by Aliyya Swaby, Lucas Waldron and Ash Ngu

Major medical associations recognize that access to gender-affirming care, also known as transition-related care, is medically necessary for transgender people, whose mental and physical health may be harmed if they are barred from getting it. Yet conservative politicians across the country have moved to restrict access to gender-affirming care. Our recent investigation found that state and local governments that deny this care to their employees are spending hundreds of thousands of dollars on lawyers to defend their policies in discrimination lawsuits.

We are interested in talking to transgender individuals who have faced barriers when seeking quality gender-affirming care; we want to hear about obstacles you’ve faced in any part of the process, from struggling to find providers to limitations in insurance coverage. Documents, such as health bills or insurance denial letters, are always welcome and helpful for our investigative reporting process.

Our team may not be able to respond to everyone personally, but we will read everything you submit. We understand that sharing personal information may feel risky, and we will not publish any of it without your permission. We appreciate you sharing your story and we take your privacy seriously. We are gathering these stories for the purposes of our reporting, and will contact you if we wish to publish any part of your story.

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

by Aliyya Swaby and Lucas Waldron

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When a sheriff’s deputy in Georgia’s Houston County sought surgery as part of her gender transition, local officials refused to change the department’s health insurance plan to cover it, citing cost as the primary reason.

In the years that followed, the central Georgia county paid a private law firm nearly $1.2 million to fight Sgt. Anna Lange in federal court — far more than it would have cost the county to offer such coverage to all of its 1,500 health plan members, according to expert analyses. One expert estimated that including transition-related care in the health plan would add about 0.1% to the cost of all claims, which would come to roughly $10,000 per year, on average.

Since at least 1998, the county’s plan has excluded coverage for “services and supplies for a sex change,” an outdated term to refer to surgeries or medications related to gender transition. In 2016, the county’s insurance administrator recommended changing the policy to align with a new federal nondiscrimination rule. But Houston County leaders said no.

The county argued that even if the cost of expanding its insurance coverage to include transition-related health care was low on average, it could amount to much more in some years. The county also claimed that expanding the plan’s coverage would spur demands to pay for other, currently excluded benefits, such as abortion, weight loss surgery and eye surgery.

“It was a slap in the face, really, to find out how much they had spent,” said Lange, who filed a federal discrimination lawsuit against the county. “They’re treating it like a political issue, obviously, when it’s a medical issue.”

Major medical associations recognize that access to transition-related care, also known as gender-affirming care, is medically necessary for transgender people, citing evidence that prohibiting it can harm their mental and physical health. And federal judges have consistently ruled that employers cannot categorically exclude gender-affirming care from health care plans, though prior to Lange’s suit, there hadn’t been a ruling covering Georgia. The care can include long-term hormone therapy, chest and genital surgery, and other services that help transgender people align their bodies with their gender identities.

But banning gender-affirming care has become a touchstone of conservative politics. At least 25 states this year are considering or have passed bills that would ban gender-affirming care for minors. Bills in Oklahoma and Texas aim to ban insurance companies from covering transition-related health care for adults as well.

At the same time, state and local government employers are waging long legal battles against covering gender-affirming care for their employees. With recent estimates showing that 0.6% of all Americans older than 13 are transgender, these employers are spending large sums to fight coverage for a small number of people.

ProPublica obtained records showing that two states — North Carolina and Arizona — have spent more than $1 million in attorney fees on legal fights similar to the one in Houston County. Both have claimed in court filings that the decisions they made not to cover the care for employees are purely financial and not discriminatory.

But budget estimates and real-world examples show that the cost of offering coverage of gender-affirming care is negligible. When the state of North Carolina briefly covered gender-affirming care in 2017, the cost amounted to $400,000 — just 0.01% of the health plan’s $3.3 billion annual budget.

Two years later, North Carolina employees sued to get their gender-affirming care covered. The state hired several expert witnesses who expressed professional beliefs contradicting the major medical associations’ standards, including that transition care is unnecessary and even harmful. One expert, whom North Carolina paid $400 per hour, stated in court proceedings that transition care might be a “fad” or “consumer fraud,” similar to the widespread medical use of lobotomies in previous decades.

Julia McKeown, a professor at North Carolina State University and one of several plaintiffs suing North Carolina officials for denying their coverage, spent more than $14,000 out-of-pocket on gender-affirming surgery, pulling from her retirement account and personal savings. “They’re always talking about saving taxpayer money and being judicious with how we spend it,” McKeown said. “But here they are throwing money left and right to score political points, to discriminate, to target.”

Julia McKeown spent more than $14,000 out-of-pocket on gender-affirming surgery after North Carolina refused to cover her care. (Annie Tritt, special to ProPublica)

Officials in North Carolina, Arizona and Houston County, Georgia, did not respond to questions from ProPublica about the amount of money they spent or their reasons for continuing to fight the lawsuits. Dan Perdue, chair of the Houston County Board of Commissioners, referred ProPublica to the county attorney, who declined to comment beyond pointing to existing court documents.

These Places Paid Lawyers Over $1 Million to Try to Avoid Paying for Gender-Affirming Medical Care The total spent includes only direct payments to private law firms from the date the lawsuit was filed through Dec. 31, 2022. Source: Billing records obtained by ProPublica.

Compared to North Carolina and Arizona, Houston County stands out for the huge legal bill it amassed relative to its small size. North Carolina’s employee health plan covers more than 700,000 people and Arizona’s covers over 130,000 people, dwarfing Houston County’s 1,500. Yet Houston County has spent a similar amount of money on legal fees as those states in a shorter time, according to records ProPublica obtained.

In fact, Houston County’s total legal fees on the Lange case have amounted to almost three times its annual physical and mental health budget. “Is this a good use of public money? No,” said Joanna Grossman, a law professor at Southern Methodist University who focuses on sex discrimination. “It’s fair to say that this is an issue where it’s pretty clear they’re going to lose.”

