by Jennifer Berry Hawes

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London Lamar rose from her chair in the Tennessee Senate last spring, stomach churning with anxiety as she prepared to address the sea of men sitting at creaky wooden desks around her. She wore a hot pink dress as a nod to the health needs of women, including the very few of them elected to this chamber, none of whom were, like her, obviously pregnant. She set her hands onto her growing belly.

The Senate clerk, a man, called out an amendment Lamar had filed. The Senate speaker, also a man, opened the floor for her to speak. The bill’s sponsor, another man, stood near her as she grasped a microphone to discuss the matter at hand: a tweak to the state’s near-total ban on abortion access for women.

Lamar glanced around at her fellow senators, three quarters of them men. The imbalance was even more stark in the state’s House of Representatives, where almost 9 in 10 members were men. And Tennessee is no anomaly. Across much of the Southeast, state legislatures are more than 80% male.

On this day, the Tennessee Senate was poised to take a final vote on a bill that would allow abortions to prevent a woman’s death or “serious risk of the substantial and irreversible impairment of a major bodily function.” Lamar stood to pitch a broader health exception.

A Democrat in the substantial minority, she could have appealed to her female Republican colleagues. Although they oppose abortion, they bring to the debate their personal knowledge of women’s bodies and experiences. But there were only three of them in the 33-member Senate. Instead, Lamar turned to the two dozen Republican men.

She reminded them that four years earlier, she was 32 weeks pregnant and serving in the House when her blood pressure suddenly spiked. Her placenta ruptured. Her son died in utero, and she faced a terrifying risk of a stroke. “It’s personally one of my biggest fears that this thing would happen again to me,” she told them. If it did, she feared the proposed law would prevent her doctor from protecting her health.

She implored the men to see her as a family member: “I’m telling you as your own colleague, as your niece, baby girl. I love you all. It is real, not only for me but for women all across the state.”

Scenes like this play out across the Southeast, even as the U.S. as a whole saw a record number of women elected to statehouses last year. Nationally, one-third of legislators are women, the most in history. In recent years, three states — Nevada, Arizona and Colorado — achieved parity.

But much of the Southeast lags far behind.

Seven States, Almost All in the Southeast, Had Legislatures That Were Less Than 20% Women in 2023

Women made up less than half of the state legislatures in nearly every state.

State legislature data provided by Reflective Democracy Campaign and current as of July 27, 2023. (Lucas Waldron/ProPublica)

More than a century after the 19th Amendment gave women the right to vote, women constitute fewer than 1 in 5 state legislators across much of the region: in Alabama, Mississippi, South Carolina and Tennessee, according to the Center for American Women and Politics at Rutgers University, which studies women’s political participation. West Virginia has the lowest percentage of any state; less than 13% of its state lawmakers are women.

As Lamar spoke, 14% of Tennessee’s legislators were women. The Republicans, including two of the three GOP women in the Senate, swiftly rejected her amendment. She sank into her chair and pressed one palm over her heart, the other onto her belly, and practiced deep breathing exercises to help keep her blood pressure from soaring again.

Men Made Up Half of Tennessee’s Population but 86% of the State’s 2023 General Assembly State legislature data provided by Reflective Democracy Campaign and current as of July 27, 2023. (Lucas Waldron/ProPublica)

Soon after, another Black woman in the chamber stood to speak. Holding the microphone, Sen. Charlane Oliver read prepared remarks calling for an exception in cases of rape. Then, she paused. She glanced to her right and bit her cheek. She cleared her throat.

Fighting tears, she began again: “I rise before this body as a sexual assault survivor.”

Sitting nearby, Lamar listened intently. She hadn’t known this about her fellow senator, yet Oliver felt compelled to share her trauma so publicly to try and sway the men around them. Tears welled in Lamar’s eyes as well. She passed her colleague a tissue.

Waiting to Run

Three decades have passed since a U.S. Senate Judiciary Committee composed entirely of men grilled Anita Hill on live TV. Some of the men were dismissive, others downright hostile toward her testimony that Clarence Thomas, her former boss, had sexually harassed her. Millions watched it on live TV, and the Senate later confirmed Thomas to the U.S. Supreme Court.

The following year, voters elected a record number of women to Congress in what became known as the “The Year of the Woman.” Yet while Congress and many states have seen steady growth in numbers of female lawmakers over the years since then, much of the Southeast has stagnated or barely inched forward.

Tennessee has fewer female legislators than it had 20 years ago. Mississippi improved less than 3 percentage points since then; South Carolina fared only slightly better. Louisiana gained 6 percentage points, and Alabama gained 7.

This leaves large majorities of men controlling policy — including laws that most impact women — at a time when the U.S. Supreme Court is sending more power to statehouse doorsteps. Abortion, a key issue of the day, provides one window: A ProPublica analysis of comprehensive legislative data kept by the Reflective Democracy Campaign found that with few exceptions, the states with legislatures most dominated by men as of July have some of the nation’s strictest abortion bans.

Of the 10 states where men made up the biggest share of the legislatures, eight have strict abortion bans, and one outlaws it at around six weeks, before many women know they are pregnant. Five don’t allow exceptions for women who are raped.

Seven of the 10 states have trigger laws in place that went into effect after Roe v. Wade was overturned. Those were adopted by legislatures years earlier. But the passage of time hasn’t always resulted in more women at the table. Four of the seven legislatures have more female lawmakers today, albeit barely, than when they passed their trigger laws. One state has remained stagnant. And two have fewer female lawmakers than when they passed their trigger laws.

These are all conservative states, so it doesn’t mean women who oppose abortion rights would have voted differently. But their voices were hardly at the table.

Men’s numeric dominance means they also control what issues get debated in the first place — and which do not. Female lawmakers have been more likely to champion issues like maternal health, children’s welfare and education, said Jean Sinzdak, associate director for the Center for American Women and Politics.

“Women’s presence is correlated with more conversation and more issues on the agenda that are related to women,” said Anna Mahoney, executive director of the Rockefeller Center for Public Policy and the Social Sciences at Dartmouth College who wrote the book “Women Take Their Place in State Legislatures.”

Women haven’t run for legislative seats as often as men for many reasons: money, history, incumbency. But no factor plays a bigger role in the Deep South than its entrenched patriarchal culture and gender norms, female legislators and experts say.

“Traditional gender roles are more deeply enforced in Southern states,” Sinzdak said. “There’s more of a paternalistic streak that runs through them culturally.”

For instance, across party lines, virtually every Southern female legislator ProPublica interviewed for this story said voters had asked her who would care for her family if she won. Carla Litrenta, a South Carolina attorney, was breastfeeding when she filed to campaign for a House race that she ultimately lost in 2022. Voters often looked at the Democrat’s two young children and asked how she would find time to serve in office. “It was ironic because the male candidates had full-time jobs,” she said, “and I was working part time.”

Statehouse gender disparities are more acute among Republicans. Across the country, two-thirds of female state legislators are Democrats. The 20 states with the lowest percentages of women in their legislatures are almost all led by Republicans.

Republican organizations “are not recruiting as many women to run and not giving as much support to run and be successful candidates,” Sinzdak said. “You reap what you sow.” South Carolina state Rep. Sylleste Davis, a Republican, agreed that the GOP needs to seek out more female candidates but added, “I don’t get the sense that they are.”

ProPublica reached out to Republican Party leaders in Southeastern states with the fewest female lawmakers asking why more women weren’t running and what they could do to recruit more female candidates. Only one responded.

Scott Golden has worked as chair of Tennessee’s Republican Party for seven years. He said the party doesn’t target recruitment based on gender. During his tenure, including working for a prominent female lawmaker, the barriers he has seen for women are primarily structural ones. The state’s legislature operates part time but requires substantial attendance during those months, and the capital of Nashville sits a four-hour drive from some districts. Both make legislative seats less appealing for women with young children who want to stick closer to home.

“Families with volleyball and softball and senior dances and homecoming parades, it’s difficult for anybody to do it — much less women to do it — during those years,” Golden said. Instead, he sees far more Republican women running for local elected offices where they can earn full-time salaries and travel less. “It’s time, money and proximity,” he said.

Indeed, like other female Republicans ProPublica interviewed, Davis did not seek a legislative seat until her children were older. Yet that decadeslong wait for women like her to run means that legislatures have fewer members who bring current firsthand experience with pregnancy, birth and child care — knowledge critical to crafting the policies that govern these issues.

Women also are also less likely to consider running unless they are asked. Rep. Anne Thayer, a Republican who hails from a particularly religious and conservative area of South Carolina, said she didn’t consider seeking public office until people approached her. Even then she demurred.

“I gave that good Southern Christian girl response in that I’ll pray about it,” she recalled. A small-business owner and mother, she had worked behind the political scenes but “never wanted to be the one driving the bus.”

Supporters kept asking, however, and today she and Davis are two of four female committee chairpeople out of 28 standing committees in a statehouse whose rolling grounds are adorned with a dozen monuments to white men. Only one specifically celebrates female South Carolinians — and it stands behind the domed building to honor Confederate women “reared by the men of their state,” as the inscription reads.

When Republican Katrina Shealy was elected to the South Carolina Senate a decade ago, she was the only woman in the chamber. A few years later, she made national news for rebuking a male colleague who had called women “a lesser cut of meat,” referencing the biblical story of God creating Eve from Adam’s rib.

Shealy made national news again last spring. By then, she had four female colleagues in the 46-member Senate. All five women united across racial and party lines to help thwart a near-total abortion ban. (A sixth woman, a Democrat, was elected to the Senate on Jan. 2.)

Whatever their views on abortion, Shealy noted, women bring to the debate personal experience with menstrual cycles, pregnancy complications and motherhood. Male lawmakers around her simply don’t have that. “When they get up and talk about women’s issues,” she said, “it is just so frustrating because they don’t know what they’re talking about.”

After she joined her female colleagues to filibuster the strict abortion ban, they called themselves the Sister Senators and later received the JFK Profile in Courage Award. But they couldn’t defeat a bill that outlawed abortion after around six weeks of pregnancy.

Months earlier, South Carolina’s legislature — one of the most male-dominated in the country — had replaced the state Supreme Court’s lone female justice with a man. (Two of the three nominees for the seat were women.) The female justice had penned the lead opinion rejecting a similar six-week ban the previous month. The newly all-male court, now the country’s only state supreme court without a female justice, promptly upheld the six-week ban.

The Backdrop of History

The case that overturned national abortion rights, Dobbs v. Jackson Women’s Health Organization, originated in Mississippi, the state where white men in particular are most overrepresented in the Legislature. They hold more than 60% of the seats even though they account for only 28% of the state’s population. That means every white man is represented more than two times over in the body, according to a ProPublica analysis of comprehensive legislative and census data tracked by the Reflective Democracy Campaign.

Women, however, are underrepresented by more than a factor of three. It’s about the same for Black women and white women.

Yet when it comes to the impact of abortion restrictions the Legislature passed, Black women are disproportionately affected. They are four times more likely to die of pregnancy-related causes than white women. They also are more likely to experience unintended pregnancies. And in 2021, 80% of abortions reported in Mississippi were performed on them, the highest percentage of any state in the nation.

This is happening against history’s disturbing backdrop: centuries of white men controlling Black women’s reproduction. Enslaved women’s health once was only as important as the human property their bodies could produce. Black women had to birth the children of white men who raped them. They were forced to breastfeed white babies.

Michelle Colon, co-founder of a reproductive justice organization in Mississippi called SHERo, said this history has created a culture of devaluing Black women that persists today. Many state lawmakers “are the descendants of white men who basically controlled Black women’s bodies,” she said.

Black women in Mississippi aren’t alone. Across most of the Southeast, a region of former slave states, the more white men are overrepresented, the more Black women are underrepresented. This relationship doesn’t exist in other states that also have at least 5.6% Black women, the national average.

States with the Lowest Representation of Black Women in Their Legislatures Also Had the Highest Representation of White Men

In most Southeastern states, white men are overrepresented at the expense of other groups, especially Black women.

The chart shows representation ratios between the proportion of a demographic group in the state legislature and the proportion of that group in the state population. A ratio of 1 implies equal representation. This chart includes only states where Black women are at least as prevalent in the state’s population as the national average. State legislature data provided by Reflective Democracy Campaign and current as of July 27, 2023. (Lucas Waldron and Irena Hwang/ProPublica)

This imbalance is most pronounced in Mississippi, the state with the nation’s largest percentage of Black residents. “It’s not the year of the woman here,” said Tracy DeVries, executive director of the Women’s Foundation of Mississippi. “There’s no priority for women’s health. None. It’s just not important.”

Democratic Rep. Omeria Scott, a Black woman, has served in the Mississippi House of Representatives for three decades and sits on its public health committee, made up of 24 men and five women. The chair is a white man. As long as she could remember, it has always been a white man.

Scott also serves on the House’s Medicaid committee. Its chair also is a white man. He and the House speaker, another white man, stymied efforts in 2022 to extend Medicaid coverage, which pays for almost 60% of births in the state.

“White men handle those appropriations,” Scott said. “They handle the policy and the money in Mississippi.”

Black and White Women in Mississippi Were Dramatically Underrepresented in the State Legislature Compared with White Men Mississippi Legislature data provided by Reflective Democracy Campaign and current as of July 27, 2023. (Lucas Waldron/ProPublica)

In 2022, House Speaker Philip Gunn spoke to The Associated Press after blocking a Senate-backed effort to extend Medicaid for the state’s poorest new mothers from the federally required two months to a year postpartum. Gunn said that he was aware of the state’s high maternal mortality rate, but he had not seen evidence that extending coverage would save money. When asked if the move could save lives, he told the AP, “That has not been part of the discussions that I’ve heard.”

Only after the state’s strict abortion ban went into effect did Gunn agree to stop blocking the extension.

Republican Gov. Tate Reeves posted on social media, “In a post-Dobbs world — we may even have to be willing to do things that make us ‘philosophically uncomfortable.’” He would support the Medicaid extension as part of a pro-life agenda. “As I’ve said many times, it will not be easy and it will not be free. But it will be worth it, as more children of God are brought into the world!”

Neither Reeves nor Gunn responded to ProPublica’s requests for comment. Scott was pleased that the men finally stopped thwarting the extension of coverage for mothers. But it also felt like a consolation prize.

Triggering Confusion

Not quite a year had passed since the Dobbs decision when a Black woman named Nancy Davis sat before a Louisiana House committee. She urged the panel, chaired by a white man, not to punish women’s doctors if they abort nonviable fetuses.

“Step out of yourself for one minute, and try to envision what it’s been like for women in Louisiana,” she said.

During her visit to the capitol, Davis wondered: Where were the lawmakers who looked like her? Only nine Black women served in the entire Louisiana State Legislature — 6% in a state where they constitute 17% of residents. Yet Davis had just experienced very personally how a policy the Legislature passed directly affected women like her.

About a month after the Dobbs decision’s release, the 36-year-old mother arrived at a hospital for a routine check up. She was 10 weeks pregnant and thrilled. When an ultrasound technician slid a wand across her belly, Davis peered eagerly at the gossamer image emerging into view on the monitor beside her.

Then, she felt everything pause.

“Why does my baby look that way?” she asked. The top of his head looked amorphous, like mist fading into the dark.

The technician slipped from the room.

Davis burst into sobs. Leaping up, she tugged on her clothes and stared at the image through tears. A physician soon explained that it appeared the top of the skull had not formed, a fatal anomaly. Davis recalled her also assuring, “This is one of the reasons for an abortion.” The doctor was referring to a narrow exception in Louisiana’s trigger ban, which had just gone into effect.

But Davis was enrolled in Medicaid, which did not cover abortions. The procedure would cost $6,000 out of pocket at the hospital, she said, so the doctor sent her to an abortion clinic. Davis found it shuttered.

When she returned to the hospital, a woman explained that the doctor could no longer provide her an abortion. “The director of the hospital shut it down because of the Louisiana abortion law and the fetus still having a heartbeat,” Davis recalled her saying. (Debate later ensued over whether the state’s abortion laws would have allowed her to get an abortion.)

For a month, Davis carried a fetus she knew would die. Some nights, she slipped outside and clutched her stomach, crying alone in the darkness so she didn’t wake her fiance, Shedric Cole, or their other three children. But what could she do?

Desperate, she emailed local news outlets. A TV reporter came to interview her, and the video went viral. She wound up in touch with Planned Parenthood of Greater New York and The Brigid Alliance, which helped her book flights to New York and pay for a hotel, child care and meals.

On Sept. 1, Davis and Cole arrived at a Manhattan clinic 1,400 miles from home. An abortion wasn’t something she could imagine a woman wanting. But she did want their nightmare over.

After they returned home to Baton Rouge, Davis became determined to give more of a voice to women. She wants to run for office.

Feeling Overwhelmed

After Lamar, the Tennessee senator, pleaded for broader abortion exceptions to protect women’s health, she drove home to Memphis, a majority-Black city in a county with the state’s highest ratio of pregnancy-associated deaths. She felt exhausted and disregarded.

“Black women are telling you, basically you’re killing me, and it’s like you don’t give a damn,” Lamar said. “My life is less valuable than theirs, and that is what hurts the most.”

Tennessee Democratic state Sen. London Lamar at the state Capitol in Nashville. (Diana King, special to ProPublica)

Four months later, in August, she gave birth to a baby boy. Although she developed postpartum preeclampsia, she recovered and celebrated her healthy son with round brown eyes and chubby cheeks.

