by Anna Clark

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On the far east side of Michigan, the future of fluoride in drinking water — long an ordinary practice for preventing tooth decay — has suddenly provoked passionate debate.

Public meetings in St. Clair County, about an hour northeast of Detroit, have filled with people weighing in. One man waved his Fixodent denture cream before the county commissioners, suggesting that his own experience showed what would happen if local communities stopped treatment.

“I am an unfluoridated child,” he declared, “with a set of uppers and lowers.”

Another man, speaking to the county’s Advisory Board of Health, said that personal responsibility should be factored into the conversation. “I think there are some 3 Musketeer bars, Snicker bars that should be accounted for. Some Coca-Colas.”

And a young man used his time in the public comments to address not just fluoridation, but the county medical director who’s trying to get rid of it. He accused him of grandstanding to land a job with Robert F. Kennedy Jr., the U.S. health and human services secretary, by making moves that “lowered the quality of life for underserved people.”

The raucous arguments were spurred by a three-page memo sent in June to the Advisory Health Board by Dr. Remington Nevin, the medical director of St. Clair County’s Health Department. It urges the department to take steps to “prohibit the addition of fluoride” to public water systems because, he wrote in bold print, the additive is “a plausible developmental neurotoxicant” — a claim that runs counter to the assessment of many leading experts and health agencies, which have long celebrated fluoridation as a public health triumph.

Nevin recommended fluoride restrictions that would apply to any system located in the county and serving county residents. Potentially, that could include the Great Lakes Water Authority, which provides water to nearly 40% of the state’s population.

Drinking water fluoridation, which was pioneered in Michigan in 1945, led to a massive drop in tooth decay. Even with the rise of fluoride in toothpaste and other products, it’s credited with a 25% decrease in cavities. But skeptics increasingly hold sway in government, as ProPublica recently reported. Those opponents include Kennedy, the nation’s top health official, who has called fluoride “industrial waste.”

Now the Centers for Disease Control and Prevention and the Environmental Protection Agency are reviewing their approaches to fluoride in drinking water, and Utah and Florida became the first states to ban fluoridation.

Local communities, though, are on the front lines of the fluoride wars in most states, typically deciding whether or not to continue fluoridating their drinking water by council vote or community referendum. The public conversation in St. Clair County offers a vivid example of how contentious the issue can become. Advocates from well beyond its borders are getting involved, saying that what happens in the county has implications for the entire state.

Home to about 160,000 residents at the base of Michigan’s Thumb, St. Clair County shares a watery border with Canada. Some 67% of its voters chose President Donald Trump in the 2024 election. (Kennedy got under 1% of the vote.) About 110,000 residents receive fluoridated drinking water, according to the state’s environmental agency, while an additional 6,510 are served by water supplies with naturally occurring fluoride.

In his memo this summer, Nevin, who is a physician epidemiologist, cited a state-of-the-science report from the National Toxicology Program last year that described an association between higher levels of fluoride exposure and lower IQs in children. (The NTP is an interagency program within the Department of Health and Human Services that’s focused on toxicology research.)

Nevin also referenced a court decision in a case filed against the EPA by groups opposed to fluoridation, where a district judge relied, in part, on the NTP report in ruling that fluoride presented an “unreasonable risk.” Even as it appeals the decision, the EPA said its review of new science on fluoride in drinking water “is being done in coordination with Secretary Kennedy and HHS.”

Dr. Remington Nevin, medical director of St. Clair County’s Health Department, issued a three-page memo urging the county to take steps to prohibit the addition of fluoride to public water systems. (Nick Hagen for ProPublica)

The NTP report, though, is contested and based on limited studies involving fluoride levels that are more than twice the amount recommended by the federal government. Its own abstract says there isn’t enough information to link lower fluoride exposure with children’s IQ.

Nevin’s memo said that the EPA may take months or years to act on fluoride, but that didn’t mean local officials had to wait. “Across the Michigan Thumb, several townships have expressed a desire for similar measures,” he wrote, “and within St. Clair County, I have received a number of resident concerns related to this issue.” He recommended new regulations that would prohibit the addition of “any form of fluoride” to public water systems in the county that serve residents.

In Michigan, each community decides for itself if it will maintain fluoride in its drinking water system. But in an email to ProPublica, Nevin laid out a process where the St. Clair County Board of Commissioners could approve regulations that, in the name of public health, restrict the ability of suppliers to use the additive — in effect, enacting sweeping change throughout the region.

“Just as items manufactured in California are often subject to more stringent California environmental and health regulations, even if the majority are sold outside the state; so too could drinking water produced in St. Clair County be subject to more stringent county regulations, even if the majority is exported to other counties,” he wrote.

Whether or not this applies to any future fluoride regulations depends on the language that is adopted and approved, he added.

The state Department of Health and Human Services says it knows of no local health departments that have attempted such restrictions. In response to ProPublica’s queries, the Great Lakes Water Authority shared a May statement about fluoride, which says that the agency is required by its owner, the city of Detroit, to fluoridate its water supply. The current dosage is well below the maximum established by the Safe Drinking Water Act and the EPA, the statement said, and is in line with the recommended target for oral health benefits.

The water authority, which serves southeast Michigan, didn’t address the St. Clair County proposal. And it’s unclear whether the push for broad county regulations will gain traction.

As medical director, Nevin has an influential voice with county officials and shares guidance with Liz King, the county’s health officer-director. King, however, expressed reservations about Nevin’s proposal at a July meeting of the Advisory Health Board, according to the minutes.

In a statement to ProPublica, King said: “I do not support county-wide mandates to remove fluoride or actions that override the authority of local jurisdictions, unless there is an emergent or urgent public health need.”

Nevin was new to Michigan when he joined the Health Department in his part-time position about two years ago. He soon established that he would be an active force. He describes it in an email to ProPublica as “counter-activism,” adding: “I am largely working to counter the radical agendas of many past and current state public health officials.”

At the January meeting of the Advisory Health Board, Nevin provided members with a 2022 book by Kennedy — “A Letter to Liberals: Censorship and COVID: An Attack on Science and American Ideals” — that’s critical of the Democratic Party and government restrictions enacted during the COVID-19 pandemic. (To the notion that he wants to work for Kennedy, Nevin told ProPublica that it’s “baseless conjecture” and that he’s happy in St. Clair County.)

Less than a year into his tenure as HHS secretary, Kennedy’s approach was challenged by six former surgeons general who served under both Republicans and Democrats. In a recent op-ed, they said that Kennedy is “endangering the health of the nation.” His agency criticized their track records in office when contacted by ProPublica about the op-ed, saying they failed to improve public health.

Nevin has moved to make vaccine exemptions easier to get, saying in an April memo that it would “improve the public’s trust in public health.” Those efforts helped earn him a tribute signed by 10 Republican state legislators, which also highlights his fluoride recommendations. Nevin also successfully pushed for the department to wind down services at school health clinics, arguing, in part, that providing direct primary care isn’t a core function of public health.

Supporters point to his training in the military and at Johns Hopkins University. In addition to a medical degree, his CV lists a master’s degree and doctorate in public health. On his website, Nevin also highlights his ability to serve as an expert witness and consultant in legal cases that involve adverse effects from certain antimalarial drugs.

Nevin told ProPublica that past experience taught him that it can take years for neurotoxic effects of certain substances to be recognized. “I have every confidence that, in due course, fluoride will also be looked upon as a neurotoxicant that has no place being ingested,” he wrote in an email.

He added that the response he’s received to his proposal from the community “has been overwhelmingly positive.”

Dr. Randa Jundi-Samman, a recently retired dentist who worked in Port Huron, Michigan, for 30 years, has been a vocal opponent of removing fluoride from St. Clair County’s drinking water. (Nick Hagen for ProPublica)

But there’s been strong pushback. Dr. Randa Jundi-Samman, a recently retired dentist in St. Clair County, was one of the health professionals speaking in support of fluoridation at public meetings. She told ProPublica that dropping fluoridation would be a serious hit to community health.

“You’d 100% get more decay, especially in children in low-income communities that don’t get the chance to go to the dentist every six months,” Jundi-Samman said. “We certainly will see that. We already see it in people who don’t have fluoride in their water.”

Dr. Mert Aksu, president of the Michigan Oral Health Coalition’s board and dean of the University of Detroit Mercy’s dental school, said he’s hustling up to the public meetings in St. Clair County because it’s the duty of professionals “to make sure that the decisions that are being made within our communities are being made based upon scientific merit.”

Speaking broadly about the influence now wielded by fluoride skeptics, Aksu said, “We have opened ourselves up to opportunities from misinformed people who want to use this issue for political purposes.”