After more than a decade working for the Houston County Sheriff’s Office, Lange came out as a transgender woman to her boss and colleagues in 2017. A therapist had diagnosed her with gender dysphoria, characterized by significant distress at the mismatch between her assigned and actual gender.

Sheriff Cullen Talton, who has been in office since the early 1970s, first thought Lange was joking, according to a legal deposition. When he realized Lange was serious, he told her that he didn’t “believe in” being transgender but that she would have her job as long as she kept working hard.

Lange let herself feel cautiously optimistic. But she soon found that the county’s health plan would not cover any of the surgeries needed to make her body align with her gender — the operations are on a list of procedures that the county explicitly opts out of paying for, which are known as exclusions.

After coming out as transgender, Lange found that her county’s health plan would not cover any of the medical procedures needed to treat her gender dysphoria. (Annie Tritt, special to ProPublica)

Lange’s insurance does cover the hormonal medication she takes regularly, but not the lab work she needs once or twice a year to monitor how her body is responding to it. She receives a bill for $400 each lab visit, which is hard to afford on her $58,000 salary. The bills go to debt collectors, and she pays off smaller amounts when her budget allows.

Lange was able to cobble together several thousand dollars from savings and retirement funds to pay out-of-pocket for a chest surgery in early 2018, but the next surgery she needs costs more than $25,000, well above what she can afford. She sent letters to the insurance administrator and the county asking them to remove the exclusion in 2018 and 2019. Her appeals were denied.

Source: Billing and court records obtained by ProPublica.

In early 2019, in a last-ditch effort, Lange walked into the county board of commissioners’ meeting to ask the board to remove the health plan’s exclusion, hopeful they might hear her out. She mentally prepared herself to broadcast some of her most personal struggles to an audience that seemed less than receptive, bringing her son and a friend with her for support.

As Lange nervously waited for her turn at the podium, she watched someone familiar step up right before her. One of her neighbors had come to ask the county not to agree to her request. Addressing the row of commissioners at the front of the room, he launched into his list of questions: How does Lange’s request relate to her work? Why should taxpayers be on the hook for her surgery? How does her request differ from any kind of elective cosmetic surgery that also isn’t covered by insurance?

Lange asked the Houston County Board of Commissioners to allow the health plan to cover her gender-affirming surgery in February 2019. (Houston Home Journal via Facebook)

Watch video ➜

Lange watched, disheartened, as a commissioner reassured the neighbor that the board would not make any changes to the health plan that year. Lange would go on to speak that evening, despite believing it was a futile exercise. “You knew right then and there that no matter what I said, that it wouldn’t matter,” she said. “It’s a really helpless feeling.”

So she turned to the legal system. She worked with a team of attorneys handling a similar case — a lawsuit brought by a transgender employee against Georgia’s university system. In September of 2019, the university system agreed to a settlement that awarded the plaintiff $100,000 and provided all of its employees access to gender-affirming care. Just weeks after the settlement, Lange filed a lawsuit against the county for employment discrimination, arguing that denying her medical care subjected her to “inferior treatment.” Soon after, commissioners unanimously voted to continue excluding gender-affirming care from health coverage for yet another year.

In response to Lange’s lawsuit, the county’s lawyers said health insurance premiums had already soared and that the county wanted to prevent a flurry of requests to remove other exclusions in the plan. The county spent $57,135 — $390 per hour — on a budget expert who concluded that keeping the exclusion in place was “reasonable and consistent with general industry practices.”

The county’s expert argued that removing the exclusion could result in a “catastrophic claim,” in which a member of the county’s health plan seeks multiple surgeries in a single year that, combined, could cost hundreds of thousands of dollars. The county’s plan is self-funded, meaning that the employer — not an insurance company — is responsible for paying all enrollees’ medical costs, making it harder for the plan to absorb a high-cost claim.

Lange’s lawyers hired their own budget expert, whose estimate was in line with what other experts, government officials and academics have found. In her report, Lange’s expert wrote that, over time, the financial impact of removing the exclusion would be small, especially since few people would use the benefit. The expert also noted that the county has a separate insurance policy to cover unexpectedly large claims. She estimated that the cost of covering gender-affirming care would be “an amount so low that it would be considered immaterial.”

Without necessary treatment, transgender people are at higher risk for depression, anxiety and thoughts of suicide. Russ Toomey, a professor of family studies and human development at the University of Arizona, has helped establish that fact through his research on the mental health of transgender youth. He also has firsthand knowledge of discrimination: Toomey is suing his employer for withholding coverage for gender-affirming care.

When he was recruited for his job in 2015, he knew the university had hired other trans faculty members and believed it was committed to supporting them. In 2016, Arizona’s Department of Administration, which controls the health care plan for public employees like Toomey, chose to keep excluding gender-affirming surgery from its health plan, ignoring the advice of its insurance vendors. That same year, Arizona commissioned an internal analysis, in which a state budget expert described the cost of covering gender-affirming care as “relatively low.” A state employee was directed to delete that sentence from the analysis, according to legal documents.

In 2018, Toomey sought coverage for a hysterectomy to alleviate the distress of his gender dysphoria, and he was denied. In 2019, he filed a lawsuit against the state and its board of regents, which oversees all three of Arizona’s state universities.

Russ Toomey, a professor at the University of Arizona, is suing the state for denying coverage of a hysterectomy. (Annie Tritt, special to ProPublia)

The experience made him “see and feel very intensely” the link he’d studied between gender discrimination and mental health. Toomey regularly feels the anguish of “knowing that I have these organs inside my body that shouldn’t be there” and not being able to afford a hysterectomy. Toomey said the unfairness of Arizona’s health plan hit hard last year, when his friend and colleague, a cisgender woman, was able to obtain coverage for her hysterectomy, while he had been denied. Arizona’s employee health plan covers medically necessary hysterectomies except as part of “gender reassignment surgery.”

