hadn’t promised to defend them.

Even three years after Barnica’s death, HCA Healthcare, the hospital chain that treated Barnica, will not disclose whether it has a policy on how to treat miscarriages.

Some HCA shareholders have asked the company to prepare a report on the risks to the company related to the bans in states that restrict abortion, so patients would understand what services they could expect and doctors would know under what circumstances they would be protected. But the board of directors opposed the proposal, partly because it would create an “unnecessary expense and burdens with limited benefits to our stockholders.” The proposal was supported by 8% of shareholders who voted.

The company’s decision to abstain has repercussions far beyond Texas; the nation’s largest for-profit hospital chain has said it delivers more babies than any other health care provider in America, and 70% of its hospitals are in states where abortion is restricted.

As the hours passed in the Houston hospital, Barnica couldn’t find relief. On the phone with her aunt Rosa Elda Calix Barnica, she complained that doctors kept performing ultrasounds to check the fetal heartbeat but were not helping her end the miscarriage.

Around 4 a.m. on Sept. 5, 40 hours after Barnica had arrived, doctors could no longer detect any heart activity. Soon after, Lima delivered Barnica’s fetus, giving her medication to help speed up the labor.

Dr. Joel Ross, the OB-GYN who oversaw her care, discharged her after about eight more hours.

The bleeding continued, but when Barnica called the hospital, she was told that was expected. Her aunt grew alarmed two days later when the bleeding grew heavier.

Go back, she told her niece.

On the evening of Sept. 7, Barnica’s husband rushed her to the hospital as soon as he got off from work. But COVID-19 protocols meant only one visitor could be in the room with her, and they didn’t have a babysitter for their 1-year-old daughter.

So he left and tried to get some sleep.

“I fully expected her to come home,” he said.

But she never did. Her family planned two funerals, one in Houston and another in Honduras.

Nine days after her death, Barnica’s husband was processing his shock, learning how to be a single dad and struggling to raise funds to bury his wife and the son he had hoped to raise.

Meanwhile, Lima was pulling up Barnica’s medical chart to make an addition to her records.

The notes she added made one point abundantly clear: “When I was called for delivery,” she wrote, “the fetus no longer had detectable heart tones.”

“They Should Vote With Their Feet”

Texas has been on the forefront of fighting abortion access.

At the time of Barnica’s miscarriage in 2021, the Supreme Court had not yet overturned the constitutional right to terminate a pregnancy. But Texas lawmakers, intent on being the first to enact a ban with teeth, had already passed a harsh civil law using a novel legal strategy that circumvented Roe v. Wade: It prohibited doctors from performing an abortion after six weeks by giving members of the public incentives to sue doctors for $10,000 judgments. The bounty also applied to anyone who “aided and abetted” an abortion.

A year later, after the Dobbs v. Jackson ruling was handed down, an even stricter criminal law went into effect, threatening doctors with up to 99 years in prison and $100,000 in fines.

Soon after the ruling, the Biden administration issued federal guidance reminding doctors in hospital emergency rooms they have a duty to treat pregnant patients who need to be stabilized, including by providing abortions for miscarriages.

Texas Attorney General Ken Paxton fought against that, arguing that following the guidance would force doctors to “commit crimes” under state law and make every hospital a “walk-in abortion clinic.” When a Dallas woman asked a court for approval to end her pregnancy because her fetus was not viable and she faced health risks if she carried it to term, Paxton fought to keep her pregnant. He argued her doctor hadn’t proved it was an emergency and threatened to prosecute anyone who helped her. “Nothing can restore the unborn child’s life that will be lost as a result,” he wrote to the court.

No doctor in Texas, or the 20 other states that criminalize abortion, has been prosecuted for violating a state ban. But the possibility looms over their every decision, dozens of doctors in those states told ProPublica, forcing them to consider their own legal risks as they navigate their patient’s health emergencies. The lack of clarity has resulted in many patients being denied care.

In 2023, Texas lawmakers made a small concession to the outcry over the uncertainty the ban was creating in hospitals. They created a new exception for ectopic pregnancies, a potentially fatal condition where the embryo attaches outside the uterine cavity, and for cases where a patient’s membranes rupture prematurely before viability, which introduces a high risk of infection. Doctors can still face prosecution, but are allowed to make the case to a judge or jury that their actions were protected, not unlike self-defense arguments after homicides. Barnica’s condition would not have clearly fit this exception.

This year, after being directed to do so by the state Supreme Court, the Texas Medical Board released new guidance telling doctors that an emergency didn’t need to be “imminent” in order to intervene and advising them to provide extra documentation regarding risks.

But in a recent interview, the board’s president, Dr. Sherif Zaafran, acknowledged that these efforts only go so far and the group has no power over criminal law: “There’s nothing we can do to stop a prosecutor from filing charges against the physicians.”

Asked what he would tell Texas patients who are miscarrying and unable to get treatment, he said they should get a second opinion: “They should vote with their feet and go and seek guidance from somebody else.”

An immigrant from El Salvador who works 12-hour shifts, Barnica’s husband doesn’t follow American politics or the news. He had no inkling of the contentious national debate over how abortion bans are affecting maternal health care when ProPublica contacted him.

Now he is raising a 4-year-old daughter with the help of Barnica’s younger brother; every weekend, they take her to see her grandmother, who knows how to braid her hair in pigtails.

All around their home, he keeps photos of Barnica so that the little girl grows up knowing how much her mother loved her. He sees flashes of his wife when his daughter dances. She radiates the same delight.

When asked about Barnica, he can’t get out many words; his leg is restless, his eyes fixed on the floor. Barnica’s family calls him a model father.

He says he’s just doing his best.

Twelve years ago, Sen. Sherrod Brown, the Ohio Democrat, took the stage at his election night party in Columbus to celebrate winning a second term. Barack Obama had just carried Ohio for the second time, after emphasizing his administration’s rescue of the auto industry. Brown wanted to proclaim that success onstage, but he was losing his voice, so his wife, the writer Connie Schultz, took over for him.

As she got to Jeep expanding its Toledo operations and General Motors building the Chevy Cruze at its rejuvenated plant near Youngstown, Brown started interjecting croaks to make sure she got the details right. “The aluminum is made in Cleveland … the transmission is made in Toledo … the engine is made in Defiance … the airbag is made in Brunswick.”

I thought about that moment often while on the campaign trail in Ohio this month. Brown is running for re-election again. But the political landscape is much changed. Ohio is no longer a presidential battleground. GM no longer makes the Cruze — the Lordstown plant where it was assembled closed in 2019. And Brown, who won his last two races by 5 and 7 points, is in a tight race against a car dealership magnate named Bernie Moreno.

Brown and a dwindling band of Democrats in Ohio are still making the case for a certain kind of Democratic Party — one that cares about the working class, that invests in their towns and factories and values the manufacturing jobs that power the nation. That case should have become easier to make of late. Over the past four years, the Biden administration has championed huge investments in renewable energy and computer chip production; two new Intel plants are under construction near Columbus. Yet the political landscape is tougher than ever for Brown and the last remaining Ohio Democrats.

There are several possible explanations. Sixty percent of Ohio residents have only a high school diploma, an associate degree or a few years of college — a relatively high percentage. Union membership has dwindled from its peak in 1989. And the Biden investments have taken a while to ramp up.

At a Brown rally outside an International Brotherhood of Electrical Workers hall in Dayton, the head of the local building trades council, David Cox, told me that his members were getting more work than they’d seen in 35 years. Then why, I asked, wasn’t this restoring support for Democrats among workers? “It takes a little while for these guys to wake up,” Cox said.

But Democrats often overlook another dynamic at play here, and that’s the role of place: Even if your own finances are secure, if you look out your window and see your city or town struggling, you believe you are, too. Some academics have referred to this as a sense of “shared fate,” and it could be a powerful force in this election, especially in small cities in the industrial Midwest — such as Reading and Erie in Pennsylvania, Saginaw and Battle Creek in Michigan, Oshkosh and Racine in Wisconsin — where Brown and other Democrats are fighting to hang on to their seats and where Kamala Harris needs to do well (or at least hold her own).

In 2007, the academic Lorlene Hoyt and the city planning consultant André Leroux assembled a nationwide list of “forgotten cities” that were old and small, with a population of 15,000 to 150,000 and a median household income of less than $35,000. Recently, the urban researcher Michael Bloomberg updated it. Of the 179 cities now on the list, 37 are in Pennsylvania, Michigan and Wisconsin. And leading the way, with 23 cities, is Ohio.

Pundits often overlook these sorts of places (they tend to focus on big blue cities, deep-red rural areas and the suburbs in between), but given how clustered these smaller cities are in Michigan, Pennsylvania and Wisconsin, they will matter greatly in the battle for both the White House and for control of Congress. Lately, two of Ohio’s have gained special prominence: Middletown (population 50,000) as the hometown of JD Vance, and Springfield (roughly 60,000) as home to a large community of Haitian immigrants that both Vance and Donald Trump have made a target of their rhetoric.

I have visited dozens of these cities. They often have handsome downtowns with stately central squares and ornate, century-old bank buildings that rise 10 or 12 stories, but it can be difficult to find a cup of coffee after 2 p.m. or a place to watch a ballgame on TV at night. The local news is full of the sort of items I found a few weeks ago in a newspaper in Lima, Ohio (population 35,000): a report that the area was getting its 12th Dollar General store and a letter to the editor lamenting the closure of a Dana Incorporated auto-parts plant with 280 jobs. Just as troubling, young people are becoming harder to find; they’re more drawn to thriving larger cities, such as Columbus, which has been vacuuming up strivers from across the state.