Dr. Mert Aksu, dean of the University of Detroit Mercy’s dental school, believes people are leveraging fluoride as an issue for political benefit. (Nick Hagen for ProPublica)

At an August meeting of the county commissioners, Kimberly Raleigh, interim executive director of the Michigan Oral Health Coalition, read a letter in support of fluoridation that was signed by the University of Michigan School of Dentistry, the Michigan Dental Association, the Indiana Dental Association, the Pennsylvania Coalition for Oral Health and dozens of others.

Nevin said in an email that the dental community “must recognize that community water fluoridation can no longer be relied upon to mask the dental problems created by our neglect of poor dietary choices.”

He argues that he has science on his side. “Scientific merit favors a recommendation to prohibit fluoride,” he wrote to ProPublica. “I have every confidence this will become much clearer in the coming months, as further federal guidance is inevitably released.”

Nevin’s recommendation is before the Advisory Health Board, which also was provided a fact sheet on fluoridation from the Health Department, submitted with Nevin’s approval. If the board endorses his proposal, King may then decide whether to propose regulations, which the Board of Commissioners would then weigh, according to the Health Department. Nevin estimated that the process could take six to 12 months.

Fluoride was on the agenda for the Advisory Health Board’s September meeting, which ended early because the members failed to reach a quorum. Nevin told ProPublica that he expects it to be discussed at this week’s meeting, and that he will present additional information then.

Meanwhile, Nevin has already influenced one of the county’s townships, Kimball, which receives treated water from Port Huron, the seat of St. Clair County.

At an August meeting, where Nevin spoke to the Board of Trustees, Kimball Township unanimously passed a resolution calling for Port Huron to discontinue fluoridation and direct any funds saved to support access to topical dental fluoride treatments.

Port Huron’s city manager declined to comment for this story, saying the township has not presented the city with any resolution or request. Nevin said in an email to ProPublica that he is “attempting to address every municipality in the county” with similar testimony.

After voting on the measure, one Kimball trustee made a point to show support for Nevin, saying “we’re blessed to have him making decisions.”

Nevin, he said, has had to overcome resistance from staff “pushing hard to make his life rather uncomfortable.”

“They’re not used to leadership,” the trustee said. “They’re not used to boldness. They’re not used to maybe some male energy that’s necessary to get things done.”

This post was originally published on ProPublica.

by Jessica Schreifels, The Salt Lake Tribune

This article was produced for ProPublica’s Local Reporting Network in partnership with The Salt Lake Tribune. Sign up for Dispatches to get our stories in your inbox every week.

The patients kept coming to the Utah oral surgeon’s office — one after another, year after year — with dental work that the surgeon said had gone wrong. He later recounted in a letter to state licensors that he had seen dental implants that had been the wrong size, patients with chronic sinus infections and one person whose implant had become lost inside their sinus cavity. These patients, he said, had all been worked on by the same dentist: Dr. Nicholas LaFeber.

The surgeon, a 30-year veteran, wrote the letter in November 2022 after Utah’s licensing division asked for his opinion of work done by LaFeber, whose license was on probation after the agency determined he had provided substandard care to more than a dozen patients. His warning was blunt: He believed LaFeber wouldn’t improve as a dentist and should not be performing dental implant procedures. He had seen LaFeber make the same mistakes in patients for years, he wrote, causing “severe” and sometimes life-changing complications.

“I believe that he is not competent to place implants,” the oral surgeon, Dr. Creed Haymond, concluded. “I give this opinion with soberness and sadness, but I feel I have a duty to aid the board in protecting the public from what appears to be an incompetent practitioner.”

His assessment of LaFeber’s skills in restorative dentistry was also mentioned in a February 2023 order regarding agency action on LaFeber’s license. Haymond did not respond to interview requests.

This was the second letter that Utah’s Division of Professional Licensing had received recommending that LaFeber be stopped or limited from practicing after more than a decade of dentistry in Utah, according to records obtained by The Salt Lake Tribune and ProPublica. The agency licenses Utah dentists and other professionals and investigates allegations of misconduct.

Two years prior, another dentist who had considered buying one of LaFeber’s practices recommended LaFeber’s license be revoked after looking through patient files: “As I started going through charts, as well as seeing the previous work, I began to realize how poor he treated these individuals,” wrote Dr. Brandon McKee. “Patients with failed implants are put on antibiotics and told to wait while the implant is continuing to heal. Some of these are for nine months.”

This letter was discussed in a September 2020 public dentistry board meeting. McKee did not respond to interview requests.

The licensing division’s dentistry board — whose members are mostly dentists and hygienists — recommended to Utah licensing director Mark Steinagel in December 2022 that LaFeber’s license be revoked after reviewing additional evidence suggesting his skills had not improved.

But despite this recommendation and the letters of warning from his colleagues, Steinagel reinstated LaFeber’s license in May 2023 after the dentist completed three years of probation, which included taking remedial classes.

Mark Steinagel, director of the state agency that licenses Utah professionals, reinstated Nicholas LaFeber’s license even though the agency’s dentistry board recommended that it be revoked. (Rick Egan/The Salt Lake Tribune)

Since LaFeber’s license was reinstated, new patients say they’ve been hurt. The Tribune and ProPublica spoke with two patients who say they saw the dentist within the last year for what they believed would be routine cavity fillings. Instead, they say they left in pain that became prolonged and ultimately required the procedures to be redone by other dentists. Neither knew when they sought dental care that LaFeber had nearly lost his license after regulators determined his work fell below the standard of care.

“I had never had this done before, so I didn’t know what’s normal,” said one patient, Michelle Lipsey. “I was just like, ‘He’s an adult, male dentist. He probably knows what he’s doing.’”

Lipsey filed a complaint against LaFeber with licensors in July detailing her experience, but the agency closed the case a month later and took no disciplinary action.

LaFeber said he would not discuss individual patients because they did not grant him permission to do so. He told The Tribune and ProPublica that he has always tried to keep his patients’ best interests in mind. “I had a few outcomes from dental work that had complications and needed further treatment,” he wrote in an email in response to questions.

“I assume every dentist encounters some percentage of negative patient outcomes and I have no reason to believe that my practice had a higher percentage than others.”

Melanie Hall, a spokesperson for Steinagel and the Division of Professional Licensing, said in response to questions that the division only revokes someone’s license when their conduct has been “especially egregious” because doing so “ends a career.”

The agency’s top priority, she said, is keeping Utahns safe — but she added that it also wants to ensure that licensees have a chance at “professional rehabilitation” and, when appropriate, can continue to work and earn money.

The state has revoked two dental licenses since June 2015, according to a Tribune and ProPublica examination of a decade’s worth of publicly available licensing division records.

Hall said that LaFeber’s license was reinstated despite the dental board’s recommendation because the dentist had finished the remedial courses that the board required him to take and his probationary period was ending. She noted that no other patients filed a complaint during that three-year period and that the dental board’s role was to only make recommendations to Steinagel and his staff.

That decision bothered some of those who served on the dental board during that time. Two former board members told The Tribune and ProPublica that they were frustrated state licensing division leaders did not listen to them and that they felt LaFeber should not practice dentistry given his record. Both spoke on the condition of anonymity because of potential professional repercussions.

“You hate to take somebody’s livelihood away from them when they’ve gone through years of dental school and had a practice,” one of the former board members said. “But the board’s job is to protect the public.”

In LaFeber’s case, the former board member said, “the public was not well-served.”

LaFeber, without knowing the identities of the board members, suggested that some might have been biased against him.

“Every One of These Cases Was Alarming”

LaFeber said in public dentistry board meetings that he came to the attention of the licensing division in late 2019 after one of his former employees filed a complaint. He said the employee, who he said he had previously fired, directed licensors to more than a dozen cases in which he admitted during a board meeting that he had provided “poor patient care.”

State licensing officials could have suspended or revoked LaFeber’s license, but instead, in early 2020, they struck an agreement with LaFeber — a common outcome in license discipline cases. According to the agreement, investigators found that some of the patients in those cases had had root canals that resulted in infections or needed to be redone. Licensors also determined that LaFeber had improperly placed permanent replacement teeth in other patients, including one whose implant extended into the sinus cavity, the document said.

LaFeber agreed to spend three years on professional probation, during which he would be under the supervision of another dentist whose time he was required to pay for. He was still allowed to perform dental work during that period, according to the stipulation, but agreed not to do implant procedures or root canals.

He was not required to tell his current or future patients about this discipline. Like most other states, Utah has no law requiring patient disclosure when a licensed professional is disciplined, and a review of more than 3,200 filings from the licensing division’s website shows the state has rarely required disclosure of unprofessional conduct to patients.