He said that he developed a panic disorder over the last couple of years due to the stress of the lawsuit and his inability to access care. When he heard that the university board had spent more than $415,000 to fight the case, Toomey was shocked. “That hurts in the gut to hear,” he said.

The Arizona Board of Regents argued in court filings that it should not be a defendant in the lawsuit because it has no control over the state plan — the board provides health care through a plan controlled by the state. And the state of Arizona argued that it was not legally required to remove the exclusion, a change that it said would be too expensive.

The case is still ongoing in federal court. The state, a named defendant in the case, now has a Democratic governor, Katie Hobbs, whose win last November ended 14 years of Republican control. In response to ProPublica’s request for comment, a Hobbs spokesperson declined to answer specific questions about whether the new administration would continue to defend the exclusion but emphasized the governor’s support for trans Arizonans.

“The Governor’s Office recognizes the need for the expansion of statewide benefits that are all inclusive,” Hobbs’ press secretary, Josselyn Berry, wrote in a statement.

15 States Offered a Health Plan That Didn’t Cover Gender-Affirming Care for State Employees in 2022 Note: Some states have multiple employee health plans with differing policies on coverage for gender-affirming medical care. North Carolina was ordered to remove its exclusion in 2022 by a federal judge, but the state is appealing the ruling. The exclusion was inactive as of December 2022. (Source: ProPublica review of health plans in all 50 states and D.C.)

Like Georgia’s Houston County and the state of Arizona, North Carolina has claimed that its key concern about removing the exclusion is cost. But the statements of officials suggest that’s hardly the only concern.

North Carolina state Treasurer Dale Folwell, one of the named parties in the lawsuit, has consistently referred to gender-affirming care as medically unnecessary, contradicting medical consensus. (North Carolina had briefly removed its exclusion in 2017, before Folwell took office and reinstated it.)

“The legal and medical uncertainty of this elective procedure has never been greater,” he said in a 2018 press release. “Until the court system, a legislative body or voters tell us that we ‘have to,’ ‘when to,’ and ‘how to’ spend taxpayers’ money on sex change operations, I will not make a decision that has the potential to discriminate against those who desire other currently uncovered elective procedures.”

The state also brought forward several expert witnesses who, rather than voice concerns about spending, expressed beliefs that transgender people should be prevented or discouraged from transitioning.

One of those witnesses, Paul Hruz, a pediatric endocrinologist in St. Louis who acknowledged he had no experience treating transgender patients for gender dysphoria, said in an expert report that in many cases the condition could stem from “social contagion” and that delaying care for children allows time for most of them to “grow out of the problem.” In his career and during the case, Hruz cited controversial theories, including that “cancel culture” and a “Gender Transition Industry” are preventing public debate on the merits of transition care. According to his deposition, Hruz has attended multiple events hosted by the Alliance Defending Freedom, a religious group that has pushed anti-trans legislation across the country.

In a deposition filed by the plaintiffs’ attorneys, a mother of a transgender child recalled a conversation she’d had with Hruz years ago about trans rights and her child’s challenging experience. She said Hruz told her, “Some children are born in this world to suffer and die.”

Hruz denied in his deposition that he made that statement. He declined to provide comment for this story.

Hruz’s views are so extreme that Judge Loretta Biggs limited what topics he was allowed to speak about during the case. “His conspiratorial intimations and outright accusations sound in political hyperbole and pose a clear risk of inflaming the jury and prejudicing Plaintiffs,” she wrote in a ruling last year. “It is the Federal Rules of Evidence, not some ‘Cancel Culture,’ that excludes this portion of Hruz’s testimony.”

She ordered North Carolina to remove its exclusion and allow transgender employees to access gender-affirming care. The state quickly appealed.

In 2020, as Lange anxiously watched her case inch through the courts, her legal chances suddenly seemed better than ever: The U.S. Supreme Court ruled that employment discrimination based on transgender status is illegal. Previously, courts had been divided on the issue.

Lange was driving to collect evidence for a financial fraud case she was investigating when she heard the news. She began to cry. “I had to pull over and just lost it,” she recalled. “I was just so happy.”

Still, Houston County kept fighting.

While the case dragged on, Lange was sometimes asked why she didn’t find another job that would cover her health care, but she felt she couldn’t afford to lose her pension benefits. She also loves her work investigating criminal cases, helping victims of violent attacks and fraud. She wondered if any other law enforcement agency nearby would hire a transgender woman, let alone one who was suing her employer. She was in her late 40s at that point and felt too old for a major career change.

“It’s been a lonely process and it’s just a grind,” Lange said. “It just tears at you each day that you go by. You’re constantly reminded that you’re still not who you’re supposed to be.”

Two more years would pass before Lange won her case in 2022, with the federal judge citing the Supreme Court decision as a major reason for ruling in her favor. “The Exclusion plainly discriminates because of transgender status,” Judge Marc Treadwell wrote in his order. A jury soon after awarded her $60,000 for “emotional pain and mental anguish.” Lange celebrated, immediately calling friends who had been there for her through years of heartache, then posting the news on social media. She scheduled an appointment with a surgeon in New York.

But Lange’s joy was cut short when the county appealed the ruling, a move that would cost it tens of thousands of additional dollars; it also meant that Lange wouldn’t get any of the money she was awarded until the process was complete. The county asked the court to let it keep its exclusion in place as the appeal moved forward, arguing again that the cost of covering Lange’s surgery could be exorbitant. In its argument, it referenced a New York Times article, “How Ben Got His Penis,” about a costly surgery not for a transgender woman but for a transgender man. That surgery is much more complicated than the one Lange sought. While the judge weighed the arguments, Lange had to postpone her surgery yet again.

Lange called her friend Shannon West when she found out the county was appealing. “She was really upset. She was crying,” West recalled. “It’s like climbing a stairwell and you get to the top. You’re about to go through the door and then somebody shuts the door and you get hit back down.”

