by Eli Cahan for ProPublica

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

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

More than 40% of inpatient mental health beds were operated by for-profit entities as of 2021, according to unpublished data from Morgan Shields, an assistant professor at Washington University in St. Louis who studies quality in behavioral health care.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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Medicate Him and Ship Him Out”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This post was originally published on ProPublica.

by Eli Cahan for ProPublica

This article describes attempted suicide.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The HHS inspector general declined to comment.

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

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

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

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

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

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

Numerous Psychiatric Hospitals Have Repeatedly Violated Emergency Care Regulations

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

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

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

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

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

Within months, Congress took action.

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

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

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

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

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

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

“I Want Peace Again”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lakeside Behavioral Health (Andrea Morales for ProPublica)

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

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

But since the clarification, violations have continued.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This post was originally published on ProPublica.

by Anna Clark

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

From Fringe to Mainstream

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tooth Decay and Regrets

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This post was originally published on ProPublica.