For decades, these smaller cities leaned Democratic, but in the past decade, they have turned redder. In 2012, Obama won Green Bay, Wisconsin, by nearly twice as large a margin as Joe Biden did in 2020; Obama won Saginaw by an extra 15 percentage points. Even in Biden’s hometown, Scranton, Pennsylvania, Obama’s margin was more than 4,000 votes larger.

What’s so perplexing to liberals about this shift is that many of the people who left the Democratic Party are doing well for themselves; these cities are full of small-business owners, factory workers and retirees with pensions getting by under a Democratic president. But seeing your small city become a shadow of its former self can open you to a hard-edge populist message even if you yourself are managing. That’s what scholars mean by “shared fate,” and it’s what’s missed when we analyze voting behavior only by income or education level or race.

Rep. Marcy Kaptur — an Ohio Democrat who is a city planner by training and, after more than 40 years in office, the longest-serving woman in the history of Congress — understands this visceral reality. Her mother was a union organizer at a spark plug factory, and she has watched these wrenching changes play out from Toledo to the smaller cities she has represented, such as Sandusky and Lorain.

It’s rare to hear her talk up the social issues that often dominate debate on the left. Instead, she is most insistent about whether the nation’s industrial base can support its military, whether small cities have economic development expertise, whether workers at Toledo’s closed power plant can find new jobs. “I believe economics isn’t destiny, but it’s 85% of it,” she told me this month during a visit to a new Cleveland-Cliffs steel plant in Toledo.

For years, she has been struggling to get Democratic leaders to care about left-behind districts such as hers. In 2018, Hillary Clinton boasted that the areas she had carried in her 2016 loss produced two-thirds of the nation’s gross domestic product, as if votes from the economically thriving areas counted more. Two years earlier, Chuck Schumer, now Senate majority leader, declared, “For every blue-collar Democrat we lose in western Pennsylvania, we will pick up two moderate Republicans in the suburbs of Philadelphia. And you can repeat that in Ohio and Illinois and Wisconsin.”

This logic confounds Kaptur, who is now in a closely fought race with a state legislator, Derek Merrin. “A country can’t survive when vast segments of your population cannot get ahead,” she told me. Last year, to impress on party leaders how much ground Democrats are losing in districts like hers, her office produced a chart ranking the 435 House districts by median income. The moral: Democrats now represented most higher-income districts — in places like the Bay Area, the Northeast and metro Washington — while Republicans dominated in many lower-income ones. Her own district was 341st on the ranking, surrounded by red ones. “Washington has trouble seeing us,” she said. “They need binoculars.”

For Brown, the plight of these small cities is personal, because he’s from an archetypal one: Mansfield (population 48,000), which has lost a string of manufacturers. This month, the first person whom I met upon arriving at its central square was a woman asking for money. Brown’s father was a doctor, but as Brown often reminds voters, he went to school with the children of factory workers, a perspective that set him, like Kaptur, against trade deals such as NAFTA that many other Democrats supported.

“Politicians of both parties have done the bidding of wealthy corporations and sold the country out over and over and over again,” he said at a United Auto Workers hall in Toledo this month.

After the event, I asked him about the difficulties facing small cities. “Those cities were even more damaged than metropolitan areas because young people often tended to leave because there wasn’t the economic opportunity,” he said. “So I pay special attention to them.”

On the campaign trail, this means making more visits to the smaller cities than most other Democrats might. These cities also figure prominently in Brown’s stump rhetoric. “I grew up in Mansfield, Ohio, a town that looks a lot like Springfield, looks a lot like Zanesville, looks a lot like Hamilton or Middletown” is how Brown opened his remarks outside the union hall in Dayton, a city also on the updated “forgotten” list. After that event, he fell into an extended conversation with a new sort of small-city leader: one of the pioneers of the Haitian community in Springfield, who now owns five houses there and had come to Dayton to see Brown speak.

Without a doubt, Brown’s and Kaptur’s understanding of such places has helped them survive as long as they have as the state turned redder. It’s not as if their opponents have been offering these small cities many concrete solutions of their own. Far from it: Moreno’s ads center on his backing by Trump, and virtually all of the tens of millions of dollars in attack ads being run against Brown by outside groups focus on transgender youth.

There’s a painful irony in this for Democrats such as Brown and Kaptur. For years, they have been urging their party to pay more heed to these scattered outposts of their base: to Mansfield and Middletown, Springfield and Sandusky, all across their state and region. They were largely vindicated in their warnings about trade policy and political fallout, and a national Democratic response finally arrived in the past few years.

But in many places, demoralization had already spread so far, and local institutions had withered so much, that it became much easier for an opposition message based on nationwide culture-war appeals to register. Brown is as vulnerable now as he has ever been — running only 4 points ahead of Harris in the latest poll — and Kaptur’s race is just as competitive. This is doubly painful for them because they have largely skirted the culture-war front over the years, concentrating instead on economic issues.

Brown and Kaptur may well survive their latest challenges. But it’s hard to see how Democrats will revive their standing in Ohio — or enhance their prospects in the nearby swing states that remain more within their reach, such as Michigan and Pennsylvania — without helping these small cities revive, too. As Kaptur told me simply, sitting in her Toledo office overlooking the Maumee River: “They need to be seen.”

A key ally to former President Donald Trump detailed plans to deploy the military in response to domestic unrest, defund the Environmental Protection Agency and put career civil servants “in trauma” in a series of previously unreported speeches that provide a sweeping vision for a second Trump term.

In private speeches delivered in 2023 and 2024, Russell Vought, who served as Trump’s director of the Office of Management and Budget, described his work crafting legal justifications so that military leaders or government lawyers would not stop Trump’s executive actions.

He said the plans are a response to a “Marxist takeover” of the country; likened the moment to 1776 and 1860, when the country was at war or on the brink of it; and said the timing of Trump’s candidacy was a “gift of God.”

ProPublica and Documented obtained videos of the two speeches Vought delivered during events for the Center for Renewing America, a pro-Trump think tank led by Vought. The think tank’s employees or fellows include Jeffrey Clark, the former senior Justice Department lawyer who aided Trump’s attempts to overturn the 2020 election result; Ken Cuccinelli, a former acting deputy secretary in the Department of Homeland Security under Trump; and Mark Paoletta, a former senior budget official in the Trump administration. Other Trump allies such as former White House adviser Steve Bannon and U.S. Reps. Chip Roy and Scott Perry either spoke at the conferences or appeared on promotional materials for the events.

Vought does not hide his agenda or shy away from using extreme rhetoric in public. But the apocalyptic tone and hard-line policy prescriptions in the two private speeches go further than his earlier pronouncements. As OMB director, Vought sought to use Trump’s 2020 “Schedule F” executive order to strip away job protections for nonpartisan government workers. But he has never spoken in such pointed terms about demoralizing federal workers to the point that they don’t want to do their jobs. He has spoken in broad terms about undercutting independent agencies but never spelled out sweeping plans to defund the EPA and other federal agencies.

Vought’s plans track closely with Trump’s campaign rhetoric about using the military against domestic protesters or what Trump has called the “enemy within.” Trump’s desire to use the military on U.S. soil recently prompted his longest-serving chief of staff, retired Marine Gen. John Kelly, to speak out, saying Trump “certainly prefers the dictator approach to government.”

Other policies mentioned by Vought dovetail with Trump’s plans, such as embracing a wartime footing on the southern border and rolling back transgender rights. Agenda 47, the campaign’s policy blueprint, calls for revoking President Joe Biden’s order expanding gender-affirming care for transgender people; Vought uses even more extreme language, decrying the “transgender sewage that’s being pumped into our schools and institutions” and referring to gender-affirming care as “chemical castration.”

Since leaving government, Vought has reportedly remained a close ally of the former president. Speaking in July to undercover journalists posing as relatives of a potential donor, Vought said Trump had “blessed” the Center for Renewing America and was “very supportive of what we do,” CNN reported.

Vought did not respond to requests for comment.

"Since the Fall of 2023, President Trump’s campaign made it clear that only President Trump and the campaign, and NOT any other organization or former staff, represent policies for the second term,” Danielle Alvarez, a senior adviser to the Trump campaign, said in a statement. She did not directly address Vought’s statements.

Karoline Leavitt, his campaign’s national press secretary, added there have been no discussions on who would serve in a second Trump administration.

In addition to running his think tank, Vought was the policy director of the Republican National Committee’s official platform committee ahead of the nominating convention. He’s also an architect of Project 2025, the controversial coalition effort mapping out how a second Trump administration can quickly eliminate obstacles to rolling out a hard-right policy agenda.

As ProPublica and Documented reported, Project 2025 has launched a massive program to recruit, vet and train thousands of people to “be ready on day one” to serve in a future conservative administration. (Trump has repeatedly criticized Project 2025, and his top aides have said the effort has no connection to the official campaign despite the dozens of former Trump aides and advisers who contributed to Project 2025.)

Vought is widely expected to take a high-level government role if Trump wins a second term. His name has even been mentioned as a potential White House chief of staff. The videos obtained by ProPublica and Documented offer an unfiltered look at Vought’s worldview, his plans for a Trump administration and his fusing of MAGA ideology and Christian nationalism.

A Shadow Government in Waiting

In his 2024 speech, Vought said he was spending the majority of his time helping lead Project 2025 and drafting an agenda for a future Trump presidency. “We have detailed agency plans,” he said. “We are writing the actual executive orders. We are writing the actual regulations now, and we are sorting out the legal authorities for all of what President Trump is running on.”