The Utah regulators who discipline licensed professionals act only when someone files a complaint, like what happened in LaFeber’s case. “We don’t have manpower or staffing for proactive investigations,” Larry Marx, the state’s health care licensing bureau manager, explained to the dental board in a 2020 public meeting.

Once LaFeber was on probation, oversight of his progress moved to the dental board, an advisory group whose role it is to interview probationers in quarterly public meetings and make recommendations to Steinagel about whether the professionals completed their probation and if they should have their licenses reinstated.

In these interviews with the dental board, LaFeber admitted his mistakes. He blamed bad outcomes on being burned out from owning four dental clinics, and he said he had done procedures on friends and acquaintances who actually needed more specialized care but didn’t have the money.

“Some of it I will just admit was a poor, poor choice on my part,” he told the board, according to a recording of the meeting. “And I can also say for some of them, they are very dear friends of mine, that I have either coached their kids or helped them in Scouts or something else, single moms, and trying to help them out.”

Dr. Nicholas LaFeber’s profile on the website of his practice, Sandy Center Dental (Screenshot by ProPublica)

In addition to the problems that the former employee initially reported to the state licensing division, one dental board member, Dr. Ruedi Tillmann, looked at more than a dozen other files of LaFeber’s during the first few months of his probation and found other cases in which Tillmann saw indications that patients had poor outcomes, according to a December 2020 board meeting.

Tillmann, a dentist, said during the online meeting that he saw “a number of cases” where LaFeber did four or five implants on a single patient and none of them properly integrated into the patient’s jawbone. “Poor margins, open margins, implant crowns not sitting on implants correctly,” he said about patient files he reviewed. “I’m sorry to be harsh. It’s just that every one of these cases was alarming to me.”

Dr. Daniel Poulson, another dentist on the board, questioned why LaFeber would do substandard work on his patients, including people he said he knew and cared about.

“With 30 cases, what that communicates to me is you didn’t learn. You just kept doing it,” Poulson said during the same meeting. “And to blame that on being stressed or overworked — we’re all stressed. Dentistry is an incredibly stressful profession. But that shouldn’t, in my mind, make an excuse for ill-treating a patient. Using a lot of antibiotics to cover infections that last years is just out of bounds.”

LaFeber told the board during this meeting that he was confident he could improve his dentistry by taking continuing education courses and by being more selective about patients and referring them more often to specialists instead of trying to do the work himself.

He also downsized to just one clinic, Sandy Center Dental, a wood-trimmed office suite in a large, tan stucco building located in a Salt Lake City suburb at the base of the Wasatch Mountains.

“They Were So Disgusted With All the Problems”

LaFeber met with the dental board 11 times during his probation in public meetings that were often conducted on video calls because of the coronavirus pandemic. He was cheerful and agreeable during meetings, even at times when board members asked him pointed, critical questions about his work.

His polite nature was noted several times in records reviewed by The Tribune and ProPublica. For example, McKee, the dentist who had considered buying LaFeber’s practice, wrote in his letter to the board that LaFeber came across as a “humble,” “very nice guy” who patients trusted. A dentist who leads a dental examination agency wrote in his summary of an exam that LaFeber took that he was “overly pleasant to the extreme.”

Members of the dental board remarked during public meetings about how “unique” LaFeber’s case was, and they questioned what the right metric would be to determine whether his dentistry had improved and he was safe to work with patients.

Utah licensors rarely discipline dentists over whether they are competent to do their jobs, an analysis by The Tribune and ProPublica found. A review of disciplinary records from the last decade shows dentists most often getting in trouble for drug or alcohol use or for overprescribing or diverting prescriptions.

Hall, the licensing division spokesperson, said the agency does not track how many standard-of-care complaints it receives, but acknowledged that proving those types of cases tends to be difficult.

“As a result, they are less likely to lead to disciplinary actions compared to cases involving drug use, unlawful behavior, or practicing outside one’s scope of practice,” she said.

But tension was growing between LaFeber and the dental board: While LaFeber had taken a few online, self-paced courses, board members felt he needed more intensive, hands-on classes to improve.

A breaking point between LaFeber and the board occurred near the end of LaFeber’s probation. At the December 2022 dental board meeting, LaFeber peppered members with questions about the board’s role governing probationers and implied that a board member had acted improperly by soliciting complaints about him.

The board seemed equally frustrated; LaFeber still hadn’t enrolled in the hands-on courses they had required him to take, programs that could have cost up to $50,000. LaFeber had instead taken a licensure exam and failed several sections, according to a copy of the exam results obtained by The Tribune and ProPublica, which was also referenced in the 2023 agency order.

LaFeber did not respond on the record to questions about these test results.

Given the test results, Poulson, who had become board chair, said in the public meeting that he worried whether LaFeber would be able to practice dentistry safely by the following February, when his probation period would end.

“I have two doctors that once tried to buy your practice. They gave it back because they were so disgusted with all the problems they were having with patients,” Tillmann, one of the board members, said in that same meeting, recalling previous conversations he had.

LaFeber’s practice, Sandy Center Dental. LeFeber was not required to tell his current or future patients about his probation. (Francisco Kjolseth/The Salt Lake Tribune)

Poulson suggested that the group make a motion recommending that the state licensing division either revoke or suspend LaFeber’s license, saying that the action would be “protecting the public from inferior care.” The board unanimously voted to recommend revocation.

A few months later, Marx issued the agency order stating that LaFeber’s license should be suspended until he could demonstrate he could practice dentistry “with reasonable skill and safety.”

LaFeber, though, had one more chance to respond before the suspension would take effect. Soon after the agency order, LaFeber enrolled in and completed his remedial training. He also hired an attorney who signaled his intent to fight the agency’s action, according to public records.

In response, Marx requested that the agency’s move to suspend LaFeber’s license be dismissed, noting that LaFeber said he had delayed complying with the dental board’s requirement that he complete further training because of “financial limitations.” Then, Steinagel reinstated LaFeber’s license.

By this point, Steinagel’s agency knew not only about the reports of patients with improper tooth implants and the failed root canals that led to LaFeber’s probation, it also knew the state dental board had recommended that LaFeber’s license be revoked.

In addition, the agency was aware LaFeber had been sued three times for medical malpractice — including by a patient who alleged he had implants placed in his sinuses, which caused sepsis, and another patient who said in her lawsuit that, after months of painful infections, she went to another dentist who found a broken dental instrument lodged in her gums. (LaFeber told The Tribune and ProPublica these lawsuits were settled by his medical malpractice insurance carrier and there was never any determination made that his treatment fell below the standard of care.)

LaFeber said in response to questions that he was not aware of any recommendation from the board to revoke his license — though according to recordings and minutes of the public dentistry board meetings, he was present when the dentistry board took its vote. The board’s revocation recommendation is also referenced in the agency order he received, which The Tribune and ProPublica obtained through a public records request.

The dentist said he felt he was treated fairly by licensors and most members of the dentistry board, but added that he felt one board member did not disclose a conflict of interest and had a “personal vendetta” against him. LaFeber did not respond on the record to follow-up questions asking for further details. He said he complied with every request by licensors and its dentistry board and “even went above and beyond” by taking additional continuing education. He noted that he passed the remediation courses and related tests that the board had requested.

“I also worked with a supervising dentist, at significant expense, who reviewed my work and provided mentoring for 3 years between 2020 and 2023,” LaFeber wrote.

After taking these courses, he said, he has been able to incorporate new technology in his practices that has improved patient outcomes. “Dentistry is an area that is constantly evolving with so much new technology,” he said, “and I welcome all information sources that can help me improve my practice.”

The Tribune and ProPublica asked the two former board members who spoke to the news organizations whether their vote to recommend LaFeber’s license be revoked would have changed if they had the opportunity to weigh in again after he had completed his remedial training.

One former board member said they didn’t think the training completed to satisfy the state was enough to overcome years of poor dentistry. Another said that nothing seems to have changed given new patient complaints. Three board members who were involved in LaFeber’s case declined to comment for this story, and four others could not be reached.

New Patients Say They Were Harmed

With his license restored, LaFeber started to once again grow his business. Public records show he still owns Sandy Center Dental, and in July 2024 he got a business license for a second clinic about 10 miles to the west. (An online ad this summer indicated LaFeber was trying to sell his second practice.)

LaFeber is referenced as the sole dentist on websites for both of these businesses. In his response to The Tribune and ProPublica, he said he owns and operates a single office, Sandy Center Dental, where he works four days a week. A Sept. 23 search of public business records show he is still listed as the registered agent and principal for both practices. LaFeber said he helped start the second office, Parkway Smile Center, but said it is now “entirely owned and managed by another dentist.” The new owner could not be reached for comment.