Houston County paid a private law firm almost $85,000 for the month of September 2022, several months after a federal judge ruled that the county’s health plan was discriminatory. The county is appealing the ruling. (Obtained by ProPublica)

This month, the door reopened: Treadwell ordered Houston County to cover transition care for its employees. He admonished the county for misrepresenting the cost of Lange’s surgery in its most recent legal argument, calling the decision “irresponsible.” He stressed that no connection existed, “anatomically or otherwise,” between the surgery mentioned in the New York Times article and the one Lange sought. The county, he added, had already received a specific, much lower estimate for the cost of Lange’s requested surgery.

Treadwell also said the county was “factually wrong” in suggesting that other transgender people would seek out even more expensive care. “It is undisputed that the Health Plan’s third-party administrator generally ‘concluded that utilization of gender-confirming care was low,’” he wrote. “In the four years this litigation has been pending, no other Health Plan members have sought gender confirmation surgery, or even identified as transgender.”

Lange heard about the ruling from her lawyer and struggled to feel excited. After the roller coaster of the previous several years, she had tamped down her optimism.

In many ways, Lange’s life has been on hold. She feels uncomfortable in her body and self-conscious about participating in activities she used to love: swimming, refereeing soccer, anything that would expose her body to heightened scrutiny. She’s divorced but has been hesitant to date. She goes to work, she comes home, on the weekends she plays tennis. She knows the surgery won’t restore the time she has lost.

Now, for the third time, she is starting the process of scheduling her surgery, hoping that the courts won’t yank the opportunity away again. She’s reluctant to book a hotel stay, already anticipating having to cancel it. “Until the case is done-done and over with, that’s when I can have some relief,” she said.

Have You Faced Barriers to Getting Gender-Affirming Care? Help Us Investigate.

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

by Jessica Miller, The Salt Lake Tribune

This story discusses sexual assault.

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

At 19 years old and about to be married, Stephanie Mateer went to an OB-GYN within walking distance of her student housing near Brigham Young University in Provo, Utah.

She wanted to start using birth control, and she was looking for guidance about having sex for the first time on her 2008 wedding night.

Mateer was shocked, she said, when Dr. David Broadbent reached under her gown to grab and squeeze her breasts, started a vaginal exam without warning, then followed it with an extremely painful examination of her rectum.

She felt disgusted and violated, but doubt also creeped in. She told herself she must have misinterpreted his actions, or that she should have known that he would do a rectal exam. Raised as a member of The Church of Jesus Christ of Latter-day Saints, she said she was taught to defer to men in leadership.

“I viewed him as being a man in authority,” Mateer said. “He’s a doctor.”

It was years, Mateer said, before she learned that her experience was in a sharp contrast to the conduct called for in professional standards, including that doctors use only their fingertips during a breast exam and communicate clearly what they are doing in advance, to gain the consent of their patient. Eventually, she gave her experience another name: sexual assault.

Utah judges, however, have called it health care.

And that legal distinction means Utahns like Mateer who decide to sue a health care provider for alleged sexual abuse are treated more harshly by the court system than plaintiffs who say they were harmed in other settings.

The chance to go to civil court for damages is an important option for survivors, experts say. While a criminal conviction can provide a sense of justice, winning a lawsuit can help victims pay for the therapy and additional support they need to heal after trauma.

Mateer laid out her allegations in a lawsuit that she and 93 other women filed against Broadbent last year. But they quickly learned they would be treated differently than other sexual assault survivors.

Filing their case, which alleged the Utah County doctor sexually assaulted them over the span of his 47-year career, was an empowering moment, Mateer said. But a judge threw out the lawsuit without even considering the merits, determining that because their alleged assailant is a doctor, the case must be governed by medical malpractice rules rather than those that apply to cases of sexual assault.

Under Utah’s rules of medical malpractice, claims made by victims who allege a health care worker sexually assaulted them are literally worth less than lawsuits brought by someone who was assaulted in other settings — even if a jury rules in their favor, a judge is required to limit how much money they receive. And they must meet a shorter filing deadline.

“It’s just crazy that a doctor can sexually assault women and then be protected by the white coat,” Mateer said. “It’s just a really scary precedent to be calling sexual assault ‘health care.’”

Mateer in 2008, the year she first saw Dr. David Broadbent, an OB-GYN, in advance of her wedding night (Courtesy of Stephanie Mateer)

Because of the judge’s ruling that leaves them with a shorter window in which to file, some of Broadbent’s accusers stand to lose their chance to sue. Others were already past that deadline but had hoped to take advantage of an exception that allows a plaintiff to sue if they can prove that the person who harmed them had covered up the wrongdoing and if they discovered they had been hurt within the previous year.

As a group, the women are appealing the ruling to the Utah Supreme Court, which has agreed to hear the case. This decision will set a precedent for future sexual assault victims in Utah.

Broadbent’s attorney, Chris Nelson, declined an interview request but wrote in an email: “We believe that the allegations against Dr. Broadbent are without merit and will present our case in court. Given that this is an active legal matter, we will not be sharing any details outside the courtroom.”

States have varying legal definitions of medical malpractice, but it’s generally described as treatment that falls short of accepted standards of care. That includes mistakes, like a surgeon leaving a piece of gauze inside a patient.

Utah is among the states with the broadest definition of medical malpractice, covering any acts “arising” out of health care. The Utah Supreme Court has ruled that a teenage boy was receiving health care when he was allowed to climb a steep, snow-dusted rock outcrop as part of wilderness therapy. When he broke his leg, he could only sue for medical malpractice, so the case faced shorter filing deadlines and lower monetary caps. Similarly, the court has ruled that a boy harmed by another child while in foster care was also bound by medical malpractice law.

Despite these state Supreme Court rulings, Utah legislators have so far not moved to narrow the wording of the malpractice act.