Vought laid out how his think tank is crafting the legal rationale for invoking the Insurrection Act, a law that gives the president broad power to use the military for domestic law enforcement. The Washington Post previously reported the issue was at the top of the Center for Renewing America’s priorities.

“We want to be able to shut down the riots and not have the legal community or the defense community come in and say, ‘That’s an inappropriate use of what you’re trying to do,’” he said. Vought held up the summer 2020 unrest following George Floyd’s murder as an example of when Trump ought to have had the ability to deploy the armed forces but was stymied.

Vought’s preparations for a future Trump administration involve building a “shadow” Office of Legal Counsel, he told the gathered supporters in May 2023. That office, part of the Justice Department, advises the president on the scope of their powers. Vought made clear he wants the office to help Trump steamroll the kind of internal opposition he faced in his first term.

Historically, the OLC has operated with a degree of independence. “If, all of a sudden, the office is full of a bunch of loyalists whose only job is to rubber-stamp the White House’s latest policy directive, whose only goal is to justify the ends by whatever means, that would be quite dangerous,” said an attorney who worked in the office under a previous Republican administration and requested anonymity to speak freely.

Another priority, according to Vought, was to “defund” certain independent federal agencies and demonize career civil servants, which include scientists and subject matter experts. Project 2025’s plan to revive Schedule F, an attempt to make it easier to fire a large swath of government workers who currently have civil service protections, aligns with Vought’s vision.

“We want the bureaucrats to be traumatically affected,” he said. “When they wake up in the morning, we want them to not want to go to work because they are increasingly viewed as the villains. We want their funding to be shut down so that the EPA can't do all of the rules against our energy industry because they have no bandwidth financially to do so.

“We want to put them in trauma.”

Vought also revealed the extent of the Center for Renewing America’s role in whipping up right-wing panic ahead of the 2022 midterms over an increase in asylum-seekers crossing at the U.S.-Mexico border.

In February 2022, Arizona Attorney General Mark Brnovich released a legal opinion claiming the state was under “invasion” by violent cartels and could invoke war powers to deploy National Guard troops to its southern border. The legally dubious “invasion” theory became a potent Republican talking point.

Vought said in the 2023 speech that he and Cuccinelli, the former top Homeland Security official for Trump, personally lobbied Brnovich on the effort. “We said, ‘Look, you can write your own opinion, but here’s a draft opinion of what this should look like,’” Vought said.

The nonpartisan watchdog group American Oversight later obtained an email in which Vought pitched the “invasion” framework to Brnovich.

Brnovich wrote in an email to ProPublica that he recalled multiple discussions with Cuccinelli about border security. But he added that “the invasion opinion was the result of a formal request from a member of the Arizona legislature. And I can assure you it was drafted and written by hard working attorneys (including myself) in our office.”

In the event Trump loses, Vought called for Republican leaders of states such as Florida and Texas to “create red-state sanctuaries” by “kicking out all the feds as much as they possibly can.”

“Nothing Short of a Quiet Revolution”

The two speeches delivered by Vought, taken together, offer an unvarnished look at the animating ideology and political worldview of a key figure in the MAGA movement.

Over the last century, Vought said, the U.S. has “experienced nothing short of a quiet revolution” and abandoned what he saw as the true meaning and force of the Constitution. The country today, he argued, was a “post-constitutional regime,” one that no longer adhered to the separation of powers among the three branches of government as laid out by the framers.

He lamented that the conservative right and the nation writ large had become “too secular” and “too globalist.” He urged his allies to join his mission to “renew a consensus of America as a nation under God.”

And in one of his most dramatic flourishes, he likened the 2024 election to moments in America’s history when the country was facing all-out war.

“We are here in the year of 2024, a year that very well [could] — and I believe it will — rival 1776 and 1860 for the complexity and the uncertainty of the forces arrayed against us,” Vought told his audience, referring to years when the colonies declared independence from Britain and the first state seceded over President Abraham Lincoln’s election. “God put us here for such a time as this.”

Vought said that independent agencies and unelected bureaucrats and experts wield far too much power while the traditional legislative process is a sham. He extended that critique to agencies like the Department of Justice and the Federal Reserve, whose independence from the White House had long been protected by both political parties.

“The left in the U.S. doesn’t want an energetic president with the power to motivate the executive branch to the will of the American people consistent with the laws of the country,” he said in the 2024 speech. “They don’t want a vibrant Congress where great questions are debated and decided in front of the American people. They don’t want empowered members. They want discouraged and bored backbenchers.”

He added, “The all-empowered career expert like Tony Fauci is their model, wielding power behind the curtains.” Fauci was one of the top public health experts under Trump at the start of the COVID-19 pandemic and a key figure in coordinating the national response.

What sets Vought apart from most of his fellow conservative activists is that he accuses powerful organizations on the right of being complicit in the current system of government, singling out the Federalist Society for Law and Public Policy Studies, the conservative and libertarian legal network co-chaired by activist Leonard Leo. The society is widely seen as an instrumental force in cultivating young conservative lawyers and building a bench of future judges whose embrace of legal theories like originalism and textualism have led to decisions overturning abortion rights, environmental protections and social welfare policies.

Yet in his 2024 speech, Vought accused the Federalist Society and “originalist judges” of being a part of the problem, perpetuating the “post-constitutional structure” that Vought lamented by not ruling more aggressively to weaken or dismantle independent regulatory agencies that Vought and his allies view as illegitimate or unconstitutional.

It was “like being in a contract quietly revoked two decades ago, in which one party didn’t tell the other,” he said. “At some point, reality needs to set in. Instead, we have the vaunted so-called Federalist Society and originalist judges acting as a Praetorian Guard for this post-constitutional structure.”

Echoing Trump’s rhetoric, Vought implicitly endorsed the false claim of a stolen 2020 election and likened the media’s debunkings of that claim to Chinese Communist propaganda.

“In the aftermath of the election, we had all these people going around saying, ‘Well, I don’t see any evidence of voter fraud. The media’s not giving enough [of] a compelling case,’” he said. “Well, that compelling case has emerged. But does a Christian in China ask and come away saying, ‘You know, there’s no persecution, because I haven’t read about it in the state regime press?’ No, they don’t.”

Vought referred to the people detained for alleged crimes committed on Jan. 6, 2021, as “political prisoners” and defended the lawyers Jeffrey Clark and John Eastman, who have both faced criminal charges for their role in Trump’s attempts to overturn the 2020 election. Federal law enforcement agencies, he added, “are keeping political opponents in jail, and I think we need to be honest about that.”

The left, Vought continued, has the ultimate goal of ending representative democracy altogether. “The stark reality in America is that we are in the late stages of a complete Marxist takeover of the country,” he said, “in which our adversaries already hold the weapons of the government apparatus, and they have aimed it at us. And they are going to continue to aim it until they no longer have to win elections.”

When Democrats called Trump an “existential threat to democracy,” they were not merely calling for his defeat at the ballot box, he said, but were using “coded language the national security state uses overseas when they are overthrowing other governments” to discourage the military from putting down anti-Trump protests should he win.

“They’re making Trump out to be a would-be dictator or an authoritarian,” he said. “So they’re actively working now to ensure, on a number of levels, that the military will perceive this as dictatorial and therefore not respond to any orders to quell any violence.”

Trump, Vought insisted, has the credibility and the track record to defeat the “Marxist” left and bring about the changes that Vought and his MAGA allies seek. In his view, the Democratic Party’s agenda and its “quiet revolution” could be stopped only by a “radical constitutionalist,” someone in the mold of Thomas Jefferson or James Madison. For Vought, no one was in a better position to fill that role than Trump.

“We have in Donald Trump a man who is so uniquely positioned to serve this role, a man whose own interests perfectly align with the interests of the country,” Vought said. “He has seen what it has done to him, and he has seen what they are trying to do to the country.

“That,” he added, “is nothing more than a gift of God.”

As she got to Jeep expanding its Toledo operations and General Motors building the Chevy Cruze at its rejuvenated plant near Youngstown, Brown started interjecting croaks to make sure she got the details right. “The aluminum is made in Cleveland … the transmission is made in Toledo … the engine is made in Defiance … the airbag is made in Brunswick.”

I thought about that moment often while on the campaign trail in Ohio this month. Brown is running for re-election again. But the political landscape is much changed. Ohio is no longer a presidential battleground. GM no longer makes the Cruze — the Lordstown plant where it was assembled closed in 2019. And Brown, who won his last two races by 5 and 7 points, is in a tight race against a car dealership magnate named Bernie Moreno.

Brown and a dwindling band of Democrats in Ohio are still making the case for a certain kind of Democratic Party — one that cares about the working class, that invests in their towns and factories and values the manufacturing jobs that power the nation. That case should have become easier to make of late. Over the past four years, the Biden administration has championed huge investments in renewable energy and computer chip production; two new Intel plants are under construction near Columbus. Yet the political landscape is tougher than ever for Brown and the last remaining Ohio Democrats.

There are several possible explanations. Sixty percent of Ohio residents have only a high school diploma, an associate degree or a few years of college — a relatively high percentage. Union membership has dwindled from its peak in 1989. And the Biden investments have taken a while to ramp up.

At a Brown rally outside an International Brotherhood of Electrical Workers hall in Dayton, the head of the local building trades council, David Cox, told me that his members were getting more work than they’d seen in 35 years. Then why, I asked, wasn’t this restoring support for Democrats among workers? “It takes a little while for these guys to wake up,” Cox said.