Yet, despite much-appreciated help from her own mother, the 33-year-old single mom quickly learned why many women with young children often don’t run for office. One day shortly after her maternity leave ended, she handled a phone call while greeting her mother, saying goodbye to her baby, saying goodbye to her mother and then rushing to her car to head to an assignment for her job overseeing a program that develops the Black teacher pipeline, stopping to fill the air in her car tires on the way.

“It’s overwhelming,” she said. “You feel like no one understands or cares, but also you know that you represent the masses of women dependent on you to be their voice.”

With January’s arrival, the Tennessee General Assembly is among legislatures across the Southeast getting back to work. Behind the door of her Senate office, Lamar hung a white board to track the bills she cares about most. It lists abortion, maternal mental health, doula certification and timely processing of rape kits.

She mustered hope for the months to come. Last year, she discovered a tactic that helped her pass a bill to study the expansion of doula services in Tennessee. She planned to employ the strategy again. To gain support from her male Republican colleagues, she had learned to present her bills as “pro-life” rather than pro-woman.

About the Data: How We Analyzed Representation in State Legislatures

ProPublica obtained a database detailing the demographic makeup of state populations and legislatures from the Reflective Democracy Campaign. The database includes race and gender information for all state legislators and was last updated in July, prior to the 2023 state elections. The state demographic data is from the 2020 census, with additional information from 2022 annual population estimates.

To assess representation of demographic groups, ProPublica calculated the ratio of percent representation of the group in the state legislature to percent representation in the state as a whole. A ratio of 1 can be interpreted as the proportion of a demographic in the state legislature equaling the proportion of that demographic among the state’s general population. A ratio larger than 1 means that the demographic is more present in the legislature than in the state population, and a ratio less than 1 means that the demographic is less present in the legislature than expected, given their prevalence in the state population. For instance, a ratio of 2 should be interpreted as there being twice the proportion of a demographic group in the state legislature as in the state population, and is described as overrepresentation by a factor of 2.

To be sure, an individual is not solely represented by the politicians who share their identity, nor does an individual politician work only towards the interests of constituents of the same identity. However, the expectation that a demographic group should be proportionally represented among politicians as in the population as a whole is intuitive and widely used as a proxy for representation in news reports.

When assessing the representation of Black women and white men, we limited our analysis to states with a meaningful proportion of Black women. Black women make up between 0.2% to nearly one-fifth of state populations. As a result, we used the average proportion of Black women in state populations, 5.6%, as a threshold and focused on the 21 states with a higher-than-average proportion of Black women. We used the U.S. Fish and Wildlife Service’s definition of the Southeast and used linear regression to assess trends in representation within and outside of the Southeast.

Irena Hwang contributed data analysis.

This post was originally published on Articles and Investigations – ProPublica.

by Kathleen McGrory and Neil Bedi

This article contains descriptions of mental illness and suicide.

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A veteran with a known history of suicidal thoughts showed up at a St. Louis hospital before dawn one morning and was left unmonitored in an exam room for hours.

Another was deemed at risk of suicide by a hospital psychiatrist in Washington, D.C., then forcibly discharged, even as he tried to stay, by the same hospital’s emergency department.

Another still in Pittsburgh was assigned a behavioral health nurse who failed to complete thorough suicide screenings or review his suicide safety plan, and didn’t follow up when he said he wished he was dead.

In all three cases, independent inspectors documented serious failures by the Department of Veterans Affairs. And in all three cases, the veterans involved went on to kill themselves or other people.

The lapses were similar to ones examined by ProPublica last week in an investigation of the VA’s handling of two veterans with serious mental disorders. Both suffered for years with inadequate care from the same clinic in Northern California, they told reporters. Their stories ended in tragedy.

The problems appear to be systemic. Over and over, the hospitals and clinics in the VA’s sprawling health care network have fallen short when it comes to treating people with mental illness.

That conclusion emerges from a ProPublica review of all of the reports published by the VA’s inspector general since 2020. That includes 162 regular surveys of facilities and 151 investigations that were triggered by a complaint or call to the office on a wide variety of alleged health care problems.

If you or someone you know needs help:

• Call the National Suicide Prevention Lifeline: 988
• Text the Crisis Text Line from anywhere in the U.S. to reach a crisis counselor: 741741
• If you are a veteran, call the Veterans Crisis Line: 988, then press 1

Issues with mental health care surfaced in half of the routine inspections. Employees botched screenings meant to assess veterans’ risk of suicide or violence; sometimes they didn’t perform the screenings at all. They missed mandatory mental health training programs and failed to follow up with patients as required by VA protocol.

One in 4 of the reports stemming from calls or complaints detailed similar breakdowns. In the most extreme cases, facilities lost track of veterans or failed to prevent suicides under their own roofs.

Sixteen veterans who received the substandard care killed either themselves or other people, the review revealed. An additional five died for reasons related to the poor care, such as a bad drug interaction that the reports say could have been prevented. Twenty-one such deaths is a meaningful count even for a health care system that has more than 9 million people enrolled, in the view of Charles Figley, a Tulane University professor and expert in military mental health. The VA has struggled with mental health care for decades, he said. “It’s a national disgrace.”

For grieving family members, it is incomprehensible. “It was never my expectation that [the VA was] going to solve his problems,” said Colin Domek, the son of the veteran in Pittsburgh. “My expectations were that someone who was saying ‘help me’ would receive some kind of help.”

The inspector general reports reviewed by ProPublica have limitations. The individual investigations can be narrow. The reports offer only broad suggestions as to whether individuals should be held accountable for breakdowns and provide little sense of whether they actually were. Even together, they don’t capture the full reality of the VA’s 1,300 health care facilities. But they do start to assemble a meaningful picture of the system’s most chronic shortcomings when it comes to treating people with mental illness.

The VA declined requests for an interview for this story. In a statement to ProPublica, VA press secretary Terrence Hayes said “there is nothing more important to VA than providing high-quality mental health care to Veterans” and that the agency was “grateful” to the inspector general’s office for its oversight. He noted that last year, more than 80% of veterans who participated in VA surveys reported being satisfied with the mental health care they received through the agency.

In a separate statement, VA Inspector General Michael Missal said, “Our reports have repeatedly illustrated that it is critical that [Veterans Health Administration] leaders remain vigilant to problems, ensure care is coordinated, and take swift, responsive actions that address root causes and promote accountability.”

The VA’s health care system is the nation’s largest. The agency operates about 170 medical centers and 1,100 outpatient sites, and it provides counseling services at some 300 facilities known as vet centers. In the last fiscal year, the VA provided mental health services to about 2 million veterans, according to agency figures.

The system has notable strengths. The VA has played an important role in developing treatments for conditions such as post-traumatic stress disorder and traumatic brain injury, and provides critical training opportunities for psychiatrists, psychologists and social workers nationwide.

But the number of suicides among veterans has remained stubbornly high, ticking up to 6,392 in 2021, the most recent year in agency statistics. And acts of violence by veterans with mental illnesses have continued making news, including two mass shootings in Atlanta last year alone.

Experts told ProPublica the failures revealed in the inspector general reports point to broad problems, including inadequate mental health staffing, outdated policies and the inability to enforce high standards across a large, decentralized health care network.

“It’s a very sad thing,” said M. David Rudd, a psychology professor at the University of Memphis for whom the Rudd Institute for Veteran and Military Suicide Prevention is named. “You can sit here today and predict with great accuracy how many deaths there are going to be over the next five years. Yet there are unlikely to be any meaningful, significant changes.”

When there are allegations of patient care issues, mistakes or policy violations inside a VA health care facility, it is often up to the agency’s independent inspector general to investigate. The office can then write a report explaining what happened and offering recommendations for improvement. Facilities typically follow the recommendations.

The inspector general’s reports don’t name the veterans or any doctors or nurses — a deliberate choice intended to protect their privacy. They obscure gender and specific dates, too. In several cases, however, ProPublica was able to match details from the reports with information contained in news stories or lawsuits and interview the veteran’s relatives.

One of those cases involved Kenneth Hagans, a 60-year-old father of four who served as a private in the Army in the early 1980s.

In September 2021, Hagans showed up at the John Cochran Veterans Hospital in St. Louis complaining of bladder problems and depression, records show. By then, he had been receiving care at the facility for more than two decades and treated for substance abuse and suicidal thoughts.

The nurse who first saw Hagans that morning determined he was not at risk of self-harm. But instead of using the computer to call up a questionaire to assess his risk of suicide, the nurse recited the questions from memory, then left Hagans unmonitored in an exam room.

The nurse claimed to have notified the on-call physician, who was “resting” on a stretcher in another exam room when Hagans arrived, according to the inspector general report on the case. But video footage did not support that claim, the report said. A second nurse alerted the physician an hour after Hagans’ arrival. But the physician was feeling the effects of a vaccine and slow to respond, the physician told investigators.

An hour after that, Hagans was found dead in the exam room. He had used a cord to take his own life.

The inspector general report, which was published in June, found that the nurse had failed to monitor Hagans and that the nurse and physician were responsible for a delay in his care. It also raised questions about the quality of the suicide screening Hagans received. (Later, when asked by investigators to recall the questions on the assessment by memory, the nurse could not, records show.)

Additionally, the report drew attention to an email sent by an emergency department leader regarding the inspector general’s investigation into Hagans’ death. “Everybody needs to know this is NOT the opportunity to air grievances,” the leader wrote to a staff physician. “The [inspector general] will be trolling for evidence of leadership and administrative malfeasance that allowed a veteran to kill himself in our [emergency department]. Appropriate responses to direct questions are: yes, no, I don’t know, and I don’t remember. BOOM!”

The inspector general recommended that the medical center standardize its processes for suicide screenings and monitoring patients — and that local leaders in St. Louis investigate the possible interference in the inspection. In a written response to the report, facility director Candace Ifabiyi did not challenge any of the inspector general’s findings and said she agreed with the recommendations.

Kenneth Hagans and his son Graie (Courtesy of Graie Hagans)

Hagans grew up as one of eight siblings in Hammond, Louisiana. As a kid, he hopped onto trucks bound for New Orleans and hung out in the French Quarter. He saw an opportunity in the Army, his son Graie told ProPublica. But in the years that followed, he struggled with drug addiction and homelessness. He was in and out of his children’s lives.

Hagans never talked about any traumatic experiences he had while serving in the military, Graie said. But in 2017, he started getting help for post-traumatic stress disorder stemming from that period in his life. The treatment, which he got through the VA, was making a difference, Graie said. “He was learning about the impact of PTSD on his life,” he said. “Some things were making more sense about his behavior.”

Graie was stunned to learn the circumstances of his father’s death, he said. His call with a hospital official that day raised questions. Shouldn’t the VA hospital system that treated his father for psychiatric issues have been familiar with his mental health history? Shouldn’t the staff have kept an eye on him?

Hagans’ death could have and should have been prevented, Graie contended. “There’s an institutional and structural failure if what happened to my dad can happen inside a VA hospital,” he said.

In a statement to ProPublica, the VA St. Louis Health Care System expressed its “deepest condolences to Mr. Hagans’ family and friends.” The statement added that health system leaders had established standard policies for suicide screenings and monitoring patients, and initiated “appropriate personnel action” for individuals involved in the case. The health system declined to share specific details.

Hagans’ case was not an anomaly, ProPublica’s review of records found. Many of the breakdowns in care involved problems with screenings for the risk of suicide and violence.

Screenings are simple; they generally entail asking a patient a few questions about their thoughts and actions to assess their potential of self-harm or violence. But research has shown they can help save lives.

Screenings played a key role in the case of Nicholas Domek, a former Army engineer and demolition expert whose three decades in the military included serving overseas in Operation Desert Storm and in the Army Reserves.

In 2018, Domek attempted suicide and was admitted to the Pittsburgh VA’s inpatient mental health unit. He also attempted to kidnap his former domestic partner and, in early 2019, was readmitted to the mental health unit for homicidal thoughts.

The VA gave Domek a designated behavioral health nurse practitioner; the two met monthly after his second hospitalization. The nurse practitioner documented Domek’s thoughts of suicide after each of their four visits, according to the inspector general report. But there was no evidence the nurse practitioner did a thorough suicide risk assessment or reviewed Domek’s suicide safety plan as protocol dictates.

Two weeks after Domek’s last meeting with the nurse practitioner, Domek killed the former domestic partner, Mary Jo Kornick. He then killed himself.

The nurse practitioner could not remember why no risk assessment was done, the report said. The inspector general determined the nurse practitioner had copied and pasted information from prior visits throughout his records, making them difficult to follow and interpret.

Domek’s son Colin told ProPublica the nurse practitioner should have done more. He said the nurse practitioner knew about his dad’s plans; he had been in the room when his father told the nurse practitioner he intended to kill both himself and Kornick, he said.

Mary Jo Kornick (Courtesy of Sherry Kornick)

Colin Domek described his father as a hard worker who enjoyed fishing and geocaching, a recreational activity in which participants search for hidden objects outdoors. He loved being a soldier, Colin said, and the whole family took pride in his service. One year at Christmastime, they decorated their tree with tiny paratroopers. The family was on the local news when Domek deployed to Iraq.

More recently, though, Nicholas Domek had had his left leg amputated and struggled with depression, Colin said. He’d started seeing a mental health professional and trying medications. “In his mind, the VA was going to take care of him,” Colin said. “It was never a thought to see someone outside the VA. That was never on the table.”

The tragedy ravaged a second family. Kornick was a loving mother and grandmother who worked at a home for older people, her daughter Sherry Kornick told ProPublica. She loved to laugh and play pranks. She made up songs to make people smile.

She was killed the day before Mother’s Day. “I don’t even want to celebrate Mother’s Day” anymore, Sherry said, breaking down into tears. “And I realized it’s not fair to my kids who want to celebrate me.”

In its investigation, the inspector general determined the nurse practitioner had made similar missteps with at least seven other patients and had copied and pasted “significant sections of notes” from prior evaluations in 97% of the 143 patients’ health records it reviewed.

The report on the case recommended that the VA’s Pittsburgh health system consult with its human resources and legal teams to “determine whether personnel action [was] warranted.” The facility director agreed with the recommendation but noted the nurse practitioner retired in January 2022.

In a statement to ProPublica, the Pittsburgh health system said it was “devastated when [it] learned about the challenges Mr. Domek faced and took immediate action to prevent another Veteran from having a similar experience.” That included developing a refresher training program for suicide-risk evaluation and management as well as a new template for electronic health records.

Nicholas Domek (National Personnel Records Center)

Other VA facilities missed screens, too, ProPublica’s review found. At one Arizona hospital, a social worker didn’t screen a veteran who called to reestablish mental health care, instead referring the veteran for psychological diagnostic testing. The veteran wasn’t offered treatment for a month and later died by suicide. A South Carolina hospital didn’t do a suicide risk assessment on another veteran who was being released from its inpatient mental health unit as VA policy requires. That veteran also died by suicide.

There were other cases, too, in which veterans with serious behavioral health issues were overlooked or didn’t get the help they needed.

The VA Medical Center in Houston, for example, lost track of a veteran with chronic schizophrenia who sought treatment at the facility’s emergency room in 2020 for back pain. The veteran was found off-site four days later in cardiac arrest and died the next day, according to an inspector general report. In interviews with the investigators, hospital staff said the veteran had been shuttled between departments due to possible COVID-19 symptoms and then wandered off. In a statement to ProPublica, Houston health system leaders said the situation did not “represent the quality health care southeast Texas Veterans have come to expect from Houston VA” and that they had improved their COVID screening processes and trained employees on wandering patients.

At the VA Medical Center in Washington, D.C., a psychiatrist found a veteran with drug withdrawal symptoms to be at moderate risk of suicide and recommended in-patient treatment. The psychiatrist walked the veteran to the facility’s emergency room for follow-up. But doctors there didn’t read the psychiatrist’s notes and determined the veteran should be discharged. When the veteran refused to leave, an attending physician called the VA police and was heard saying the veteran could go shoot himself. The veteran died from a self-inflicted gunshot wound six days later.

Hospital leaders agreed with the findings in the inspector general report and noted that the physician who made the insensitive remark was replaced as a contract provider. They told ProPublica in a statement that a second physician on contract had resigned from the facility.

Experts say such missteps often stem from the fact that employees are overworked and undertrained.

Demand for mental health services within the VA has been surging, and the system has long endured mental health provider shortages. A survey published by the inspector general in August found that more than three quarters of the VA’s 139 networks of hospitals and associated clinics had reported “severe” shortages of psychiatrists, psychologists or both.

Separately, a report from the Government Accountability Office from 2022 concluded that one-fifth of all large VA health care facilities failed to meet requirements that mental health providers be available within primary care settings to help assess veterans and follow up with their care. The facilities said “persistent staffing challenges” were largely to blame.

The VA is far from the only health care organization that has had difficulty filling critical behavioral health positions amid a national shortage of providers in recent years. But Carl Castro, a professor at the University of Southern California and director of its Center for Innovation and Research on Veterans and Military, said the VA in particular has struggled to compete for providers.

“The system doesn’t pay them enough money,” he said. “It works them to the bone. That’s why it is hard to recruit people.”