The lawsuit against Broadbent — and the questions it raises about the broadness of Utah’s medical malpractice laws — comes during a national reckoning with how sexual assault survivors are treated by the law. Legislators in several states have been rewriting laws to give sexual assault victims more time to sue their attackers, in response to the growing cultural understanding of the impact of trauma and the barriers to reporting. Even in Utah, those who were sexually abused as children now have no deadline to file suits against their abusers.

That isn’t true for sexual abuse in a medical setting, where cases must be filed within two years of the assault.

These higher hurdles should not exist in Utah, said state Sen. Mike McKell, a Utah County Republican who works as a personal injury attorney. He is trying to change state law to ensure that sexual assault lawsuits do not fall under Utah’s Health Care Malpractice Act, a law designed to cover negligence and poor care, not necessarily deliberate actions like an assault.

Utah Sen. Mike McKell introduced a bill that would clarify that sexual assault claims should not be considered medical malpractice, removing legal obstacles for survivors who have been assaulted by health care workers. (Leah Hogsten/The Salt Lake Tribune)

“Sexual assault, to me, is not medical care. Period,” he said. “It’s sad that we need to clarify that sexual assault is not medical care. But trying to tie sexual assault to a medical malpractice [filing deadline] — it’s just wrong.”

“Your Husband Is a Lucky Man”

Mateer had gone to Broadbent in 2008 for a premarital exam, a uniquely Utah visit often scheduled by young women who are members of The Church of Jesus Christ of Latter-day Saints.

Leaders of the faith, which is predominant in Utah, focus on chastity when speaking to young, unmarried people about sex, and public schools have typically focused on abstinence-based sex education. So for some, these visits are the first place they learn about sexual health.

Young women who get premarital exams are typically given a birth control prescription, but the appointments can also include care that’s less common for healthy women in other states — like doctors giving them vaginal dilators to stretch their tissue before their wedding night.

That’s what Mateer was expecting when she visited Broadbent’s office. The OB-GYN had been practicing for decades in his Provo clinic nestled between student housing apartments across the street from Brigham Young University, which is owned by The Church of Jesus Christ of Latter-day Saints.

The Provo, Utah, office building where Broadbent once practiced (Leah Hogsten/The Salt Lake Tribune)

So Mateer was “just totally taken aback,” she said, by the painful examination and by Broadbent snapping off his gloves after the exam and saying, “Your husband is a lucky man.”

She repeated that remark in her legal filing, along with the doctor’s advice for her: If she bled during intercourse, “just do what the Boy Scouts do and apply pressure.”

“The whole thing was like I’m some object for my husband to enjoy and let him do whatever he wants,” Mateer said. “It was just very violating and not a great way to start my sexual relationship with my new husband, with these ideas in mind.”

Mateer thought back to that visit over the years, particularly when she went to other OB-GYNs for health care. Her subsequent doctors, she said, never performed a rectal exam and always explained to her what they were doing and how it would feel, and asked for her consent.

She thought about Broadbent again in 2017, as the #MeToo movement gained momentum, and looked him up online. Mateer found reviews from other women who described Broadbent doing rough examinations without warning that left them feeling the same way she had years before.

Then in December 2021, she spoke out on “Mormon Stories,” a podcast where people who have left or have questioned their Latter-day Saint faith share their life stories. In the episode, she described the painful way he examined her, how it left her feeling traumatized and her discovery of the reviews that echoed her experience.

“He’s on University Avenue, in Provo, giving these exams to who knows how many naive Mormon 18-year-old, 19-year-old girls who are getting married. … They are naive and they don’t know what to expect,” she said on the podcast. “His name is Dr. David Broadbent.”

After the podcast aired, Mateer was flooded with messages from women who heard the episode and reached out to tell her that Broadbent had harmed them, too.

Mateer and three other women decided to sue the OB-GYN, and in the following weeks and months, 90 additional women joined the lawsuit they filed in Provo. Many of the women allege Broadbent inappropriately touched their breasts, vaginas and rectums, hurting them, without warning or explanation. Some said he used his bare hand — instead of using a speculum or gloves — during exams. One alleged that she saw he had an erection while he was touching her.

Broadbent’s actions were not medically necessary, the women allege, and were instead “performed for no other reason than his own sexual gratification.”

The lawsuit also named as defendants two hospitals where Broadbent had delivered babies and where some of the women allege they were assaulted. The suit accused hospital administrators of knowing about Broadbent’s inappropriate behavior and doing nothing about it.

After he was sued, the OB-GYN quickly lost his privileges at the hospitals where he worked. Broadbent, now 75, has also voluntarily put his medical license in Utah on hold while police investigate 29 reports of sexual assault made against him.

Prosecutors are still considering whether to criminally prosecute Broadbent. Provo police forwarded more than a dozen reports to the Utah County attorney’s office in November, which are still being reviewed by a local prosecutor.

A spokesperson for Intermountain Health, the nonprofit health system that owns Utah Valley Hospital, where some of the women in the suit were treated, did not respond to specific questions. The spokesperson emphasized in an email that Broadbent was an “independent physician” who was not employed by Utah Valley Hospital, adding that most of the alleged incidents took place at Broadbent’s medical office.

A representative for MountainStar Healthcare, another hospital chain named as a defendant, denied knowledge of any allegations of inappropriate conduct reported to its hospital and also emphasized that Broadbent worked independently, not as an employee.

“Our position since this lawsuit was filed has been that we were inappropriately named in this suit,” said Brittany Glas, the communications director for MountainStar.

Debating Whether Sexual Abuse Is Health Care

For the women who sued Broadbent, their case boiled down to a key question: Were the sexual assaults they say they experienced part of their health care? There was a lot hanging on the answer.

If their case was considered medical malpractice, they would be limited in how much money they could receive in damages for their pain and suffering. If a jury awarded them millions of dollars, a judge would be required by law to cut that down to $450,000. There’s no cap on these monetary awards for victims sexually assaulted in other settings.