But Democrats often overlook another dynamic at play here, and that’s the role of place: Even if your own finances are secure, if you look out your window and see your city or town struggling, you believe you are, too. Some academics have referred to this as a sense of “shared fate,” and it could be a powerful force in this election, especially in small cities in the industrial Midwest — such as Reading and Erie in Pennsylvania, Saginaw and Battle Creek in Michigan, Oshkosh and Racine in Wisconsin — where Brown and other Democrats are fighting to hang on to their seats and where Kamala Harris needs to do well (or at least hold her own).

In 2007, the academic Lorlene Hoyt and the city planning consultant André Leroux assembled a nationwide list of “forgotten cities” that were old and small, with a population of 15,000 to 150,000 and a median household income of less than $35,000. Recently, the urban researcher Michael Bloomberg updated it. Of the 179 cities now on the list, 37 are in Pennsylvania, Michigan and Wisconsin. And leading the way, with 23 cities, is Ohio.

Pundits often overlook these sorts of places (they tend to focus on big blue cities, deep-red rural areas and the suburbs in between), but given how clustered these smaller cities are in Michigan, Pennsylvania and Wisconsin, they will matter greatly in the battle for both the White House and for control of Congress. Lately, two of Ohio’s have gained special prominence: Middletown (population 50,000) as the hometown of JD Vance, and Springfield (roughly 60,000) as home to a large community of Haitian immigrants that both Vance and Donald Trump have made a target of their rhetoric.

I have visited dozens of these cities. They often have handsome downtowns with stately central squares and ornate, century-old bank buildings that rise 10 or 12 stories, but it can be difficult to find a cup of coffee after 2 p.m. or a place to watch a ballgame on TV at night. The local news is full of the sort of items I found a few weeks ago in a newspaper in Lima, Ohio (population 35,000): a report that the area was getting its 12th Dollar General store and a letter to the editor lamenting the closure of a Dana Incorporated auto-parts plant with 280 jobs. Just as troubling, young people are becoming harder to find; they’re more drawn to thriving larger cities, such as Columbus, which has been vacuuming up strivers from across the state.

For decades, these smaller cities leaned Democratic, but in the past decade, they have turned redder. In 2012, Obama won Green Bay, Wisconsin, by nearly twice as large a margin as Joe Biden did in 2020; Obama won Saginaw by an extra 15 percentage points. Even in Biden’s hometown, Scranton, Pennsylvania, Obama’s margin was more than 4,000 votes larger.

What’s so perplexing to liberals about this shift is that many of the people who left the Democratic Party are doing well for themselves; these cities are full of small-business owners, factory workers and retirees with pensions getting by under a Democratic president. But seeing your small city become a shadow of its former self can open you to a hard-edge populist message even if you yourself are managing. That’s what scholars mean by “shared fate,” and it’s what’s missed when we analyze voting behavior only by income or education level or race.

Rep. Marcy Kaptur — an Ohio Democrat who is a city planner by training and, after more than 40 years in office, the longest-serving woman in the history of Congress — understands this visceral reality. Her mother was a union organizer at a spark plug factory, and she has watched these wrenching changes play out from Toledo to the smaller cities she has represented, such as Sandusky and Lorain.

It’s rare to hear her talk up the social issues that often dominate debate on the left. Instead, she is most insistent about whether the nation’s industrial base can support its military, whether small cities have economic development expertise, whether workers at Toledo’s closed power plant can find new jobs. “I believe economics isn’t destiny, but it’s 85% of it,” she told me this month during a visit to a new Cleveland-Cliffs steel plant in Toledo.

For years, she has been struggling to get Democratic leaders to care about left-behind districts such as hers. In 2018, Hillary Clinton boasted that the areas she had carried in her 2016 loss produced two-thirds of the nation’s gross domestic product, as if votes from the economically thriving areas counted more. Two years earlier, Chuck Schumer, now Senate majority leader, declared, “For every blue-collar Democrat we lose in western Pennsylvania, we will pick up two moderate Republicans in the suburbs of Philadelphia. And you can repeat that in Ohio and Illinois and Wisconsin.”

This logic confounds Kaptur, who is now in a closely fought race with a state legislator, Derek Merrin. “A country can’t survive when vast segments of your population cannot get ahead,” she told me. Last year, to impress on party leaders how much ground Democrats are losing in districts like hers, her office produced a chart ranking the 435 House districts by median income. The moral: Democrats now represented most higher-income districts — in places like the Bay Area, the Northeast and metro Washington — while Republicans dominated in many lower-income ones. Her own district was 341st on the ranking, surrounded by red ones. “Washington has trouble seeing us,” she said. “They need binoculars.”

For Brown, the plight of these small cities is personal, because he’s from an archetypal one: Mansfield (population 48,000), which has lost a string of manufacturers. This month, the first person whom I met upon arriving at its central square was a woman asking for money. Brown’s father was a doctor, but as Brown often reminds voters, he went to school with the children of factory workers, a perspective that set him, like Kaptur, against trade deals such as NAFTA that many other Democrats supported.

“Politicians of both parties have done the bidding of wealthy corporations and sold the country out over and over and over again,” he said at a United Auto Workers hall in Toledo this month.

After the event, I asked him about the difficulties facing small cities. “Those cities were even more damaged than metropolitan areas because young people often tended to leave because there wasn’t the economic opportunity,” he said. “So I pay special attention to them.”

On the campaign trail, this means making more visits to the smaller cities than most other Democrats might. These cities also figure prominently in Brown’s stump rhetoric. “I grew up in Mansfield, Ohio, a town that looks a lot like Springfield, looks a lot like Zanesville, looks a lot like Hamilton or Middletown” is how Brown opened his remarks outside the union hall in Dayton, a city also on the updated “forgotten” list. After that event, he fell into an extended conversation with a new sort of small-city leader: one of the pioneers of the Haitian community in Springfield, who now owns five houses there and had come to Dayton to see Brown speak.

Without a doubt, Brown’s and Kaptur’s understanding of such places has helped them survive as long as they have as the state turned redder. It’s not as if their opponents have been offering these small cities many concrete solutions of their own. Far from it: Moreno’s ads center on his backing by Trump, and virtually all of the tens of millions of dollars in attack ads being run against Brown by outside groups focus on transgender youth.

There’s a painful irony in this for Democrats such as Brown and Kaptur. For years, they have been urging their party to pay more heed to these scattered outposts of their base: to Mansfield and Middletown, Springfield and Sandusky, all across their state and region. They were largely vindicated in their warnings about trade policy and political fallout, and a national Democratic response finally arrived in the past few years.

But in many places, demoralization had already spread so far, and local institutions had withered so much, that it became much easier for an opposition message based on nationwide culture-war appeals to register. Brown is as vulnerable now as he has ever been — running only 4 points ahead of Harris in the latest poll — and Kaptur’s race is just as competitive. This is doubly painful for them because they have largely skirted the culture-war front over the years, concentrating instead on economic issues.

Brown and Kaptur may well survive their latest challenges. But it’s hard to see how Democrats will revive their standing in Ohio — or enhance their prospects in the nearby swing states that remain more within their reach, such as Michigan and Pennsylvania — without helping these small cities revive, too. As Kaptur told me simply, sitting in her Toledo office overlooking the Maumee River: “They need to be seen.”

Republican vice-presidential nominee JD Vance’s appearance at a far-right Christian revival tour last month may have broken tax and election laws, experts say.

On Sept. 28, Vance held an official campaign event in Monroeville, Pennsylvania, in partnership with the Courage Tour, a series of swing-state rallies hosted by a pro-Trump Christian influencer that combine prayer, public speakers, tutorials on how to become a poll worker and get-out-the-vote programming.

Ziklag, a secretive organization of wealthy Christians, funds the Courage Tour, according to previously unreported documents obtained by ProPublica and Documented. A private donor video produced by Ziklag said the group intended to spend $700,000 in 2024 to mobilize Christian voters by funding “targeted rallies in swing states” led by Lance Wallnau, the pro-Trump influencer.

Even before the Vance event, ProPublica previously reported that tax experts believed Ziklag’s 2024 election-related efforts could be in violation of tax law. The Vance event, they said, raised even more red flags about whether a tax-exempt charity had improperly benefited the Trump-Vance campaign.

According to Texas corporation records, the Courage Tour is a project of Lance Wallnau Ministries Inc., a 501(c)(3) charity led by Wallnau. There have been five Courage Tour events this year, and Vance is the only top-of-the-ticket candidate to appear at any of them.

Wallnau has said that Vice President Kamala Harris is possessed by “the spirit of Jezebel” and practices “witchcraft.” As ProPublica reported, Wallnau is also an adviser to Ziklag, whose long-term goal is to help conservative Christians “take dominion” over the most important areas of American society, such as education, government and entertainment.

The Vance campaign portion was tucked in between Courage Tour events, and organizers took pains to say that Wallnau’s podcast hosted the hourlong segment, not the Courage Tour. Two signs near the stage said Wallnau’s podcast was hosting Vance. And during Vance’s conversation with a local pastor, the Courage Tour’s logo was replaced by the Trump-Vance logo on the screen.

An email sent by the Courage Tour to prospective attendees promoted the rally and Vance’s appearance as distinct events but advertised them side by side:

But the lines between those events blurred in a way that tax-law experts said could create legal problems for Wallnau, the Courage Tour and Ziklag. The appearance took place at the same venue, on the same stage and with the same audience as the rest of the Courage Tour. That email to people who might attend assured them that they could remain in their same seats to watch Vance and that afterward, “We will seamlessly return to the Courage Tour programming.”