In the nearly two years since LaFeber’s full return to practice, at least two more patients have publicly complained they were harmed under his care, both of whom The Tribune and ProPublica contacted after they left negative online reviews.

Michelle Lipsey had been a patient at Sandy Center Dental for nearly eight years, but she said in an interview that she hadn’t been to the dentist for a couple years after her second child was born. She said LaFeber told her during an October 2024 appointment that she needed five cavities filled. She returned a week later for the procedures.

For weeks after, Lipsey was in pain, and she returned to Sandy Center Dental later that month, complaining that she couldn’t sleep and was only able to eat soft food, according to her medical records. LaFeber redid some of the fillings, medical records show, but Lipsey said the pain persisted. She said a second dentist told her that LaFeber hadn’t properly sealed the fillings and had drilled far deeper than he needed to.

LaFeber noted in her medical records that he tried to call and text Lipsey after she left a negative review online. “Remember patient was very nervous,” her patient file reads. “We tried our best to help calm but at no point had the appointment gone as she described in the post.”

Haley Stafford described a similar experience earlier this year. She said that, based on what LeFeber told her, she was expecting to have two cavities filled during a March appointment; instead, he put fillings in seven teeth. She recalled in an interview that his hands shook when he gave her numbing shots. (The testing exam results reviewed by The Tribune and ProPublica also noted LaFeber’s unsteady hands.)

“That was the first time he actually did work on me,” she said. “And it was completely botched.”

She’s been in near-daily pain since, she said, and has needed more dental work on her affected teeth, including two root canals. Stafford found a new dentist, but the repair work has cost her thousands of dollars.

Both Stafford and Lipsey said LaFeber contacted them about refunding their money.

LaFeber said he doesn’t recall refunding money to any patients after a complaint. He said he could not comment on specific cases to protect patient privacy, but said that sensitivity and pain can happen after a treatment.

“We try to do all we can to minimize it,” he said. “The presence of pain does not demonstrate treatment that fell below the standard of care.”

Lipsey filed a complaint with licensors in late July and said she was interviewed by an investigator and shared X-rays from before and after LaFeber filled her cavities.

Licensors sent Lipsey an email in late August saying that they were closing the case and that “appropriate action was taken,” according to a screenshot of the email Lipsey shared with The Tribune and ProPublica. They would not tell her what that action was, saying the investigative record was considered private under Utah law. Licensing officials declined to comment on the outcome of Lipsey’s complaint.

If licensors had disciplined LaFeber, it would be considered a public record. The agency has the option to address a complaint informally by giving a verbal warning to a licensed professional or writing a letter of concern. Those measures typically are not disclosed to the public.

LaFeber told The Tribune and ProPublica that Lipsey’s complaint was dismissed and he did not receive any warnings or a letter of concern. Licensors “investigated it thoroughly and found it to be meritless,” he said.

LaFeber’s license remains in good standing, according to the state’s licensing database in September.

Stafford hasn’t filed a complaint with the state and said she had no idea LaFeber had nearly lost his license until a reporter reached out to her.

How does a dentist nearly “lose their license and get it back,” she asked, “and patients are not aware of that?”

This post was originally published on ProPublica.

by Eli Cahan for ProPublica

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As the share of U.S. adults receiving mental health care treatment steadily grows, for-profit companies are playing an increasingly important role.

More than 40% of inpatient mental health beds were operated by for-profit entities as of 2021, according to unpublished data from Morgan Shields, an assistant professor at Washington University in St. Louis who studies quality in behavioral health care. That’s up from about 13% in 2010. (The number of mental health beds held relatively constant during that time.)

Experts tie this growth to provisions of the Affordable Care Act, which made mental health care an essential health benefit that all insurance plans are required to cover.

Before the law, millions of Americans lacked meaningful mental health care coverage by their insurers — if they had any coverage at all. That changed with the law’s passage in 2010. Three years later, the Obama administration went further, issuing rules that require plans to pay more for mental health care, and to pay for it as long as patients need it. (Some plans had previously imposed hard caps on the number of days they would cover.)

Wider access to and increased reimbursement of mental health services piqued the interest of for-profit corporations, said Eileen O’Grady, who until recently served as program director at the Private Equity Stakeholder Project, a nonprofit organization that researches the industry.

“Investors in for-profit entities see that as an opportunity to make money,” she said, “in a space that had not historically been seen as super profitable.”

Shields and other researchers have repeatedly flagged concerns about lower quality of care at mental health facilities owned by for-profit corporations, in part due to efforts to cut staff and reduce costs. Companies have defended the quality of care they provide.

ProPublica reported Monday that over 90 psychiatric hospitals across the country have violated the Emergency Medical Treatment and Labor Act in the past 15 years. The vast majority of them — around 80% — are owned by for-profit corporations.

Yet only a handful have faced any consequences from either the U.S. Centers for Medicare and Medicaid Services or the inspector general of the Department of Health and Human Services, both of which are responsible for regulating the law. In the rare cases when hospitals have faced fines, the penalties have been trivial compared to the earnings of each for-profit hospital chain, the investigation found.

According to ProPublica’s analysis of CMS data, about half of all the hospitals cited were owned by just two corporations — Universal Health Services and Acadia Healthcare — which together operate hundreds of inpatient and outpatient behavioral health facilities, in addition to psychiatric hospitals. (UHS made nearly $16 billion in revenue last year, and Acadia collected more than $3 billion.)

From 2010 through the second quarter of this year, 34 of UHS’ psychiatric hospitals had been cited with EMTALA violations. Two, Brentwood Behavioral Healthcare of Mississippi and Three Rivers Behavioral Health in South Carolina, settled with the HHS inspector general for a total of $375,000.

In its May 9 enforcement action against Brentwood, the inspector general of HHS found that, in June 2021, the hospital’s interim CEO directed staff to refuse to accept seven patients from other facilities under the pretense that the facility “did not have the capacity” to treat them. “In each instance, however, Brentwood had the capacity,” an inspector general press release accompanying the enforcement action said, “but refused the transfer because the individual needing treatment was uninsured.”

UHS spokesperson Jane Crawford said the company has 134 facilities that are subject to EMTALA. “While there have been isolated citations associated with technical EMTALA compliance over the 15-year time period in question at some of our facilities, over 75% of UHS Behavioral Health (BH) facilities did not have any EMTALA citations during this time period,” Crawford said. “As such, the narrative or belief that UHS’ facilities as a whole do not comply with EMTALA or attempts to circumvent its requirements is inaccurate and incorrect.”

In a separate statement, she said the company’s psychiatric hospitals “do not select patients based upon insurance status or ability to pay. All UHS facilities are committed to complying with their EMTALA obligations as applicable and provide the requisite care and treatment to all patients who present to the facility regardless of ability to pay.”

As for what happened at Brentwood, Crawford said that the hospital “inadvertently violated rules and regulations” due to “poor internal communication and process failure in a one-month period of time.” Brentwood “promptly revised its practices to address any such future concerns and has not had any EMTALA related issues since that time,” she added.

On the events at Three Rivers, Crawford said that of the 11 patients that CMS said it denied to accept for transfer, citations related to 10 of them were ultimately “rescinded as it was determined that EMTALA did not apply to those patients.” She added that “at no time did Three Rivers fail to respond or accept a fax request based upon any prospective patient’s insurance status or ability to pay.” CMS did not respond to requests to clarify whether the citations were rescinded, but they remain on its website.

Inspectors have cited 12 Acadia hospitals for EMTALA violations since 2010. However, only one — Park Royal Hospital in Florida — has been fined by the inspector general; in 2019, the agency fined the hospital just over $52,000.

“Our goal is always to provide the best quality care to anyone seeking treatment at one of our facilities, and we take our compliance obligations very seriously,” Acadia spokesperson Tim Blair said in an email. He did not respond to subsequent questions about quality of care at Park Royal.

Dr. Jane Zhu, an associate professor of medicine at Oregon Health and Science University, said decisions made by for-profit psychiatric hospitals may be driven by financial interests. Denying care to patients without insurance or with lower-paying forms of insurance can help increase profits, Zhu said.

Those same financial incentives may drive for-profit hospitals to turn away more complicated patients — such as those who are aggressive or violent while in the throes of a mental health crisis, Zhu added. In these situations, hospitals can save on staffing and other costs if they admit healthier patients and avoid patients with the most severe psychiatric needs — a tactic she called “cream-skimming.”

Both CMS and the HHS inspector general declined to comment on why psychiatric hospitals owned by for-profit corporations have so infrequently faced consequences for EMTALA violations.