They would also be required to go before a panel, which includes a doctor, a lawyer and a community member, that decides whether their claims have merit. This step, aimed at resolving disputes out of court, does not block anyone from suing afterward. But it does add cost and delay, and for sexual assault victims who’ve gone through this step, it has been another time they were required to describe their experiences and hope they were believed.

The shorter, two-year filing deadline for medical malpractice cases can also be a particular challenge for those who have been sexually abused because research shows that it’s common to delay reporting such assaults.

Nationwide, these kinds of malpractice reforms were adopted in the 1970s amid concerns — largely driven by insurance companies — that the cost of health care was rising because of frivolous lawsuits and “runaway juries” doling out multimillion-dollar payouts.

Restricting the size of malpractice awards and imposing other limits, many argued, were effective ways to balance compensating injured patients with protecting everyone’s access to health care.

State laws are generally silent on whether sexual assault lawsuits should be covered by malpractice laws, leaving courts to grapple with that question and leading to different conclusions across the country. The Tribune and ProPublica identified at least six cases in which state appellate judges sharply distinguished between assault and health care in considering whether malpractice laws should apply to sexual assault-related cases.

An appellate court in Wisconsin, for example, ruled in 1993 that a physician having an erection and groping a patient was a purposeful harm, not medical malpractice.

Florida’s law is similar to Utah’s, defining allegations “arising” out of medical care as malpractice. While an earlier ruling did treat sexual assault in a health care setting as medical malpractice, appellate rulings in the last decade have moved away from that interpretation. In 2005, an appellate court affirmed a lower-court ruling that when a dentist “stopped providing dental treatment to the victim and began sexually assaulting her, his professional services ended.”

Similarly, a federal judge in Iowa in 1995 weighed in on the meaning of “arising” out of health care: “Rape is not patient care activity,” he wrote.

But Utah’s malpractice law is so broad that judges have been interpreting it as covering any act performed by a health care provider during medical care. The law was passed in 1976 and is popular with doctors and other health care providers, who have lobbied to keep it in place — and who use it to get lawsuits dismissed.

Broadbent’s name has been removed from the directory outside his former office suite. (Leah Hogsten/The Salt Lake Tribune)

One precedent-setting case in Utah shows the law’s power to safeguard health care providers and was an important test of how Utah defines medical malpractice. Jacob Scott sued WinGate Wilderness Therapy after the teen broke his leg in 2015 when a hiking guide from the center allowed him to climb up and down a steep outcrop in Utah’s red rock desert.

His parents are both lawyers, and after they found that Utah had a four-year deadline for filing a personal injury lawsuit, court records said, they decided to prioritize “getting Jacob better” for the first two years after the accident. But when Scott’s suit was filed, WinGate argued it was too late — based on the shorter, two-year deadline for medical malpractice claims.

Scott’s attorneys scoffed. “Interacting with nature,” his attorneys argued, “is not health care even under the broadest interpretation of … the Utah Health Care Malpractice Act.”

A judge disagreed and threw out Scott’s case. The Utah Supreme Court unanimously upheld that ruling in 2021.

“We agree with Wingate,” the justices wrote, “that it was acting as a ‘health care provider’ and providing ‘health care’ when Jacob was hiking and rock climbing.”

Last summer, the women who had sued Broadbent and the two hospitals watched online as lawyers debated whether the abuse they allegedly suffered was health care.

At the hearing, attorneys for Broadbent and the hospitals argued that the women should have pursued a medical malpractice case, which required them to first notify Broadbent and the hospitals that they wanted to sue. They also argued to Judge Robert Lunnen that the case couldn’t move forward because the women hadn’t gone before a pre-litigation panel.

Attorneys for Broadbent and the hospitals argued, one after the other, that the painful and traumatic exams the women described arose out of health care treatments.

“Accepting the allegations of the complaint as true — as we must for purposes of this proceeding — we have to assume that [Broadbent] did something that was medically unnecessary, medically inappropriate,” argued David Jordan, a lawyer for Intermountain Health.

“But it doesn’t change the fact that it’s an act performed to a patient, during the patient’s treatment,” he said. “Because that’s what the patient is doing in the doctor’s office. They’re there for treatment.”

The attorney team for the women pushed back. Terry Rooney argued that if Broadbent’s actions fell under medical malpractice laws, many women would be knocked out of the case because of the age of their claims, and those who remained would be limited in the amount of money in damages they could receive.

“That’s really what this is about,” he argued. “And so it’s troubling — quite frankly it’s shocking to me — that we’re debating heavily the question of whether sexual abuse is health care.”

The judge mulled the issue for months. Lunnen wrote in a September ruling that if the allegations were true, Broadbent’s treatment of his patients was “insensitive, disrespectful and degrading.”

But Utah law is clear, he said. Malpractice law covers any act or treatment performed by any health care provider during the patient’s medical care. The women had all been seeking health care, Lunnen wrote, and Broadbent was providing that when the alleged assaults happened.

Their lawsuit was dismissed.

“I Felt Defeated”

Brooke, another plaintiff who alleges Broadbent groped her, remembers feeling sick on the June day she watched the attorneys arguing. She asked to be identified by only her first name for this story.

She alleges Broadbent violated her in December 2008 while she was hospitalized after experiencing complications with her first pregnancy.

Brooke, one of the women suing Broadbent, says the OB-GYN groped her when she was in the hospital after having complications with her first pregnancy. (Leah Hogsten/The Salt Lake Tribune)

The nearest hospital to her rural town didn’t have a special unit to take care of premature babies, and her doctors feared she might need to deliver her son six weeks early. So Brooke had been rushed by ambulance over a mountain pass in a snowstorm to Utah Valley Hospital.

Brooke and her husband were terrified, she said, when they arrived at the Provo hospital. Broadbent happened to be the doctor on call. With Brooke’s husband and brother-in-law in the room, Broadbent examined her late that evening, she said, listening to her chest with a stethoscope.