The Trump-Vance campaign promoted the event as “part of the Courage Tour” and said Vance’s remarks would take place “during the Courage Tour.” And although the appearance included a discussion of addiction and homelessness, Vance criticized President Joe Biden in his remarks and urged audience members to vote and get others to vote as well in November.

Later in the day, Wallnau took the stage and asked for donations from the crowd. As he did, he spoke of Vance’s appearance as if it were part of the Courage Tour. “People have been coming up to us, my staff, and saying we want to help you out, what can we do, how do we do this? I want you to know when we do a Courage Tour, which will be back in the area, when we’re in different parts of the country,” he said. Asking for a show of hands, Wallnau added: “How many of you would like to at least be knowing when we’re there? Who’s with us on the team? If we have another JD Vance or Donald Trump or somebody?”

An employee of Wallnau’s, Mercedes Sparks, peeked out from behind a curtain. “I just wanted to clarify: You said they came to the Courage Tour,” Sparks said. “They didn’t. For legal reasons, the podcast hosted that. It was very separate. I don’t need the IRS coming my way.”

Despite the disclaimers, Vance’s campaign appearance at the Courage Tour raises legal red flags for several reasons, according to experts in tax and election law.

Both Lance Wallnau Ministries and Ziklag are 501(c)(3) charities, the same legal designation as the Boys & Girls Club or the United Way. People who donate to charities like these can deduct their gift on their annual taxes. But under the law, such charities are “absolutely prohibited from directly or indirectly participating in, or intervening in, any political campaign on behalf of (or in opposition to) any candidate for elective public office,” according to the IRS.

Internal Ziklag records lay out how the Courage Tour could influence the 2024 election. “Our plan,” one private video states, “is to mobilize grassroots support in seven key swing states through large-scale rallies, each anticipated to attract between 5,000 and 15,000 participants. These ‘Fire and Glory’ rallies will primarily target counties critical to the 2024 election outcome.” Wallnau said he later changed the name of his swing-state tour from Fire and Glory to the Courage Tour, saying the original name “sounds like a Pentecostal rally.”

Four nonpartisan tax experts told ProPublica and Documented that a political campaign event hosted by one charitable group, which is in turn funded by another charitable group, could run afoul of the ban on direct or indirect campaign intervention by a charitable organization. They added that Wallnau’s attempt to carve out Vance’s appearance may not, in the eyes of the IRS, be sufficient to avoid creating tax-law problems.

“Here, the [Trump] campaign is getting the people in their seats, who have come to the c-3’s event,” Ellen Aprill, an expert on political activities by charitable groups and a retired law professor at Loyola Law School, wrote in an email. “I would say this is over the line into campaign intervention but that it is a close call — and that exempt organization lawyers generally advise clients NOT to get too close to the line!”

Roger Colinvaux, a professor at Catholic University’s Columbus School of Law, said that regulators consider whether a consumer would be able to distinguish the charitable event from the political activity. Does the public know these are clearly separate entities, or is it difficult to distinguish whether it’s a charity or a for-profit company that’s hosting a political event?

“If it looks like the (c)(3) is creating the audience, then that again is potentially an issue,” he said.

Ziklag, Wallnau and the Vance campaign did not respond to requests for comment.

Marcus Owens, a tax lawyer at Loeb and Loeb and a former director of the IRS’ exempt organizations division, said there were past examples of the agency cracking down on religious associations for political activity similar in nature to Vance’s Courage Tour appearance.

In the 1980s, the Pentecostal televangelist Jimmy Swaggart used his personal column in his ministry’s magazine to endorse evangelist Pat Robertson’s campaign for president. Even though the regular column, titled “From Me to You,” was billed as Swaggart’s personal opinion, the IRS said that it still crossed the line into illegal political campaign intervention. Swaggart had also endorsed Robertson’s campaign for president during a religious service.

In that case, the IRS audited Swaggart’s organization and, as a result, the organization publicly admitted that it had violated tax law.

Phil Hackney, a professor of law at the University of Pittsburgh who spent five years in the IRS’ Office of Chief Counsel, said the fundamental question with Vance’s Courage Tour event is whether the 501(c)(3) charity that hosted the event covered the cost of Vance’s appearance.

“If the (c)(3) bore the cost, they’re in trouble,” Hackney said. “If they didn’t, they should be fine.” The whole arrangement, he added, has “got its problems. It’s really dicey.”

And even though Ziklag did not directly host the Vance event, tax experts say that its funding of the Courage Tour — as described in the group’s internal documents — could be seen as indirect campaign intervention, which federal tax law prohibits.

“The regulations make it clear that 501(c)(3) organizations cannot intervene in campaigns directly or indirectly,” Samuel Brunson, a law professor at Loyola University Chicago, said. “So the fact that it’s not Ziklag putting on the event doesn’t insulate Ziklag.”

Potential tax-law violations aren’t the only legal issue raised by Vance’s appearance.

Federal election law prohibits corporations from donating directly to political campaigns. For example, General Motors, as a company, cannot give money to a presidential campaign. That ban also applies to nonprofits that are legally organized as corporations.

Election experts said that if the funding for the Vance appearance did come from a corporation, whether for-profit or nonprofit, that could be viewed as an in-kind contribution to the Trump-Vance campaign.

Former President Donald Trump’s media company has forced out executives in recent days after internal allegations that its CEO, former Rep. Devin Nunes, is mismanaging the company, according to interviews and records of communications among former employees.

Several people involved with Trump Media believe the ousters are retaliation following what they describe as an anonymous “whistleblower” complaint regarding Nunes that went to the company’s board of directors.

The chief operating officer and chief product officer have left the company, along with at least two lower-level staffers, according to interviews, social media posts and communications between former staffers reviewed by ProPublica. The company, which runs the social media platform Truth Social, disclosed the departure of the chief operating officer in a securities filing Thursday afternoon.

ProPublica has not seen the whistleblower complaint. But several people with knowledge of the company said the concerns revolve around alleged mismanagement by Nunes. One person said they include allegations of misuse of funds, hiring of foreign contractors and interfering with product development.

In a statement, a spokesperson for Trump Media did not answer specific questions but said that ProPublica’s inquiry to the company “utterly fabricates implications of improper and even illegal conduct that have no basis in reality.”

“This story is the fifth consecutive piece in an increasingly absurd campaign by ProPublica, likely at the behest of political interest groups, to damage TMTG based on false and defamatory allegations and vague innuendo,” the statement said, adding that “TMTG strictly adheres to all laws and applicable regulations.”

Trump Media’s board comprises a set of powerful figures in Trump’s world, including his son Donald Trump Jr., former U.S. Trade Representative Robert Lighthizer and the businesswoman Linda McMahon, a major donor and current co-chair of Trump’s transition planning committee.

Nunes was named CEO of the company in 2021, with Trump hailing him as “a fighter and a leader” who “will make an excellent CEO.” As a member of Congress, Nunes was known as one of Trump’s staunchest loyalists.

After the internal allegations about Nunes were made at Trump Media, the company enlisted a lawyer to investigate and interview staffers, according to a person with knowledge of the company.

Then, last week, some employees who were interviewed by the lawyer were notified they were being pushed out, the person said. The employees being pushed out include a human relations director and a product designer, along with Chief Operating Officer Andrew Northwall and Chief Product Officer Sandro De Moraes. The person with knowledge of the company said Trump Media asked the employees to sign an agreement pledging not to make public claims of wrongdoing against the company in exchange for severance.

On Thursday afternoon, Northwall posted on Truth Social announcing he had “decided to resign from my role at Trump Media,” adding that he was “incredibly grateful” to Trump and Nunes “for this opportunity.”

“As I step back, I look forward to focusing more on my family and returning to my entrepreneurial journey,” the statement said.

De Moraes now identifies himself on his Truth Social bio as the “Former Chief Product Officer” of the company.

Some word of the departures became public earlier this week when former Trump Media employee Alex Gleason said in a social media post that “Truth Social in shambles. Many more people fired.”

Trump personally owns nearly 60% of the company. That stake, even after a recent decline in the company’s stock price, is worth nearly $2 billion on paper, a significant chunk of Trump’s fortune. He said last month he was not planning to sell his shares. What role Trump plays, if any, in the day-to-day operations of the company is not clear.

Since it launched in 2021, the company has become a speculation-fueled meme stock, but its actual business has generated virtually no revenue and Truth Social has not emerged as a serious competitor to the major social media platforms.

Among Nunes’ moves as CEO, as ProPublica has reported, was inking a large streaming TV deal with several obscure firms, including one controlled by a major political donor. He also traveled to the Balkans over the summer and met with the prime minister of North Macedonia, a trip whose purpose was never publicly explained by the company.

Trump Media has a formal whistleblower policy, adopted when the company went public in March, that encourages employees to report illegal activity and other “business conduct that damages the Company’s good name” and business interests.

For headline-grabbing drama, few Supreme Court decisions could equal the justices’ July ruling that former presidents are immune from criminal prosecution for virtually all of their official acts. But a decision in the seemingly humdrum realm of administrative law could end up having far broader consequences, affecting vast areas of American life by slashing the power of federal regulatory agencies that police pollution, food safety, health care and countless other aspects of modern society.

Lower court judges have already cited the Supreme Court’s 6-3 decision, in a case known as Loper Bright, to halt implementation of Biden administration rules on overtime pay and health care discrimination. In the past three months, Loper Bright also has been invoked to challenge regulations on everything from hidden airline fees to gun sales to abortion referrals.