Indeed, in exit interviews, VA psychologists cited insufficient pay, too much work and job stress as among the top five reasons they left their positions, according to data published by the VA in October.

The VA, for its part, has steadily increased its funding for mental health over time, federal budget data shows. In 2022, the figure surpassed $13 billion, up from about $6 billion a decade earlier. In 2022, mental health was about 13% of the total health care budget. In 2012, it was about 12%.

Agency leaders have acknowledged that growing the mental health workforce is a priority. They recently announced a targeted hiring initiative intended to bring 5,000 new mental health professionals into the system over the next five years. The agency also boosted the pay range available for staff psychiatrists last year and is offering more flexible schedules to employees to help battle burnout, it said.

“We are fully engaged in a multi-faceted strategy to attract qualified candidates, leverage all flexibilities and incentives to meet the workforce needs, and monitor staffing ratios and other data regularly to help inform facility staffing priorities and decisions,” the agency said in a statement to ProPublica.

Aside from staffing issues, experts said the VA struggles with consistency across its huge system, which is broken down into 18 regional networks and dozens of smaller hospital systems, each with its own leaders and policies. “If you’ve seen one VA facility,” said Alyssa Hundrup, a director on the Government Accountability Office’s health care team, “you’ve seen only one VA facility.”

The national policies alone have generated confusion, the reports showed. According to the inspector general’s office, two of the handbooks describing the mental health policies all VA facilities must follow had been outdated for years. One was missing the agency’s most recent guidance on managing patients at risk of suicide or suffering from PTSD or major depressive order.

Dr. Sandro Galea, dean of the Boston University School of Public Health who chaired a congressionally mandated committee on the treatment of PTSD in military and veteran populations a decade ago, said the individual tragedies highlight the need for a wholesale look at the VA’s mental health care system “to identify gaps and holes.”

“That needs to happen,” Galea said. “It’s clearly time.”

Emma Dash is sure something needs to be done. Her husband, a 33-year-old Army veteran named Brieux Dash, was struggling with PTSD when he was involuntarily committed to West Palm Beach VA Medical Center in 2019. He took his own life during his stay.

Brieux Dash and his family (Courtesy of Emma Dash)

Dash had been a wheeled vehicle mechanic in the Army from 2006 until 2015. He deployed to Iraq twice, his Army records show. When he returned home the second time, he was different, Emma said. He would scream in the middle of the night. Sometimes, he erupted into violence in his sleep.

Emma, who worked in the West Palm Beach VA medical center’s pharmacy department, had her husband committed to the medical center’s inpatient mental health unit once before, she said. “It got him back to being him,” Emma recalled. So when he attempted suicide at home in 2019, she followed a similar course of action.

The VA’s inspector general later found that a nursing assistant who had been assigned to do patient safety checks every 15 minutes the day Brieux Dash died had also carried out other tasks contrary to unit protocol. In addition, video cameras that were supposed to help monitor patients hadn’t worked in years.

The findings shocked Emma, who had believed the facility was the best equipped to help her husband. She sued the VA in 2022 and settled for $5.75 million last year, an amount her lawyer characterized as “historic.”

In a statement to ProPublica, the West Palm Beach VA Medical Center said it installed sensor alarms and new surveillance cameras after Dash’s death and added a new checklist to address environmental risks for patients on inpatient mental health units. “Anytime a Veteran in our care dies by suicide,” the statement said, “it is heartbreaking.”

Emma Dash had a simple message for the VA, she told ProPublica: “Do better!”

If you have information about mental health care services provided by the VA, email VAmentalhealth@propublica.org.

This post was originally published on Articles and Investigations – ProPublica.

by Kathleen McGrory and Neil Bedi, ProPublica, photography by Loren Elliott for ProPublica

This article contains descriptions of mental illness, violence and sexual assault.

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

Marty and Candy Larsen were in their pajamas, getting ready to watch a movie in the living room, when they heard their 27-year-old daughter scream.

“I need help!” Julia cried.

They could see her standing just a few feet away, her long blond hair unkempt, her blue-gray eyes at once alert and vacant. She’d looked like this in other moments when fear overtook her and reality slipped away. But a new sight jolted them upright: their daughter’s fingers, wrapped around a pink handgun.

Julia pounded the weapon against a wall, then squeezed its trigger, sending a bullet down an empty hallway. “Help me!” she shrieked.

The parents scrambled in different directions. Candy was on with 911 while Marty reached toward his daughter. “Julia, stand down,” he said. “How can we help you if you don’t stand down?”

But Julia fired again, repeating her plea like a mantra.

“Help me!” she cried. “Help me!”

The need had been building for almost six years, since she returned home from a stint as a Navy firefighter aboard a warship in the Persian Gulf. She was tormented by the rippling trauma of an on-duty sexual assault and grappling with symptoms that led her to be diagnosed with a psychotic disorder.

She was dependent on the Department of Veterans Affairs for care. Just that morning, when her latest crisis began, a nurse at the local VA clinic in Chico, California, had told her mother to bring her in. When they arrived, a telehealth provider was too busy to see Julia. A social worker asked questions to gauge her risk of suicide or violence; even though Julia refused to answer, she was sent out into the world and told to return for the next available appointment, in 11 days.

If you or someone you know needs help:

• Call the National Suicide Prevention Lifeline: 988
• Text the Crisis Text Line from anywhere in the U.S. to reach a crisis counselor: 741741
• If you are a veteran, call the Veterans Crisis Line: 988, then press 1

Such dysfunction had become the norm at the Chico clinic, one of several hundred such community facilities designed to serve veterans who live far from the nation’s big cities. From the outside, it looked like a haven for heroes: a state-of-the-art building with a gleaming atrium, a large American flag flying out front. But the clinic hadn’t had a full-time, on-site psychiatrist in five years. A single nurse was responsible for connecting hundreds of veterans, some with serious mental illness or active suicidal thoughts, with an ever-changing lineup of telehealth providers in different time zones.

The military has long drawn recruits from remote towns across America, promising them a lifetime of health care in return for their service. But the VA has seldom staffed those same communities with the mental health professionals needed to help them once they return home. Two decades of war in Iraq and Afghanistan have turned this chronic shortcoming into an emergency. The demand for mental health care has grown at a rate that’s triple the rate of growth for all VA medical services. Anguished employees, doing what they can with threadbare staffing and glitchy technology, are burning themselves out trying to avert disasters that feel inevitable. In Chico, nurses and social workers cried after their shifts, and the new site manager, a veteran and longtime health care administrator, had made a grim prediction: “We are going to kill someone,” she told colleagues.

If hindsight is 20/20, agency officials should have exquisite vision by now. Their files are littered with cautionary tales of missed screenings and insufficient follow-up; in at least 16 instances since 2019, veterans who received inadequate care wound up killing themselves or other people; an additional five died for reasons related to the poor quality of care. Each time, investigators with the VA’s Office of Inspector General swooped in to determine whether the system failed; each time, they concluded it had.

To plug the holes, the VA grew its nationwide mental health workforce by more than 4,000 last year and plans to hire an additional 5,000 professionals over the next five years. But the sense of dread lingers. It’s a “perfect storm of real potential for gaps in care,” said Alyssa Hundrup, a director on the Government Accountability Office’s health care team.

Just as violence was erupting in Julia’s home on Jan. 3, 2022, another veteran sat alone in his dark bedroom, not far away, ruminating. Deep circles hung below his eyes. An unruly beard covered his chin.

Andrew Iles, 33, had come to believe the government was monitoring him and that his mother was in on the conspiracy. He, too, had tried to get help at the Chico clinic but for years was passed from provider to provider. Recently, all he could get was a psychiatric pharmacist who prescribed him pills. He felt abandoned, concluded the VA had never wanted to help him and slipped into a state of paranoia so intense that he threw away his belongings and holed himself up inside his mother’s house.

His sister, once his protector and closest ally, had stopped bringing her family to see him. His mother had tried to remove all of the firearms from the house but missed a few. Andrew had stowed them away.

Concow Elementary School (Loren Elliott for ProPublica)

Chico, California, sits in the northern Sacramento Valley, in the shadow of the Sierra Nevada mountain range. It’s a college town home to museums and breweries, funky cottages and trendy restaurants. Climb into the foothill elevation, though, and you enter another world. Aside from some big-box stores and picturesque downtowns, it’s mostly wilderness dotted with private homes. Cellphone service is spotty. Roads snake through dense forests.

Andrew Iles grew up in a particularly isolated community called Concow. When he was a kid, only a few hundred people lived there. They drove the same mountain roads, shopped at the same convenience store. There were enough children for a small school, but each grade level had just a handful of students. Most were eligible for free lunch.

Andrew’s family lived a mile off the main road in a one-room, A-frame home that sometimes had no electricity or running water. His parents, Glen Iles and Sue Hill, used methamphetamines. They disappeared, often for days at a time, and let other drug users hang around the house. Some of them forced Andrew and his big sister, Ashley Hill, to engage in horrific sex acts. The kids stayed quiet about the abuse. “We were so afraid to say anything,” Ashley recalled.

The siblings sought refuge on the mountainside. It was their own wild playground, full of creeks to splash in and salamanders to chase. But violence was never far. Once, when Andrew and Ashley were in grade school, they found their mother handcuffed to a refrigerator, bleeding from three gunshot wounds. A few years later, they watched Glen hold Sue at gunpoint and threaten to shoot her. Ashley called 911. Glen fled into the forest on his ATV but was caught and sent to prison. The ordeal made the local newspaper.

The arrest was a turning point. Sue stopped using drugs. She found a new partner and moved the family a few times, ultimately settling in a small city in the foothills called Oroville. After finding steady work at a rent-to-own furniture store and a new place to live, she started rebuilding her family.

Andrew grew into a gangly teenager with a sly sense of humor who wore braces, dyed his hair bright colors and swept his long bangs across his face. He and his friends were emo kids; they listened to Fall Out Boy and spoke out against the war in Iraq. Andrew dated the same girl for years. He showered her with attention and wrote her silly notes. He put considerably less effort into his schoolwork. As graduation neared, he started to believe he needed structure and discipline, and he thought the Air Force might provide it. Plus, he had a mind for math and technology, and the idea of working on multimillion-dollar airplanes appealed to him. “If I don’t do something like this,” he told his mother, “I’ll be in Oroville for the rest of my life.”

As a new airman, Andrew was stationed in Arizona as an aircraft electrical and environmental systems apprentice. His supervisors rated his performance as “truly among the best.” His first evaluations touted his “unrivaled initiative” and described him as a “superior performer” and “stellar airman.” One evaluation ended with a simple declaration: “Promote now!”

Andrew raised his hand for an assignment on Kunsan Air Base in the Republic of Korea where he could work on F-16 fighter jets. He traveled the country by train, visiting university cities so he could meet people his age. He found it thrilling to be somewhere so different from Concow with such freedom to explore.

His next tour took him to Ramstein Air Base outside Frankfurt, Germany, to work on hulking C-130s. He was 22 then, excited to visit Berlin, Amsterdam and Paris. But he was increasingly looking over his shoulder, wondering what his peers were saying about him.

Around that time, Andrew sent emails to his mother and sister that described neighbors spying on him. Sue and Ashley found the letters troubling. In some ways, Andrew sounded like his father, who had never been diagnosed with mental illness but was prone to paranoia and conspiracy theories.

Andrew had reached the age when, experts say, a typical life can start to veer off course. It is generally believed that some people have a greater biological risk of developing psychotic disorders than others. Genetics can play a role. Environmental factors like stress can trigger the onset of illness or make it worse than it would have been. Symptoms tend to begin when people are in their late teens or early 20s, as their brains mature.

Andrew sought out behavioral health services on the base, he said. But he was certain his bosses saw him differently after that. He felt some treated him like he was less capable, while others seemed to think he was faking. He considered ending his life.

In late 2010, long before Andrew was supposed to leave Germany, he wrote his commanding officer saying he no longer believed he could do his job and asking to leave the military, he recalled. The Air Force approved his request for separation, giving him an honorable discharge, records show, but required him to transfer his remaining active duty service to the reserves, he said.

When asked about the circumstances of Andrew’s separation, an Air Force spokesperson, Michael T. Dickerson, said he could not comment on anything related to an individual’s physical or mental health or the nature of his or her discharge.

Andrew flew back to the United States. He was active in reserves in northern California for a period. But his growing fears about government surveillance kept his mind in constant motion. At night, he thought he could hear strangers talking about him through doors and windows. By 24, he’d moved back in with his mom and stepdad in Oroville, the one place he’d dreaded ending up.

First image: Andrew Iles and his sister, Ashley Hill, as young children. Second image: Andrew’s high school ID card. Third image: Andrew’s Air Force portrait. (First and second image: Courtesy of Ashley Hill. Third image: United States Armed Forces.)

Julia Larsen grew up a 40-minute drive from Andrew in a quaint foothills town called Paradise. Her father worked for the post office. Her mother ran a home day care. The youngest of three daughters, Julia was bound by few rules. She spent most of her time outdoors, searching for animals or digging in the red earth. A treasured family photo shows her holding a catfish she reeled in herself.

People who knew Julia as a teenager describe her as bubbly and a free spirit. Her senior superlative in high school was “biggest daredevil.” Her family was always camping or hiking together. On weekends, when her friends came over for backyard sleepovers, her mother often joined them around the campfire. In Julia’s mind, Paradise lived up to its name. But like many young people, Julia was eager to escape the place she was from. So one day, she and some girlfriends struck up a conversation with the local Navy recruiter.

Julia told her parents while the family ate dinner together at the kitchen table. Marty, a Navy veteran with an anchor tattooed to his forearm, was elated. “I couldn’t stop bragging about her,” he would later recall. Candy worried about Julia’s safety overseas but trusted her to make the right decision. The two were more like sisters sometimes than mother and daughter.

Julia arrived at boot camp outside Chicago in June 2012. She was 18. She traded a colorful sweater and jeans for a Navy-issued T-shirt and shorts and lined up to have her hair cut. The recruits marched and swam and studied and shot. It was easier than she expected. Her parents and middle sister came to watch her graduate. They cheered from the bleachers and then celebrated over deep-dish pizza and White Castle hamburgers.

When it came time to specialize, Julia became a flight deck firefighter. She went for additional training in the Florida Panhandle, where she learned to work a high-pressure hose and handle rescue equipment. That fall, she was assigned to the USS Theodore Roosevelt, an aircraft carrier undergoing major upgrades near the Naval base in Norfolk, Virginia. Her home was a cramped bunk with a flimsy mattress deep in the ship’s belly. She placed the few personal possessions she had in a tiny locker and reported for duty.

She doesn’t remember much about the first day or even the first week. But she remembers the comments a supervisor started making about her body, and the way he pressed himself against her when she was chopping lettuce for the salad bar. Later, while she was on dishwashing duty in the ship’s scullery, he approached again, she said. He grabbed her arms and folded them across her chest. Unbuttoned her top. Turned her around. He was bulky, much taller than her 5-foot-7-inch frame, and had a thick, dark mustache. Julia had never felt so helpless. She fought to free herself from his grasp, burning her right wrist on a hot dishwasher in the struggle, but was completely overpowered. Before he could get much further, another young sailor walked in. The supervisor got spooked and scurried out.

Julia told a friend. Then she told the team that handled sexual assault allegations, she said. She wasn’t afraid of repercussions. She had been so excited to enlist. Was this what the rest of her military experience would be like? The Navy gave her the option to transfer to a different ship. For Julia, it was an easy call. She no longer wanted to be on the Roosevelt.

But while the Navy offered Julia a fresh start, it didn’t offer her mental health services, she said, as Department of Defense policies demanded. “I would have taken them up on it,” she told ProPublica. Asked to respond, a U.S. Navy spokesperson said, “While we cannot comment on the care Ms. Larsen may or may not have received, the Navy takes mental health for our Sailors seriously.”

It was, experts said, a crucial missed step. Research shows a clear association between military sexual trauma and mental health conditions including post-traumatic stress disorder, depression and suicidal ideation. Studies have shown treatment can help reduce PTSD and depression symptoms, which sometimes emerge years after the traumatic event.

Julia was assigned to the USS Kearsarge, a massive assault ship that was already in the Middle East to support troops in the global war on terrorism. During her second deployment to the region, in the spring of 2016, a Harrier jet burst into flames departing from the Kearsarge’s flight deck. Julia was startled by the deafening pop. She sprinted toward the burning aircraft with the other firefighters to battle the blaze. “Her initial response, quick action and knowledge during an AV-9B Harrier fire on the flight deck was pivotal in the prevention of a major catastrophe and loss of lives,” her supervisors wrote in her performance evaluation.

Almost four years to the day after she began boot camp, Julia returned to California. She moved into a house in the southern Central Valley with her boyfriend from the Navy and enrolled at the local college. She set a goal of earning a degree in social work and becoming someone who could help veterans. But Julia couldn’t shake the feeling that something was wrong. She had trouble concentrating on schoolwork. Some nights, she couldn’t sleep. She sought out counseling through the VA.

By June 2017, Julia had started feeling scared of the world around her. One night, she was certain she could hear people walking on her roof and called the police. The officers who showed up made her feel even more anxious. She worried they would take advantage of her. She pushed one and wound up at the police station. She was later taken to a psychiatric unit.