Federal law caps the amount that the HHS inspector general can fine for EMTALA violations, an agency spokesperson said. In 2024, that amount was about $66,000 per violation for hospitals with fewer than 100 beds, and $133,000 per violation for hospitals with more than 100 beds. (The figure increases annually for inflation.)

Since 2010, in four of the five cases in which the agency settled with psychiatric hospitals for EMTALA violations, the amounts were well below the maximum allowable. The inspector general’s office declined to comment why.

Former staffers from both CMS and the inspector general’s office said that the lack of consequences for EMTALA violations may be emboldening hospitals to turn away patients that could hurt their bottom line.

“There are a lot of CEOs who will take that risk — they say, ‘Yeah, we know we dumped that patient,’ or, ‘They’re not going to fine us anyhow,’” said a former CMS official focused on EMTALA who spoke on the condition of anonymity because of ongoing work in the industry.

And even in the cases when facilities do face fines, the sums have been minimal compared to chains’ bottom lines.

“Hospitals may see those small-dollar figures as just the cost of doing business,” said a former senior official in the HHS inspector general’s office who spoke on the condition of anonymity for fear of affecting future job opportunities. “They weren’t seen as a particular deterrent.”

U.S. Rep. Frank Pallone Jr., D-N.J., ranking member of the House Energy and Commerce Committee, said ProPublica’s findings are cause for concern.

“In the face of a large mental health crisis, we should be doing more, not less, to ensure people have access to the care and treatment they need,” he said in a statement.

“Medicate Him and Ship Him Out”

Perimeter Healthcare is one such company whose growth came years after passage of the ACA. In September 2016, Perimeter — backed by $8 billion private equity firm Ridgemont Equity Partners — acquired another company and, with it, five residential treatment facilities and three psychiatric hospitals.

By May 2019, Perimeter acquired its six and seventh hospitals. The hospitals’ former parent company, SAS Healthcare, was indicted months earlier for violating the Texas mental health code. It later pleaded guilty to one count and paid a $200,000 fine; the county dropped the other charges.

The hospitals in Dallas and Arlington aimed to “serve as the gold standard for inpatient psychiatric care,” Rod Laughlin, Perimeter’s founder, said in a press release announcing the acquisition.

But within years of Perimeter taking over, the Dallas hospital again was in the spotlight.

In August 2023, CMS found that Perimeter Behavioral Hospital of Dallas violated EMTALA in four ways when staff refused to examine a patient who had tried to kill himself. (“If that is the patient I am thinking of, he can’t be here,” a hospital staff member told a police officer at the time, according to CMS records. “All we can do is medicate him and ship him out.”) Under the law, hospitals are required to screen and stabilize all emergency patients before discharging them.

And less than a year later, at the same hospital, staff pushed for another patient to be transferred elsewhere after he started flipping chairs.

That led to a standoff between staff and police as the patient slammed against the walls, trying to escape.

“Legally we can’t touch him because he is not our patient,” a hospital staff member told an officer during the exchange, according to CMS records.

With that, the officer called another officer, who asked hospital staff if there was “a particular reason” they were refusing to admit the patient.

“This individual here is beyond our ability to treat” due to his “extreme aggression,” a staff member responded. “We can’t manage him.”

“Under EMTALA since he is on your grounds EMTALA says you guys are responsible — so we are having a disagreement here,” the second officer responded. “I guess,” the officer added, “my next call is to CMS.”

“It is not even necessary to call CMS,” the hospital staff member said, “but feel free to do that.”

Eventually, CMS was called. And some two weeks after the incident, the agency found that the hospital had violated EMTALA in three ways, including failing to provide even the most basic care through a medical examination of the patient — beyond just eyeballing him.

When hospitals breach the law, they are required to send plans to CMS detailing how they will avoid violating EMTALA in the future. Plans of correction filed by Perimeter Behavioral Hospital of Dallas said the hospital would revise some of its materials, including training slides, a test, a self-attestation form used in staff training and a medical screening form for patients. Officials also said they would monitor compliance with the law by reviewing patient logs daily. But the hospital also noted multiple instances in which officials believed “no changes were needed” to its policies.

Beyond responding to CMS with these plans, the hospital did not face consequences from the agency, or from the HHS inspector general for either set of findings. The agencies have not responded to questions about the lack of follow-up in the Perimeter Dallas cases.

Perimeter Healthcare and Ridgemont Equity Partners did not respond to requests for comment.

Lately, lawmakers and regulators have expressed particular alarm about health facilities owned by private-equity companies — like Ridgemont Equity Partners — which typically take control of a business for a relatively short time, restructure it, and resell it at a profit.

Data on for-profit health facilities, in general, shows worse results for both hospitals and nursing homes after they are acquired by private equity firms. A January report by HHS, before the end of the Biden administration, attributed quality differences in part to private-equity firms’ tendency to “dramatically reduce the operational costs” of health care facilities.

Recent research demonstrates that private equity is playing an increasing role in psychiatric hospitals, and that has some federal officials worried. In January, the Senate Budget Committee released a bipartisan congressional staff report investigating private equity’s growing presence in health care.

Officials from the Healthcare Private Equity Association, the trade group that represents medical facilities owned by over 100 investment firms, did not respond to requests for comment.

“Instead of helping families, billionaire corporations are denying sick patients legally protected emergency care to turn healthy profits,” Sen. Jeff Merkley, D-Ore., ranking member of the Senate Budget Committee, said in a statement to ProPublica.

“This unchecked corporate greed is leading to worse outcomes for patients,” Merkley added, “particularly those who struggle with mental health crises.”

This reporting was supported by the McGraw Center for Business Journalism at CUNY’s Newmark Graduate School of Journalism, the Fund for Investigative Journalism and the National Institute for Health Care Management Foundation.

This post was originally published on ProPublica.

by Eli Cahan for ProPublica

This article describes attempted suicide.

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

Late one Saturday night in May 2023, Melissa Keele’s phone rang. Her son had been found alone in the desert of Colorado’s Grand Valley. He was naked; his clothes, phone, keys and car were nowhere to be found.

Keele rushed out to her own vehicle and floored it, her headlights piercing through the pitch black. For years, her son had been dealing with severe mental illness. At the peak of the COVID-19 pandemic, he hit a breaking point and attempted suicide by driving off a cliff on the highway. “God told him he needed to die,” Keele recalled him telling her.

Eventually, she picked him up — and he didn’t look good. Fearing for his safety, Keele immediately took her then-21-year-old son to West Springs Hospital in Grand Junction.

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

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

The facility, which called itself “Colorado’s Best Psychiatric Hospital,” touted “exceptional psychiatric care in a world-class environment,” including a “state-of-the-art” 63,000-square-foot facility decked out with crafts areas, light therapy rooms and “cozy nooks.”

During the intake process, Keele said she told a nurse about her son’s yearslong battle with mental illness, how he had struggled to keep up with his treatments, hold down a job and keep a roof over his head. How he had stopped taking his psychiatric medications. How just before he left that night he had told his fiancee that he wanted “some alone time” in the valley’s rolling hills.

But 102 minutes after he arrived at West Springs, a nurse discharged him.

Back at home, he slipped out a few hours later while his fiancee was at work. Police found him and quickly called his mother. He again was naked; this time, he was also sunburned and dehydrated. He couldn’t explain what had happened, and he didn’t understand why he was there. Police took him to another emergency room, which deemed him “gravely disabled.”

That determination was critical. It meant that the doctors believed sending Keele’s son home could put him in imminent danger. And it meant, legally, that they could keep him against his will until he was safe. Ultimately, he was transferred to a psychiatric hospital 240 miles east in Denver, where he stayed for more than a week.

The speed with which West Springs released him prompted federal officials to investigate the hospital for failing to properly screen and stabilize him before his discharge. Within days, regulators determined the hospital had violated federal law.

The hospital had failed to comply with the Emergency Medical Treatment and Labor Act, better known as EMTALA. The law, enacted in 1986, requires hospitals to screen and stabilize all emergency patients regardless of whether they have insurance. West Springs, the inspectors found, had missed key red flags related to Keele’s son’s grave disability, which could have left him seriously harmed.

It was the second time in a year that West Springs had violated EMTALA. In October 2022, inspectors declared that patients were in “immediate jeopardy” of harm or death because the hospital had failed to properly screen and treat 21 patients who showed up to its emergency room.

Two other times, it was cited for providing deficient emergency care in violation of other rules, according to federal regulators. Just one day after the October 2022 inspection report, regulators found that the hospital did not ensure that some low-level staff were “trained” or “qualified” to monitor patients being assessed for a crisis. And in February 2023, the hospital was hit with another violation for discharging suicidal patients without “evidence of being stabilized and deemed safe.”