Justice Neil Gorsuch, who was part of the conservative majority in Loper Bright, described it as placing “a tombstone” on a doctrine that had existed for 40 years. That doctrine, known as Chevron deference, was named after the 1984 Supreme Court case in which it emerged, and it offered an answer to a recurring question: What happens when Congress passes a law granting power to a federal agency but fails to precisely define the boundaries of that power?

In such situations, the doctrine of Chevron deference instructed federal judges to rely on the interpretations made by federal agencies, as long as those interpretations were reasonable, since agencies typically have greater expertise in their subject areas than judges. The Loper Bright decision erased that, commanding federal judges to “exercise their independent judgment in deciding whether an agency has acted within its statutory authority.”

Dissenting, Justice Elena Kagan noted that federal courts had cited Chevron deference 18,000 times, making it “part of the warp and woof of modern government, supporting regulatory efforts of all kinds — to name a few, keeping air and water clean, food and drugs safe, and financial markets honest.” She warned of “large-scale disruption.”

Legal experts view Loper Bright as a major transfer of power from agencies to judges. “You have incredibly technical areas of law for which the U.S. Supreme Court in Loper Bright has now paved a path for individual judges, or panels of three judges, to make decisions without having the technical expertise,” said Sanne Knudsen, a professor at the University of Washington School of Law, whose scholarship on deference doctrines has been cited by the Supreme Court.

Critics of the Chevron doctrine argued that letting agencies make legal interpretations led to constant uncertainty, with each presidential administration appointing new agency leaders who theoretically could change their interpretation of the law. But critics of the Loper Bright ruling counter that the same risk exists today — at the hands of judges rather than regulators.

Dan Weiner, director for elections and government at the Brennan Center for Justice, sees Loper Bright as the capstone of a series of recent Supreme Court rulings that limit agency power. Weiner called it the “culmination of a broader project to just cut the legs out from under government as we’ve known it since the New Deal.”

In theory, Congress could respond by writing more detailed legislation when it comes to federal agency power. But in the current political landscape, Knudsen said, that’s unlikely. As she put it, “cases like Loper Bright put more power in the hands of individual judges to decide policy questions, taking them further from the hands of the experts that Congress has otherwise delegated power to.”

Loper Bright has been celebrated by foes of regulation. The decision “gives us the thunder and lightning we need to beat back the aggressive anti-gun agenda of the rogue Biden Administration,” Gun Owners of America exulted in a press release after the ruling.

The advocacy group Democracy Forward counted 110 federal cases in which parties or judges have cited Loper Bright as of Sept. 6 — and that figure will only rise in the coming months and years. Here are some of the most consequential pending cases.

Who is eligible for overtime pay?

It took only hours for the decision to ripple into a lower court. On June 28, the day Loper Bright was announced, a federal judge in Texas issued a preliminary injunction against a new Department of Labor rule expanding eligibility for overtime pay. The judge blocked the rule from being enforced against the state of Texas as an employer, explaining that his decision “carefully follows Loper Bright’s controlling guidance.”

Among other things, the regulation seeks to prevent employers from deeming someone an “executive,” and thus exempt from overtime pay, if that person’s salary is below $43,888 (or below $58,656 next year). “Too often, lower-paid salaried workers are doing the same job as their hourly counterparts but are spending more time away from their families for no additional pay,” acting Secretary of Labor Julie Su said when the regulation was announced in April. “That is unacceptable.”

Texas challenged the rule, arguing the DOL had exceeded the authority granted by Congress in the Fair Labor Standards Act; the judge wrote that he expects to reach a final decision “in a matter of months.”

Does Obamacare protect transgender people from discrimination?

On July 3, three federal judges in different states, all citing Loper Bright, issued orders blocking implementation of a new rule from the Department of Health and Human Services that would prohibit discrimination in health care based on gender identity.

Mary Rouvelas, legal advocacy director for the American Cancer Society Cancer Action Network, said her group had supported the regulation because “nondiscrimination is critical for LGBTQ individuals, who suffer a disproportionate cancer burden.” However, the rule had become “a political football” amid debates over gender affirming care, Rouvelas said, and under Loper Bright federal judges no longer had to defer to HHS’ determination that gender identity is protected under the Affordable Care Act, which prohibits discrimination “on the basis of sex” but does not use the phrase “gender identity.”

Fifteen states sued in Mississippi federal court, arguing that HHS overstepped its authority. The states claimed the rule would force them to “use taxpayer funds to pay for unproven and costly gender-transition interventions through Medicaid and state health plans — even for children who may suffer irreversible harms.” District Judge Louis Guirola Jr. issued a nationwide injunction against the rule. The case will continue while the regulation is on hold, as will similar cases in Texas and Florida.

Can a federal agency force airlines to reveal fees?

The Department of Transportation issued a rule in April that requires airlines to, in the words of Secretary Pete Buttigieg, “inform you, before you buy a ticket, of fees they will charge you.” The rule specifies that baggage, change and cancellation fees must be disclosed the first time an airline quotes a price to a customer. At present, according to DOT court filings, “surprise costs” cause consumers to “overpay by half a billion dollars annually.”

In May, a group of airlines sued to stop the rule, claiming that the DOT exceeded its authority. According to the airlines, the agency can order them to halt unfair or deceptive practices after they’ve occurred, but it cannot tell them what their practices should be going forward. The airlines sought a stay. The DOT counters that its new regulation is based on “well-established” legal authority.

On July 1 — the Monday following the Friday issuance of the Loper Bright ruling — lawyers for the airlines cited the case, telling the 5th U.S. Circuit Court of Appeals that “resolving this statutory-interpretation issue is a task for this Court, especially because, with Chevron overruled, only courts have ‘the power to authoritatively interpret the statute.’”

At the end of July, a panel of three 5th Circuit judges stayed the rule, concluding that the airlines had “made a strong showing that the Rule exceeds the agency’s authority.” They placed the case on an expedited path toward a final determination of whether the rule should be struck down.

Can the FTC ban agreements that prohibit employees from joining a rival company?

In April, after six years of study, the Federal Trade Commission issued a rule banning noncompete agreements, which restrict workers from accepting employment with competitors for a period of time after leaving their current jobs. The FTC determined the rule was needed because such contracts impair “the fundamental freedom of workers to change jobs,” harm innovation and are “often exploitative.” Of the more than 26,000 comments the agency had received about the proposed ban, over 25,000 were supportive, the FTC said. A group of plaintiffs that includes the U.S. Chamber of Commerce filed suit in federal court in Texas, arguing the FTC had exceeded its authority.

On Aug. 20, citing Loper Bright, the judge in this case agreed with the plaintiffs and issued a final order that set aside the ban on noncompetes, declaring that the FTC had “promulgated the Non-Compete Rule in excess of its statutory authority.” The Chamber of Commerce called it a “significant win” in the group’s “fight against government micromanagement of business decisions.” An FTC spokesperson told ProPublica that the agency is “seriously considering a potential appeal” and added that the “decision does not prevent the FTC from addressing noncompetes through case-by-base enforcement actions.”

Can the government require background checks for firearms sold at gun shows?

In April, the Bureau of Alcohol, Tobacco, Firearms and Explosives issued a rule that would close a loophole through which guns are sold without background checks online and at gun shows. Attorney General Merrick Garland called it “one of the most significant gun regulations in decades.” Under the rule, he said: “It does not matter if guns are sold on the internet, at a gun show or at a brick-and-mortar store. If someone sells a gun predominantly to earn a profit, they must be licensed, and they must conduct a background check to ensure that the buyer is not barred by law from having a gun.”

In May, 21 states sued to block the regulation in federal court in Arkansas. The complaint noted that the Supreme Court would soon be hearing arguments in Loper Bright and contended the ATF had exceeded its authority in adopting the rule.

Another group of plaintiffs filed suit in the Northern District of Texas, also seeking to block the ATF rule. Those plaintiffs include the states of Texas, Louisiana, Mississippi and Utah, as well as Gun Owners of America, which has called the rule “tyrannical.” On June 11, weeks before Loper Bright was decided, the judge in the Texas case, Matthew Kacsmaryk, issued a preliminary injunction banning enforcement of the rule against any of the plaintiffs in the Texas case. Kacsmaryk based his decision in part on his belief that the plaintiffs would likely succeed in proving, in further proceedings, that the ATF had exceeded its authority. The Justice Department appealed the preliminary injunction to the 5th Circuit.

On July 10, less than two weeks after the Loper Bright decision, the judge in Arkansas went the opposite direction from the judge in Texas, denying the request from the 21 other states that he block the ATF rule closing the gun-show loophole. In doing this, the Arkansas judge cited a passage in Loper Bright that he views as supporting the ATF’s authority to close the loophole.

Much remains to be argued in the Texas and Arkansas lawsuits; both injunction rulings are being appealed on multiple grounds. But the Arkansas judge’s use of Loper Bright to support an agency’s authority to regulate highlights the still-unsettled nature of the high court’s pronouncements in Loper Bright. As the U.S. Chamber of Commerce noted, there is a need for lower courts to “interpret” certain aspects of the decision going forward.

Can federal aid for family planning be withheld from states that prohibit abortion?