As soon as Marty heard what happened, he drove six hours to pick up his daughter. He packed her belongings into suitcases and hitched her car to the back of his truck. On the ride back, Julia was convinced they were being followed. She begged her father not to draw attention by driving too fast or changing lanes. Marty was stunned to see his easygoing daughter acting so out of character. “It was like a switch had flipped,” he recalled.

First image: Julia and her father, Marty Larsen, fishing in the 1990s. Second image: Julia and her mother, Candy Larsen, on a family trip. Third image: Julia’s senior portrait at Paradise High School. Fourth image: Julia’s Navy portrait. (First, second and third image: Courtesy of Marty Larsen. Fourth image: United States Armed Forces.)

For veterans in the foothills like Andrew and Julia, the Chico clinic was all they had.

Its mental health team had been trying for years to convince regional leaders to add more positions. Even when the staff included two psychiatrists and a psychologist, plus a nurse, counselor, social workers and designated mental health administrators, the team struggled to keep up with growing demand, former employees told ProPublica. The clinic had more than 500 mental health patients, many of whom had complex illnesses.

The department’s longtime manager, a psychiatrist named Russell Cottrell, recalled once noticing that other rural mental health departments in the region had more personnel per patient than Chico did, he said. When he asked about the discrepancy, his bosses stopped sharing the data. He fumed, he said.

“I don’t think they paid attention to the growth we had,” Cottrell told ProPublica. “I would point it out and I’d get in trouble.”

By the summer of 2016, the staff had gotten smaller, and Cottrell was the only psychiatrist in the building. Cottrell was no stranger to hard work; an Army veteran, he had devoted his career to treating the most challenging mental health cases. But he was tired of begging for personnel and running out of energy. That fall, he made plans to retire.

The lead mental health nurse, Michelle Angela, sent an email to a regional mental health leader in the wake of Cottrell’s retirement announcement. “We would like to invite you to come visit us at Chico Behavioral/Mental Health for an update on what the plan will be,” she wrote. “In addition to our concerns as staff members, our local veterans have been asking if there will be [a medical doctor] on site for their mental health needs.”

No such doctor was hired. Instead, the clinic filled the gap with a combination of visiting doctors and doctors in other locations who connected with patients through computer screens.

In many ways, the Chico clinic was on the forefront of telepsychiatry, then an emerging way to deliver treatment that had the potential to broaden access to veterans in remote locations. But some mental health professionals had reservations. While virtual sessions might work for some patients, they worried others needed the trust and connection that could only be established in person.

For Andrew, who started coming in for treatment after his father died in 2013, the changes were disorienting. Andrew had been seeing Cottrell and starting to untangle his thoughts. When Cottrell retired in February 2017, Andrew was assigned to a temporary doctor, then a specialized pharmacist who wrote prescriptions, he said. Andrew resented the arrangement. “I wanted to talk to someone routinely,” he said, “not just get a load of meds.”

Julia first arrived at the clinic on June 23, 2017. She wouldn’t maintain eye contact with anyone; while in the waiting room, she rearranged the chairs. That day, clinic staff offered her little in the way of answers. “She was informed that Chico VA Behavioral Health is an outpatient clinic and we do not have a psychiatrist on site,” a social worker wrote in her medical records.

The following month, Julia started coming into the clinic for telehealth appointments with an off-site provider. Her records show she was diagnosed with PTSD from combat and military sexual trauma and bipolar disorder, the latter of which she disputes.

For a while, the patchwork system in the clinic’s mental health department seemed to be working, current and former employees told ProPublica. But cracks started to show. In 2018, the psychologist left. And the clinic sometimes found itself without a telehealth provider available to refill medications or see patients in crisis, emails obtained by ProPublica show.

That November, a wildfire started burning up in the foothills. It was called the Camp Fire because it originated off Camp Creek Road. The blaze grew into a raging inferno that affected virtually everyone in the region. More than 10,000 homes were destroyed, including the one belonging to Marty and Candy Larsen where Julia grew up. At least 85 people died.

The day after the fire, when the air was still heavy with smoke and ash, Cottrell showed up at the clinic to help. He knew the fire would increase the demand for mental health services, he said. Seven months later, he came back on a part-time basis to help out until the clinic could hire a new full-time psychiatrist on site.

Months passed without a hire. Meanwhile, the Chico clinic moved into a gleaming new facility just a few miles away. The VA’s website trumpeted its status as a green building with energy-reducing and cost-saving features. But none of that improved the mental health department, former employees said. In fact, the new building eliminated a designated waiting area for veterans in crisis as well as private offices for mental health practitioners, meaning patients were seen in bare-bones exam rooms that evoked a school nurse’s office.

Amid the turmoil, Andrew struggled. When he noticed Cottrell back in the clinic, he wondered if Cottrell hadn’t really retired but had discarded him as a patient. Experts who were not involved in Andrew’s care told ProPublica that the constant provider changes would likely have reinforced Andrew’s paranoia and made him feel less connected to his care. One said the churn would have felt like a parent continually rejecting their child.

Julia’s life had become a rollercoaster. Some days, she felt great. She enrolled at Chico State and floated around its red-brick campus. “She could be very lucid and be her old self,” Marty recalled. “We kept thinking, she’s over it.” But stressors would trigger her. She would flash back to her darkest moments, start feeling paranoid. It wasn’t unusual for her to go days without sleeping.

She wanted counseling, she told ProPublica. But at the clinic, there was never enough time to get into it all. The focus seemed to be more on medication than talk therapy, she said. “They wanted to help me and [then] shoo me along,” she said.

An abandoned swimming pool in Paradise (Loren Elliott for ProPublica)

The strain on the clinic would only get worse.

The same month that COVID-19 swept across the country, the mental health team learned its designated administrative assistant would be shared by several departments. That made managing appointments even more difficult. Not long after that, one of the two telepsychiatrists started seeing fewer Chico patients.

Cottrell had had enough, he said. He decided he would retire for good at the end of the year. “I saw it as a lost cause,” he told ProPublica.

That summer, a psychiatrist on the East Coast was hired to do virtual visits on a part-time basis. But increasingly, technical problems were disrupting appointments.

In emails to regional mental health leaders, Chico’s front-line workers insisted that hiring an on-site psychiatrist should be the priority and noted the VA’s own guidelines, which said veterans who were suicidal, violent or in need of immediate medical attention should not be referred for telehealth services. “We currently have numerous serious suicidal ideation patients,” a nurse named Diana McMaster wrote. “With losing Dr. Cottrell, do we not need a psychiatrist in the building? A lot of times it is left up to Michelle and me to manage what happens with these patients on our side of the video. … That puts us in a precarious position.”

Dr. David Gellerman, the chief medical director for mental health services in the VA’s Northern California region, replied, writing, “No, we are not placing anyone in a precarious position. We can’t hire someone who does not exist… if we get a good psychiatrist or [psychiatric nurse practitioner] candidate who can be on location, we can try, but so far we have not had any acceptances.”

Gellerman pointed out that precautions were being relaxed in the pandemic. “Care by telehealth is better than no care at all,” he added.

Reached by email by ProPublica, Gellerman did not comment on the correspondence. He referred a reporter to the VA’s public affairs office that covers the broader region of Northern and Central California, Nevada, Hawaii and the Philippines, which did not respond. A national spokesperson said agency guidance does not establish absolute conditions under which virtual care should not be given.

By then, Andrew had been diagnosed with schizoaffective disorder, a mental illness marked by a combination of schizophrenia and mood disorder symptoms. People with the disorder can experience psychotic symptoms, losing their connection to reality.

Andrew hadn’t been employed since returning to Oroville. He had come to believe people were trying to kill him, even his family. He spent most of his time alone in his bedroom. He slept upright in his computer chair and ate only food that came in a can so nobody could poison him.

Sue quit her job to care for her son. She made sure he had canned food to eat and drove him back and forth from his VA appointments. In conversations with her sister, Sue worried Andrew’s doctors were always changing and he wasn’t getting the help he needed. Ashley felt helpless watching her little brother slip away. He was withdrawn and angry, a far cry from the outgoing kid she remembered. She thought back on how she had tried to protect him when they were children. “It felt like I’d failed,” she said.

The pandemic had rekindled Julia’s paranoia, too, so much so that she began to believe strangers wanted her dead. That May, her oldest sister, Jordan Pepper, a clinical mental health counselor in Ohio, traveled to Chico and helped her to seek in-patient treatment at the VA hospital near Sacramento, California. Doctors there diagnosed her with general psychotic disorder.

Records show Julia went to the Chico clinic in the weeks and months that followed. Candy and Marty took turns accompanying her. Candy made it a point to get to know the people who cared for her daughter, in some cases getting their personal cellphone numbers. She tried to stay optimistic.

In the fall of 2021, the telepsychiatrist who had been seeing Julia stopped seeing Chico patients. That November, Julia had a virtual appointment with a psychiatric nurse practitioner she had never seen before who prescribed a drug called atomoxetine to help her concentrate, her medical records show. But two days later, Julia called back and asked for something that would work faster. The nurse practitioner prescribed an antidepressant called bupropion and instructed Julia to take the two medications together, her records show.

More than a year later, in its report on Julia’s case, the VA’s inspector general would note that the combined use of atomoxetine and bupropion can trigger psychotic or manic symptoms. The nurse practitioner told investigators that despite what his notes said, he had not intended for Julia to take both. It isn’t clear which, if any, Julia took. She doesn’t remember.

Around that time, Julia began taking note of unusual things she believed were happening to her: strangers following her at the dog park, electronic files going missing. She installed a camera in her car and started carrying a pink handgun she bought after separating from the Navy.

The Chico clinic’s mental health department, meanwhile, fell further into disarray, current and former employees told ProPublica. Several other telehealth providers left, including the Connecticut-based telepsychiatrist who was seeing Andrew. Those who stayed buckled under the weight. “We were abandoned,” said Belva Fay, a senior social worker who was also the clinic’s acting manager for eight months. “We were trying to run a clinic with nobody to prescribe medications, nobody to see emergency cases, nobody to talk to these clients who are angry. …

“We kept saying, there is going to be a problem,” Fay said. “This is going to blow up.”

By the time Michelle Gradnigo started as the clinic’s site manager in October 2021, disaster felt all but certain. Gradnigo, a retired lieutenant colonel in the Army and longtime military health care administrator, was so troubled by the lack of on-site mental health care providers that she asked if the clinic’s primary-care physicians could handle some of the load, she said. The answer was no, she recalled.

“I reached out to anyone at the time who would listen and said we are going to kill someone,” she told ProPublica.

Michelle Gradnigo, the clinic’s former site manager (Loren Elliott for ProPublica)

VA officials told ProPublica the Chico clinic was trying to recruit mental health professionals by offering special salary rate increases, education debt reduction and relocation incentives.

Northern California VA leaders were also trying to grow the virtual mental health program. A proposal obtained by ProPublica through a Freedom of Information Act request shows that mental health vacancies were dogging clinics across the region and that “painstaking and time-consuming recruitment efforts” were bearing little fruit. The only positions drawing quality applicants, according to the presentation, were virtual.

The new Chico VA clinic (Loren Elliott for ProPublica)

When the sun rose over the Sierra Nevada mountains on the third morning of 2022, Julia’s eyes were already open.

She had been awake for days, a fact she blamed on what felt like a constant barrage of electric shocks. She had tried to stop them by covering her walls in aluminum foil, but it wasn’t helping. She wanted pills to calm her down. At 8 a.m., she left a message at the clinic that she was “in crisis and very anxious,” government records show. An hour later, she started texting her mother, who called the clinic in tears. The mental health nurse was home that day with COVID, so a nurse from another department took the call.

The nurse sent an instant message to Julia’s nurse practitioner, who was seeing patients from another location, asking if Julia should come into the Chico clinic or go to the VA hospital in Sacramento. The nurse practitioner wanted Julia to go to Sacramento, government records show. But the nurse misunderstood and told Julia’s mother to bring her to Chico.

Marty and Candy brought Julia to the clinic around 2:30 p.m. Her body was tense, her eyes red and heavy with tears. But the nurse practitioner never evaluated her. He had nine appointments that day and no time to see Julia, a violation of VA policy requiring same-day availability for patients in crisis.

A triage social worker tried to ask Julia questions to help determine her risk of suicide or violence, but Julia wouldn’t engage, records show. Instead, she quibbled with her diagnoses and voiced frustration over the recent change in her mental health provider. The social worker should have posed the questions to Julia’s mom, who was inside the clinic while Julia’s dad waited in his truck. Instead, she marked Julia’s disposition as “routine” and concluded she wasn’t a threat to herself or others. There is no indication the social worker asked about Julia’s access to guns or other lethal means.

Later, in an interview with the inspector general’s office, the social worker said she was unfamiliar with the protocols. She ultimately gave Julia the nurse practitioner’s next available appointment, in 11 days.

Julia stormed out of the clinic, furious that she had not been given the medication she wanted, her father recalled. Candy was frustrated; she wanted clear direction on how to help. Exhausted, they all headed back to Candy and Marty’s home, a cozy ranch on a remote hillside outside of Red Bluff, California.

Marty at his home in Red Bluff (Loren Elliott for ProPublica)

Back at home, Candy offered Julia some soup and a sandwich and tried to help her calm down. Julia was still agitated, but around 10 p.m., she took a sleeping pill and retired to her parents’ bedroom. When it was quiet, Candy and Marty got ready to watch a movie in the living room, hoping it might help them relax.

Just before 11 that night, a call came into 911 dispatch.

The recording captured Julia as she pleaded for help, then fired one gunshot, then another. The line stayed open for an hour, chronicling all that unfolded.

After the second bullet fired into nowhere, Candy was determined to lower the temperature. “We are trying to help,” she assured her daughter. “You gotta put the gun down first, honey.” Marty followed suit. “We’re here for you, OK?” he told Julia. “It’s not too late. Nothing bad has happened.”

For a moment, it seemed like Julia might relent. “OK,” she said quietly. “OK.”

Instead, she fired again.

Acting on intuition, Marty lept at his daughter in an effort to disarm her. He wrapped his arms around her, he said, and tried to overpower her. Could it have felt to her, in that moment, like she was back in the ship scullery, trying to escape the grip of her attacker? It’s impossible to know. But she felt threatened and thrashed with all the strength she could summon, smashing at his ribs and clawing his eyes.

The gun fired again. This time, a bullet struck her mother in the thigh, tearing through a large blood vessel.

Julia didn’t realize. She fought her father for control of the gun for the next 10 minutes, pistol whipping his head until he started slipping out of consciousness. After that, she told him she loved him and went outside. He came to, and by the time she returned, had retrieved his own pistol from a drawer in the kitchen. He warned Julia he would shoot and then did, he said, striking her once in each shoulder and once in the thigh.

When the police had Julia in their custody around midnight, both she and her father were seriously injured. Her mother was dead.

The morning after the shooting, her bereaved sister Jordan called the Chico clinic, she said. She wanted someone there to explain Julia’s mental illness to the authorities, to advocate for her sister. The staff member who answered knew nothing about the shooting. “Oh shit,” Jordan recalled hearing from the other end of the phone.

That afternoon, just before 4, the clinic’s phone rang again.

It was Andrew, who was in a particularly rough place. The departure of his telepsychiatrist had made him feel cast aside yet again. He’d enrolled in an intensive VA program for people with serious mental illness, but abruptly withdrawn, believing the VA didn’t really want to help him. On the call, he asked to speak to a doctor, he recalled. When he didn’t get one, he told a pharmacist that he had not been taking his medication and was feeling paranoid again. The pharmacist encouraged him to restart the prescription and scheduled a follow-up appointment in two days.

“Vet does not appear to be a harm to himself or others,” the pharmacist wrote in Andrew’s notes.

The next day, Jan. 5, Andrew sought out the family shotgun. While Sue had gotten rid of most of the firearms in the house just a few months earlier, Andrew had kept three in his possession.

Around 12:30 p.m., Andrew called 911 and told the dispatcher he had shot his mother. He was standing in the driveway when deputies arrived.

Sue died on the scene.

Ashley first learned there had been a shooting at her mother’s house when a friend called. She initially thought Andrew had taken his own life. She and her husband raced to the house, arriving alongside first responders. Deputies wouldn’t let her on the property until well after night had fallen. Ashley struggled to make sense of what had happened. Officials told her Andrew had performed CPR on his mother. “He tried saving her life,” Ashley said.

Background: A roadside sign in Paradise First image: Marty holding his wedding photos. Second image: Andrew and his mother, Sue Hill, at his boot camp graduation. (Background and first image: Loren Elliott for ProPublica. Second image: courtesy of Ashley Hill.)

Over the course of about 36 hours, employees’ worst fears about the Chico clinic had become reality. Many returned to the office in a state of shock.

Gradnigo, the site manager, requested a chaplain be brought into the clinic. But when she asked her supervisors what the next steps would be, she got no response, she said. Hoping the VA’s central office might intervene, she sent a tip about the shootings to the agency’s inspector general’s office, she said. She withheld her name so she wouldn’t face retaliation.

Gradnigo was fired in March 2022. The reasons provided to her were “inappropriate” comments and interactions with colleagues, records show. Gradnigo says the allegations about her conduct are exaggerated or false. She believes she lost her job because she reported wrongdoing and she is Black. She is pursuing a discrimination claim against the VA. The agency did not comment on the claim and told ProPublica it does not comment on personnel matters.