In each instance, the Centers for Medicare and Medicaid Services, the agency primarily responsible for enforcing EMTALA, asked West Springs to come up with a plan for how it would ensure the problems didn’t happen again. (ProPublica requested the plans of correction in May 2025 from CMS but has not yet received the records.) CMS could have terminated the hospital’s Medicare funding. Another arm of the federal government, the inspector general of the Department of Health and Human Services, could have imposed monetary penalties for the EMTALA violations.

But neither of those things happened, though the state of Colorado increased its own oversight of the hospital, mandating that it hire an outside management company in order to keep treating patients.

First image: A road near where Melissa Keele’s son attempted suicide during the peak of the COVID-19 pandemic. Second image: West Springs Hospital in Grand Junction, Colorado, violated a federal law guaranteeing emergency treatment on two separate occasions in one year. (Rachel Woolf for ProPublica)

West Springs Hospital did not respond to repeated inquiries from ProPublica over a year of reporting about what actions it took to prevent future EMTALA violations. In public statements, it said it was committed to providing quality care and subsequently noted that the state restored its full unconditional license at the end of 2024. Keele’s son did not respond to multiple requests for comment and we are not publishing his name; this account is based on documents and interviews with his mother.

Over 90 psychiatric hospitals across the country have violated EMTALA in the past 15 years and almost all have faced the same lack of consequences, a ProPublica investigation has found.

Since 2019, the HHS inspector general has only issued three penalties involving EMTALA violations by psychiatric hospitals. Taken together, these penalties totalled $427,000. (The inspector general has levied additional fines against medical hospitals for inadequate care of patients with mental illness.)

CMS has pulled Medicare certification, and funding, from a handful of psychiatric hospitals, and a number of others have shut down after officials threatened to stop paying. But those cases have been the exception.

“Facilities are not facing consequences for providing poor quality of care,” said Morgan Shields, an assistant professor at Washington University in St. Louis who studies the quality of care that behavioral health patients receive.

“The market isn’t punishing them and regulators are not punishing them,” Shields added. “That’s an excellent environment to make money.”

The HHS inspector general declined to comment.

For its part, CMS said that West Springs “was given the opportunity to correct their deficiencies” and subsequently “was able to demonstrate compliance.” (CMS has an online portal to report suspected EMTALA violations.)

The widespread violations of EMTALA by psychiatric hospitals — and the lack of enforcement — come even as America’s mental health crisis is reaching a fever pitch, with suicide rates near record highs.

Democrats in Congress say they are concerned that budget cuts under the Trump administration may impair oversight further. In March, the administration’s Department of Government Efficiency announced that it was shuttering half of HHS’ 10 regional offices and purging 25% of the agency’s staff.

In recent months, Rep. Lloyd Doggett, a Texas Democrat, and other members of the House and Senate have requested details on how cuts made by President Donald Trump may impact the core functions of HHS, such as ensuring compliance with regulations like EMTALA.

“The abrupt firing of so many dedicated public servants weakens the ability of the Centers for Medicare and Medicaid Services (CMS) to conduct important oversight and enforcement work,” Doggett said in a statement responding to inquiries from ProPublica, meaning that “those who violate EMTALA and other federal health and safety laws will be able to continue avoiding accountability.”

As of yet, those requests for information have gone unanswered. “CMS will continue to enforce EMTALA,” an agency spokesperson said in response to inquiries from ProPublica. The White House did not respond to requests for comment about the impact of the DOGE cuts.

Numerous Psychiatric Hospitals Have Repeatedly Violated Emergency Care Regulations

Psychiatric hospitals that have been cited for violating the Emergency Medical Treatment and Labor Act since 2019.

View the full table on [ProPublica’s site](FINAL URL TK). “More and More Cracks”

Nearly four decades ago, a group of doctors noticed a pattern among the patients transferred into Chicago’s largest public hospital from private facilities.

Of 467 patients transferred in, 87% were brought to Cook County Hospital “because they lacked adequate medical insurance.” Some 89% of these patients were Black or Hispanic; 81% were unemployed. Almost one-quarter of these patients were medically unstable at time of transfer, and they were more than twice as likely to die as patients who weren’t transferred.

The research, published in the New England Journal of Medicine, described that “strong economic incentives” raised serious questions about for-profit hospitals’ ability to “consider the condition and well being of patients objectively.”

Within months, Congress took action.

In April 1986, President Ronald Reagan signed a law to prevent what became known as “patient dumping.” EMTALA is the only law that requires universal care for “emergency medical conditions” regardless of a person’s insurance status.

In the decades since, authorities have documented thousands of EMTALA violations by hospitals across the country.

In a number of cases, patients died just hours after failing to receive the care to which they were legally entitled.

Patients with mental health conditions have also been regularly denied emergency care, according to federal agencies. Since 2010, CMS has found more than 300 EMTALA violations by psychiatric hospitals specifically.

These include sending home gravely disabled patients like Keele’s son, turning away actively suicidal patients, screening out uninsured patients, and rejecting “frequent flyers,” those who return repeatedly, due to how they’ve interacted with staff in the past — among other issues. That’s despite the fact that, in some of these cases, patients met criteria for imminent risk of harm to themselves or others

“Most Americans take it as a given that they can get emergency health care when they go to a hospital, but that promise, enshrined in EMTALA, is showing more and more cracks,” Sen. Ron Wyden, an Oregon Democrat, said in a statement responding to inquiries from ProPublica.

“I Want Peace Again”

When hospitals release patients experiencing mental health crises prematurely or turn them away entirely, the consequences can be even more severe than what happened to Keele’s son in 2023.

Six years earlier and 1,500 miles to the southeast, Tom Swearengen was discharged from Lakeside Behavioral Health System in Memphis, Tennessee. Less than a week later, a neighbor in their leafy cul-de-sac noticed that “something seemed off” — Swearengen’s blinds had been open, for days, at all hours.

Upon entering the home, the neighbor found Tom’s body — and that of his wife, Margaret — on the living room floor. Margaret had sustained multiple gunshot wounds; Tom had suffered just one, in what police later classifed a murder-suicide.

It was a brutal end to a relationship that, in some ways, had seemed magical at the outset: A conversation kicked off at a Kroger butcher counter had blossomed, and Tom’s easygoing demeanor “put us at ease,” said Bret Boscaccy, Margaret’s son from a previous marriage, “because he seemed harmless.”

That perception changed when, one day, Margaret told Boscaccy and his brother that Tom was “losing his fight with alcoholism.” The news came as a surprise, Boscaccy recalled. “We didn’t see any of it,” he said.

A family photo album shows images from early in Tom Swearengen’s marriage to Margaret. (Andrea Morales for ProPublica)

On Valentine’s Day in 2017 — eight days after Tom cracked a couple ribs, split his right clavicle and bruised his lung amid a spate of drinking — he reached out for help. That’s when he and Margaret found themselves at Lakeside Behavioral.

In the ER that day, Tom’s pain was overwhelming.

“I don’t want to be here,” Tom told the Lakeside Behavioral clinician, according to a government inspection report. “I just wish something would take me. … I want peace again.” At one point in the interview, he said he wanted to hurt himself. At another, Tom described a desire to “die right now.” At a third, he shared that they had guns at home.

Under the “Suicide and Homicide/Violence Risk Factors” section of the assessment, Lakeside Behavioral’s intake clinician noted 10 distinct concerns. Tom also scored three times the threshold for hospitalization based on his recent drinking habits.

But Tom’s insurance wouldn’t cover psychiatric hospitalization, the inspection report said.

So the intake clinician called a psychiatrist, who was home, and got permission to discharge him. She characterized him as “low to no risk” of suicide or homicide. Make an appointment with your old psychiatrist, she told him. And go to Alcoholics Anonymous.

After the murder-suicide, inspectors visited the hospital and determined that the care Swearengen received violated EMTALA: There was no evidence that Lakeside Behavioral helped him in a meaningful way or that he was safe to go home.

Since August 2000, Lakeside has been owned by Universal Health Services, a for-profit corporation that operates hundreds of inpatient and outpatient behavioral health facilities, in addition to psychiatric hospitals, and made $16 billion in revenues last year. In response to inquiries about decisions made by Lakeside staff in Swearengen’s case, Universal Health Services spokesperson Jane Crawford said the company “was not going to get into details” but that it “contested the findings from CMS,” maintaining that Swearengen’s insurance status was reviewed after the medical screening exam was performed and that all EMTALA obligations were satisfied. CMS did not respond to Lakeside’s contention that its report was inaccurate, though the findings remain on the agency’s website.