In 2021, HHS issued a rule related to Title X grants, which have existed since 1970 and are intended to fund family planning programs. This rule, as described by the 6th U.S. Circuit Court of Appeals, requires states receiving Title X grants to “provide neutral, nondirective counseling and referrals for abortions to patients who request it.” Tennessee had received Title X grants for more than 50 years. But after the Supreme Court overturned Roe v. Wade in 2022, Tennessee banned abortions with exceptions only to “prevent the death of the pregnant woman or prevent serious risk of substantial and irreversible impairment of a major bodily function.” Tennessee said it would provide counseling and referrals only for abortions that are legal in the state. In response, HHS ended Tennessee’s Title X funding. The state sued, seeking an injunction to prevent the grant from ending and claiming that HHS exceeded its authority by requiring unbiased abortion counseling and referrals as a condition for Title X aid.

Just a year earlier, the 6th Circuit, in a similar case, had ruled that HHS did have the statutory authority to condition Title X funding in this manner. In doing so, the 6th Circuit relied on Chevron deference, finding that the new HHS regulation was based on a reasonable interpretation of this ambiguous statute. (The appeals court also cited a second precedent, a Supreme Court decision from 1991 that applied Chevron deference to the same Title X issue.)

Given the end of Chevron deference, should the 6th Circuit’s 2023 decision upholding HHS’ abortion counseling and referral rule be stripped of any precedential effect? Tennessee certainly thought so. But two judges from the 6th Circuit disagreed, pointing to a line in Loper Bright that says “we do not call into question prior cases that relied on the Chevron framework.” Therefore, the 6th Circuit reasoned, its 2023 precedent upholding HHS’ rule had withstood the death of Chevron deference and, as a result, the injunction requested by Tennessee was unwarranted. One judge on the 6th Circuit’s three-judge panel disagreed, however, citing different passages from Loper Bright to reach the opposite conclusion. The case is now continuing in the Tennessee district court where it was originally filed.

Can the FTC stop a tax-preparation company from making misleading claims?

In January, after an investigation prompted by ProPublica’s reporting, the FTC concluded that Intuit, the maker of TurboTax, used deceptive advertising to lure customers into paying for tax preparation services when they were eligible to file for free under a program sponsored by the government. Purchases by such customers generated roughly $1 billion in revenue for Intuit and other tax prep companies in 2019 alone, according to a government audit.

The FTC ordered Intuit to cease and desist from making any misleading “free” claims in its advertising. In response, Intuit appealed the FTC’s ruling to the 5th Circuit and asserted that Loper Bright had strengthened its argument for jettisoning the decision. “Whatever ‘deference’ the FTC claimed its interpretation of the FTC Act was due did not survive the Supreme Court’s intervening holding,” lawyers for the company wrote.

Intuit is also citing a recent Supreme Court decision that found the Securities and Exchange Commission can’t bring certain kinds of suits before its own administrative law judges; Intuit argues the decision, which focused on a securities fraud case in which civil penalties were sought, should apply to the FTC, too. The FTC disagrees, arguing that its action, originally brought before an FTC administrative law judge, is different from the relevant SEC action. For example, no civil penalties were involved in the action against Intuit. In a sign of how much rides on the outcome in this appeal, amicus briefs have been filed on both sides by a group of more than 20 states; numerous consumer advocate groups, including Public Citizen and the Consumer Federation of America; business groups like the U.S. Chamber of Commerce and the National Federation of Independent Business; and the libertarian Cato Institute.

Can a judge review the revocation of an immigrant’s opportunity for citizenship by marriage?

During the Supreme Court’s next term, it will hear a case involving the intricate rules for becoming a U.S. citizen through marriage. The case, Bouarfa v. Mayorkas, asks the justices to consider a very specific scenario, in which a Palestinian national married a U.S. citizen named Amina Bouarfa, who then petitioned to make her new husband eligible for citizenship through marriage. The United States Citizenship and Immigration Services approved Bouarfa’s petition but then, two years later, revoked that approval, saying the couple’s union had been “a sham marriage” for “the purpose of evading immigration laws.” The question in this case is whether that revocation is subject to judicial review.

The case also reveals an unexpected potential consequence of the Loper Bright ruling. It’s typically perceived as a victory for conservative foes of regulation, but liberals may be able to use the ruling to their advantage in certain areas. For example, in the realm of immigration, conservatives typically want more vigorous federal regulation. But in this case, liberal advocates of immigration reform are attempting to use Loper Bright to check the power of an immigration agency. “We’ll see whether the people who advanced Loper Bright might end up having a little bit of buyer’s remorse,” Weiner, of the Brennan Center for Justice, said.

Advocates for immigration reform have filed an amicus brief that supports Bouarfa’s right to judicial review by citing passages from Loper Bright. In addition, lawyers for Bouarfa have cited another major administrative law ruling last term from the Supreme Court’s conservative majority, Corner Post v. Board of Governors of the Federal Reserve, which greatly expanded the possibilities for suing federal agencies. That ruling led dissenting Justice Ketanji Brown Jackson to warn that the “tsunami of lawsuits against agencies that the Court’s holding in this case and Loper Bright have authorized has the potential to devastate the functioning of the Federal Government.”

It’s too early to say whether a legal tsunami is coming, but with the Supreme Court set to open its new term in two weeks, it’s clear that a wave is already growing.

Year after year, while Roe v. Wade was the law of the land, Texas legislators passed measures limiting access to abortion — who could have one, how and where. And with the same cadence, they added millions of dollars to a program designed to discourage people from terminating pregnancies.

Their budget infusions for the Alternatives to Abortion program grew with almost every legislative session — first gradually, then dramatically — from $5 million starting in 2005 to $140 million after the U.S. Supreme Court overturned the right to an abortion.

Now that abortion is largely illegal in Texas, lawmakers say they have shifted the purpose of the program, and its millions of dollars, to supporting families affected by the state’s ban.

In the words of Rep. Jeff Leach, a Republican from Plano, the goal is to “provide the full support and resources of the state government … to come alongside of these thousands of women and their families who might find themselves with unexpected, unplanned pregnancies.”

But an investigation by ProPublica and CBS News found that the system that funnels a growing pot of state money to anti-abortion nonprofits has few safeguards and is riddled with waste.

Officials with the Health and Human Services Commission, which oversees the program, don’t know the specifics of how tens of millions of taxpayer dollars are being spent or whether that money is addressing families’ needs.

In some cases, taxpayers are paying these groups to distribute goods they obtained for free, allowing anti-abortion centers — which are often called “crisis pregnancy centers” and may be set up to look like clinics that perform abortions — to bill $14 to hand out a couple of donated diapers.

Distributing a single pamphlet can net the same $14 fee. The state has paid the charities millions to distribute such “educational materials” about topics including parenting and adoption; it can’t say exactly how many millions because it doesn’t collect data on the goods it’s paying for. State officials declined to provide examples of the materials by publication time, and reporters who visited pregnancy centers were turned away.

For years, Texas officials have failed to ensure spending is proper or productive.

They didn’t conduct an audit of the program in the wake of revelations in 2021 that a subcontractor had used taxpayer funds to operate a smoke shop and to buy land for hemp production.

They ramped up funding to the program in 2022 even after some contractors failed to meet their few targets for success.

After a legislative mandate passed in 2023, lawmakers ordered the commission to set up a system to measure the performance and impact of the program.

One year later, Health and Human Services says it’s “working to implement the provisions of the law.” Agency spokespeople answered some questions but declined interview requests. They said their main contractor, Texas Pregnancy Care Network, was responsible for most program oversight.

The nonprofit network receives the most funding of the program’s four contractors and oversees dozens of crisis pregnancy centers, faith-based groups and other charities that serve as subcontractors.

The network’s executive director, Nicole Neeley, said those subcontractors have broad freedom over how they spend revenue from the state. For example, they can save it or use it for building renovations.

Pregnancy Center of the Coastal Bend in Corpus Christi, for instance, built up a $1.6 million surplus from 2020 to 2022. Executive Director Jana Pinson said two years ago that she plans to use state funds to build a new facility. She did not respond to requests for comment. A ProPublica reporter visited the waterfront plot where that facility was planned and found an empty lot.

Because subcontractors are paid set fees for their services, Neeley said, “what they do with the dollars in their bank accounts is not connected” to the Thriving Texas Families program. “It is no longer taxpayer money.”

The state said those funds are, in fact, taxpayer money. “HHSC takes stewardship of taxpayer dollars, appropriated by the Legislature, very seriously by ensuring they are used for their intended purpose,” a spokesperson said.

None of that has caused lawmakers to stop the cash from flowing. In fact, last year they blocked requirements to ensure certain services were evidence-based.

Leach, one of the program’s most ardent supporters, said in an interview with ProPublica and CBS News that he would seek accountability “if taxpayer dollars aren’t being spent appropriately.” But he remained confident about the program, saying the state would keep investing in it. In fact, he said, “We’re going to double down.”

What’s more, lawmakers around the country are considering programs modeled on Alternatives to Abortion.

Last year, Tennessee lawmakers directed $20 million to fund crisis pregnancy centers and similar nonprofits. And Florida enacted a 6-week abortion ban while including in the same bill a $25 million allocation to support crisis pregnancy centers. John McNamara, a longtime leader of Texas Pregnancy Care Network, has been working to start similar networks in Kansas, Oklahoma and Iowa. He’s also reserved the name Louisiana Pregnancy Care Network.

And U.S. House Republicans are advocating for allowing federal dollars from the Temporary Assistance for Needy Families program — intended to help low-income families — to flow to pregnancy centers. In January, the House passed the legislation, and it is pending in the Senate. Rep. Elise Stefanik, R-N.Y., castigated Democrats for voting against the bill.

“That’s taking away diapers, that’s taking away resources from families who are in need,” she said in an interview with CBS News after the vote.