The inspector general’s office went on to investigate Julia’s case. Its report, which was published in February 2023, ticked off all the ways the clinic had failed, from medication mismanagement to not having a same-day access availability and improperly assessing her risk of violence. But the report did not mention a second patient involved in a violent act. It did not address systemic staffing issues. In fact, the office said it did not substantiate employee claims that facility leaders had failed to address their concerns about mental health staffing. The report found facility leaders had “ensured the use of telehealth and community care.”

The inspector general’s office declined to say why it did not include Andrew’s case in its report or publish a separate review. Spokesperson Fred Baker said the office reviews all complaints it receives. With respect to the employee concerns about staffing, he said, the inspector general’s office “found that leadership was taking steps to fill vacancies.”

The VA declined to make a clinic leader or official at its regional office in Sacramento available for an interview. In a statement, a Washington, D.C.-based spokesperson, Joseph Williams, said the agency “fell short” in treating Julia. “This incident does not represent the quality of care Veterans have come to expect from our facilities, or the standard to which we hold ourselves accountable, and we have taken several measures to ensure that it does not happen again,” he wrote.

The agency later said it could not answer specific questions about the care Julia or Andrew received due to privacy concerns.

After the shootings, the Chico clinic hired an on-site psychiatrist and an additional social worker, according to the inspector general report. The psychiatric nurse practitioner who prescribed the medications to Julia resigned. For the last several months, the mental health team has been fully staffed, the VA told ProPublica.

Andrew was charged with his mother’s murder in January 2022. He remains in the Butte County Jail. As early as this month, a judge could determine whether Andrew was legally sane at the time of the killing.

In an interview with ProPublica, Andrew described being stuck in a loop when he fired the shotgun. He was convinced his mom was poisoning him, something he now says was a delusion. “I love my mom,” he said. “I wish she was here.”

The Butte County Jail (Loren Elliott for ProPublica)

He doesn’t want to scapegoat the military or the VA for what happened, he said. He accepts responsibility. But he stressed that he had tried to get help from the VA repeatedly. “I do believe if there had been some form of intervention on their end, this might not have happened,” he said.

Ashley stayed in Oroville for a while, but it became impossible to go grocery shopping without someone staring at her or asking about her mother. “It felt like we were on display,” she said. Over the summer, she moved to Texas with her husband, young son and stepfather. She’s hoping to give her son the childhood she and Andrew never had.

Ashley is still mourning her mother, whom she described as a devoted grandmother and her closest friend. She has also been doing whatever she can to support Andrew in jail. She calls and texts him regularly and makes sure he has enough money in his account for the commissary. When he texted about playing Dungeons & Dragons recently, she replied like a mother might. “I’m so happy that you’re doing something fun,” she wrote. “I love you, Andrew.”

Ashley and her family at home in Texas (Loren Elliott for ProPublica) Andrew in court in December (Loren Elliott for ProPublica)

Julia was also charged criminally for her mother’s death. In January 2023, she was found not guilty by reason of insanity. She is now a patient at Patton State Hospital, a sprawling forensic psychiatric complex at the base of the San Bernardino Mountains about 60 miles east of Los Angeles. She reads books in the library, helps organize group activities like bingo and keeps her fingernails painted vibrant colors. She has a journal with positive affirmations on each page; she writes down the things she’s grateful for.

For some time after the shooting, Julia didn’t know she had caused her mother’s death. It was only after listening to the 911 recording months later that she began to understand what had happened. Coming to grips with that has been excruciating, she said. Her mom was her best friend. On a recent afternoon, during an open mic event at the hospital, she read a poem she wrote about their relationship. Audience members were brought to tears, she said.

It is hard to say what prompted the shooting. She recalls hearing an explosion in the distance — maybe a gas tank — and feeling like she needed to protect herself from some unknown threat. “It felt like I was unconscious, not awake,” she told a psychologist who evaluated her in January 2023, records show. “It felt like I was in a video game.” The psychologist speculated the explosion triggered her PTSD and may have put her in a dissociated state.

Julia isn’t sure how long she’ll be at Patton. She would have to be cleared by the hospital and the court to be released for supervised treatment in the community.

First image: Julia at Patton State Hospital. Second image: The poem Julia recently wrote and recited. (First image: Loren Elliott for ProPublica. Second image: Courtesy of Julia Larsen.)

It has taken many months for Marty to begin recovering. His ribs were fractured and his back was broken in two places. He needed 15 staples in his head. The emotional recovery, he knows, will be much longer. He’s chosen to stay in the hilltop ranch where the shooting took place. He bought the property to grow old there, and that’s what he still intends to do. He finds comfort in his fruit trees and livestock and the sweeping mountain views.

He said he forgives his daughter. He keeps her military photo in his wallet. But he is furious at the VA. “I want to punch VA in the face,” he said one afternoon late in the summer, while the sun poured into his den. To him, it was obvious what had needed to happen and what went wrong.

It crystallized deep in his mind the night of the shooting, after Julia had finally relented and he picked up Candy’s cellphone to speak with the 911 operator.

“She really, really needs help,” he told the operator while waiting for the police to come and arrest his daughter. “We tried to get her help at the VA. And, God, the VA didn’t really help that much.”

The dispatcher was empathetic. She’d heard Julia’s cries for help all night; dozens of them were captured in a recording of the call.

“I’m sorry the VA didn’t help her,” the dispatcher said.

Editor’s Note

After reading a February 2023 report by the Department of Veterans Affairs’ Office of Inspector General about inadequate mental health care at a VA clinic in Chico, California — a document that did not name any veterans or health care professionals or provide specific dates — ProPublica reporters wanted to more fully understand the tragedy that unfolded and what lessons it offered for the larger VA health care system. They spent months investigating the case at the center of the report involving a veteran named Julia Larsen as well as a second case involving a veteran named Andrew Iles who was also treated at the clinic.

The reporters interviewed Julia in person at Patton State Hospital near San Bernardino, California, and spent many hours interviewing her by telephone and video call. They traveled to St. Louis to meet with her attorneys. They reviewed hundreds of pages of her military personnel and medical records, as well as police reports from the night of the shooting and transcripts of interviews Julia gave to detectives and psychologists after her arrest. They listened to the 911 call Julia’s mother, Candy Larsen, made before she died. They interviewed Julia’s father, Marty Larsen, at his home in Red Bluff, California. They interviewed her sister Jordan Pepper, childhood friend Brittney Apel and former boyfriend Ignacio Gutierrez by telephone. In addition to Brittney and Ignacio, who served in the Navy with Julia, they interviewed four other people who knew Julia from the military, one of whom Julia told about the sexual assault and corroborated her recollections. They also interviewed Laurie Smith, a close friend of Julia’s mother.

The reporters interviewed Andrew in person at the Butte County Jail in Oroville, California, and by telephone. They reviewed some of his medical records, military performance reviews and discharge records, as well as his court records and family photos from his childhood. They interviewed his sister, Ashley Hill, at her home in Texas and his half-brother William Iles, aunt MaryJo Hendricks, former girlfriend Kayley Reni and childhood friend Alex Kenworthy by telephone. They interviewed a second childhood friend who declined to be named.

Both Julia and Andrew consented to ProPublica publishing information from their medical records about their diagnoses and medical histories.

To better understand the issues at the Chico clinic, the reporters interviewed a half-dozen current and former employees. They reviewed emails sent between 2016 and 2022 that detailed staffing issues, as well as hundreds of pages in former site manager Michelle Gradnigo’s discrimination complaint. They also reviewed an internal proposal from 2021 to grow the virtual mental health program and documents from the Office of Inspector General’s investigation obtained through Freedom of Information Act requests.

To put the case into broader context, the reporters reviewed and analyzed more than 300 routine inspections and investigative reports published by the VA’s inspector general since January 2020, some examining events that occurred in 2019. They brought their findings to experts and interviewed the relatives of three veterans who died by suicide after receiving inadequate mental health care from the VA. They reviewed national reports on mental health staffing and outcomes.

Overall, the reporters spoke to more than a dozen mental health professionals, researchers and policy experts. They consulted with some on how to interview people who have experienced trauma and been diagnosed with severe mental illness. They asked others to describe how the treatment Julia and Andrew received from the Chico VA clinic differed from generally established standards of care and offer insight into the issues facing the VA’s health system.

Loren Elliott contributed reporting. Design and development by Anna Donlan.

If you have information about mental health care services provided by the VA, email VAmentalhealth@propublica.org.

This post was originally published on Articles and Investigations – ProPublica.

by Ruth Talbot

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

The quality of care that residents receive in a nursing home can be profoundly affected by who owns it, studies have shown. It’s not always clear who should be held accountable, though: Many nursing homes are owned by companies that are owned by other companies, obscuring who has the ultimate decision-making power. As more nursing homes are sold, information about an incoming owner’s performance in other homes becomes more relevant, as it may provide insight into how their latest acquisitions will fare.

To help navigate the confusing world of nursing home ownership, ProPublica’s Nursing Home Inspect now publishes detailed ownership information for facilities and an upgraded search to help you sift through the information.

The data comes from the Centers for Medicare & Medicaid Services, which publishes “affiliated entities” for nursing homes — lists of people or companies that have an ownership stake in or operational control over multiple nursing homes. CMS’ goal is to provide a better understanding of an owner or operator’s performance across all the nursing homes they are associated with. Some entities are affiliated with only a handful of homes, while others, like Genesis HealthCare or The Ensign Group, are affiliated with hundreds of homes across multiple states. Because CMS does not provide this data in a way that’s easy for most people to use, we’ve added it to our Nursing Home Inspect tool.

Our new affiliated entity pages allow users to easily explore data on each company or person who is responsible for nursing homes, listing all homes associated with that entity and showing recent serious deficiencies —  failure to meet care requirements — found at those homes. You can even view a list of all affiliated entities nationwide.

We also added detailed ownership information to individual nursing home pages, allowing users to see who has an ownership stake in the home, as well as who has managerial control over the facility and how long they have held that position.

To go along with these additions, we’ve also expanded the database’s advanced search capabilities so journalists and others can quickly identify affiliated entities that have a history of serious deficiencies or other problems. For instance, users can search for all serious deficiencies associated with Life Care Centers of America.

Separately, users can also now filter searches by F-tags, which are a system for specifying the types of compliance issues that may be found during a CMS inspection. These tags allow users to narrow their search beyond broad categories such as “infection control deficiencies” to more targeted queries such as deficiencies associated with reporting COVID-19 data to residents and families or ensuring staff are vaccinated against COVID-19.

ProPublica plans to continue enhancing Nursing Home Inspect with new data and features in the coming months. If you write a story using this new information, come across bugs or issues, or have ideas for improvements, please let us know!

This post was originally published on Articles and Investigations – ProPublica.

by Audrey Dutton

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

One night in March 1976, a young advocate for people with mental illness arrived at the Idaho statehouse with a warning.

Marilyn Sword urged lawmakers not to ratify a system that would ultimately lock away some of Idaho’s most debilitated psychiatric patients in the tiny, concrete cells of a maximum security prison — a kind of solitary confinement with no trial, no conviction and often no charges.

Idaho didn’t have any psychiatric hospitals secure enough for patients whose break with reality made them lash out in fear, anger or confusion. What it did have was a maximum security prison.

Sword said putting prison officials in charge, as lawmakers were contemplating, could violate the civil rights of patients committed by the court for hospitalization. She said it would burden them with “the double stigma of being mentally ill and then being placed in a maximum security unit at the penitentiary,” minutes of the meeting show.

Idaho leaders plunged forward with the legislation anyway.

In the five decades since, Idaho has continued to ignore warnings over and over that its law fails mental health patients by sending them to a cell block, ProPublica found in a review of legislative records and news clips.

“I think it’s really tragic that it has been this many years, and we’re still at this point,” Sword, now 77, said in an interview this summer.

Marilyn Sword was among the first mental health advocates to warn Idaho lawmakers in the 1970s that Idaho’s plan to house “dangerously mentally ill” patients in prison may violate their civil rights. Sword testified in 1976 as president of the Idaho Mental Health Association. (Sarah A. Miller for ProPublica)

Governors, lawmakers and state officials have been put on notice at least 14 times since 1954 that Idaho needs a secure mental health unit that is not in a prison.

They also have been told publicly at least eight times since 1974 that Idaho may be violating people’s civil rights by locking them away without a conviction, and that the state could be sued for it.

The most recent warning came this year, when Idaho’s corrections and health and welfare directors wrote that the practice was a problem “not only because of our lack of appropriate levels of care for this population but because the treatment violates the patients’ civil rights.”

Idaho will soon be the last state to legally sanction the practice of imprisoning patients who are “dangerously mentally ill,” to use Idaho’s parlance, but who are not criminals. New Hampshire is phasing it out.

State leaders repeatedly have defended Idaho’s approach — in 1977, 2007 and 2017 — as a temporary measure while the state worked on a stand-alone clinical unit or a permanent secure wing in a hospital. Those facilities never materialized.

At the start of this year, the Legislature refused to use any of Idaho’s $1.4 billion surplus to build a $24 million mental health facility for patients, opting to continue holding them without charges at the state’s maximum security prison south of Boise.

In placing patients who have not been charged with crimes in prison instead of in a treatment facility, Idaho is at odds with the U.S. Substance Abuse and Mental Health Services Administration. Holding prisoners with mental illness in prolonged seclusion also goes against recommendations of the American Psychiatric Association, the American College of Correctional Physicians, federal courts and the United Nations.

ProPublica and Mississippi Today have reported on a related issue recently: how Mississippi keeps hundreds of people with mental illness in county jails as they await appropriate hospital beds.

Idaho’s practice touches far fewer people and typically addresses more extreme behaviors. But it also stands apart because the Idaho patients are locked up longer — an average of 110 to 160 days in recent years — and in solitary confinement, in a maximum security facility, under a program fully endorsed in Idaho statute.

C Block holds the acute behavioral health unit of the Idaho Maximum Security Institution. The prison block is divided into three sections, one of which has nine cells for men considered “dangerously mentally ill.” They include patients who haven’t been charged or convicted of a crime. (Sarah A. Miller for ProPublica)

Joe Stegner, a former Republican leader, helped bring Idaho closer than ever toward building a hospital to replace the cell block in 2007 and 2008. Yet the project he championed was no match for Idaho’s inertia and austerity.

The defeat helped seal his retirement from politics.

“I started thinking, ‘You know, if you can’t have some wins in the Legislature, why are you kicking yourself around?’” Stegner, who served as a senator, said in an interview this summer.

“I set out to make a difference,” he said.

“The Damned and the Forgotten”

Two men sat in the Idaho Maximum Security Institution’s C Block near Boise on a recent day, neither of them convicted or charged in a crime.

The cell block was silent. An occasional face peered through a cell-door window the size of a computer keyboard. Inside each cell, another tiny window offered a view of razor wire, floodlights and rocks on the prison grounds.

First image: Patients admitted to the Idaho Security Medical Program spend months, on average, in cells like this one in a state prison near Boise. Second image: A view of the prison yard and desert surroundings from a cell in C Block. (Sarah A. Miller for ProPublica)

About a half-dozen civilly committed psychiatric patients a year are housed here and at a women’s prison in eastern Idaho under the Idaho Security Medical Program, state data shows.

The men share a block of nine cells with patients facing criminal charges and needing treatment before they can stand trial. Occasionally, a convicted felon with mental illness joins the mix. The women’s prison has one isolated cell.

Patients who end up here have conditions that can trick them into believing strangers are aliens who must be destroyed, or that the phlebotomist drawing their blood is implanting something in their arm, or that a nurse intends to infect them with a lethal virus. They react with violence.

A part-time psychiatrist, a part-time nurse practitioner and a dozen full-time staff members are expected to bring the patients back from shattered realities.

Certified nursing assistant Emma Wilson makes rounds inside the Idaho Security Medical Program’s section of C Block. (Sarah A. Miller for ProPublica. Patient document blurred by ProPublica.)

Civilly committed patients with the most severe symptoms spend as much as 23 to 24 hours a day confined to cells the size of a parking space.

Confinement can become necessary because it takes time to find effective medications that stabilize a patient before cognitive and behavioral therapies can begin, corrections spokesperson Jeff Ray said in an email. Until then, he said, “it is in the patient’s best interest they be kept safely in their cell, so they do not hurt themselves or others.”

Every patient gets checked on at least twice an hour, according to the corrections department. They can leave to shower, handcuffed, shackled and accompanied by guards.

Patients who take their medications, follow the rules and remain calm are allowed to spend time in the common area. There, they can watch television, use a microwave or sit in caged-in phone booths to make calls and send email on a terminal designed for prisoners. There are metal “restraint desks,” designed for shackling a person ’s ankles, bolted to the floor.

“There’s no color. There’s no nice pictures. There’s no couches,” said Kacey Abercrombie, a statewide coordinator for the Idaho Department of Health and Welfare, whose job includes regular in-person visits to these patients at the prison.

“It is prison,” Abercrombie told a roomful of attorneys and judges at a July Idaho State Bar meeting. “And when you think about this population in that setting, it is probably dawning on you how wild this is.”

The men spend hours peeling paint from the walls of their cells, a habit so universal that prison workers debate whether it makes sense to repaint between patients.