The doctor then suddenly grabbed her breasts, she recalled — his movements causing her hospital gown to fall to expose her chest. She recounted this experience in her lawsuit, saying it was nothing like the breast exams she has had since.

“It was really traumatizing,” she said. “I was mortified. My husband and brother-in-law — we just didn’t say anything about it because it was so uncomfortable.”

Brooke voiced concerns to the nurse manager, and she was assigned a new doctor.

She gave birth to a healthy baby a little more than a month later, at the hospital near her home.

Hearing the judge’s ruling 14 years later, Brooke felt the decision revealed how Utah’s laws are broken.

“I was frustrated,” she said, “and I felt defeated. … I thought justice is not on our side with this.”

If the Utah Supreme Court rules that these alleged sexual assaults should legally be considered health care, the women will likely refile their claims as a medical malpractice lawsuit, said their attorney, Adam Sorensen. But it would be a challenge to keep all 94 women in the case, he said, due to the shorter filing window. Only two women in the lawsuit allege that they were harmed within the last two years.

The legal team for the women would have to convince a judge that their claims should still be allowed because they only recently discovered they were harmed. But based on previous rulings, Sorensen believes the women will have a better chance to win that argument if the civil suit remained a sexual assault case.

Regardless of what happens in their legal case, the decision by Brooke and the other women to come forward could help change state law for victims who come after them.

Last week, McKell, the state senator, introduced legislation to clarify that civil lawsuits alleging sexual assault by a health care worker do not fall under Utah’s Health Care Malpractice Act.

“I don’t think it’s a close call. Sexual assault is not medical care,” he said. “I know we’ve got some bizarre rulings that have come down through our courts in Utah.”

Both an association of Utah trial lawyers and the Utah Medical Association, which lobbies on behalf of the state’s physicians, support this reform.

“We support the fact that sexual assault should not be part of health care medical malpractice,” said Michelle McOmber, the CEO for the Utah Medical Association. “Sexual assault should be sexual assault, regardless of where it happens or who’s doing it. Sexual assault should be in that category, which is separate from actual health care. Because it’s not health care.”

MountainStar doesn’t have a position on the bill, Glas said. “If the laws were to change via new legislation and/or interpretation by the courts, we would abide by and comply with those new laws.”

But lawmakers are running out of time. With only a week and a half left in Utah’s legislative session, state senate and house leaders have so far prioritized passing new laws banning gender-affirming health care for transgender youths and creating a controversial school voucher program that will provide taxpayer funds for students to attend private school.

Utah lawmakers were also expected to consider a dramatic change for other sexual assault victims: a bill that would remove filing deadlines for civil lawsuits brought by people abused as adults. But that bill stalled before it could even be debated.

Brooke had been eager to share her story, she said, in hopes it would help the first four women who’d come forward bolster their lawsuit against Broadbent. She later joined the case as a plaintiff. She read in their lawsuit about one woman who complained about him to the same hospital seven years before she did, and about another woman who said Broadbent similarly molested her two days after Brooke had expressed her own concern.

“That bothered me so much,” she said. “It didn’t have to happen to all these women.”

Brooke doubts she’ll get vindication in a courtroom. Justice for her, she suspects, won’t come in the form of a legal ruling or a settlement against the doctor she says hurt her years ago.

Instead, she said, “maybe justice looks like changing the laws for future women.”

Help ProPublica and The Salt Lake Tribune Investigate Sexual Assault in Utah

If you need to report or discuss a sexual assault in Utah, you can call the Rape and Sexual Assault Crisis Line at 801-736-4356. Those who live outside of Utah can reach the National Sexual Assault Hotline at 800-656-4673.

Mollie Simon contributed research.

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

by Ava Kofman

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Less than three weeks after ProPublica and the New Yorker published an exposé of hospice fraud, members of Congress have called on the Department of Health and Human Services to “immediately investigate this situation.”

In a letter sent Friday to the Centers for Medicare and Medicaid Services and the Office of Inspector General, the bipartisan leaders of the Comprehensive Care Caucus wrote that “Medicare fraud cannot be tolerated, especially when it is being perpetrated on our nation’s most vulnerable patients.”

The ProPublica-New Yorker investigation described how the lucrative design of the Medicare benefit incentivizes many profit-seeking hospices to cut corners on care and target patients who are not actually dying. It chronicled the lack of regulation and the frustrated efforts of whistleblowers to hold end-of-life care conglomerates accountable. And it drew on state and federal data to reveal how, in the absence of oversight, the number of for-profit hospice providers in California, Texas, Arizona and Nevada has lately exploded.

The letter’s signatories — Sen. John Barrasso, R-Wyo., Sen. Jacky Rosen, D-Nev., Sen. Deb Fischer, R-Neb., and Sen. Tammy Baldwin, D-Wis. — decried the “troubling trend” spotlighted by the reporting and requested a briefing from the agencies within two weeks about plans to “address the proliferation of fraudulent hospice providers.”

The story’s findings are also being cited by lawmakers and lobbyists in New York, where Gov. Kathy Hochul is considering signing legislation to outlaw the creation of new for-profit hospice providers in the state. At the moment, all but two of New York’s 41 hospices are nonprofit. Assemblyman Richard Gottfried introduced a bill, which passed this summer, to keep things that way. “We can close the barn door before the horses have gotten out,” he said. “The article raised the level of awareness around issues with for-profit care.”

Published last month, the investigation provoked what industry leaders have called a “much-needed” conversation on how Americans die — along with demands to improve those deaths. “The abuses detailed in the article call for a reform of the Medicare hospice benefit that can reduce the opportunities for fraud and abuse,” the National Partnership for Healthcare and Hospice Innovation, a group for nonprofits, said in a statement. In public letters, LeadingAge, another association for nonprofit providers, and the American Academy of Hospice and Palliative Medicine, an organization for hospice professionals, separately emphasized that “change is needed.”