But, as Texas shows, more funding doesn’t necessarily pay for more diapers, formula or other support for families.

Lawmakers rebranded Alternatives to Abortion as Thriving Texas Families in 2023. The program is supposed to promote pregnancies, encourage family formation and increase economic self-sufficiency.

The state pays four contractors to run the program. The largest, which gets about 80% of the state funding, is the anti-abortion group Texas Pregnancy Care Network.

Human Coalition, which gets about 16% of the state funding, said it uses the money to provide clients with material goods, counseling, referrals to government assistance and education. Austin LifeCare, which gets about 3% of the state funding, could not be reached for comment about this story. Longview Wellness Center in East Texas, which receives less than 1% of the funds, said the state routinely audits its expenses to ensure it’s operating within guidelines.

Texas Pregnancy Care Network manages dozens of subcontractors that provide counseling and parenting classes and that distribute material aid such as diapers and formula. Parents must take a class or undergo counseling before they can get those goods.

The state can be charged $14 each time one of these subcontractors distributes items from one of several categories, including food, clothing and educational materials. That means the distribution of a couple of educational pamphlets could net the same $14 fee as a much pricier pack of diapers.

A single visit by a client to a subcontractor can result in multiple charges stacking up. Centers are eligible to collect the fees regardless of how many items are distributed or how much they are worth. One April morning, a client at McAllen Pregnancy Center, near the Texas-Mexico border, received a bag with some diapers, a baby outfit, a baby blanket, a pack of wipes, a baby brush, a snack and two pamphlets. It was not clear how much the center invoiced for these items.

McAllen Pregnancy Center and other Texas Pregnancy Care Network subcontractors were paid more than $54 million from 2021 to 2023 for distributing these items, according to records.

How much of that was for handing out pamphlets? The state said it didn’t know; it doesn’t collect data on the quantities or types of items provided to clients or whether they are essential items like diapers or just pamphlets, making it impossible for the public to know how tax dollars were spent.

Neeley said in an email that educational materials like pamphlets only accounted for 12% of the money reimbursed in this category last year, or roughly $2.4 million out of $20 million. She did not respond to questions from ProPublica and CBS News about evidence that would corroborate that number.

The way subcontractors are paid, and what they’re allowed to do with that money, raised questions among charity experts consulted for this investigation.

In the nonprofit sector, using a fee-for-service payment model for material assistance is highly unusual, said Vincent Francisco, a professor at the University of Kansas who has worked as a nonprofit administrator, evaluator and consultant over the past three decades. It “can run fast and loose if you’re not careful,” he said.

Even if nonprofits distribute items they got for free or close to it, the state will still reimburse them. Take Viola’s House, a pregnancy center and maternity home in Dallas. Records show that it pays a nearby diaper bank an administrative fee of $1,590 for about 120,000 diapers annually — just over a penny apiece. Viola’s House can then bill the state $14 for distributing a pack of diapers that cost the center just over a quarter.

But before they can get those diapers, parents must take a class. The center can also bill the state $30 for each hour of class a client attends.

Rep. Donna Howard, a Democrat from Austin, said the program could be more efficient if the state funded the diaper banks directly. Last year, she proposed diverting 2% of Thriving Texas Families’ funding directly to diaper banks, but the proposal failed.

Records show that in fiscal year 2023, Viola’s House received more than $1 million from the state in reimbursements for material support and educational items plus another $1.7 million for classes. Executive Director Thana Hickman-Simmons said Viola’s House relies on funding from an array of sources and that just a small fraction of the diapers it distributes come from the diaper bank. She said the state money “could never cover everything that we do.”

In some cases, reimbursements have created a hefty cushion in the budgets of subcontractors. The state doesn’t require them to spend the taxpayer funds they get on needy families, and Texas Pregnancy Care Network said subcontractors can spend the money as they see fit, as long as they follow Internal Revenue Service rules for nonprofits.

McAllen Pregnancy Center received $3.5 million in taxpayer money from Texas Pregnancy Care Network over three years, but it spent less than $1 million on program services, according to annual returns it filed with the IRS. Meanwhile, $2.1 million was added to the group’s assets, mostly in cash. Its executive director, Angie Arviso, asked a reporter who visited in person to submit questions in writing, but she never responded.

“This is a policy choice Texas has made,” said Samuel Brunson, associate dean for faculty research and development at the Loyola University Chicago School of Law, who researches and writes about the federal income tax and nonprofit organizations. “It has chosen to redistribute money from taxpayers to the reserve funds of private nonprofit organizations.”

Tax experts say that’s problematic. “Why would you give money to a recipient that is not spending it?” said Ge Bai, a professor of accounting and health policy at Johns Hopkins University.

The tax experts disagree with Texas Pregnancy Care Network’s argument that the money is no longer taxpayer dollars after its subcontractors are paid.

“It’s still the government buying something,” said Jason Coupet, associate professor of public management and policy at Georgia State University, who has studied efficiency in the public and nonprofit sectors. “If I were in the auditor’s office, that’s where I would start having questions.”

State legislators and regulators haven’t installed oversight protections in the program.

Three years ago, The Texas Tribune spotlighted the state’s refusal to track outcomes or seek insight into how subcontractors have spent taxpayer money.

Months later, Texas Pregnancy Care Network cut off funding to one of its biggest subcontractors after a San Antonio news outlet alleged the nonprofit had misspent money from the state.

KSAT-TV reported that the nonprofit, A New Life for a New Generation, had used Alternatives to Abortion funds for vacations and a motorcycle, and to fund a smoke shop business owned by the center’s president and CEO, Marquica Reed. It also spent $25,000 on land that was later registered by a member of Reed’s family to produce industrial hemp.

In an interview with ProPublica, a former case manager recalled how Reed would get angry if employees forgot to bill the state for a service provided to a client.

The former case manager, Bridgett Warren Campbell, said employees would buy diapers from the local Sam’s Club store, then take apart the packages. “We’d take the diapers out and give parents two to three diapers at a time, then she would bill TPCN,” said Campbell.

Reed declined to comment to a ProPublica reporter or to answer follow-up questions via email or text. Neeley, the Texas Pregnancy Care Network’s executive director, said the pregnancy center was removed from the program because its nonprofit status was in jeopardy, not because it had used money on personal spending. She said the network wasn’t responsible for monitoring how A New Life for a New Generation spent its dollars: “The power to investigate these matters of how nonprofits manage their own funds is reserved statutorily to the Texas Attorney General and the IRS.”

The Texas attorney general’s office would not say whether it has investigated the organization. Records show that after KSAT’s story, state officials referred the case to an inspector general and that the Texas Pregnancy Care Network submitted a report detailing how it monitored the subcontractor.

The state requires contractors to submit independent financial audits if they receive at least $750,000 in state money; Texas Pregnancy Care Network meets this threshold. However, its dozens of subcontractors don’t have to submit these audits — something experts in nonprofit practices said should be required. In the fiscal year before the alleged misspending came to light, A New Life for a New Generation received more than $1 million in reimbursements from the state, records show.

When ProPublica and CBS News asked how the Health and Human Services Commission detects fraud or misuse of taxpayer funds, Jennifer Ruffcorn, a commission spokesperson, said the agency “performs oversight through various methods, which may include fiscal, programmatic, and administrative monitoring, enhanced monitoring, desk reviews, financial reconciliations, on-site visits, and training and technical assistance.”

Through a spokesperson, Rob Ries, the deputy executive commissioner who oversees the program at Health and Human Services, declined to be interviewed.

The agency has never thoroughly evaluated the effectiveness of the program’s services in its nearly 20 years of existence.

It is supposed to make sure its contractors are meeting a few benchmarks: how many clients each one serves and how many they have referred to Medicaid and the Nurse-Family Partnership, a program that sends nurses to the homes of low-income first-time mothers and has been proven to reduce maternal deaths. The Nurse-Family Partnership does not receive Alternatives to Abortion funding.

In 2022, the Texas Pregnancy Care Network failed to meet two of three key benchmarks in its contract with the state: It didn’t serve enough clients and it didn’t refer enough of them to the nursing program. The state didn’t withhold or reduce its funding. McNamara disputed the first claim, saying the state changed its methodology for counting clients, and said the other benchmark was difficult to hit because too few clients qualified for the nursing program.

In May 2023, when lawmakers passed the bill rebranding the program, the state also ordered the agency to “identify indicators to measure the performance outcomes,” “require periodic reporting” and hire an outside party to conduct impact evaluations.

The agency declined to share details about its progress on those requirements except to say that it is soliciting for impact evaluation services. Records show the agency has requested bids.

Lawmakers decided last year against enacting requirements that would ensure certain services were evidence-based — proven by research to meet their goals — instead siding with an argument that they would be too onerous for smaller nonprofits.

Texas’ six-week abortion ban took effect in 2021, and more than 16,000 additional babies were born in the state the following year. Academics expect that trend to continue.

But the safety net for parents and babies is paper thin.

Texas has the lowest rate of insured women of reproductive age in the country and ranks above the national average for maternal deaths. It’s last in giving cash assistance to families living beneath the poverty line.

Mothers told reporters they are struggling to scrape together enough diapers and wipes to keep their babies clean. A San Antonio diaper bank has hundreds of families on its waitlist. Outside an Austin food pantry, lines snake around the block.

Howard, the Austin state representative, said ProPublica and CBS News’ findings show that the program needs more oversight. “It is unconscionable that a [Thriving Texas Families] provider would be allowed to keep millions in reserve when there is a tremendous need for more investment in access to health care services,” she said.