First image: Members of the prison staff try to keep patients occupied with worksheets, word searches, sudoku puzzles, radios and, in some cases, activities outside their cells. But the men often spend time in isolation peeling paint off the walls. Second image: A phone for the men in this section of C Block is inside a metal cage. (Sarah A. Miller for ProPublica)

“We try to do what we can with what we’re given,” said Mallory Logan, a prison social worker who works with civilly committed patients. But she said her unit can’t match the resources of a true forensic hospital.

Prison employees keep an imaginary barrier between convicted inmates who are in C Block for mental health care and the other patients with no convictions or charges.

There’s a “C” taped to the door of “civil” patients, a reminder that the person inside is not there as punishment. Signs around C Block remind staff members not to let the “civils” commingle with the inmates when they’re out of their cells.

Signs throughout C Block remind staff members not to let the “civils” commingle with criminally convicted inmates when they’re out of their cells. (Sarah A. Miller for ProPublica)

Little else separates patients. They are guarded, medicated and fed by the same prison employees. They have the same rules and reward systems that can allow them to have a radio or buy candy from the commissary.

Like many other states, Idaho can hospitalize people against their will under a court-ordered involuntary mental health commitment. At least two professionals must agree that such patients are likely to injure themselves or others or are “gravely disabled” due to mental illness.

If patients lash out — maybe punching or threatening to kill hospital workers — Idaho’s law says the state can ask the court to declare them “dangerously mentally ill” so they can be moved to a maximum security facility.

The typical patient isn’t a character who “really tugs on your heartstrings,” says Walter Campbell, chief psychologist for the Idaho Department of Correction.

“These are the damned and the forgotten,” he says.

Idaho is one of two states known to put people with mental illness in a prison without a criminal charge. The other, New Hampshire, just broke ground on a 24-bed secure mental health facility that will allow the state to end the practice — but not before a patient died last spring.

Psychiatrists and legal scholars commissioned by SAMHSA, the federal government’s main mental health agency, say it shouldn’t happen, period. In a 2019 report prepared for the agency that describes “principles for law and practice” in treating mental illness, the authors wrote, “Unless already incarcerated for a criminal offense, or facing criminal charges … no person who has been committed should be placed in a correctional facility for treatment services.”

One former patient’s mother provided ProPublica with copies of her son’s medical records and documentation of 15 uses of force on him during his stays in the Idaho Security Medical Program while under civil commitment. ProPublica is not naming the 38-year-old man to protect his privacy.

The records show that he was alone in his cell for days on end, aside from showers and short check-ins from staff. He didn’t always take his medications as required under his court-ordered commitment, so officers were called to hold him down for the drugs to be injected. Once, they fired pepper spray through a hatch in the cell door before entering.

His mother said she believes his confinement in a prison cell made it harder for him to recover. It was months before he was released last June to a state psychiatric hospital, where he remains.

The number of times force was used on the patient is unusually high, according to Ray, the prisons spokesperson.

“This is an extreme case which is not representative of the typical patient’s experience,” Ray said, adding that the use of pepper spray “is rare but on some occasions necessary.”

While acknowledging that prison is not the most therapeutic environment for people with severe mental illness, Ray described corrections officers assigned to the unit as “carefully selected, specially trained, and expected to consistently meet high performance standards.”

“They are some of the best correctional professionals in our department,” he said.

The prison psychiatrist who treated this patient wrote, in another medical record, that he told Idaho health and corrections leadership that prison was an inappropriate setting for this patient, who had been placed under involuntary civil commitment and had a history of injuring staff members at hospitals. Idaho’s health and corrections directors later asked legislators to fund a new secure mental health facility. (Obtained by ProPublica)

According to psychiatrists and researchers, forced solitude can exacerbate conditions for people with profound mental illness, making them lash out more.

“Solitary confinement is recognized as difficult to withstand; indeed, psychological stressors such as isolation can be as clinically distressing as physical torture,” Jeffrey L. Metzner and Jamie Fellner wrote in 2010 in The Journal of the American Academy of Psychiatry and the Law.

It is “the mental equivalent of putting an asthmatic in a place with little air,” according to a ruling by the 9th U.S. Circuit Court of Appeals, which covers Idaho.

Legal experts said Idaho is on shaky legal footing with its practice.

When told about Idaho’s system by ProPublica, David Fathi, director of the American Civil Liberties Union National Prison Project, called it “shocking beyond belief” and a likely violation of patients’ constitutional rights.

“I think the state has considerable exposure here,” Fathi said, “and I would urge them to discontinue this practice before they get sued over it.”

Megan Schuller, legal director for the Judge David L. Bazelon Center for Mental Health Law, said Idaho may also be violating the Americans with Disabilities Act and should invest in community-based care that keeps people from needing a secure facility.

“The bottom line is, you’re imprisoning people for having a mental health condition — for the manifestations of that condition,” Schuller said. “And that is just absolutely not equal treatment to how we treat any other type of health condition or even mental disability.”

Decades of Warnings

The idea of locking Idahoans with mental illness in a penitentiary was around as far back as 1954, when the Idaho Statesman reported that a county prosecutor had pressed for a place to incarcerate the “criminally insane.” At the same meeting where the prosecutor spoke, an influential Republican suggested putting the ward in the state prison. But Idaho’s health director argued a prison ward wasn’t appropriate; people with illnesses belonged in a hospital.

In the 1970s, a new generation of Idaho health and law enforcement officials offered an alternative. They would jointly operate a secure mental health facility, on the grounds of the new Idaho state corrections complex that was going up south of Boise.

The state health agency would provide psychiatric care, furniture, medical equipment and first aid; the state corrections agency would take care of security and room and board. The unit would house up to 17 patients including “persons considered mentally ill and dangerous” but who committed no crime.

Health and corrections leaders called it “a historical first” and “a new era” for Idaho. The Legislature approved, and the joint unit was open by 1972.

The collaboration quickly unraveled. In 1976, citing “numerous problems with management and operation,” the state prisons director pushed legislation that would give him full control over the unit.

Corrections officials were poised to start running the show, and critics were stunned.

Sword and other mental health advocates quoted in legislative records that year urged the state to keep a separation between civil patients and prisoners.

Marilyn Dorman, a regional behavioral health board chair, argued that mental health care decisions should not be made by corrections officials but by someone “who has the training in mental health and mental hygiene needed to best represent the patients.”

A supervisor at the psychiatric unit, Jeffrey Toothaker, was so outraged that he spoke out publicly against his boss, Idaho health director Milton Klein. In a letter to the editor of the Idaho Statesman, Toothaker said he found it “difficult to work with a good conscience for a department that has at its head a director that supports such a bill.”

Klein acknowledged to lawmakers that the arrangement wasn’t ideal. Without money to build a new secure psychiatric facility, he said, placing patients in the state pen was the best compromise available.

And that approach was designed to be temporary, authorized for only one year. In 1977, legislative minutes show, lawmakers said a secure unit for civilly committed patients would open in 1978 at Idaho’s State Hospital South, replacing the prison ward.

One senator said that while the U.S. Supreme Court might not look kindly upon placing civilly committed patients in prison, it would probably give Idaho a pass if a better solution was in the works.

It’s unclear what happened to construction at the hospital. But in 1979, a year after the ward was supposed to have opened, the Legislature made the civil commitment unit at the state penitentiary permanent.

It’s drawn criticism ever since.

The prison unit where civilly committed patients are housed has the trappings of a place designed for incarceration, such as these metal “restraint desks.” (Sarah A. Miller for ProPublica)

A national mental health advocate in 1990 called the unit a “dumping ground” for those with severe mental illness. “Death Row is just down the hall,” said psychiatrist and mental health advocate E. Fuller Torrey, according to an Idaho Statesman article. “Their major crime is schizophrenia.”

The same year, a complaint from a disability rights organization drew a U.S. Department of Health and Human Services civil rights investigation, according to an Idaho Statesman report. The federal agency could find no documentation of the outcome when asked recently by ProPublica.

The state’s behavioral health administrator told lawmakers in 2006 that “Idaho desperately needs a secure psychiatric facility or facilities for these people” instead of prison.

None of the criticism seemed to make an impression. Only once since 1976 have Idaho’s political leaders been united in their desire to give patients the right treatment in the right place.

Stegner, the state senator, was among those leading the charge.

The Hospital Takes Shape

Stegner ran his family’s grain-elevator business in north-central Idaho before jumping into politics. He ascended the Republican ranks to become the Senate assistant majority leader by the mid-2000s.

It struck Stegner as wrong when he learned Idaho was locking people with mental illness in prison without a conviction. In 2007, three decades after his predecessors assured people a new hospital wing for civilly committed patients was on its way, Stegner saw an opportunity to make it finally happen.

Sen. Joe Stegner, left, at the Capitol in Boise in 2005. Stegner has since retired from the Legislature. (Dianne Humble/Idaho Press Tribune via AP)

State mental health administrators who’d been making a renewed push to build a secure facility had fully scoped it out.

The building would house 300 beds for patients committed to the state as a result of their mental illness, as well as convicted criminals with severe mental illness and violent behaviors. The two groups would be kept in separate areas.

Stegner persuaded fellow lawmakers to set aside $3 million to design the facility. Construction was estimated at $70 million — roughly $101 million in today’s dollars.

Stegner still remembers driving out to the dusty sagebrush-covered land south of Boise to choose the site where the building would go: “a little low draw” behind a hill that would keep the prison out of view from the new psych unit.

State officials toured high-security psychiatric facilities in California, Kansas and Missouri.

Gov. Butch Otter put the project in his budget for the following year and highlighted it in his January 2008 State of the State address.

The House and Senate voted to allow bonds for the project, noting the demonstrated need for a standalone treatment facility.

Several legislators signed a resolution saying people placed in civil commitment and not serving a criminal sentence “should not be housed in correctional facilities.”

Stegner could see a future where Idahoans whose psychiatric diseases made them lash out would have a place to be safely treated. There was political support for it. There was money. There was even an architectural rendering.

And then nothing.

The governor’s office dropped its support, Stegner said.

Otter told ProPublica the plan stalled because of bureaucratic disputes over where to build the facility and, later, because of the 2008 financial crisis. “We all agreed we needed it,” he said of the new mental health facility, but there wasn’t enough money to go around. “And we all agreed we didn’t want to raise taxes,” he said.

Stegner believes one factor made it easier to kill the project. A year before, acting on a proposal from the Otter administration, legislators had tweaked wording in Idaho’s law governing the mental health unit to put corrections officials on firmer ground in the event of a lawsuit. It may have lessened the urgency to build a hospital.

“That was really a crushing defeat for me — one that changed my attitude about remaining in the Legislature, and one that is one of my biggest regrets in my legislative career,” Stegner told ProPublica.

Idaho officials went on to back away from or block the development of a mental health facility two more times.

Most recently, legislators this year failed to take up Gov. Brad Little’s proposal to use a fraction of Idaho’s record-breaking budget surplus to build a 26-bed facility on state land near the state prison.

One additional expense lawmakers did tack on to the budget: $750,000 to enable the execution of death row inmates by firing squad.

The Next Opening

Stegner and Sword, the activist who testified against imprisoning civilly committed patients in the 1970s, are looking to Little again in 2024. The governor made mental health care a focus of his administration when he took office in 2019. After getting nowhere on his proposal for a new secure facility this year, Little has signaled he plans to try again.

Based on a request from his administration, the state’s building advisory council gave its blessing Nov. 14 to a $25 million facility. That could bolster Little’s chances of legislative approval. Little’s press secretary told ProPublica the governor sees the building as “a critical part of our state’s behavioral health infrastructure.”

The Department of Health and Welfare would provide the mental health care for patients there. The Department of Correction would provide security. They would operate the facility together, and patients would no longer be held in prison cells.

It would be, by and large, just as state lawmakers envisioned more than 50 years ago.

This post was originally published on Articles and Investigations – ProPublica.

by Cezary Podkul

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A bipartisan group of six U.S. representatives has introduced a bill that would prohibit insurers and their intermediaries from levying fees on doctors for paying them electronically. The legislation comes in the wake of a ProPublica investigation that detailed the toll of such fees, which add up to billions of dollars that could be spent on care but are instead funneled to insurers and payment processors.

The charges are akin to having an employer deduct 1.5% to 5% to provide a paycheck electronically if an employee prefers to receive a payment directly into their bank account rather than via a paper check. Yet that’s the choice many insurers are increasingly forcing on doctors.

“We don’t tolerate paying fees to receive direct deposit of a paycheck, likewise, doctors and patients should not be forced to pay predatory fees on electronic payments on essential health services,” the bill’s lead sponsor, Republican Rep. Greg Murphy of North Carolina, said in a statement announcing the legislation. Murphy’s bill would effectively force the Centers for Medicare & Medicaid Services, the federal government’s chief regulator on health care payments, to prohibit the fees.

As it happens, that would bring the giant agency back to its original position. CMS prohibited fees for electronic funds transfers until it was lobbied by a payment processor called Zelis. The agency changed its position in 2018, then went even further in 2022, explicitly stating that such fees are not prohibited. A spokesperson for CMS said the agency does not comment on proposed legislation. Zelis did not reply to a request for comment on Murphy’s bill, but the company previously told ProPublica that its services remove “many of the obstacles that keep providers from efficiently initiating, receiving, and benefitting from electronic payments.”

CMS’s about-face was detailed in copious internal records meticulously collected by a New York City urologist, Dr. Alex Shteynshlyuger, who has made it his mission to fight the costly fees. His crusade now appears to have found a sympathetic ear in Congress: Like Shteynshlyuger, Murphy is a urologist, and he co-chairs the House GOP Doctors Caucus. Three Democrats and two Republicans thus far have signed on as co-sponsors of his bill.

The proposed legislation has the backing of the American Medical Association, whose policymaking body voted last month to adopt a new resolution opposing “growing and excessive” fees on electronic funds transfer payments. Shteynshlyuger, who has spent six years trying to convince CMS to ban the fees, introduced a proposal at New York state’s medical society that then made its way to the AMA. He said of the new federal bill: “I’m happy that the legislators got involved.”

Administrators at small medical clinics are hoping the bill will bring them relief from the fees, which are “doing nothing for us but costing us money,” said Rebecca Hamilton, who manages an arthritis and rheumatology clinic in Wichita, Kansas.

Often, it’s independent clinics like Hamilton’s that suffer the most from such fees, since medical practices collect the vast majority of their revenues through EFT payments, according to the Medical Group Management Association. The winners are the recipients of the fees: large insurers and payment processors like Zelis.

One form of electronic fee is not addressed by Murphy’s bill: charges for use of so-called virtual credit cards, which Shteynshlyuger has also been campaigning against. Virtual credit cards are temporary card numbers that are typically used for one payment. Fees for VCC use run as high as 5% versus a typical 2.5% for other kinds of electronic payments.

ProPublica’s investigation showed how Matthew Albright, a lobbyist for Zelis, used a combination of cajoling, argument and the threat of litigation to get CMS to withdraw a 2017 notice prohibiting fees for electronic payment. CMS had posted the notice, which was based on a federal rule from 2000, on its website after hearing complaints from doctors. Internal CMS emails detailed how Albright repeatedly demanded that CMS withdraw and revise the notice, and when CMS ultimately refused, a law firm representing Zelis threatened to sue the agency. Within days, CMS removed the notice. It later stated that fees are allowed.

CMS previously told ProPublica that it reversed its position because it concluded that it had no legal authority to “flat-out prohibit fees.”

Albright, like CMS, has changed his public position on the fees. Before he joined Zelis, Albright worked for the federal agency, where he wrote the rules implementing electronic health care payments. Shortly after his time at CMS, at a 2015 conference for health care business managers in Las Vegas, Albright expressed unequivocal opposition to fees for electronic payments. When Albright outlined the agency’s rules, audio of the event shows, the mere mention of virtual credit cards prompted some members of the audience to cry, “Evil!” Albright asked if that sentiment was unanimous, prompting a wave of yeses.

Doctors Shouldn’t Have to Pay to Get Paid

Before he became an industry lobbyist, Matthew Albright expressed opposition to electronic payment fees at a conference in Las Vegas in 2015.

Laughter ensued, and Albright, who has a master’s degree in divinity, joked that he was preaching to the choir. His sermon? “What other industry does not get paid for the services they’re doing, and when they do get paid, they have to pay for getting paid? What other industry, right? It’s ridiculous!”

Reached by telephone for comment, Albright said, “I can’t speak to you.”

This post was originally published on Articles and Investigations – ProPublica.

by Aliyya Swaby, with research by Mollie Simon

This story mentions attempted suicide.

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

One Saturday morning in September 2022, Terrence Steyer, the dean of the College of Medicine at the Medical University of South Carolina, placed an urgent call to a student. Just a year prior, the medical student, Thomas Agostini, had won first place at a university-sponsored event for his graduate research on transgender pediatric patients. He also had been featured in a video on MUSC’s website highlighting resources that support the LGBTQ+ community.

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Now, Agostini and his once-lauded study had set off a political firestorm. Conservative activists seized on one line in particular in the study’s summary — a parenthetical noting the youngest transgender patient to visit MUSC’s pediatric endocrinology clinic was 4 years old — and inaccurately claimed that children that young were prescribed hormones as part of a gender transition. Elon Musk amplified the false claim, tweeting, “Is it really true that four-year-olds are receiving hormone treatment?” That led federal and state lawmakers to frantically ask top MUSC leaders whether the public hospital was in fact helping young children medically transition. The hospital was not; its pediatric transgender patients did not receive hormone therapy before puberty, nor does it offer surgical options to minors.