Lobbying groups whose members include for-profit providers — the National Hospice and Palliative Care Organization and the National Association for Home Care & Hospice — took issue with the investigation’s focus on “bad actors” but said in a joint statement that its members look forward to working with lawmakers “to implement solutions to address the isolated problems highlighted by the article without jeopardizing access to the Medicare hospice benefit.”

Dr. Ira Byock, a palliative care physician, author and former president of the American Academy of Hospice and Palliative Medicine, echoed the calls for greater monitoring of the hospice system in the wake of the investigation. “Hospice in America is gravely ill,” Dr. Byock wrote in an op-ed published last week by STAT, the health care news site. “I am hopeful that the article will spark a long-overdue internal reckoning by the field — my field — and the industry we gave rise to.”

Hospice began more than 60 years ago as a countercultural charity movement to help patients die with comfort, support and as little pain as possible. After the 1980s, when President Ronald Reagan authorized Medicare to cover the service, dying became a big business. In 2000, less than a third of all hospices were for-profit. Today, more than 70% are. Between 2011 and 2019, the number of hospices owned by private equity firms tripled. For profit-seeking providers, hospice is lucrative: Medicare pays a fixed rate per patient a day, regardless of how much help is offered. The aggregate Medicare margins of for-profit providers hover around 20% compared with just 5% for nonprofits.

Studies have found that for-profit hospices are more likely than their nonprofit counterparts to have less skilled staff, reduced clinical services and fewer home visits in the last days of life. Their patients have longer stays and leave hospice alive at higher rates. Last year, citing the research, three members of the Senate Finance Committee requested information on the quality of hospice services provided by Kindred at Home, the country’s largest home care chain. (Kindred’s hospice subsidiary was recently spun-off and sold to a private equity firm.) “We are concerned that when applied to hospice care, the private equity model of generating profit on a rapid turnaround can occur at the expense of dying patients and their families,” they wrote. Analysis of the data is ongoing, senate staffers said.

Assemblyman Gottfried said that the pending legislation in New York is an attempt to prevent the profiteering that’s unfolded elsewhere from seizing his home state. Jeanne Chirico, who heads the Hospice and Palliative Care Association of New York State, said that her group regularly fields calls from venture capitalists looking to break into the market. So do her members. Mary Crosby, the CEO of East End Hospice, a nonprofit located on Long Island, said that once or twice a month investors make offers. “We’re a particularly attractive acquisition target because we struggle financially and we’re not linked to a larger health care system,” Crosby told me. “But if you’re actually providing the kind of interdisciplinary care that is based on the original hospice mission, as we are right now, you’re not going to be making a lot of money.” Her hospice covers around 20% of its operating costs from donations, she said.

New York would not be the first state to bear down on its hospice sector. California has enacted a temporary ban on new hospice licenses, after the Los Angeles Times uncovered a dramatic increase in hospices that far outpaced the demand for services. In a report released this spring, state auditors found that since 2015 the Department of Public Health had never suspended a hospice license and had revoked a license only once. “The state’s weak controls have created the opportunity for large-scale fraud and abuse,” they said.

ProPublica and the New Yorker’s reporting outlined how California’s pattern of disproportionate growth is spreading to other states. In Arizona, Nevada and Texas, the rise in new Medicare-approved hospices since 2018 now accounts for around half of all hospices in each state. Unlike New York, these states don’t have “certificate of need” requirements for hospices, which means there’s no strict limit to the number of providers that can open in a given area.

The simplest way to understand the recent hospice boom is to see it.

Rapid Rise in Hospices Concentrated in West and Southwest

A ProPublica analysis of Medicare data reveals a sharp uptick in providers since 2018.

(Source: <a href="https://data.cms.gov/provider-data/topics/hospice-care">CMS data set of Medicare-certified hospices.</a> Chart by Lena Groeger.)

This chart represents Medicare hospices — it does not include the dizzying rise in state licenses — and therefore undercounts the total explosion in end-of-life care providers. (Hospices must first obtain a state license before they can be certified to bill Medicare for their services.) Federal data, for instance, shows just 22 Medicare-certified hospices packed into a building on Friar Street in Los Angeles, but California’s data reveals an additional 107 state hospice licenses registered at the same address. (Although California’s moratorium bars new providers, it does not stop the thousand-plus owners already in possession of state licenses from obtaining Medicare certification and billing the government.)

Industry leaders have expressed alarm about the loopholes in the state and federal certification process that enable sudden clusters of for-profit providers to materialize. A ProPublica review of hospice data in Phoenix showed that a raft of new entities shared the same addresses and network of owners. Some of the Arizona entrepreneurs already operate several hospices in Los Angeles, including out of the building on Friar Street. “These small entities aren’t required to publicly report quality of care data, are often not audited and, because of how the per diem is set up, it’s a gold mine,” said Larry Atkins, the chief policy officer of the National Partnership for Healthcare and Hospice Innovation. “You could very quickly figure out whether a hospice is a real place or a mill that’s simply signing up and burning through patients to bill Medicare. But no one is really doing that.”

Eric Rubenstein, who worked as a special agent at the Department of Health and Human Services’ Office of Inspector General until 2019, said that the Centers for Medicare and Medicaid Services and its contractors are often focused on auditing bigger billers. For the “smaller circuses and clowns,” the government’s lax payment system can be easy to exploit. “The demand for these licenses is predicated on the fact that there’s a huge amount of money to be made quickly in hospice fraud,” he said.

CMS said in a statement to ProPublica that the agency “is aware of the increase in the number of new hospices” requesting Medicare certification, and is “working to ensure they meet all applicable requirements for participation in the Medicare program.”

Last month, four national hospice associations banded together to ask CMS to enact targeted moratoriums in high-growth regions. “In addition to action at the state level, increased federal oversight is needed to protect hospice patients and their families,” they wrote. The groups are currently scheduling a meeting with CMS to discuss their concerns.

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