The hospital did not face financial penalties after the incident and has not violated EMTALA since, according to federal inspection records. Both CMS and the HHS inspector general declined to comment on why no further action was taken against Lakeside.

Lakeside Behavioral Health (Andrea Morales for ProPublica)

About six years ago, in the effort to resolve confusion about the scope of EMTALA, federal regulators sought to make explicit that the law applies to psychiatric hospitals, even if they don’t have ERs.

“The hospital is expected to … address any immediate needs,” the July 2019 guidance from CMS read, and to “keep the patient safe and as stable as possible.”

But since the clarification, violations have continued.

The inspector general declined to comment on why so few enforcement actions have been taken since the clarification, even though CMS has cited 37 psychiatric hospitals for EMTALA violations since then. (Federal watchdogs have long said the law receives only limited enforcement. In a 2001 report, the Government Accountability Office described that “the numbers of EMTALA violations and fines have been relatively small,” and highlighted the need for “effective enforcement.”)

“The law is clear: if you want to accept taxpayer money, you must see any patient who shows up to the emergency room — regardless of their ability to pay,” said Massachusetts Sen. Elizabeth Warren, a Democrat, in a statement to ProPublica. “CMS should investigate these troubling allegations and hold accountable any hospitals that have violated the law.”

Boscaccy still remembers how he learned about his mother’s death. Five days after his stepfather was discharged by Lakeside, two unmarked police cars pulled up at Boscaccy’s home. The detectives knocked and asked if he knew who Margaret Swearengen was.

“As soon as they said that,” Boscaccy said, “I knew something bad happened.”

And when he learned from a reporter years later that Lakeside Behavioral never faced any consequences from the government, Boscaccy was at a loss.

“I’m kind of shocked that nothing happened,” he said. “You would think at least something — some kind of, something, would happen.”

Bret Boscaccy at his home. Boscaccy’s stepfather murdered his mother before killing himself, according to police. (Andrea Morales for ProPublica) “A Totally Different Place”

In December 2023, six months after he was found naked in the desert, Keele’s son hit another rough patch.

During a mental health crisis that brought him to a different emergency room, he became physically aggressive toward staffers. (After their experiences with West Springs the preceding May, Keele and her son had avoided going back.)

In June 2024, her son was arrested on a warrant for assaulting the staff and brought to jail. Since then, he’s been in and out of jail. Then the hospital. Then jail again.

“‘Spiral’ is a great word for it,” Keele said. “All this stuff ripples.”

On May 16, Keele’s son was sentenced on felony charges to three years in community corrections. Keele worries that his tumble into the criminal-legal system has “just kind of compounded” his mental illness — “It’s been a long, frustrating decline,” she said.

After the incident, West Springs experienced a period of instability.

The same month as her son was discharged prematurely, the state of Colorado put West Springs under a conditional license for a series of problematic inspections, according to reporting from the Grand Junction Daily Sentinel. Amid the scrutiny, the hospital’s parent company was required to contract with another health provider to help run it for a year. Then, in November 2024, the company’s board of directors announced a “significant new chapter”: the hospital and the organization that owns it was ceding control to Larkin Health System — a for-profit that owns three hospitals in South Florida. A month later, the state restored the hospital’s full license.

In February, however, West Springs announced that it was closing. The hospital’s parent organization cited low patient volume as one key driver of financial pressures. In March, the hospital officially shut its doors. “It is with a heavy heart that we announce the upcoming closure of West Springs Hospital,” the hospital’s parent organization wrote in a press release. “This decision was not made lightly, and we understand the profound impact it will have on our patients, staff, and community.”

Hospital officials did not respond to multiple inquiries from ProPublica for further details about the decision. Officials from Larkin Health System also declined to comment.

Keele, for her part, wonders how her son’s life might be different had he gotten the care he needed before things turned for the worse.

“I just wish I could have gotten people to work with me when this all started,” she said “We’d be in a totally different place if we had a plan — before it got so out of control.”

Keele had hoped that West Springs, under Larkin, could “turn things around.” Given that suicide rates in the Western Slope of Colorado remain well above those in the rest of the state and the U.S., their community needed to hang on to the only psychiatric facility in the region, she said. The alternative — nothing — would certainly be worse.

Now, with West Springs’ closure, that’s their reality, Keele said. And she isn’t sure what comes next. But she does know one thing.

“For those who need care,” she said, “Denver is pretty far away.”

This reporting was supported by the McGraw Center for Business Journalism at the City University of New York’s Newmark Graduate School of Journalism, the Fund for Investigative Journalism, and the National Institute for Health Care Management Foundation.

This post was originally published on ProPublica.

by Anna Clark

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

Just 15 months after receiving an award from the Centers for Disease Control and Prevention for excellence in community water fluoridation, the city of Grayling, Michigan, changed course.

With little notice or fanfare, council members voted unanimously in May to end Grayling’s decadeslong treatment program. The city shut down the equipment used to deliver the drinking water additive less than two weeks later.

Although it already paid for them, the town returned six unopened barrels of the fluoride treatment to the supplier.

Personal choice was the issue, said City Manager Erich Podjaske. “Why are we forcing something on residents and business owners, some of which don’t want fluoride in their water?” he said. He saw arguments for and against treatment in his research, he said, and figured that those who want fluoride can still get it at the dentist or in their toothpaste.

Drinking water fluoridation is widely heralded as a public health triumph, but it’s had critics since it was pioneered 80 years ago in Grand Rapids, about 150 miles southwest of Grayling. While once largely on the fringes, fluoridation skeptics now hold sway in federal, state and local government, and their arguments have seeped into the mainstream.

Even in the state where the treatment began, communities are backpedaling. And because customer notice requirements are patchy, people may not even know about it when their fluoridation stops.

Robert F. Kennedy Jr., secretary of the Department of Health and Human Services, has called fluoride “industrial waste” and supports an end to community water fluoridation. The head of the Food and Drug Administration said on a newscast that the CDC’s online description of water fluoridation as one of the greatest public health achievements is “misinformation.”

The CDC, which is in the midst of a leadership exodus and staff revolt, and the Environmental Protection Agency are reviewing their respective approaches to fluoride in drinking water. At the same time, President Donald Trump’s administration dismantled the CDC’s Division of Oral Health, which, among other initiatives, provided research and technical assistance on fluoridation. That’s the office that helped present awards for well-run programs like the one in Grayling.

Since Kennedy was elevated to the nation’s top health post, Utah and Florida became the first states to ban communities from adding fluoride to public drinking water. The Utah ban included measures to make prescription fluoride supplements more accessible — but now, the FDA is moving to remove certain types of those supplements for children from the market.

Altogether, legislation was introduced this year in at least 21 states to prohibit or roll back provisions related to adding fluoride to public water systems, according to Abby Francl, policy analyst at the National Conference of State Legislatures. In addition, citing Kennedy’s “Make America Healthy Again” initiative, Oklahoma’s governor issued an executive order instructing state agencies to cease promotion of fluoridation in the public water supply while it reviews the practice.

Some local communities across the country opted to stop treatment this year, including at least four in Alabama, the state with the second-lowest number of dentists per resident. Others are debating it. On Michigan’s east side, the medical director of St. Clair County’s health department urged the agency to take steps to “prohibit the addition of fluoride” to public water systems. Two Upper Peninsula cities with a shared water system had special council meetings this summer on fluoridation. In Hillsdale, the acting mayor has said that ending fluoridation is a top priority.

“I want to reform the water system now that we have RFK in Health and Human Services,” Joshua Paladino told a local paper in November. Paladino added in an email to ProPublica that he sees public water fluoridation as an imprecise tool because it gives a standard dose across the population.

According to Michigan’s environmental agency, some communities had temporarily stopped fluoridation and were “hesitant to restart because of uncertainty.” That prompted it to issue a five-page statement with the state health department in March, stressing that the levels recommended for water suppliers — 0.7 milligrams per liter of water — have no adverse health effects and that fluoridation benefits everyone.

“Local anti-fluoride movements can be vocal and persistent, but do not necessarily represent the viewpoints of the greater community,” the statement said.

Communities that end fluoridation will see more decaying teeth, according to Margherita Fontana, a professor at the University of Michigan School of Dentistry. Young children, older adults, people with disabilities and people who are poor are especially at risk, she said, but everyone will be vulnerable. Excessive tooth decay in children can require treatment in hospitals, under anesthesia. In rare but extreme cases, it can lead to death.

“It’s unfortunate, because we know how to prevent the disease,” Fontana said. “So it just seems like we’re going backwards in time rather than forward.”