The dean’s call went to voicemail. A person familiar with the call shared the voice message with ProPublica.

After reassuring Agostini that he had done nothing wrong and wasn’t in trouble, Steyer pressed him for more detail about his research. “I’m really getting some pressure from the state Legislature and the leadership at MUSC,” he said in the message. He asked Agostini to give him “in particular the number of people at each age that was seen and the youngest child who received gender-affirming therapy for transgender issues.” Agostini declined to comment for this story. Steyer did not respond to a request for comment, but an MUSC spokesperson told ProPublica that Steyer wanted to “ensure we had all the facts as the situation was unfolding.”

Excerpt of the Dean’s Voicemail

The day after a student’s research on pediatric transgender patients came under attack on social media, Terrence Steyer, dean of the Medical University of South Carolina’s College of Medicine, left the student a message acknowledging the pressure he was facing from lawmakers and university leaders.

(Obtained by ProPublica)

It had been three months since South Carolina’s Legislature had banned the state’s flagship medical university from using public money to provide any treatment “furthering the gender transition” of children under 16. Before and after the directive went into effect, hospital leaders told lawmakers and reporters that they didn’t use state money to care for transgender patients. And the chief of children’s and women’s care said that the ban would not affect the services the hospital offered, according to an email he sent to colleagues, which was among hundreds of MUSC emails that ProPublica obtained through a public records request.

Then came the blowback from Musk’s tweet. (Musk did not respond to an email seeking comment.)

In the months after the tweet, as conservative lawmakers and activists sought more information on the hospital’s transgender patients, MUSC employees expressed concern that hospital leaders went too far to appease lawmakers, according to emails. The emails show hospital leaders eventually buckling under the pressure and excluding doctors and other key employees from the decision-making process.

By the beginning of December, the hospital’s leaders came to an agreement that MUSC would cut off access to hormones for gender transition for minors of all ages — including 16- and 17-year-olds, which went beyond what the Legislature sought. At the time, MUSC leaders told reporters that they were no longer legally allowed to offer the care, an about-face from their initial pronouncement that the Legislature’s action would not impact regular functions. They also gave no public explanation of how providing the care to older teens could be considered illegal.

In response to ProPublica’s questions, MUSC spokesperson Carter Coyle called cutting off care for older teens an “operational decision made by hospital leadership,” but failed to elaborate. She said MUSC and its providers “took immediate steps” to comply with the state’s ban once it went into effect.

The hundreds of emails released to ProPublica do not indicate exactly why or when MUSC leaders made these decisions. But from last September through this spring, the emails show leaders painstakingly attempting to avoid the appearance of support for transgender people or LGBTQ+ causes on social media, concerned about garnering further political backlash.

In banning state funding, South Carolina lawmakers wielded one of many tools conservative-run states are using to restrict access to gender-affirming care. Over the last several years, Republican elected officials in many states have elevated anti-transgender issues in their political platforms, used misinformation about transgender people when introducing bills to restrict gender-affirming care and spent public money waging extended court battles to limit access to care for trans children and adults.

More than 20 states have passed bills that restrict care for transgender young people. Several of those laws are facing court challenges, including one in Tennessee, where opponents have petitioned the U.S. Supreme Court to take up the case. South Carolina conservatives tried and failed to get a ban passed this year and are expected to try again when the Legislature reconvenes in January. These attempts contradict the recommendations of major medical associations, which support access to gender-affirming care for transgender young people.

Even before states pass outright bans, hospitals and clinics, especially those reliant on state contributions, often bow to political pressure. In Mississippi, for example, the University of Mississippi Medical Center decided to stop providing puberty blockers and hormone therapy to trans youth months before state lawmakers banned care. Mississippi Today obtained emails showing UMMC cut off care after receiving pressure from lawmakers who were angry that the facility was providing any gender-affirming care to youth. UMMC declined to comment either to Mississippi Today or for this story.

In South Carolina, after it became clear last December that MUSC was halting transition-related care for all minors, conservative lawmakers celebrated their victory. “I went after the Medical Center of South Carolina with 19 other of my door-kicking, rock-ribbed, and South Carolina’s most Conservative legislator friends,” Republican state Rep. Thomas Beach wrote in a Facebook post. “It feels good to be a gangster.”

Some transgender youth and their families found out the care was no longer available well after the decision was made. Max, a 17-year-old transgender patient at MUSC, didn’t know until this spring that he’d be cut off from testosterone therapy after more than a year on it, time in which he’d become more confident in his body and gender. “I can’t watch myself go back in time like that,” he recalled thinking. “I was like, ‘I don’t think I’m gonna survive this.’”

In the days after Musk’s tweet, hospital staff and executives were scrambling to minimize the damage and to telegraph to the Legislature that they were not violating the ban.

“It’s been a whirlwind few days, with LOTS of cooks in the kitchen,” MUSC communications director Heather Woolwine wrote on the morning of Sept. 20 to the hospital’s director of LGBTQ+ health services. Woolwine asked him to review “the messaging that has been approved at the leadership level, after much back and forth.”

In her email, Woolwine reported that staff was checking all of the hospital’s online pages for “about 35 key terms to see if there is any other content out there that might place us in anyone’s crosshairs.” (Those terms included “affirming providers,” “questioning” and “queer.”) She acknowledged that the hospital didn’t want to “swing too far in the other direction” in responding to the threat of political retaliation. “We MUST keep respect of our patient, family and employee audiences at the forefront of any decision-making,” she wrote.

But that commitment was already faltering. By the time she sent the email, MUSC had determined that it would no longer provide hormones or puberty blockers to transgender children under 16.

The recipient of Woolwine’s email, MUSC’s first top-level employee focused exclusively on LGBTQ+ health, quickly wrote back. Chase Glenn explained that the hospital’s principal provider of gender-affirming care for transgender youth had told him about the lack of “any direct communication to her patients under 16 and their parents about the current legal reality.” One of her patients had come in the day before, he noted, only to learn that the care was no longer available.

“The patient’s mother was extremely angry and of course that’s out of concern for their child,” Glenn wrote, adding that the doctor herself “is hoping for some proactive, thoughtful, patient-centered communication that would at least make impacted patients/parents aware of the situation.”

Woolwine asked Glenn to help tackle that problem and suggested getting hospital leaders together for a discussion. But the emails over the following several months suggest that plan fell by the wayside. Woolwine didn’t respond to ProPublica’s questions. Glenn declined requests for comment.

Within days, U.S. Rep. Nancy Mace, a South Carolina Republican, posted a video on social media attacking political opponent Annie Andrews, a pediatrician at MUSC who was not connected to the endocrinology clinic. The video scrolled white block letters over a photo of Andrews: “Sex change surgery, puberty blockers, gender changing hormones for children?! That’s not protection. That’s child abuse.” Andrews took unpaid leave from her job and worked with MUSC to coordinate extra security for herself and her kids.

About a week later, MUSC leaders discouraged pediatric residents who wanted to send a letter to all hospital leaders defending Andrews against Mace’s political attacks. “They left me out on a limb,” said Andrews, who has since resigned from the hospital. “What disappointed me so deeply was their refusal to support these vulnerable youth in our community by making a statement that gender-affirming care is not child abuse.”

MUSC told ProPublica it reminded residents that state guidelines prevent public institutions from using state resources to advocate for political candidates. “If MUSC had issued a public statement it could have been interpreted as an endorsement of a candidate running for office,” Coyle said in an email.

In October, conservative politicians and activists started filing public records requests with MUSC to get the data behind Agostini’s abstract. Activists called the pediatric endocrinology clinic pretending to be parents of trans children, attempting to catch providers violating the clinic’s own stated policies regarding gender-affirming care. At least one lawmaker took to social media to threaten MUSC’s $188.9 million in state funds — 3.5% of its budget. “If MUSC is mutilating or castrating children, I won’t stop until they are stripped of public funding,” Beach, a member of the far-right Freedom Caucus, tweeted. Beach did not respond to a request for comment.

In an Oct. 5 email, MUSC leaders shared a news article about Oklahoma’s governor threatening massive budget cuts to the children’s hospital affiliated with the public hospital if it continued to offer gender-affirming care. “Could be the road we end up on,” wrote Mark Scheurer, chief of children’s and women’s care.

MUSC leaders also repeatedly pulled back on messaging related to LGBTQ+ issues, overriding the decisions of their LGBTQ+ health director. Glenn, a transgender man and longtime LGBTQ+ activist, had joined MUSC in 2021 to help the institution become a vanguard of LGBTQ+ health care in the state. By spring of 2022, Glenn had successfully organized the hospital’s first LGBTQ+ Health Equity Summit, bringing providers and students together virtually to learn about challenges in serving queer patients.

But as tension built that fall, Glenn found he had less and less power to do his job.

In November, Woolwine sent Glenn an email discouraging him from promoting a meeting that MUSC students had with the Department of Health and Human Services’ assistant secretary for health, Rachel Levine, the first openly trans person confirmed by the U.S. Senate. Several months prior, the hospital had proudly touted Levine’s appearance at the health equity summit Glenn had organized. Now, officials worried that promoting her involvement would make the hospital a target.

Glenn agreed to stand down. “I’ll note though that the fact that Admiral Levine is transgender is not the emphasis of the post,” he wrote back.

That same month, Woolwine advised a drastic edit to a social media post Glenn had helped draft to commemorate the annual Transgender Day of Remembrance, honoring “the memory of the lives lost due to acts of anti-transgender violence.” Woolwine stressed that lawmakers in the Freedom Caucus would soon be receiving information they had requested from the hospital about the state of gender-affirming care. “I have no doubt that in the week or two that follows, there’s going to be some sort of external messaging from them on transgender issues and their ‘findings,’ probably in social and in news media,” she wrote. “That post for the remembrance day, as written, may then have us looking like we are ‘firing back,’ since lives lost messaging may be interpreted as a shot across the bow.”

The resulting post barely mentioned transgender people at all.

On Dec. 1, an email from Patrick Cawley, the CEO of MUSC Health, landed in the inboxes of three of the hospital’s top leaders: “We need to update the website,” he wrote, referring to the page that described services for pediatric transgender patients. Cawley followed up with another email the next day, giving his preferred edits in red text. To the preexisting sentence that read, “We do not offer surgical treatments,” he added “or gender affirming hormonal interventions.” David Zaas, then the CEO of the Charleston division of MUSC Health, and Scheurer quickly agreed to the change.

Though MUSC Health’s CEO had been ready to make the change public on the website, the decision to cut off the care had not been communicated to Glenn. He asked MUSC leaders about the edit in an email the next day: “Can you confirm for me if this is accurate?” Cawley, Zaas and Scheurer did not respond to ProPublica’s requests for comment.

For some families, the news that their child’s care would be cut off came not from their MUSC provider but from media coverage, including a December Post and Courier article. As the information reached the public in mid-December, Glenn emailed MUSC leaders yet again to push them to communicate with patients. “After the news pieces began airing, I started receiving texts and emails and panicked Facebook messages from concerned parents who wanted to know exactly what this was going to mean for them and their children,” Glenn wrote. “Frankly, I’m frustrated that this communication is indirectly falling on me and embarrassed that we have left many of these patients scared about how they’re going to be able to continue this treatment.”

In response to ProPublica’s questions, MUSC spokesperson Montez Seabrook wrote that the hospital chose to have its providers reach out directly to affected patients during regularly scheduled visits instead of sending out a broader message to trans youth and their families: “This was to ensure that patients and families had an opportunity to discuss any concerns directly with their providers.” He also said, “This personalized approach took a little time to complete.”

In early January, Glenn resigned. “I strongly object to a number of actions recently taken by MUSC leadership that have directly impacted LBGTQ+ individuals’ access to health care services, health care providers’ access to educational resources specific to LGBTQ+ care and my ability to fulfill my responsibilities,” he wrote in a letter explaining his decision.

“[MUSC’s leaders] have created a hostile environment where it will no longer be possible for me, in good conscience, to represent MUSC as a leader in LGBTQ+ care.”

—Chase Glenn, in his letter resigning from his role as LGBTQ+ health services director

He criticized leaders for removing pages of LGBTQ+ resources from MUSC’s website and “unilaterally” postponing the next LGBTQ+ Health Equity Summit just three months before it was going to be held. He also cited leadership’s decision to voluntarily stop providing hormone therapy for 16- and 17-year-olds as one of the reasons for his resignation.

“These decisions and others have created a hostile environment where it will no longer be possible for me, in good conscience, to represent MUSC as a leader in LGBTQ+ care in our state and within the LGBTQ+ community– my own community,” he wrote. “I wish the MUSC all the best in the future and hope that there will come a time when they will meaningfully renew their commitment to being a leader in LGBTQ+ health care.”

When asked about its response to the letter, MUSC told ProPublica it could not comment on a personnel matter.

As the news of Glenn’s resignation spread through the hospital, at least one top employee shared his frustration.

“This is, in my opinion, both terribly sad and entirely predictable,” MUSC pediatrician and Chief Quality Officer Dr. David Bundy emailed other members of the Charleston division’s leadership team. Bundy’s son Eli, who is transgender and attends college out of state, has frequently addressed the Legislature to oppose anti-transgender bills. “MUSC needs to take a long look in the mirror and ask ourselves what our values are.” Bundy declined to comment.

This March, months after MUSC cut off hormone therapy for young transgender people, pediatric endocrinologist Dr. Deborah Bowlby asked Scheurer and the pediatrics chair for guidance on how to communicate the decision to patients. Bowlby was the main doctor who had been treating transgender youth who experienced gender dysphoria, and she repeated concerns she had shared with Glenn the previous fall.

“I have been told that the current policy is that the pediatric endocrinology clinic is not to be providing endocrine care regarding gender transition for pediatric patients. I want to abide by MUSC policies and am not comfortable seeing these patients,” she wrote. “Are you going to arrange to have these patients taken off my schedule and advise them that we are not providing endocrine care regarding gender transition for pediatric patients?”

Scheurer advised Bowlby to refer patients who wanted gender-affirming care to the adolescent medicine providers, who would help coordinate further care. Bowlby was not the only one who was confused. That week, an employee in the psychiatry department emailed colleagues to ask how they were notifying parents and families that they could no longer provide gender-affirming hormone therapy for minors.

At the time MUSC doctors were pleading with leaders for guidance, 17-year-old Max was unaware that MUSC had cut off his care. (Because Max is a minor, ProPublica is protecting his identity by using just his first name and not identifying his parents.) Max, who’d been treated by Bowlby since 2021, had little reason to think anything was amiss when he’d gone in for a follow-up visit in February 2023. His medical notes from that visit reference his preexisting testosterone prescription, as well as his history of gender dysphoria and suicidal ideation. Bowlby did not inform Max or his parents that MUSC had decided to end his hormone therapy.

In late March, Max’s father reached out to Bowlby for a testosterone prescription refill. She didn’t respond. Confused and a little concerned, Max’s dad called the endocrinology clinic’s office and was told by an administrative staff member that his son could no longer get hormone therapy at MUSC.

If you or someone you know needs help, call or text the National Suicide Prevention Lifeline: 988

For Max and his parents, the journey to find the right doctor and medical care was hard-fought. Even when Max was in elementary school, the idea of going through a cisgender girl’s puberty — getting a period and wearing a bra — felt terrifying. At the beginning of high school, Max’s parents took him to a therapist to help with his mental health struggles. The therapist recommended Prozac to address his anxiety and depression. It didn’t work. Max’s anxiety spiked and his gender dysphoria worsened. He began experiencing thoughts of suicide.

In May 2021, he tried to kill himself and was committed to inpatient psychiatric care at MUSC. Once he was released, Max and his parents decided he should see an MUSC pediatric endocrinologist so he could finally start hormone replacement therapy. He immediately trusted Bowlby, who seemed much more knowledgeable about transgender health than some of his previous doctors. Over the course of several months, she guided the family through the process of assessing whether Max was a good candidate for testosterone, patiently explaining the steps she would take to understand his dysphoria.

For Max, getting on testosterone in early 2022 sparked a second puberty at age 16. His voice cracked, he felt hungrier, his skin broke out in acne. “But I felt happier,” Max told ProPublica. “I just mentally felt more relieved, like I’m excited to continue transitioning and things are feeling right.”

Max said he believed that Bowlby would advocate for him. He remembers her referencing the bans on gender-affirming care that were starting to pass in conservative states and reassuring him that she would never stop providing treatment.

When Bowlby abruptly stopped responding to their messages after Max had been on testosterone for more than a year, Max’s dad wrote a second message to Bowlby in the patient portal: “You know how amazingly supportive and grateful we are for your advocacy over the years in these matters, while trans kids (and parents) are under attack. I just wish the office had told us that your office was no longer prescribing testosterone. Now we are a bit behind the 8 ball trying to remedy this.” Bowlby never responded, according to Max’s dad. She declined to be interviewed for this story.

“I’ve been trying to reach everyone and make sure they have a plan for care but it’s been very slow going.”

—Dr. Elizabeth Wallis, of efforts to communicate changes to MUSC’s policies regarding pediatric transgender patients

MUSC staff recommended Max’s parents connect with Dr. Elizabeth Wallis, the adolescent medicine provider who had volunteered to help coordinate care. “I’ve been trying to reach everyone and make sure they have a plan for care but it’s been very slow going,” Wallis wrote to Max’s dad in response to his email. She apologized for the “colossal mess” and promised to help them find a solution. But Max’s dad said that didn’t work out either. (Wallis did not respond to ProPublica’s requests for comment.)

After about a month, Max’s dad found a Facebook group for parents of trans young people in South Carolina, who suggested the family try Planned Parenthood. Max got a renewed prescription soon after.

Now back on testosterone, Max looks forward to turning 18 early next year, which will help ensure he can access gender-affirming care. South Carolina considered a bill earlier this year that would ban medical transitions for anyone younger than 21, but it didn’t go anywhere.

Max and his father still have questions: Why did MUSC cut off Max’s hormone therapy when the state Legislature didn’t even mention 16- and 17-year-olds in its ban? Couldn’t MUSC have prevented the chaos by communicating better with its patients? Why did Bowlby disappear instead of warning them?

“Knowing what happened would be nice,” Max’s dad said. “We figured it out — but we had to figure it out.”

Coyle, the university spokesperson, told ProPublica that MUSC did communicate the change to its doctors. “Physicians are notified of regulatory changes regarding medicine in various ways, including department leadership discussions, discussions with colleagues, information from specialty societies, and mainstream media,” Coyle wrote.

But as recently as May, some MUSC providers were unsure about the policy.

On the afternoon of May 23, after a conversation with her department chairperson, an OB-GYN sent an email to a physician’s assistant in family medicine, an adult endocrinologist and Bowlby. The subject line was “Question about transcare for teens.” She had only just learned that MUSC doctors were “restricted from prescribing transgender affirming care for people under 18yo,” she wrote. “Is this the case? How are y’all navigating that?”

“I have referred to Deb in the past,” the physician’s assistant responded, referring to Bowlby, “but MUSC has made some changes.”

This post was originally published on Articles and Investigations – ProPublica.

by Rose Lundy, The Maine Monitor

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

One lunchtime in 2021, a longtime resident at Woodlands Memory Care of Rockland started throwing up. His fingernails turned purple, and his skin became red all over. He was lethargic and fidgety, and his breathing grew shallow, according to the facility’s daily care notes.

The resident was well known at this residential care facility in Maine’s Midcoast region. Former facility employees told The Maine Monitor and ProPublica that he was a nationally renowned concert pianist who continued to play a portable keyboard in his room even as his Alzheimer’s disease advanced.

It wasn’t until a family member arrived and asked if the resident had eaten peanuts that employees realized that he was having an allergic reaction to the peanut butter sandwich that he had been served for lunch, according to the facility care notes. Staff used an EpiPen to treat his anaphylactic shock and took him to the hospital. He died days later, though no official records were made available that show the cause of his death.

The employee who gave the sandwich to the resident wrote in the facility care notes the day after the incident that they “didn’t know” that the resident “was allergic to peanuts.”

In interviews with the Monitor and ProPublica, however, four former employees said the resident’s severe peanut allergy had been documented throughout the facility: in his resident profile, in his room and posted in the kitchen.

“It said it everywhere you looked around him that he was allergic to peanut butter,” said Stacy Peterson, who served as the human resources coordinator at Woodlands of Rockland from 2018 to 2020.

So it was a mystery to the former employees how the resident had been served a peanut butter sandwich that day for lunch.

After receiving an anonymous complaint, the Maine Department of Health and Human Services investigated the incident and cited Woodlands of Rockland for two resident rights violations — first by failing to protect the resident from a severe allergic reaction and the second time by not reporting the case to the state. (The citations do not identify the resident.)

Under state regulations, the health department had the power to impose a fine of up to $10,000 or issue a conditional license that would bar Woodlands of Rockland from accepting new residents for up to 12 months. But it did neither. Instead, it simply required the facility to submit a report, called a plan of correction, stating how it intended to address the deficiencies.

In that plan, Woodlands of Rockland acknowledged that the resident’s allergy had been documented but disputed the health department’s characterization that the facility violated the resident’s rights in the incident. Still, it promised to discipline the employee who served the sandwich and to retrain others on how to handle allergies and to report incidents.

The Maine Department of Health and Human Services found that Woodlands Memory Care of Rockland violated a resident’s right to be free “from abuse, neglect or exploitations” by serving him a peanut butter sandwich despite his documented peanut allergy. (Obtained by The Maine Monitor and ProPublica. Highlighted by ProPublica.)

The health department’s modest response to the peanut allergy incident exemplifies its approach to oversight, an investigation by the Monitor and ProPublica found. The health department rarely imposes fines or issues conditional licenses against the state’s roughly 190 largest residential care facilities, classified as Level IV, which provide less medical care than nursing homes but offer more homelike assisted living alternatives for older Mainers.

From 2020 to 2022, the health department issued “statements of deficiencies” against these facilities for 59 resident rights violations and about 650 additional violations — involving anything from medication and record-keeping errors to unsanitary conditions and missed mandatory trainings. Despite these violations, however, it imposed a fine only once: a $265 penalty against a facility for failing to comply with background check rules for hiring employees. And it issued four conditional licenses: three in response to administrative or technical violations and one in response to a variety of issues, including a violation of a resident’s privacy rights.

By contrast, Massachusetts, which has 269 assisted living facilities, doesn’t shy away from imposing stiff sanctions. From 2020 to 2022, the state suspended eight facilities’ operations for regulatory violations.

The paucity of sanctions in Maine comes at a time when Level IV facilities like Woodlands of Rockland — which are similar to what are known generally as assisted living facilities in other states — are expanding their presence in the state. The share of Maine’s population that is 65 or older, 21.7%, is the highest percentage in the country.

As the Monitor and ProPublica have reported, the state’s decision in the mid-1990s to tighten the requirement to qualify for nursing home placement helped spur thousands of older Mainers, many with significant medical needs, to move to these nonmedical facilities — which are subject only to state regulations that hold them to much lower minimum staffing, nursing and physician requirements than nursing homes, which face both state and federal scrutiny.

In stark contrast to how rarely Level IV facilities face sanctions, nursing homes in Maine are often hit with considerable fines for regulatory violations.

Health department spokesperson Jackie Farwell said that plans of correction are often sufficient for improving conditions at facilities. She added that as part of an effort to improve the long-term care system in Maine, the state has been considering rules changes to “establish fines and sanctions as more meaningful deterrents.” But she declined to elaborate on the specifics.

Dan Cashman, spokesperson for Woodlands Senior Living, which runs 14 Maine facilities including the one in Rockland, said the company has “a zero-tolerance policy” and has taken disciplinary actions against any employees who were found to have violated residents’ rights.

Cashman added that the company is in favor of stronger state action against individuals found to have violated residents’ rights to prevent them from working in residential care settings again.

But long-term care advocates say the health department is not doing enough to crack down on facilities, as opposed to individuals, and is allowing poor conditions to persist for vulnerable residents.

Richard Mollot, executive director of the Long Term Care Community Coalition, a national advocacy group focused on improving nursing homes and assisted living facilities, said stiff sanctions should be imposed more, so that there’s a “meaningful ladder of sufficient penalties to ensure that facilities are properly motivated to take steps to ensure resident safety.”

Otherwise, Mollot said, facilities have no incentive to change their behavior. “To pussyfoot around resident neglect or abuse,” he said, “is essentially encouraging. It’s allowing it to happen.”

A review by the Monitor and ProPublica of state inspection records from 2020 to 2022 shows that the health department employed the lowest intervention possible, even for some of the most serious abuse and neglect incidents.

In the summer of 2021, for instance, a resident at Crawford Commons in midcoast Maine was found to have sexually abused another resident multiple times, according to the state’s investigation. The health department cited the facility for two resident rights violations but only required it to submit a plan of correction.

A year later, a resident in Jed Prouty Residential Care Home in the Penobscot Bay region was found around 6:30 a.m., naked and asleep on the floor, “soaking wet with urine,” after falling sometime after 10 p.m. Witnesses said the resident had been crying for help and complaining of thirst until medics responded. No efforts had been made by staff to move the resident from the floor or provide clothing, according to the state’s investigation. Again, the health department cited the facility for a resident rights violation but only required it to submit a plan of correction.

Similarly, in 2021 and 2022, the health department also investigated Woodlands of Rockland for two other serious incidents. In one, a certified nursing assistant at the facility slapped a resident who had spit at and attempted to bite her, according to the state’s investigation. In the other, a resident wandered out to the facility’s locked courtyard, but employees didn’t notice that she was missing until they went to give her medications nearly two hours later, according to the state’s investigation. When the resident was found outside in the snow at around 8:40 p.m., employees wrapped her in blankets and called for emergency medical care. The resident died in hospice days later, and the state investigation cited the cause as “complications of hypothermia.” In the end, both incidents also led to plans of correction.

The Maine Department of Health and Human Services cited Woodlands Memory Care of Rockland for not protecting “a resident’s health and welfare” after the resident wandered out unsupervised into the facility’s locked courtyard. (Obtained by The Maine Monitor and ProPublica. Highlighted by ProPublica.)

Woodlands of Rockland has been disputing the health department’s characterization that the facility violated the resident’s rights in the courtyard incident. But Cashman declined to elaborate on the specifics.

Edward Sedacca, CEO of Magnolia Assisted Living, which runs Jed Prouty, said his company took over the operation of the facility in August 2022, a month before the incident, and has since made it a priority to enhance its staffing and training. “The staff we inherited was lacking in overall general knowledge,“ he said. “Magnolia has built an infrastructure well beyond that required under regulation to enable us to provide a higher level of care to all of our residents.”

Crawford Commons did not respond to requests for comment.

For Maine’s nursing homes, however, the response to similar incidents has been very different.

From 2020 to 2022, more than half of nursing homes in Maine received fines — 98 penalties in all, totaling nearly $700,000 — according to U.S. Centers for Medicare and Medicaid Services reports. These fines were imposed in response to a range of violations, including not following COVID-19 infection prevention protocol, making medication errors, not reporting unexpected deaths and failing to protect residents from harm.

In 2020, for instance, an employee at Pinnacle Health & Rehab, a nursing home in Canton in western Maine, “lost it” when a resident became combative, according to CMS investigation records. The employee punched the resident, who ended up with a black eye and bruising around the eyebrow. CMS fined the facility $41,650.

A year later, a resident at Heritage Rehab and Living Center, a nursing home in central Maine, wandered off the premises at night using a walker and was found later by police by the side of a road in the rain. No one at the facility had noticed that the resident was missing, according to CMS investigation records. CMS fined the facility $71,243.

Ken Huhn, administrator of Pinnacle, said the employee was fired, and he made it clear that “that type of behavior would not be tolerated” at his facility.

Heritage did not respond to requests for comment.

Even without the involvement of CMS, which does not regulate assisted living facilities around the country, the health department has the power to adopt a tougher approach toward Level IV facilities. Under state regulations, for instance, it can impose a fine when an incident poses “a substantial probability of serious mental or physical harm to a resident.”

Long-term care advocates told the Monitor and ProPublica that under this standard, some of the egregious abuse and neglect incidents in recent years at Level IV facilities should have resulted in stiff sanctions.

“Because the incidents are so egregious and show such disregard for the well-being of residents, they would have warranted some significant penalty and not just a pro forma requirement that the facility submit a plan of correction,” said Eric Carlson, director of long-term services and support advocacy at Justice in Aging, a national legal advocacy nonprofit focused on ending poverty among seniors.

Paula Banks, who has served as the executive director of another Woodlands facility in Cape Elizabeth and as an assistant administrator of a Maine nursing home, said the fear of such sanctions would be effective. If she were still helping run a residential care facility, she said, it would spur her to take immediate action to address any problems.

“What’s the impetus to change if there’s no consequence?” said Banks, who now runs a geriatric consulting and care management firm.

But Dr. Jabbar Fazeli, who has served as medical director at multiple residential care facilities and nursing homes in Maine, said that rather than imposing sanctions, the state should require more medical attention by increasing nursing hours and requiring a medical director to be on the premises.

“If they had more medical care, I would say 50% of these issues will self-resolve,” Fazeli said.

The health department metes out sanctions in only a small percent of the incidents it hears about each year. Most of the time, it hardly does anything.

To better understand the health department’s process for looking into potential issues, the Monitor and ProPublica analyzed a database of incidents reported to the state by Level IV facilities themselves. Unlike the state inspection records, the database of facility-reported incidents gives a window into what happens earlier in the health department’s enforcement process.

Level IV facilities are required to report an incident to the state when a regulatory violation may have occurred or when a resident’s safety was put at risk. We focused particularly on reports of incidents with the potential for direct harm: the cases of abuse and neglect.

From 2020 to 2022, the state received more than 550 reports of abuse and neglect incidents from Level IV facilities, according to the Monitor and ProPublica analysis. Of those, 342 cases involved residents abusing other residents, 102 cases involved “elopement,” in which residents wandered away unsupervised, and 61 cases involved a staff member abusing a resident.

The analysis shows that in nearly 85% of these incidents, state investigators took “no action” — which, according to Farwell, means that the health department decided not to investigate. She said this could have been for a range of reasons, such as when a facility has already taken corrective action, when state investigators do not expect to find a regulatory violation, or when an incident is being investigated as part of another case or is expected to be reviewed later.

The analysis also shows that the health department did not step up its enforcement even when individual facilities repeatedly reported similar issues.

From 2020 to 2022, 13 Level IV facilities, including Woodlands of Rockland, each had at least 10 abuse and neglect incidents, collectively reporting 348 cases to the state. Even after these facilities had reported multiple cases, the health department still took no action in 91% of them, the analysis shows.

Farwell said state investigators do pay attention to repeated incidents. “If patterns are observed, specific issues may be flagged for follow-up at the next scheduled survey,” she said.

But such follow-ups might not happen for many months, depending on the timing of the next inspection required for license renewal, which takes place only once every two years.

Dionne Mills, who served as the program coordinator at Woodlands of Rockland from 2019 to 2021 and also worked at two other Level IV facilities, said she became aware of the lack of state oversight during her time at the Rockland facility. She said she reported multiple incidents to the state until eventually a state investigator told her that they were too overwhelmed with complaints and that she would have more success taking her concerns to the media.

“The state is so super busy that they only have time to look into the absolute worst-case scenario,” Mills said.

Dionne Mills outside her home in Northport, Maine (Tara Rice for ProPublica)

Farwell disputed Mills’ account, noting that state investigators made seven visits to Woodlands of Rockland from 2020 to 2022, the time period when the facility was under investigation for the courtyard, peanut allergy and slapping incidents. Mills’ account “is inconsistent with the number of onsite visits that were conducted at this facility,” she said.

According to Farwell, the health department has 13 investigators — and is in the process of hiring two more — to inspect more than 1,100 assisted housing facilities in the state for license renewals and to investigate any incidents.

Mollot, of the Long Term Care Community Coalition, said the health department needs to do more against facilities with a history of repeated incidents, such as requiring independent monitoring and, possibly, revoking licenses.

“Faced with the fact that these facilities have reported over and over and over and over and over again incidents of abuse and neglect, why have there been a paucity of enforcement acts?” Mollot said.

Several former employees told the Monitor and ProPublica that the history of repeated incidents at Woodlands of Rockland illustrates what can happen to a facility’s standards when the health department takes little enforcement action.

Stacy Peterson, a former human resources coordinator at Woodlands Memory Care of Rockland, said facility managers made little effort to address recurring problems when she worked there. (Tara Rice for ProPublica)

From 2020 to 2022, Woodlands of Rockland had the highest number of abuse incidents reported by a Level IV facility — 48 cases in all, including 38 in which a resident abused another resident, according to the health department database.

But the health department investigated only five of the incidents that Woodlands of Rockland reported, took no action on the rest and imposed no sanctions other than requiring the facility to submit one plan of correction.

With little pressure from the health department, efforts to address recurring problems “were nonexistent when I worked there,” Mills, the former program coordinator, said.

Joshua Benner, who served as a residential care aide at Woodlands of Rockland from 2018 to 2020, said he found it concerning that when the facility was cited by the health department, none of the managers at the facility shared with employees what problems had been found.

“Every other health care place that I’ve ever worked, you have interventions, usually after the state comes in, to go over what you’re dinged on and what can be improved,” said Benner, who has worked at a nursing home and two other residential care facilities.

Cashman, the Woodlands spokesperson, denied that Woodlands of Rockland had “an ongoing or systemic problem” with abuse incidents, noting that the bulk of the cases involved a small number of residents “whose progressively worsening dementia-related behaviors became more and more challenging.”

In response to these residents’ behaviors, Cashman said Woodlands of Rockland has been proactive and taken “multiple interventions,” including resident care plan updates, medication modifications, referrals for hospital treatment and discharge planning.

Cashman said Woodlands of Rockland and its employees have been doing “their best to manage what can be extremely difficult behaviors by individuals living with significant cognitive impairments.”

But Banks said something is amiss if any facility has repeated incidents, noting that she would have been alarmed to see more than one or two incidents of abuse in three years, let alone 30 or more as Woodlands of Rockland did.

“When you have people in your building and you took them in and you told their families you would take care of them and you took their money,” Banks said, “I don’t care what’s going on. I don’t care if you have a staff of three. You’ve got to take care of your people.”

Mariam Elba contributed research.

This post was originally published on Articles and Investigations – ProPublica.