A handful of states require customer notification when fluoridation ends. New York mandates such notice, yet fluoridation in Buffalo lapsed for years before it was widely known. Outside Detroit, the city of Wyandotte suspended treatment about a decade ago, despite saying on its website until early this summer that it used fluoride. The claim was removed only after a local reporter raised the issue.

Michigan doesn’t have a statewide protocol for notifying residents when fluoridation stops. The environmental agency’s spokesperson said in an email that while it strongly recommends that communities inform customers, it doesn’t have the authority to compel them.

Grayling’s water operator, Josh Carlson, said a district engineer at the agency told him he just needed to tell the state if the town decided to stop fluoridating the water.

“It was almost like she was caught off guard that we actually did it,” Carlson said.

From Fringe to Mainstream

Water fluoridation began in 1945 in Grand Rapids, Michigan’s second-largest city, as part of a planned trial intended to last 15 years. Muskegon, on the Lake Michigan shore, served as the control, meaning its water was not treated with a fluoride additive. An Illinois city with naturally occurring fluoride in its water was another point of comparison.

Six years in, Muskegon officials withdrew from the trial after determining that the health benefits were so significant, they couldn’t deny treatment any longer to Muskegon’s children. Similar studies elsewhere continued for years, showing positive outcomes.

“It was very usual to have dentures at a very young age” at the time, Fontana said. Fluoride treatment “was such a fantastic discovery, something so easy that nature already provided. It was already there. It was the greatest discovery, really, for oral health.”

Grand Rapids celebrates its role in public health history with plaques and a totemic sculpture. But the treatment has been criticized since the early days as, variously, a Communist plot, forced mass medication and an industrial byproduct that causes more harm than good. (Fluoride additives are commonly derived from the processing of phosphate fertilizer.)

Even as fluoridation became widespread, opposition persisted. Today’s critics note that fluoride is now available in toothpaste, as well as in ingestible drops and tablets like the ones for children that the FDA is working to remove from the marketplace. Dental care is also more accessible than it was in the 1940s. The need that fluoridated water was meant to address, critics say, isn’t as urgent.

While progress has made fluoridation’s effects less dramatic, they’re still significant. It was initially credited with a 65% reduction in tooth decay; now, it’s about 25%. No other fluoride source compares to the cost-effectiveness of drinking water, proponents say, especially for those least able to access dental care, either because of cost or because they live in areas with a shortage of dental providers.

“Steel Water,” a sculpture by artist Cyril Lixenberg, was erected in 2007 in Grand Rapids to celebrate the community’s role in advancing water fluoridation. (Joel Seewald, HMdb.org)

Community water fluoridation is supported by the American Academy of Pediatrics, the American Dental Association and the American Medical Association. The CDC, at least for the moment, still recommends it.

Advocates say that its benefits are so pervasive, they’ve become invisible to many.

“Known benefits that are not visible, they take it for granted, whereas unknown risks are what they are always worried about,” said Jayanth Kumar, lead researcher on a systematic review of community water fluoridation and IQ. “Florida didn’t ban alcohol. Florida didn’t ban cigarettes. But they banned fluoride.”

Critics say the National Toxicology Program’s “state of the science” report from last year shows an association between fluoridated drinking water and a lowered IQ in children. But that assessment — which is both contested and much-cited — involves fluoride levels that are more than twice what the federal government recommends for drinking water, and it’s based on limited studies conducted outside the U.S., with different water conditions.

A post made on Gov. Ron DeSantis’ X account, celebrating Florida’s ban on local governments adding fluoride to public drinking water, was sent to ProPublica in response to a query to the governor’s office about the state’s policy. (Obtained by ProPublica)

Even the report’s abstract says that “more studies are needed to fully understand the potential for lower fluoride exposure to affect children’s IQ.”

In a lawsuit brought against the EPA by groups opposed to water fluoridation, a district judge relied in part on the NTP analysis in ruling that fluoridation presents such an “unreasonable risk” that the agency must take action. Even as it appeals the decision, the EPA said its review of new science on fluoride in drinking water “is being done in coordination with Secretary Kennedy and HHS.”

The court ruling, the NTP report and the wavering stance of federal agencies have empowered a backlash to fluoridation in state and local governments.

Stuart Cooper, executive director of the Fluoride Action Network, said he’s seen momentum shift over the last two decades as his group sought to eliminate fluoride treatment, not least as a plaintiff in the EPA lawsuit. Kennedy has given a jolt to the movement, he said. Now, “we have allies at every level.”

“Legislators and city councilors are calling us instead of me having to do vice versa,” he said.

Tooth Decay and Regrets

In Grayling, questions about fluoridation were brewing for at least a year before the town changed course. Podjaske, the city manager, said he discussed it off and on with Carlson, the city’s water operator. When it came time to reorder the fluoride additive, Podjaske wondered: Is this really necessary?

Carlson asked the state’s environmental agency about the protocol for discontinuing treatment and was told to keep the state posted. In April, Podjaske suggested adding the fluoridation question to the City Council’s agenda. At the May meeting, the council voted 4-0 to end treatment.

“I figured the best option was don’t push it on people,’’ council member Jack Pettyjohn said about his vote. “Don’t force them to have it in their water.”

There wasn’t any outreach to the public or health experts ahead of the vote. Meeting minutes say that Podjaske and Carlson discussed the removal of the fluoride additive after the water operator received “additional education and training.”

But both men say that isn’t right. Fluoridation was already on the agenda when Carlson attended a training that wasn’t about the treatment, but where he had an informal conversation with an instructor that made him worry about fluoride’s safety.

The vote would’ve occurred even without Kennedy’s activism, Podjaske and Pettyjohn said. Carlson, though, noted how Grayling’s pivot played out in context of “some of the new narratives coming out of Washington.”

“There’s a lot of mixed feelings about RFK Jr., but he seems to be anti-fluoride,” Carlson said. “I don’t know if that’s driving people’s complaints about fluoride.” With the proliferation of social media, he said, “I could see that being a factor, in the fact there’s more people with an opinion now.”

At the same time, he said, locals are more tuned in to water issues following the Flint water crisis and the contamination of waterways with PFAS chemicals linked to a nearby military base. PFAS are a group of “forever chemicals” that can carry a cancer risk.

Carlson said that in the occasional feedback he’s gotten on fluoridation over the last couple of decades, “the negatives were more than the positives in recent years.”

Following input from the state environmental agency, Grayling posted a notice about the change online in August, 10 weeks after treatment stopped. Some people didn’t see it. Mary Bobenmoyer, owner and general manager of Our Town Coffee & Treats, didn’t know until a reporter asked her about it in late August. “They did it?” she said.

Bobenmoyer spent seven years as a dental assistant. She encourages children especially to get fluoride treatment at the dentist. But, she said, “I personally don’t think it should be filtered in our water. We should have free and clear water.”

Over in Grand Rapids, there’s sporadic pushback on fluoridation, said water system manager Wayne Jernberg. But he hasn’t noticed any recent escalation. And he doesn’t see why there would be.

“We rely on the science of us,” Jernberg said. “We’ve been adding it for 80 years, OK? And we don’t see any issues in our community.”

Meanwhile, reports on dental health have caused some communities that dropped fluoridation to reconsider.

In Canada, just across the river from Detroit, the City Council of Windsor, Ontario, voted to stop fluoridation in 2013 after lengthy public debate. Less than six years later, the county health agency reported troubling outcomes from oral health screenings at area schools. It found that the percentage of children with decay or requiring urgent care increased 51% in five years, while the percentage of children that didn’t require any care decreased by 43%. The Windsor council soon decided to reintroduce water fluoridation, citing it as “a key prevention strategy.”

In the province of Alberta, Calgary’s council voted in 2011 to stop fluoridation in part because of community skepticism and because expensive repairs to the equipment were needed, according to Councillor Gian-Carlo Carrà. But in time, researchers found that local children developed significantly more cavities than their peers in Edmonton, where water is fluoridated.

“We saved ourselves some money,” said Carrà. “Fast-forward 10 years, and the results are clear that dental outcomes for Calgarians are worse after 10 years of not having fluoride in the water.”

When fluoridation was put on the ballot in 2021, 62% of voters supported its reintroduction. It took more than 28 million Canadian dollars and several years to start treatment again.

But, Carrà said, those costs — and the money to run the system — seem worthwhile. “I’m just much more interested in doing as much good as I possibly can,” Carrà said.

In Grayling, speaking more than two months after voting to end the treatment, Pettyjohn said he has an open mind about the future of fluoridation. “I would totally look at readdressing it, especially if the people of Grayling really wanted us to,” he said.

For now, though, he said he’s heard nothing negative from residents.

This post was originally published on ProPublica.